GALLSTONE ILEUS: A 15-YEAR EXPERIENCE WITH THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM
Jeremy Chang*1, Yutao Su1, Mala Sharma1, Catherine Tran1, Dakota T. Thompson1, Paolo Goffredo2, Aditi Mishra1, Imran Hassan1
1University of Iowa Hospitals and Clinics, Iowa City, IA; 2University of Minnesota Health, Minneapolis, MN
Background: Gallstone Ileus is a rare cause of mechanical obstruction, occurring when a biliary-enteric fistula allows entry of a gallstone into the intestinal tract. Surgical management includes enterolithotomy or bowel resection alone for relief of obstruction with delayed cholecystectomy and fistula closure. Recurrence rates of up to 8% after enterolithotomy alone have been reported leading to one stage simultaneous cholecystectomy being described as an option, however controversy remains regarding its safety.
Methods: A retrospective review of the ACS National Surgical Quality Improvement Program (NSQIP) database was performed from 2006 to 2020. Adults with ICD9/10 postoperative diagnosis code of Gallstone ileus were identified. Only patients who underwent enterolithotomy or enteric resection were included to exclude patients receiving the second operation for staged management of a biliary-enteric fistula. Demographic, clinical, and outcomes data were abstracted. Patients were subgrouped for analysis based on whether they received simultaneous cholecystectomy vs management of obstruction only based on CPT code. Univariate and multivariable analyses were performed to assess for associations between minor and major complications (major = Clavien Dindo > III).
Results: A total of 607 patients were identified. The majority was female (70.0%) with median age of 73 years [65-83]. Most patient received enterolithotomy (73.6%) vs enteric resection (35.6%), while 38 patients (6.3%) received simultaneous cholecystectomy. There was no significant difference between baseline patient characteristics (age, race, ASA class, preoperative steroid use, preoperative albumin, emergency status) between patients receiving simultaneous cholecystectomy vs management of obstruction alone. Receipt of simultaneous cholecystectomy was associated with increased operative time (145 min vs 62 min, p<0.001) and length of stay (11 [7-16.75] vs 8 [5-11] days, p=0.027). A greater proportion of patients undergoing a cholecystectomy received enteric resection (44.7% vs. 24.9%, p=0.008). For the entire cohort major and minor complication rates were 5.3% and 23.6%, respectively. In multivariable analysis, higher ASA class was associated with increased rate of minor complication (OR = 1.78, p = 0.049). However, neither simultaneous cholecystectomy nor enteric resection were associated with increased risk of any complications.
Conclusion: Gallstone ileus is a rare cause of mechanical bowel obstruction necessitating surgical intervention and is associated with acceptable postoperative morbidity. However, in this contemporary cohort a cholecystectomy was uncommonly preformed and while this did not increase complication rates, it was associated with increased operative time and length of hospital stay.
Table 1. Multivariable Analysis for Major Complication (defined as Clavien Dindo > 3)
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