Rare complication of gallstone disease is gallstone ileus. The common location is the small intestine, followed by the stomach. The rarest location is colonic gallstone ileus (CGI). To summarize and define the most appropriate diagnostic methods and therapeutic options for CGI based on the paucity of published data. Literature searches of English-, German-, Spanish-, Italian-, Japanese-, Dutch- and Portuguese language articles included and Italian-language articles using PubMed, EMBASE, Web of Science, The Cochrane Library, and Google Scholar. Additional studies were identified from the references of retrieved studies. 113 cases of CGI were recorded with a male to female patient ratio of 1:2.9. The average patient age was 77.7 years (range 45-95 years). The usual location of stone impaction was the sigmoid colon (85.8%), followed by a descending colon (6.6%), transverse colon (4.7%), rectum (1.9%), and lastly, ascending colon (0.9%). Gallstones ranged from 2 to 10 cm. The duration of symptoms was variable (1 day to 2 months), with commonly reported abdominal distension, obstipation, and vomiting; 85.2% of patients had previous biliary symptoms. Diverticular disease was present in 81.8% of patients. During the last 23 years, CT scan was the most common imaging method (91.5%), confirming the ectopic gallstone in 86.7% of cases, pneumobilia in 65.3%, and cholecytocolonic fistula in 68%. The treatment option included laparotomy with cololithotomy and primary closure (24.7%), laparotomy and cololithotomy with diverting stoma (14.2%), colonic resection with anastomosis (7.9%), colonic resection with a colostomy (12.4%), laparoscopy with cololithotomy with primary closure (2.6%), laparoscopy with cololithotomy with a colostomy (0.9%), colostomy without gallstone extraction (5.3%), endoscopic mechanical lithotripsy (success rate 41.1%), extracorporeal shock wave lithotripsy (1.8%). The cholecystectomy rate was 46.7%; during the initial procedure 25%, and as a separate procedure, 21.7%; 53.3% of patients had no cholecystectomy. The survival rate was 87%. CGI is the rarest presentation of gallstone ileus, mainly in women over 70 years of age, with gallstones over 2 cm, and predominantly in the sigmoid colon. Abdominal CT is diagnostic. Nonoperative treatment, particularly in subacute presentations, should be the first-line treatment. Laparotomy with cololithotomy or colonic resection is a standard procedure with favorable outcomes. There are no robust data on whether primary or delayed cholecystectomy is mandatory as a part of CGI management.

Due to the rarity of recurrent gallstone ileus (RGSI), its epidemiological and clinical features are elusive. With a focus on mortality and the site of impaction, this study consolidates the key clinical characteristics of index GSI (IGSI) and RGSI.

A meta-analysis of cases reported on RGSI was performed. Risk factors for mortality and site of impaction were examined, and a subgroup analysis was performed for age, sex, and site of impaction (jejunum, ileum, or others).

In the final analysis, 50 (56 individual cases) studies were included. The paired data for the site of impaction was available for 45 patients. Women accounted for 87.3% of all RGSI cases included in the pooled analysis. The median age (interquartile range, IQR) of the patients was 70 (63-76) years, and the median time of recurrence (IQR) was 20.5 (8.5-95.5) days. The overall mortality rate was 11.8%, without correlation between the mortality rate and age, the time of recurrence, or the site of impaction. The region in which the stone was found in RGSI and IGSI was similar in most cases (p=0.002). Logistic regression also revealed a higher probability of stone impaction in the ileum in RGSI if it was the site of impaction in IGSI. In most cases, enterolithotomy was the preferred method.

A high index of suspicion for RGSI should be maintained for older women with a history of GSI. The region where the stone was impacted during IGSI should be investigated first in such patients.

To help the surgeon in decision making when treating a patient with recurrent gallstone ileus (RGSI).

A systematic review related to RGSI was performed using the databases CINAHL, EMBASE, MEDLINE via PubMed from May 1912 to April 2015. All languages were included and the grey literature was also searched. The abstracts were explored for relevance to the topic and full texts obtained as appropriate. A manual search was carried out by scrutinising the reference lists of all the full text articles and further articles were identified and obtained. Total of 903 articles were identified, 656 were excluded after abstract review, 247 full text articles were reviewed and 91 articles selected for final analysis. There were 113 cases of RGSI.

There were 113 cases of RGSI reported in 91 articles. The majority of the recurrences, 62.6%, occurred within 6 wk of the index event. The male to female ratio was 1:7. The mean age was 69.6 years (SD 11.2) with a range of 38-95 years. The small bowel was the commonest site of impaction (92.2%). Treatment data was available for 104 patients. The two main operations performed were: (1) Enterolithotomy without repair of biliary fistula in 70.1% of all patients with a procedural mortality rate of 16.4% (12/73) and (2) a single stage surgery approach involving enterolithotomy with cholecystectomy and repair of the biliary enteric fistula in 16.3% with a procedural mortality of 11.7% (2/17). A subset analysis over last 25 years showed mortality from eneterolithotomy was 4.8% while single stage mortality was 22.2%. Enterolithotomy alone was the commonest operation performed for RGSI with four patients (5.4%) having a further recurrence of gallstone ileus.

Enterolithotomy alone or followed by a delayed two-stage treatment approach is the preferred choice offering low mortality and reduced risk of recurrence.