Sao Paulo Med. J. vol.113 número1

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I s r a e l S z a jn b o k , F e r n a n d o L o r e n z i, A I d a J u n q u e ir a R o d r ig u e s J r . , L u is F e r n a n d o C o r r e a Z a n t u t , R e n a t a S e r g io P o g g e t t i, E lia n S t e in m a n , D a r ia B ir o lin i

Gallstone ileus resulting in strong intestinal obstruction

Trauma Surgery Discipline, First Aid Unity, Hospital das Clinicas,

Faculdade de Medicina,

Universidade de Silo Paulo - Silo Paulo, Brazil

M echanic intestinal obstruction, caused by the passage of biliary calculus from vesicle to intestine, through fistulization, although not frequent, deserve study due to the m orbi-m ortality rates.

Incidence in elder people explains the association w ith chronic degenerative diseases, increasing com plexity in term s of therapy decision.

Literature discusses the need and opportunity for the one or tw o-phase surgical attack of the cholecyst-enteric fistule, in front of

the resolution on the obstructive urgency and m akes reference to G allstone Ileus as an exception for strong intestinal obstruction. T he m ore frequent intestinal obstruction observed is w hen it occurs a G allstone Ileus im pacting in term s of ileocecal valve.

T he authors subm it a G allstone Ileus m anifestation as causing strong intestinal obstruction, discussing aspects regarding diagnostic and treatm ent.

U N IT E R M S : Intestinal obstruction. G allstone ileus. C olycist-enteric (biliodigestive) fistule.

IN T R O D U C T IO N

G

caused

allstone Ileus is a mechanical

by the impacting

of the calculus

obstructive

situation

on the

intestine, originated from the biliar vesicle through

the cholecyst-enteric

fistule.

It was observed

during

the last years,

in the most

developed

countries,

that

the life-time

increased

and,

consequently,

the

incidence

of Gallstone

Ileus.

This

A d d r e s s f o r c o r r e s p o n d e n c e : L u is F e r n a n d o C o r r e a Z a n t u t A v . B r ig a d e ir o L u is A n t o n io , 4 5 2 S a o P a u lo - S P - B r a s il- C E P 0 1 4 0 1 - 0 0 2

incidence

is statistically

significative

in

people

over 70

years age, predominating

in women.

It represents

a 1

-4% of the strong abdominal

obstructions

(4,10,14).

Patients of the above mentioned

group age present

a

80%-90%

of disease

association,

reaching

one or more

organic systems, being predominant

the cardiovascular

and

diabetes

mellitus

diseases

(4,6,7,10,19).

Mortality

ranges

from

12%-27%,

being

mortality

related

to the seriousness

of the clinical

behavior

and,

mostly, to the associated

diseases

(4,6,8).

Most of the calcules cause intestine obstruction

when

impacting

at the ileus-termini

(8,10,19).

Treatment

continues

controverse,

discussions

being

held

on the need

and the opportunity

of undertaking

cholecyst-enteric

fistule during the initial surgery (1,4,6,17).

We found as being opportune

the publishing

of the

Gallstone-Ileus

case,

with

high

intestine

obstruction,

diagnosticated

in the pre-operative

through

computerized

tomography

and to discuss

adequacy

of the treatment

establi shed.

D E S C R IP T IO N

O F T H E C A S E

P a tie n t 8 0 y e a r s o ld , p r e s e n tin g s lig h tly c a r d ia c

in s u f f ic ie n c y a n d tw o p r e v io u s c e r e b r a l- v a s c u la r a c c id e n ts

w ith m in im u m c o n s e q u e n c e s , w a s a tte n d e d a t a n o th e r

s e r v ic e u n ity , p r e s e n tin g a 4 - d a y s e m e s is , c o n ta in in g

a lim e n ta r y r e s ts , w ith o u t p r e c e d in g c h o le c y s to p a tic

s y m p to m s .

D ig e s ti v e e n d o s c o p y p r e s ~ n te d g a s tr o d u o d e n a l

a lim e n ta r y - e s ta s is , a c u te g a s tr o d u o d e n itis ; p a tie n t

c o n tin u e d u n d e r o b s e r v a tio n .

O n th e s u b s e q u e n t d a y s , b e s id e s th e s in g le

r a d io g r a p h y , c o m p u te r iz e d a b d o m in a l u ltr a s o n o g r a p h y a n d

to m o g r a p h y w e r e p e r f o r m e d . E x a m e s s h o w e d a e r o b ily

p r e s e n tin g n o c a lc u le s in th e b ilia r v e s ic le , d u o d e n a l tis s u e s

in c r e a s e a n d s u g g e s tiv e r a d io p a q u e im m a g e o f th e c a lc u lu s

a c c o r d in g to th e T r e itz a n g le le v e l ( F ig . 1 ) .

I n s e q u e n c e , p a tie n t b e g a n to p r e s e n t p a in a n d

a b d o m in a l d is te n s io n , w o r s e e m e s is le v e ls , c e a s in g o f g a s /

in te s tiv e f u n c tio n s , b e in g th e n tr a n s f e r e d to o u r u n ity .

A d m itte d 7 d a y s a f te r th e b e g in n in g o f th e s y m p to m s ,

u n ic te r ic a n d f e v e r le s s , in d ic a tin g a c u te a b d o m in a l

o b s tr u c tiv e s itu a tio n .

A f te r p r e - o p e r a tiv e c a r e , w a s s u b m itte d to a m e d iu m

la p a r o to m y b e in g f o u n d c h o le c y s t- d u o d e n a l f is tu le w ith

in te n s iv e f ib r o s e , ir r e g u la r 3 ,5 .c m c a lc u lu s p la c e d o n th e

d is ta l je ju n e , h ig h d is te n s io n a n d v e n o u s e s ta s is . C a lc u lu s

w a s f r a g m e n te d c a s u a lly d u r in g m a n ip u la tio n . M a n u a l

p r o p u ls io n o f f r a g m e n ts in d ir e c tio n to th e c o lo n , to g e th e r

w ith th e e s ta s is e n te r ia c o n te n t, w a s c h o s e n a f te r th is .

A s th e c lin ic a l e v a lu a tio n o f th e p a tie n t w a s a d e q u a te ,

s h e w a s s u b m itte d to a c h o le c y s te c to m y a n d

c h o le c y s to r r h a p h y o f th e s e c o n d d u o d e n a l p o r tio n , p la c e

o f th e f ls tu le , w ith a tr a n s v e r s e s u tu r e in tw o le v e ls .

R a d io lo g ic e x a m in a tio n o f th e b ilia r y d u c t, in th e p r e

-o p e r a tiv e w a s n o r m a l a n d p e r ito n e a l c a v ity w a s d r a in e d .

T o ta l a n e s th e s ic p e r io d w a s o f 6 h o u r s a n d n o b lo o d

tr a n s f u s io n a p p e a r e d n e c e s s a r y .

P a tie n t s h o w e d ile o a d y n a m ic c o m p lic a tio n d u r in g

5 d a y s , w ith o u t a n y o th e r o c c u r r e n c e . C o n s id e r e d in

c o n d itio n s to le a v e h o s p ita l o n th e 1 3 th d a y .

D IS C U S S IO N

C lin ic a l s itu a tio n r e g a r d in g G a lls to n e I le u s is

c h a n g e a b le . S y m p to m s m a y s ta r t f r o m 4 to 8 d a y s b e f o r e

th e c le a r o b s tr u c tiv e m a n if e s ta tio n , s h o w in g in th is c a s e

in te r m ite n t m o v e m e n t o f th e c a lc u lu s u n til its f in a l

im p a c tin g . T h is o c c u r s , g e n e r a lly , jo in tly th e ile u s - c e c a l

v a lv e ( 4 ,8 ,1 0 ,1 9 ) .

I n th e p r e s e n t c a s e , c lin ic a l s itu a tio n in itia lly

s u g g e s te d im p a c ts o f th e c a lc u lu s in th e d if f e r e n t s e g m e n ts

o f th e s m a ll in te s tin e . T h is e x p la in s n o t o n ly th e

m o d if ic a tio n o f th e s y m p to m s p r e s e n te d , b u t a ls o th e

s u r g ic a l p o in t in a d is ta n t s e g m e n t f r o m th e in d ic a te d in

th e p r e - o p e r a tiv e c o m p u te r iz e d to m o g r a p h y .

Phisiotherapy

B ilio - d ig e s tiv e f is tu le s h a v e m a n y w e llk n o w n c a u s e s .

O n e o f th e m is th e d u o d e n a l u lc e r p e r f o r a te d 'to th e b ilia r

d u c ts , th a t s h o u ld n o t b e c o n f u s e d w ith th e c h o le c y s

t-e n tt-e r ic f is tu le s , c o n s e q u e n c e o f r e p e a te d v e s ic le

in f la m a to r y o c c u r r e n c e s .

T h e s e o c c u r r e n c e s r e s u lt in p e r ic h o le c y s tis a n d

a d h e r e n c e to th e tis s u e s o f th e c lo s e r o r g a n s . T is s u e

a d h e r e n c e s b e in g p r e s e n t, c a lc u lu s im p a c ts o c c u r r in g in

th e in te r io r o f th e v e s ic le , th e r e is a r is k o f v is c e r a l tis s u e

s c a r if ic a tio n a n d , a s a c o n s e q u e n c e , a ls o th e in te s tin a l r in g

p r o b a b ly a d h e r e d th e r e , e n a b lin g th e p a s s a g e o f th e f is tu le

to th e in te s tin e .

Clinical situation

A b o u t 1 /3 o f p a tie n ts d o n o t m e n tio n a n y p r e v io u s

b ilia r d is e a s e a n d 1 /3 o n ly m a k e r e f e r e n c e to o c c u r r e n c ie s

r e s e m b lin g to a c u te c h o le c y s titis r e c e n tly h a p p e n e d

( 7 ,8 ,1 0 ,1 8 ) . I n s p ite o f d if f ic u ltie s in c o lle c tin g in f o r m a tio n

r e s u ltin g f r o m th e p r e v io u s c e r e b r a l v a s c u la r a c c id e n t, o u r

p a c ie n t d e n ie d s y m p to m s o f a p r e v io u s b ilia r d is e a s e .

A c a lc u le p a s s in g th r o u g h th e f is tu le , m a y b e

e llim in a te d th r o u g h e m e s is , o r im p a c t in in te s tin e ( 4 ) .

T h e G a lls to n e I le u s is f r e q u e n tly c h a r a c te r iz e d b y

a b d o m in a l c o llic p a in s , b ilio u s e m e s is o r , e v e n tu a lly ,

f e c u le n t, s e ld o m ic te r u s . I ts d if f e r e n c e in d ia g n o s tic

in c lu d e s o th e r c a u s e s th a n th e in te s tin a l o b s tr u c tio n a n d

m e s e n te r ic is c h e m ia .

D ia g n o s tic is n o t a lw a y s im m e d ia te . T h e r e a r e c a s e s

w h e r e th e c o n f ir m a tio n o f th e d ia g n o s tic h y p o th e s is is o n ly

p o s s ib le in th e in te r - o p e r a tiv e . S o m e a u th o r s c o m m e n t o n

s u r g e r ie s in d ic a te d 3 o r 5 d a y s a f te r h o s p ita l e n tr y , a s r e s ~ lt

o f d ia g n o s e d if f ic u lty o r f o r e s ta b lis h in g a s s o c ia te d o r g a n ic

Subsidiary exames

T h e c lin ic e v a lu a tio n is c o m p le m e n te d b y

ra d io g ra p h ie s , u ltra s o n o g ra p h y , c o m p u te riz e d to m o g ra p h y

a n d d ig e s tiv e e n d o s c o p y .

S in g le a b d o m in a l ra d io g ra p h y o f th e G a lls to n e Ile u s

m a y s h o w -u p a c c o rd in g th e R ig le r's tria d : m e c h a n ic a l

o b s tru c tio n , a e ro b ily a n d ra d io p a q u e c a lc u lu s in u n u s u a l

p o in t o r p ro g re s s iv e lo c a l c h a n g in g (2 ,3 ,1 0 ). T w o o f th e s e

3 s ig n a ls a p p e a r in a t le a s t h a lf o f th e p a tie n ts p re s e n tin g

G a lls to n e Ile u s .

A e ro b ily fre q u e n tly a p p e a rs a s s o c ia te d to p re c e d e n t

b ilia r-s u rg e ry o r to th e O d d i S p h in c te r in s u ffic ie n c y . In

o rd e r to o c c u r in th e c h o le c y s t-e s te ric fis tu le , c y s tic d u c t

m u s t b e a c q u a in ta n t o r a b ilia r d u c t fis tu le m u s t b e p re s e n t.

A n o ~ h e r ra d io lo g ic s ig n a l is th e a p p e a rin g o f tw o

h y d ro a e re a lle v e ls in th e rig h t h y p o c h o n d ria c , th e m e d ia l'

c o rre s p o n d in g to d u o d e n e a n d th e la te ra l to th e b ilia r

v e s ic le . T h e fre q u e n t g a s in te rfe re n c e o n th e c a lc u le p la c e d

o u t o f th e v e s ic le e v e n w h e n b e in g ra d io p a q u e , m a k e s its

v is u a liz a tio n d iffic u lt.

T h e c o n tra s tin g ra d io g ra p h y m a y id e n tify th e

p re s e n c e o f th e fis tu le a n d th e le v e l o f th e m e c h a n ic a l

o b s tru c tio n .

In th e a b d o m in a l u ltra s o n o g ra p h y c ;h o le c y s t-e n te ric

fis tu le n la y b e o b s e rv e d ,s o a s th e re s id u a l c h o le lith ia s is

a n d c a lc u le s im p a c te d in th e in te s tin e (2 ,4 ,1 8 ). H o w e v e r,

tw o fa c to rs m u s t b e c o n s id e re d : firs t, th e re s id u a l

c h o le lith ia s is m a y n o t o c c u r; s e c o n d , th a t its p re s e n c e m a y

b e n o te d , e v e n tu a lly , o n ly th ro u g h u ltra s o n o g ra p h y .

A b d o m in a l c o m p u te riz e d to m o g ra p h y m a y s h o w -u p

c a lc u le s n o t o b s e rv e d th ro u g h s in g le to m o g ra p h y o r

u ltra s o n o g ra p h y . It m a y id e n tify a ls o th e g a s p re s e n c e o r

c o n tra s ts in th e b ilia r d u c t o r v e s ic le , w h ic h p re s e n c e is

u n d e rs to o d a s a b ilio -d ig e s tiv e fis tu le o c c u rre n c e (2 ).

H ig h d ig e s tiv e e n d o s c o p y e n a b le s v is u a liz a tio n o f

e v e n tu a l c a lc u lu s im p a c te d in th e d u o d e n e . S o m e tim e s ,

id e n tific 'a tio n is fo llo w e d b y its p ro m p t re m o v a l. W h e n

th is is n o t p o s s ib le , s u rg ic a l re m o v a l is in d ic a te d (4 ).

Diagnostic

S y n d ro m ic d ia g n o s e w a s d o n e th ro u g h th e

in te rp re ta tio n o f th e c lin ic e v a lu a tio n " a fte r d e v e lo p m e n t

o f th e s ig n a l a n d s y m p to m s c le a rly o b s tru c tiv e . A s o n th e

s in g le ra d io g ra p h y th e c a lc u le im a g e w a s v e ry s lig h t,

e tio lo g ic a l d i a g n o s tic w a s s ta te d o n ly a fte r th e

c o m p u te riz e d to m o g ra p h y .

R e tro s p e c ti v e ly , R ig le r tria d w a s p o s s ib le to b e

re c o g n iz e d th ro u g h th e s in g l~ ra d io g ra p h y o r o u r p a tie n t.

Surgical treatment

S u rg ic a l tre a tm e n t is a d o p te d fo r th e G a lls to n e Ile u s .

A s a lre a d y to ld , \v h e n th e re is a d u o d e n a l im p a c t,

e n d o s c o p ic re m o v a l is p o s s ib le .

T h e re s till is a s m a ll g ro u p o f p a tie n ts th e lith o trip s ia

b y w a v e s o f s h o c k is u s e d fo r (4 ).

In th e s u rv e y s o n th e G a lls to n e Ile u s s u rg e rie s ,

c a lc u lu s im p a c te d in th e s h o rt in te s tin e a re a lm o s t a lw a y s

fo u n d . A c c o rd in g th e a u th o rs , im p a c t o c c u rs in 5 0 % to

7 0 % o f th e ile u s te rm in a l c a s e s , in c lu d in g th e ile u s -c e c a l

v a lv e . A b o u t 2 0 % to 4 0 % in th e p ro x im a l o r je ju n e ile u s

a n d th e re m a in in g 1 0 % in th e d u o d e n u m (4 ,1 3 ,1 5 ).

T h e m a in lo c a l o f im p a c ta tio n in th e c o lo n is th e

s ig m o id . U s u a lly o c c u rs in th e p re s e n c e o f c h o le c y s

t-c o lo n it-c fis tu le s a n d p re v io u s s ig rn o id e a n e s te n o s is , c a u s e d

b y p re c e d in g d iv e rtic u litis m a n ife s ta tio n . C a lc u le s a b le to

c a u s e o b s tru c tio n a t th is le v e l w o u ld n o t p a s s th ro u g h th e

ile u s -c e c a l v a lv e s in c a s e th e fis tu le w ith v e s ic le w o u ld

n o t o c c u r w ith th e c o lo n ic s e g m e n t (1 3 ,1 5 ).

In th e m o s t o f th e tim e s th e o b s tru c tiv e c a lc u lu s is

th e o n ly o n e a n d d ia m e te r v a rie s fro m 2 to 5 e m (4 ,8 ,1 3 ,2 0 ).

F re q u e n c y o f fis tu le s a lo w in g p a s s a g e o f c a lc u lu s

a re in d e c re a s in g o rd e r in fro n t o f th e c h o le c y s t-d u o d e n a l,

c h o le c y s t-c o lo n ic , c h o le c y s t-d u o d e n o c o lo n ic a n d , b y la s t,

th e c h o le d o c itis -d u o d e n a l. In th e c a s e o f th e c o lo n ic o n e s ,

th e y o c c u r m o re fre q u e n tly w ith th e h e p a tic a n g le , b e in g

p o s s ib le to o c c u r w ith th e tra n s v e rs e o n e a n d ,

e x c e p tio n a lly , d ire c tly w ith th e s ig m o id . (1 0 ,1 2 ).,

T h e p re m a tu re re la p s e o c c u rs w h e n th e re a re m u ltip le

v e s ic le c a lc u le s a n d th e fis tu le is n o t a d e q u a te ly b o a rd e d .

M u ltip le c a lc u le a re g e n e ra lly m u ltifa c e d ..

A s m ig ra tio n o f tw o o r m o re c a lc u le s is p o s s ib le , it

is re c o m m e n d e d , d u rin g th e s u rg e ry , to in s p e c t a ll th e

in te s tin e s e g m e n ts (1 ,3 ,5 ,1 2 ).

L ite ra tu re d is c u s s e s a b o u t e x te n s io n o f th e s u rg ic a l

ile u s -b ilia r tre a tm e n t, c o m p ris in g th re e o p tio n s .

T h e firs t o n e c o n s is ts in th e e n te ro lith o to m y s o lv in g

o b s tru c tio n o n ly .

T h e s e c o n d is th e . tw o -p h a s e s u rg e ry . In th e firs t,

e n te ro lith o to m y is d o n e a n d , in th e s e c o n d , a fte r 3 o r 4

w e e k s , c h o le c y s te c to m y a n d th e c h o le c y s t-e n te ric fis tu le

re s o lu tio n .

T h ird o p tio n is th e o n e -p h a s e s u rg e ry ,

e n te ro lith o to m y a n d c h o le c y s te c to m y w ith c o rre c tio n o f

th e c h o le c y s t-e n te ric fis tu le .

C rite ria th a t s h o u ld d ire c tio n tre a tm e n t a re th e a g e

o f th e p a tie n t, a c id -b a s ic a n d h y d ro e le tro litic b a la n c e

c o n d itio n s , a s s o c ia te d d is e a s e s , re s id u a l c h o le litia s is a n d

p re s e n c e o f a c u te in fIa m a to ry p ro c e s s in th e c h o le c y s

t-e n tt-e ric fis tu le (1 ,1 4 ,2 0 ).

4

F ig u re 1 - A b d o m in a l C o m p u te riz e d T o m o g ra p h y : A e ro b ilia a n d a 3 ,5 c m im a g e o f c a lc ific a tio n s a re o b s e rv e d , la m in a te d p e rife ric a lly a n d c ru d e in th e c e n te r, c o rre s p o n d in g to c a lc u lu s im p a c te d a t th e T re itz a n g le le v e l

Surgical techniques

E n te ro lith o to m y sh o u ld b e p e rfo rm e d b y a lo n g itu d in a l in c isio n , n e a r to th e o b stru c tio n a t th e c o n tra -m e se n te ric e d g e , fo llo w e d b y tra n sv e rse re a p p ro x im a tio n . A n e n te re c to m y m a y b e n e e d e d e v e n tu a lly , m a in ly if th e re . is a n in te stin a l p e rfo ra tio n .

M a n u a l p ro p u lsio n to th e c e c o , so a s a trip sis o f th e c a lc u lu s m a y b e d o n e in se le c tiv e c a se s, w ith th e risk o f re su ltin g in in ju ry o f th e e n te ric tissu e (4 ,9 ).

W h e n th e re a re m u ltip le c ,a lc u le s, a n in c isio n n e x t to th e h ig h e r c a lc u lu s e n a b le s th e re m o v a l o f th e sm a lle r o n e s. In c a se o f th e o b stru c tio n o f th e sig m o id c o lo n , th e a u th o rs d e sc rib e a p ro x im a l c o lo to m y fo r th e c a lc u lu s re m o v a l, so a s th e e x tra c tio n th ro u g h a c o lo n o sc o p y . H o w e v e r, p re fe re n c e is fo r th e re -se c tio n in g o f sig m o id w h e n ste n o se d , re m o v in g th e se g m e n t a tta c k e d a n d th e c a lc u le s (1 3 ,1 5 ).

A s in th e p re se n t c ~ se a d e m o n stra tio n th ro u g h th e e x a m e s o f th e p re -o p e ra tiv e im a g e o f th e re sid u a l c a lc u le a b se n ~ e w a s a v a ila b le , a tw o -p h a se su rg e ry c o u ld h a v e b e e n c h o se n . H o w e v e r, a s th e c lin ic a l c o n d itio n s a lo w e d , th e o n e -p h a se su rg e ry w a s a d o p te d , b e in g th e p a tie n t's sa tisfa c to ry re a c tio n a c o n firm a tio n th a t rig h t th e ra p y h a s b e e n d e c id e d u p o n .

It m u st b e n o te d th a t, a lth o u g h th e p ro p u lsio n o f c a lc u le is c o n d e m n e d d u e to risk o f in ju ry to th e rin g s tissu e a n d d ista l o b s~ ru c tio n o f th e sig m o id c o lo n , in th is c a se it w a s p e rfo rm e d d u e to th e sp o n ta n e o u s fra g m e n ta tio n o f th e c a lc u le d u rin g th e in itia l m a n ip u la tio n .

Post-operative results

T h e sp o n ta n e o u s c lo sin g o f th e c h o le c y st-e n te ric fistu le m a y o c c u r a fte r th e c a lc u lu s m ig ra tio n , w h e n th e re w o u ld n o t b e re sid u a l c a lc u le s a n d th e c h y stic d u c t e n a b le s p a ssa g e (1 1 ,1 6 ,1 7 ).

W h e n c h o le c y ste c to m y a n d b ilio -d ig e stiv e c o rre c tio n o f fistu le is n o t p e rfo rm e d , so m e c o m p lic a tio n s m a y o c c u r,su c h a s c h o la n g itis, a c u te c h o le c y stitis, in te stin a i o b stru c tio n re la p se , c h o le d o c o litis, b le e d in g th ro u g h fistu le a n d b ilia r v e sic le 'n e o p la sy .

C h o la n g itis o c c u rs in 1 0 % o f c a se s w ith p e rsiste n c e o f th e c h o le c y st-e n te ria fistu le a n d '6 0 % o f th o se w ith c h o le c y st-c o lo n ic fistu le . A c u te c h o le c y stitis m a y o c c u r th ro u g h re sid u a l c h o le litia sis a n d re la p se o f ile o -b ilia r is v e rifie d in 5 % to 1 0 % o f th e c a se s. C h o le d o c o litia sis e v e n tu a lly in sta lle d m a y b e c a u se o f c h o la n g itis a s w e ll. B le e d in g m a y o c c u r th ro u g h th e p a ssa g e o f th e c a lc u lu s th ro u g h th e fistu le . N e o p la sia o f v e sic le in c id e s in 1 5 % o f p a tie n ts w ith fistu le p e rsiste n c e , v e rsu s th e 0 ,8 % o f p o p u la tio n in g e n e ra l (5 ,7 ,1 1 ,1 6 ).

C O N C L U S IO N

D e fin ite c o rre c tio n o f b ilia r d u c to , a lth o u g h re q u irin g m o re a n e sth e sic /su rg ic a l tim e , d o e s n o t in c re a se m o rta lity ra te s in c o m p a riso n to th e o th e r ty p e s o f tre a tm e n t (1 ,4 ,6 ,1 9 ,2 0 ).

O n e -p h a se su rg e ry se e m s to b e th e in d ic a te d o n e , w h e n th e lo c a l a n d g e n e ra l c o n d itio n s a re fa v o ra b le . T w o -p h a se tre a tm e n t d o e s n o t in c re a se m o rta lity , b u t im p lie s in a lo n g e r c o n fin e m e n t. U su a lly , im p lie s in tw o d iffe re n t p ro c e d in g s in o ld a g e d p a tie n ts.

W h e n th e b ilia r so lu tio n is n o t p o ssib le in th e in itia l su rg e ry , b ilia r d ise a se sy m p to m s o r re sid u a l c h o le litia sis ju stify a n e w se le c tiv e su rg e ry . '

In high risk patients that, after enterolithotom y, present residual cholelithiasis, should be studied possibility of the use of litotripsia by w aves of shock, chem ical dissolution of the calcules, although the consequence of

these procedings on the ,chronically inflam ated areas are not yet w ellknow n, such as the found in the cholecyst-enteric fistules (4).

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