The most important complication that should be considered is the higher rate of mortality when performing a two-stage procedure and performing a cholecystectomy as well as closing the fistula in the presence of acute inflammation associated with gallstone ileus. The rate of recurrence of gallstone ileus from leaving the gallbladder intact is less than 5%. Therefore, advocating for a single enterolithotomy is favored, particularly in frail or elderly patients.

Failure to palpate for and extract any additional stones is the most likely cause of recurrence. Attempting to extract the stone through an antegrade enterotomy can result in significant mucosal injury and is therefore not recommended. The impacted stone can be large enough to cause complete obstruction and cause pressure ischemia of the bowel wall at the site of impaction. Therefore, the bowel should be carefully inspected for any signs of ischemia prompting bowel resection. The enterotomy is made proximally for this same reason and to avoid dehiscence from a suture line at that site that can become compromised. The purposeful enterotomy is then closed in a transverse fashion to avoid narrowing.