Gallstone ileus is an uncommon complication of cholelithiasis in the elderly with a high morbidity and mortality rate. This study aims to clarify the current surgical management.In a retrospective survey over the past 11 years there were 9 patients with gallstone ileus, all elderly (mean age, 77 years), among 2242 cholecystectomies (0.4%) and 243 operated small intestinal obstructions (3.7%). Urgent laparotomy confirmed gallstone obstruction and a cholecystoduodenal (89%) or cholecystocolonic (11%) fistula. The operation included enterolithotomy alone (3 high-risk cases) or plus fistula repair and cholecystectomy (6 cases). There were 3 postoperative complications including wound dehiscence, wound infection, and obstructive jaundice (morbidity, 37.5%) and 1 death due to myocardial infarction (mortality, 11%). On follow-up (mean, 5 years), 6 patients with cholecystectomy (in 1 case it was performed 2 months after the initial operation) and 1 patient with enterolithotomy alone are well; there was 1 death from an unrelated cause after 1 year.It seems that a one-stage procedure (enterolithotomy plus fistula repair and cholecystectomy), when feasible, should be the first choice. Enterolithotomy alone should be reserved for only unstable and difficult cases.