An 88-year-old woman with a history of dementia, end- stage renal disease, hypertension, and chronic cholelithiasis presented with nausea and non-bloody emesis of two- day duration. She reported no abdominal pain, fever, melena, or hematochezia. The patient was hospitalized two years prior for a similar presentation, during which a CT scan revealed a large gallstone within the gallbladder (Fig. 1). At that time duodenopathy with a post-bulbar duodenal stricture was identified via EGD, the etiology of which was believed to be chronic cholelithiasis leading to inflammatory changes of the duodenum with resultant stricture formation. Pathological examination failed to demonstrate malignancy and testing for Helicobacter pylori infection was negative. The patient refused surgical intervention at that time and was treated conservatively with dietary modifications.

The patient presented two years later with moderate abdominal distention. On exam she was non-tender. Laboratory data were significant for an elevated white blood cell count of 16.7×10⁹/L with a left shift and an alkaline phosphatase of 283 unit/L [25-100]. Her blood urea nitrogen was 11.8 mmol/L and creatinine was 556 mmol/L, which was expected due to end-stage renal disease. Additional hepatic, hematologic and metabolic studies were unremarkable. An abdominal roentgengram revealed an abnormal gas pattern with a distended gastric silhouette and gastrectasis that was increased from prior studies. There was no pneumoperitoneum or significant calcifications in the right upper quadrant. The initial abdominal CT scan showed a large gallstone measuring 4 cm in the duodenum. A second abdominal CT scan was obtained five days later that showed progression of the large gallstone to the duodenal bulb with interval development of pneumobilia; there was no evidence of small bowel obstruction.

Initial management included nasogastric (NG) decompression followed by EGD, which revealed a normal appearing esophagus, gastric antrum and pylorus. A large gallstone measuring 4 to 5 cm was visualized at the apex of the duodenal bulb with surrounding mucosal edema. Several attempts were made to extract the stone endoscopically without success due to the angulation of the duodenum and the extensive inflammatory changes surrounding the stone.

Surgical intervention was pursued following failed endoscopic extraction. The abdomen was entered laparoscopically and with hand-assistance. The gallstone in question was palpated; however, movement was difficult within the confines of the hand port. At this point, the procedure was converted to open. The lesser sac was entered and dissection was carried down to the duodenum. The gallstone failed to be manipulated proximally into the stomach secondary to dense adhesions. Despite meticulous lysis of adhesions and performing a limited Kocher maneuver, the attempts to move the stone into stomach were ultimately unsuccessful. Accordingly, the decision was made to pass the stone more distally in an attempt to extract it through a jejunal enterotomy. The stone moved freely down to the inferior and ascending portions of the duodenum; however, advancement beyond the ligament of Treitz was unsuccessful even after its release leading to the decision to proceed with a duodenotomy for stone extraction. The stone was manipulated back to descending portion of the duodenum and removed via duodenotomy on the antimesenteric border. The fistula was left intact and the duodenum was repaired primarily and covered with an omental patch. A feeding tube was left distally in anticipation of potential obstruction secondary to intramural hematoma. The patient was admitted for post-operative management. Tube feedings were started post-operative day 2 through the jejunostomy tube, while the gastrostomy tube remained to gravity. An upper gastrointestinal study was obtained on post-operative day 7 which showed no evidence of leak. The patient’s diet was subsequently advanced as tolerated. She had return of gastrointestinal function on post-operative day 11 and was discharged home on post-operative day 14. She is now over 24 months post-surgery without recurrence of symptoms.

An 80 year old female with a history of hypertension, hypothyroidism, hyperlipidemia, and endometrial cancer status post pelvic radiation and hysterectomy, with previous abdominal surgery secondary to iatrogenic colonic perforation during colonoscopy, presented to an outside facility four days prior to arrival at our institution due to severe colicky epigastric, periumbilical, and right upper quadrant pain of one day duration associated with nausea and chills. Patient was made NPO with NG decompression in addition to receiving empiric meropenem at the outside facility where a cholecystoduodenal fistula with large gallstone in the duodenal lumen was identified by abdominal CT. Upper GI was performed on hospital day four at the outside facility, which revealed failure of stone progression prompting transfer to our institution for definitive management. On intake exam her vitals were stable within normal limits and she was found to have no abdominal tenderness and no distention. Her laboratory values were without any significant abnormalities.

Gastroenterology attempted endoscopic retrieval of the duodenal gallstone, at which time the stone was noted to be 3.5 cm in diameter and obstructing the lumen of the bulbar duodenum. Endoscopic retrieval attempts resulted in partial fragmentation of the stone but were ultimately unsuccessful. The following day repeat abdominal CT revealed migration of the stone into the proximal jejunum (Fig. 2).

The decision to proceed with surgical removal hinged on the concern that further distal transit of the stone may result in it becoming lodged in a bowel loop contained in the patient's incisional hernia or a pelvic loop due to previous pelvic radiation. The abdomen was entered laparoscopically. Multiple areas of adhesions were encountered requiring adhesiolysis and ultimately the insertion of a hand port. The stone-containing small bowel was located and delivered through the hand port after which two stay sutures were placed on the antimesenteric border. An enterotomy was then made through which the gallstone was subsequently delivered (Fig. 3). Closure of the enterotomy was achieved via two transverse layers of suture and the bowel was returned into the abdomen. The cholecystoduodenal fistula was left intact for closure at a later date. The patient was transferred back to the general medical/surgical floor for post-operative recovery. Her diet was advanced on post-operative day 1 and she experienced return of gastrointestinal function on post operative day 2. The patient was discharged home on post operative day 2. She is now 16 months post-surgery and has had no recurrent symptoms.

A 68 year old female with history of sarcoma, non-small cell lung cancer, breast cancer, diabetes, nephrolithiasis, hyperlipidemia, and surgical history of hysterectomy approximately one year prior to presentation, presented with intermittent periumbilical abdominal pain of one day duration. She reported multiple episodes of non-bloody non-bilious emesis with subsequent but transient resolution of the presenting pain. The patient reported a recent 25 pound unintentional weight loss. On exam she was afebrile and hemodynamically stable with mild tachycardia. Her abdominal exam was significant for periumbilical guarding and right upper quadrant tenderness. Laboratory values revealed an elevated lactic acid as well as a leukocytosis. All other laboratory values were without significant abnormalities. An abdominal CT scan revealed extensive inflammation of the gallbladder fossa along with a choledochoenteric fistula and gallstone within the jejunum.

The decision was made to proceed to the operating room for diagnostic laparoscopy with possible small bowel resection. The abdomen was entered laparoscopically. Multiple areas of adhesions were encountered requiring adhesiolysis. A hand port was later added secondary to the severe extent of adhesions. The gallstone-containing loop of bowel was identified and delivered through the hand port. Two stay sutures were placed, an enterotomy was created, and the gallstone was delivered (Fig. 4). The enterotomy was then closed with two layers of transverse sutures and the bowel loop was returned into the abdominal cavity. The fistula was left intact to be addressed at a later date. The patient was transferred to the general medical/surgical floor for post-operative recovery. She experienced respiratory insufficiency post-operatively requiring high flow supplemental oxygen; her NG remained in place until post-operative day 2. Bowel function returned by post-operative day 3 and she tolerated advancement of diet without any issues. The patient remained hospitalized until post-operative day 5 in an attempt to improve her respiratory insufficiency with aggressive pulmonary toilet; however, she was ultimately discharged with home oxygen, which she had previously required earlier in the year. The patient expired nine months later due to an unrelated etiology; she did not experience obstruction or cholecystic symptoms from the time of operative management until her unrelated death.