Branden Hawara, MS1, Ryan D Horsley, DO2. 1Geisinger Commonwealth School of Medicine, 2Geisinger Community Medical Center
We present a unique case of an 86 year-old male with multiple comorbidities including, but not limited to, chronic kidney disease, cirrhosis, atrial fibrillation, coronary artery disease, and cholecystitis. Over one year prior he underwent percutaneous transhepatic cholecystostomy tube placement for sepsis secondary to acute calculous cholecystitis. On admission he presented with nausea, vomiting, lethargy, and poor appetite. He was found to have gastric outlet obstruction secondary to a cholecystoduodenal fistula with gallstone impacted in the second portion of the duodenum, which was found on initial cross-sectional imaging. Nasogastric tube (NGT) decompression was attained and he was placed on aspiration precautions. His supra-therapeutic INR (>4) was reversed with vitamin K. An esophagogastroduodenoscopy (EGD) was then performed for a planned endoscopic removal of the gallstone. The presence of a cholecystoduodenal fistula was noted, however, the gallstone was not seen. A repeat CT scan was obtained with oral contrast, which showed the gallstone to be lodged in the mid portion of the jejunum. Therefore, the patient was brought into the operating room for definitive care via diagnostic laparoscopy and laparoscopic enterolithotomy and removal of gallstone with intracorporeal two-layered closure of the small bowel. Examination of the gallstone after removal in the operating room revealed it to measure over 4 cm at its greatest diameter. The procedure was successful and the patient had an unremarkable post-operative course and was ready for discharge on post-op day #3 but ultimately, was discharged on post-op day #5 to rehab. The patient’s clinical presentation represented a classic case of Bouveret Syndrome – a rare presentation of gallstone ileus representing only 2-3% of gallstone ileus and is often associated with high morbidity and mortality rates. We present a unique minimally invasive, total laparoscopic approach, which resulted in an uneventful post-operative course without complication. Cholecystectomy was deferred at this time. Further discussion regarding elective cholecystectomy and repair of cholecystoduodenal fistula will be explored at future follow up visits.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94725
Program Number: V103
Presentation Session: Exhibit Hall Theater Video Session IV
Presentation Type: EHVideo