Cholecystocholedochal fistula and choledocolithiasis of great elements: A surgical challenge

Introduction: Choledocholithiasis, the most frequent complication of cholelithiasis, is defined as the presence of stones in the common bile duct. Mirizzi syndrome, a rare complication of cholelithiasis, appears with the impaction of stones in Hartmann’s pouch. Large element choledocholithiasis is considered when stones measure ≥15 mm. Case Report: A 36-year-old female patient arrived at the emergency department presenting acute abdominal pain in the epigastrium, irradiated to the right hypochondrium accompanied by vomiting, choluria, and acholia. Hepatobiliary ultrasound showed cholelithiasis plus dilation of the bile ducts. Preoperative tests showed hyperbilirubinemia of 7.46 mg/dL with an obstructive pattern and alteration of liver function tests. Endoscopic retrograde cholangiopancreatography was performed and failed to mobilize the stone. During surgery a scleroatrophic gallbladder was identified without being able to identify the cystic duct and artery, suspecting a cholecystocholedochal fistula. A choledochotomy of 30 mm was performed to begin laparoscopic bile duct exploration. The extraction of 3 stones was achieved, the largest measuring 29 mm in diameter. Afterward, partial cholecystectomy was performed and a T-tube was placed through the choledochotomy. Intraoperative cholangiography was performed through a T-tube with adequate passage into the extrahepatic bile ducts toward the duodenum. Currently the patient is in her late postoperative period with a satisfactory evolution. Conclusion: Secondary choledocholithiasis is a common disease as a complication of chronic cholelithiasis that, thanks to multiple advances, has been easily resolved due to ERCP with sphincterotomy and balloon sweep. However, there are cases such as choledocholithiasis of large elements in which its resolution through ERCP is not feasible.