Perforation of a horizontal duodenal diverticulum with simultaneous choledocholithiasis following lumbar spine surgery in an elderly patient: a case report

Perforation of a duodenal diverticulum in the third (horizontal) part (D3) is an exceedingly rare surgical emergency for which operative intervention remains the mainstay of treatment. Duodenal diverticula, particularly periampullary ones, have been linked to choledocholithiasis. To our knowledge, no cases of simultaneous surgical management of a perforated horizontal (D3) duodenal diverticulum and common bile duct stones have been reported. We report the case of a 79-year-old woman who developed duodenal diverticular perforation complicated by common bile duct dilatation following lumbar spinal surgery. Emergency exploratory laparotomy confirmed perforation of a duodenal diverticulum in the third (horizontal) part (D3), which was managed by diverticular repair combined with proximal duodenostomy. Intraoperative choledochoscopy revealed choledocholithiasis with biliary dilatation, and concurrent choledochoscopic stone extraction with T-tube drainage was performed. The patient recovered uneventfully and was discharged after intensive perioperative management. This case of a 79-year-old woman illustrates several important clinical considerations. First, it highlights the potential of duodenal diverticulitis, possibly exacerbated by postoperative stress and corticosteroid exposure, to precipitate perforation of a duodenal diverticulum in the third (horizontal) part (D3)—a rare anatomical location. Second, the coexistence of a perforated duodenal diverticulum with choledocholithiasis and common bile duct dilatation is noteworthy, although the mechanism linking them in this patient remains uncertain. Third, although this report describes a successful one-stage surgical approach, we do not advocate it as a standard protocol; rather, it underscores the importance of individualized decision-making and comprehensive intraoperative assessment in rare and complex clinical scenarios. The complicated postoperative course, including multidrug-resistant infection and postsurgical gastroparesis, further emphasizes the challenges of managing elderly patients with such rare presentations.