A 67-year-old Caucasian female presented with 4 days of vomiting associated with coffee ground materials, loss of appetite, and new onset of occasional heartburn. She denied any abdominal pain. The physical exam was pertinent for severe obesity with Body-Mass-Index of 52 and frequent desaturations on room air from 90 to 84%. The patient was lethargic, with clear lungs and a 2/6 systolic murmur over the base. Her abdomen was non-distended and non-tender with normal bowel sounds. Significant bilateral lower extremity edema was noticed. Her liver tests were all within normal limits. Initial chest and abdominal radiographs were normal. An esophagogastroduodenoscpy was performed using a GIF-1T 140 (Olympus, Melville, NY), which has 10.9 mm diameter and single channel 3.7 mm. In the duodenum just beyond the bulb, very large gallstone was obstructing the lumen measuring about 4 cm x 2 cm (Figure 1). The adjacent duodenal walls appeared ulcerated and friable. Computed tomography of the abdomen showed pneumobilia, distended stomach and a 4 cm mass with calcified rim in the duodenum. The gallbladder was adjacent to the mass and contained an air fluid level (Figure 2). Because of the patient's high surgical risk, secondary to obstructive sleep apnea with pulmonary hypertension, severe aortic stenosis and morbid obesity, treatment with endoscopic laser lithotripsy followed by endoscopic removal of the fragments was planned.
A holmium: yttrium-aluminum-garnet laser (Ho:YAG) was used via a flexible fiber through the biopsy channel of the GIF-2T 160 endoscope which has 12.6 mm diameter and dual channel (2.8 mm, 3.7 mm). Olympus dedicated flushing pump was used for fluid irrigation and cleaning the debris using sterile water. Initially a 0.55 mm, then a 1 mm fiber was used. The laser pulse energy and rate settings were 0.5 J and 5 HZ respectively. Higher settings were avoided because of the severe ulceration of the duodenal wall and the fear of perforation. The shell of the gallstone was easily penetrated by the laser, but large cracks were not produced. Two sets of endoscopic therapy with laser application resulted in partial fragmentation of the gallstone, but it still could not be retrieved from the duodenum (Figure 3). Each session continued for about one hour. Considering the general status of the patient and the presence of multiple comorbidities, further attempts to break down and retrieve the stone were postponed for further sessions. After the second session the patient had several episodes of abdominal pain and vomiting. A third session of laser lithotripsy was planned but the EGD revealed that the gallstone was no longer in the duodenum. No fistula was noticed.
A repeat computed tomography showed the gallstone in the distal ileum (Figure 4). The patient underwent surgery with an enterotomy, which revealed a 4.5x3.5x2.5 cm gallstone in the terminal ileum. The patient recovered well without repair of the cholecystoduodenal fistula and had no biliary problems at two years follow up.