Laparoscopic one-stage management of cholecystoduodenal fistula with gallstone ileus: the role of prophylactic jejunostomy - a case report and literature review.

Introduction and importance: Cholecystoduodenal fistula (CDF) is a rare complication of gallstone disease. The passage of a large gallstone through such a fistula can lead to gallstone ileus, a condition associated with significant morbidity. Preoperative diagnosis is challenging, and the optimal surgical management, particularly the feasibility and safety of a one-stage laparoscopic procedure, remains a subject of debate. This case highlights the importance of a systematic diagnostic approach and reports the successful integration of a prophylactic jejunostomy in a totally laparoscopic one-stage repair. Case presentation: A 74-year-old woman presented with symptoms of intestinal obstruction. Preoperative enhanced CT scan revealed Rigler's triad, suggesting gallstone ileus. Subsequent gastroscopy confirmed a CDF opening at the duodenal bulb-descending junction, and biopsy ruled out malignancy. The patient underwent a totally laparoscopic one-stage procedure including enterolithotomy, cholecystectomy, primary duodenal fistula repair, and prophylactic jejunostomy. The surgery was successful with minimal blood loss. Clinical discussion: This case demonstrates that a definitive preoperative diagnosis of CDF with gallstone ileus is achievable through the sequential use of enhanced CT and gastroscopy with biopsy. For selected patients, a totally laparoscopic one-stage procedure is a feasible and safe option. The intentional use of prophylactic jejunostomy, based on intraoperative assessment of a large fistula size and friable duodenal tissue, is a key strategic consideration. It serves to mitigate the risk of leakage at the repair site, facilitates early enteral nutrition, and supports an enhanced recovery, contributing to the favorable outcome observed in this complex case. Conclusion: Preoperative diagnosis of CDF with gallstone ileus can be effectively established using a combination of enhanced CT and gastroscopy. A totally laparoscopic one-stage management strategy is viable. The incorporation of a prophylactic jejunostomy is a valuable adjunct to prevent duodenal leakage and promote postoperative recovery in high-risk cases. To our knowledge, this represents the first reported case where prophylactic jejunostomy was successfully and intentionally integrated into a totally laparoscopic one-stage repair for this condition.