Old men seem to be attracting gall stone disease like the swine flu. Unfortunately, for them, they also seem to be progressing to choledochoduodenal fistulas (gall bladder bursting into the first part of the intestines for non medicos) far too often for comfort. They also seem to be ending up with us for laparoscopic cures. Of course it's good experience and it's something you don't get to see too much of in your career, so it was great in that sense.
The case we had was nice too. We could get the fistula separated quite easily and managed to suture off the duodenal orifice well. The gall bladder came out with some effort but was not a problem either. Then what? There must be something or it wouldn't have reached this blog, right? Right!
The stone which had passed into the intestine decided to be stubborn and play hide and seek with us. We knew it was fairly big (approx 6-7 cms) so it couldn't hide forever. We also knew that it was causing some amount of obstruction distally since that was what he presented with.
We managed to find it at the upper end of the jejunum and traced it all along till it was close to the umbilical port. We had decided to basically extend the umbilical port incision, exteriorise the bowel and take the stone out and completely close the enterotomy before repositioning it into the abdomen. Good idea right?
The stone had other ideas. In spite of having held on to the bowel, it started slipping back once we extended the incision. We had left the grasper so we were trying to finger our way in and coax it out. The scared little stone ran far back and ultimately we could feel it no more. We had to reinflate the abdomen, and try and locate it again. Of course, we couldn't. It became agonisingly obvious that it had gone all the way up to the DJ (not me, duodeno-jejunal junction). We really did not want it to go further up to the duodenal anastomosis. We tried getting a head high, tried feeling our way to bring it down. We figured that we would need a gastroscope to try and push it down.
As is expected in such situations, it was the middle of the night (as usual) and we did not have a gastroscope on hand. So, we had to call the endoscopy department and try and arrange for it to come in at midnight. The nurse who had the keys had, of course, left for home and had to come all the way back. We were told it would take half hour. We then started praying for it to come down, sang to it, did a little dance when we saw something filling up, stopped dancing when we realised it was just gas...(reminds me of infants smiling because of gas!).
Finally, the scope came. We connected everything, inserted the end into the mouth and just before we could do anything more, down comes the stone rolling out of the DJ. From then on, it was routine and we closed up around 2 am, with me returning home only to get sleep around 3.30!