# Balancing Urgency and Strategy in the Surgical Management of a Complex Case of Gallstone Ileus: A Surgical-Video-Based Case Report of a 60-Year-Old Female

## TL;DR

A 60-year-old woman with gallstone ileus underwent successful surgical removal of a large gallstone causing intestinal blockage, highlighting the importance of individualized treatment strategies in complex cases.

## Contribution

The paper presents a surgical-video-based case report emphasizing the decision-making process in choosing a two-stage approach for gallstone ileus management.

## Key findings

- A two-stage surgical approach was successfully used to manage gallstone ileus in a patient with comorbidities.
- Enterotomy without immediate cholecystectomy minimized operative risk while resolving the obstruction.
- The case highlights the importance of individualized management plans in elderly patients with complex conditions.

## Abstract

Gallstone ileus is an uncommon but potentially life-threatening complication of gallstone disease, characterized by the obstruction of the gastrointestinal tract by a gallstone, typically at the ileocecal valve. This condition predominantly affects elderly patients and carries a high risk of morbidity and mortality due to delayed diagnosis and the complexity of associated comorbidities.

We report the case of a 60-year-old woman with a history of hypertension and cholelithiasis who presented with a four-day history of intermittent epigastric pain, nausea, vomiting, and an inability to pass stool or flatus. Initial imaging studies, including ultrasonography and computed tomography, revealed a biliary-enteric fistula with a large obstructing gallstone at the ileocecal valve. Despite conservative management with intravenous fluids, nasogastric tube suction, and antibiotics, the patient’s symptoms persisted, necessitating surgical intervention. A midline laparotomy was performed, during which the gallstone was successfully removed via enterotomy. The patient recovered without complications and was discharged in stable condition.

The complexity of management, particularly in elderly patients with multiple comorbidities, necessitates careful consideration between the one-stage and two-stage surgical approaches. In this case, the decision to perform an enterotomy without immediate cholecystectomy reflects a two-stage strategy, aimed at minimizing operative risk while addressing the immediate obstruction. This approach underscores the need for individualized management plans, where the choice between one-stage and two-stage surgery is guided by the patient's overall clinical status.