›Penicillin allergy alternative
›Ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours
›Covers aerobic gram-negatives and anaerobes
›Use aztreonam 2 g IV every 8 hours if severe beta-lactam allergy (plus metronidazole)
›Duration
›Pre-operative prophylaxis: single dose cefazolin 2 g IV within 60 minutes of incision
›Active infection: continue 48–72 hours post-operatively or until afebrile and WBC normalizing
›Perforation with peritonitis: 5–7 days of broad-spectrum coverage
Surgical management — definitive treatment
›Enterolithotomy alone — preferred approach
›Enterotomy proximal to stone impaction, stone extraction, bowel closure
›Most commonly performed procedure (62% of cases)
›Lowest mortality on multivariate analysis
›Associated with OR 2.86 reduction in mortality vs one-stage procedure
›Post-extraction bowel assessment
›Systematic palpation of entire bowel — mandatory
›Second ectopic stones found in 16% of cases — must not be missed
›Assess bowel viability at impaction site — resection if ischemic
›Preferred patient profile
›Elderly patients with high comorbidity burden
›ASA class 3–4
›Hemodynamically unstable or physiologically compromised
›One-stage procedure — enterolithotomy plus cholecystectomy plus fistula repair
›Enterolithotomy plus cholecystectomy plus fistula closure in single operation
›Mortality approximately 17% — higher than enterolithotomy alone
›OR 2.86 higher mortality vs enterolithotomy alone
›Preferred patient profile
›Low-risk patients with good physiologic reserve
›Duodenal or colonic impaction — fistula in same operative field
›Cholecystocolonic fistula — one-stage preferred to prevent reflux cholangitis
›Advantages
›Prevents recurrent gallstone ileus
›Eliminates persistent fistula risk (cholangitis, carcinoma)
›Avoids second operation
›Two-stage procedure
›Enterolithotomy first, then interval cholecystectomy and fistula repair at 4–6 weeks
›Appropriate for moderate-risk patients with persistent biliary symptoms
›Allows physiologic recovery before definitive biliary surgery
›Lower overall mortality than one-stage in moderate-risk patients
›Monitoring between stages
›Recurrent gallstone ileus < 5% between stages
›Cholangitis from persistent fistula requires earlier second stage
›Bowel resection — when required
›Indications
›Bowel necrosis or perforation at impaction site
›Non-viable bowel segment after stone removal
›Higher morbidity — OR 1.98 for major complications vs enterolithotomy alone
›Primary anastomosis vs stoma decision based on contamination and patient stability
›Damage control surgery if severely contaminated or unstable
›Laparoscopic-assisted enterolithotomy
›Feasible with comparable outcomes to open surgery
›Potentially fewer major complications
›Shorter hospital stay in selected patients
›Technical considerations
›Significant bowel distension may limit visualization
›Conversion to open if unable to safely manipulate dilated bowel
›Surgeon experience with laparoscopic bowel surgery required
Bouveret syndrome management
›Gallstone impacted in duodenum
›Endoscopic approach first if feasible
›ERCP with mechanical lithotripsy or electrohydraulic lithotripsy
›Success rates limited — stone often too large for endoscopic fragmentation
›GI specialist with advanced endoscopy expertise required
›Surgical management if endoscopy fails
›Enterolithotomy via duodenotomy
›One-stage repair preferred — duodenal fistula in same operative field
›Pyloric exclusion if duodenal injury is extensive
›Monitoring priorities
›Renal function — AKI in 30% of patients post-operatively
›Daily creatinine until stabilizing
›Nephrology consult if creatinine doubling or oliguria persists
›Wound and infection surveillance
›Superficial surgical site infection most common wound complication
›Fever beyond post-operative day 3 — image for intra-abdominal abscess
›Diet advancement
›NPO until return of bowel function (flatus or bowel movement)
›Clear liquids then advance to regular diet over 24–48 hours
›Nutritional support if prolonged ileus or malnutrition