At the focal point

Endoscopic removal of gallstones through a cholecystoduodenal fistula

Commentary

Seneca, the Roman philosopher of the first century AD, said that luck is what happens when preparation meets opportunity. Well, opportunity was provided by Mother Nature in the availability of the passage connecting the gallbladder and duodenum, and, clearly, these authors were well prepared to take advantage of it. I believe further luck was involved, however, in the fact that the patient did well without developing intestinal obstruction (ie, gallstone ileus). The rule about a gallstone needing to be at least a square centimeter in size before it may obstruct the intestinal lumen—absent a stricture encountered along the way—was written for 1 stone, not 50 stones all entering the intestine at the same time. The potential sizes that aggregates of 50 stones, each of which is 5 to 10 mm in size, can form could only be calculated by someone who is mathematically gifted—or by a modern teenager with minimal computer skills. I am reminded of Robert Frost's famous poem, “The Road Not Taken.” These authors seemed to have chosen wisely, and “that has made all the difference.”

Lawrence J. Brandt, MD

Associate Editor for Focal Points