Atypical operative sequence in Barnard's syndrome: managing gallstone ileus after biliary reconstruction

Cholecystoenteric fistulas are uncommon complications of chronic gallstone disease and may present insidiously, leading to delayed diagnosis. We describe a male patient in his early 70s who developed biliary ileus secondary to a cholecystoduodenal fistula, initially manifesting as right upper quadrant pain, bilious vomiting and progressive oral intolerance. CT imaging demonstrated pneumobilia, a large ectopic gallstone and small-bowel obstruction consistent with Rigler's triad. At laparotomy, he underwent partial cholecystectomy, closure of the duodenal defect, pyloric exclusion and decompressive procedures; however, an enteric leak required reoperation with omental patch repair, gastrojejunostomy and enterolithotomy. His recovery was complicated by intra-abdominal sepsis and ventilator-associated pneumonia but improved with intensive care management.This case highlights the diagnostic challenge of gallstone ileus from cholecystoduodenal fistula and the need for prompt CT evaluation and flexible, staged surgical decision-making in patients with significant inflammation or postoperative complications.