J. Machi et al. / The American Journal of Surgery 183 (2002) 56 –57 57factors such as the extent of the inﬂammation around the with adhesion was noted at the hepatoduodenal ligamentbiliary tract, the condition and location of biliary enteric ﬁstula area. Intraoperative ultrasonography showed a contracted(some ﬁstulas close with ﬁbrous remnant), and the presence or gallbladder containing small stones and air. Cholecystoduo-absence of biliary obstruction due to bile duct stones. Intraop- denal ﬁstula was identiﬁed and accurately localized by ul-erative cholangiogram can provide valuable information but trasonography, which demonstrated the dynamic movementmay be difﬁcult to perform because cannulation for contrast of ﬂuid and air between the gallbladder and duodenum ininjection is not easy or possible. Intraoperative ultrasonogra- real-time (arrows in Fig. 4). The bile duct was normal inphy is helpful in this setting, because the ultrasound scanning size (6 to 7 mm) without stones or pneumobilia on ultra-can be performed without any tissue dissection. sound examination. Because the patient was in a stable In this patient, laparotomy was performed with the use of condition, cholecystectomy was performed. The ﬁstula wasintraoperative ultrasonography. Near the terminal ileum, detected and excised. The duodenal opening was closed bythere was a palpable stone, conﬁrmed by intraoperative sutures with an omental patch. Although the patient hadultrasonography (arrow in Fig. 3). The 3.5 ϫ 2 cm stone renal failure and respiratory failure, he recovered from thesewas removed through ileotomy. A marked inﬂammation postoperative complications and was discharged.