Bouveret Syndrome: A Rare Case of Instance and Treatment in a Younger Patient

Abstract

Bouveret syndrome, a specific form of gallstone ileus, is the obstruction of the gastric outlet by a gallstone, which can enter the duodenum through a fistula. While the average age of individuals with Bouveret syndrome is 74 years, our patient was 42 years of age at the time of operation, significantly younger than the average patient afflicted with this condition. In the treatment of our patient's condition, the operation conducted entailed a partial duodenectomy, gastrojejunostomy, cholecystectomy, common bile duct exploration, extraction of bile duct stones, and insertion of a t-tube in the bile duct. e patient was found to be in healthy condition upon check-up six months after the operation. e outcome of our case suggests that younger Bouveret patients can safely undergo multiple surgical procedures in the treatment of Bouveret syndrome. Our case also suggests that a cholecystectomy and the removal of the obstructing gallstone can both be carried out within one operation, although coupling these two procedures in one operation might be riskier for patients within the normal age range of Bouveret syndrome. We also suggest that fistula repair be carried out for younger Bouveret patients in particular and that the patient be subjected to a CT scan in the diagnosis of Bouveret syndrome when this condition is suspected.

Post hoc validation of a tool that accurately predicts the outcome of endoscopic therapy in Bouveret syndrome

“…The median stone sizes for patients undergoing first-line surgical therapy and second-line surgical therapy were 40 mm (IQR 30–58 mm) and 50 mm (IQR 40–60 mm), respectively; the difference between both groups was not statistically significant ( P = 0.16); 96.8% (30/31) of cases that underwent laparotomy were successful (defined as relief of mechanical obstruction and discharged from hospital), whereas 27.3% (3/11) of laparoscopic cases required conversion to laparotomy. Three cases did not specify whether surgery was via a laparoscopic or open approach [ 18 , 27 , 29 ]. Complications (categorized according to the Clavien Dindo Classification; Supplementary Table 3 ) were reported in 29.5% (13/44) of surgical cases [ 6 , 8 , 18 , 22 , 41 , 43 , 44 , 46 , 47 , 50 , 59 , 61 ], including one post-operative fatality [ 61 ].…”

Bouveret Syndrome Resolved by a Two-Staged Endoscopic and Surgical Approach

“…The simple abdominal CT scan has a sensitivity of 93% and specificity of 100%; it is feasible in a coronal view to detect the Rigler's triad, as was initially described [5], when this study is accompanied by oral contrast medium, it can show the passage of the contrast medium through the fistula, to the gallbladder or the bile duct [5,7,9]. Finally, endoscopy can be diagnostic and therapeutic; it has been suggested as the initial or definitive procedure, as it offers a less invasive therapeutic option [15][16][17]. Stone impaction at the duodenal level is ideal for an endoscopic approach; once the impacted stone has been identified in the first portion of the duodenum, it should be attempted to displace it, followed by fracture of the stone, with the removal of the large fragments up to 1.5 cm, and avoid the attempt on those stones larger than this size so that they can be removed by esophagus; the minor fragments can be chosen to be left in the stomach for future radiological monitoring with close follow-up, to avoid possible complications.…”

“…The ideal is to have different equipment such as baskets, forceps, biliary balloons, laser lithotripsy, extracorporeal lithotripsy, or intracorporeal electrohydraulic lithotripsy, or the combination of these to offer different therapeutic procedures [3,17,18]. However, by means of endoscopy in Bouveret's syndrome, at the moment, it does not correct the existing fistula, in addition, it is not possible to assess the existence of stones distally coupled with the high probability of failure since much experience is needed from the specialist to obtain good results.…”

A Unique Presentation of Bouveret’s Syndrome: Two Large Gallstones Obstructing Both the Gastric Outlet and the Common Bile Duct Simultaneously

“…A T-tube was placed into the bile duct in the end. The patient recovered appropriately without major complications [ 13 ]. It shared some similarities with our case, that one stage surgery was performed and that there were CBD stones present concomitantly in the context of Bouveret's syndrome.…”