Management of Bouveret Syndrome with Subsequent Gallstone Ileus

Introduction: Biliary disease is one of the most common surgical entities in the United States.1 When associated with chronic inflammation, local ischemia with resultant cholecystoenteric fistula and stone migration may occur.2 Bouveret syndrome is a rare form of gallstone ileus secondary to cholecystoduodenal or cholecystogastric fistula with resultant gastric outlet obstruction. Gallstone ileus itself is a rare complication, arising in 0.3% to 0.5% of patients with cholelithiasis.3–5 Of these cases, Bouveret syndrome is reported in only 1% to 3%.3–6 Bouveret syndrome is most frequently seen in elderly females, of the sixth or seventh decade, with multiple medical comorbidities, and history of biliary disease.6 Symptoms on presentation are consistent with gastric outlet obstruction; 85% will present with emesis and 70% with abdominal discomfort.7 Radiographic features are similar to those found in gallstone ileus, including pneumobilia and ectopic gallstone.4 However, in Bouveret syndrome, gastric dilation is observed, as opposed to small bowel obstruction as seen in Rigler's triad, for which is classically referenced describing Gallstone ileus. These findings may be appreciated on abdominal X-ray, however, are better demonstrated on computed topography (CT).3 We present an 86-year-old male with multiple comorbidities, including chronic kidney disease, cirrhosis, atrial fibrillation, and coronary artery disease found to have Bouveret syndrome. Over 1 year before presentation, he underwent percutaneous transhepatic cholecystostomy placement for sepsis secondary to acute calculus cholecystitis. On admission, he presented with nausea, vomiting, and lethargy. He was found to have gastric outlet obstruction secondary to a cholecystoduodenal fistula with gallstone impacted in the second portion of the duodenum. Laparoscopic gallstone extraction through enterolithotomy with intracorporeal closure is demonstrated in the accompanying 9 minute and 56 second video. Methods: Upon admission, the patient received intravenous resuscitation, nasogastric tube decompression, and reversal of supratherapeutic international normalized ratio (>4) with vitamin K. An esophagogastroduodenoscopy (EGD) was initially performed with plan for endoscopic removal of the gallstone. On EGD the presence of a cholecystoduodenal fistula was noted, however, gallstone not observed. A repeat CT scan was obtained, demonstrating the gallstone to be lodged in the mid portion of the jejunum. Results: The patient underwent diagnostic laparoscopy, laparoscopic enterolithotomy, and removal of gallstone with intracorporeal two-layered closure of the small bowel. Total operative time was 119 minutes. Intraoperative examination revealed a gallstone >4 cm. His postoperative course was unremarkable with Coumadin resumption and discharge to rehabilitation on postoperative day 5. Conclusion: Our patient's initial presentation exemplifies a classic case of Bouveret syndrome. The overall therapeutic goal of Bouveret syndrome is to alleviate the obstruction; however, there remains no standardized practice of treatment.2–6 Definitive intervention by means of concominant cholecystectomy and fistula take down is debated. The literature demonstrates only 10% of patients will require additional intervention if definitive treatment is not sought, and ~30% mortality with single-stage definitive procedure.3 However, owing to theoretical concern of malignant transformation, some still advocate for definitive intervention.3 Ultimately, discussion should be held between the surgeon and patient to devise an appropriate plan. We present a unique minimally invasive total laparoscopic approach, with uneventful postoperative course. All authors included have received no financial or other substantive assistance for the funding of this study. All individuals mentioned have given permission to be named. Runtime of video: 9 mins 56 secs Prior abstract presentations: SAGES Annual Meeting, April 3–6, 2019, Baltimore, MD, USA.