Endoscopic Treatment of Bouveret Syndrome: Electrohydraulic Lithotripsy and Stone Basket Retrieval

CASE REPORT Bouveret syndrome consists of gastric outlet obstruction from a gallstone in the stomach or proximal duodenum, after entering via a bilioenteric fistula. It is an uncommon complication that typically affects elderly, comorbid patients. Surgery is an effective but high-risk retrieval method.1,2 Endoscopic retrieval methods have become more common due to the reduced morbidity and shorter recovery time. Higher endoscopic success rates have been reported with electrohydraulic or laser lithotripsy and subsequent stone retrieval.3,4 Limitations of endoscopy are difficulty with larger stones, equipment and expertise requirements, and a higher rate of recurrence.3,5 Our patient was a 77-year-old man who presented with coffee ground emesis and abdominal pain. His medical history included congestive heart failure and coronary artery disease. Computed tomography showed a bilioenteric fistula and a large gallstone obstructing the pylorus (Figure 1). Due to his high perioperative risk, endoscopic stone retrieval was performed (Video 1). Endoscopy showed a large gallstone obstructing the pylorus and preventing access to the postbulbar duodenum (Figure 2). The location of the tip of the endoscope is shown in the fluoroscopic image (inset, Figure 2). Electrohydraulic lithotripsy (Autolith; Boston Scientific, MA), where stones are fragmented with shear forces and cavitation bubbles, was used to fragment the stone. A stone basket fragmented larger fragments in the stomach to facilitate retrieval via the esophagus and to prevent distal small bowel impaction (Figure 3). Fluoroscopic image shows the fistula between the gallbladder and duodenum at the D2 segment (Figure 4). Total fragmentation time was 2.5 hours. The patient tolerated the procedure well and had no immediate complications. After 11-month follow-up, the patient has had no further episode of hematemesis, cholecystitis, or biliary obstruction. He is under the care of palliative care for end-stage heart disease. No further investigations are planned.Figure 1.: Axial (left) and coronal (right) computed tomography showing the gallstone impacted at the duodenum (arrow) and bilioenteric fistula (arrowhead). Pneumobilia is present (white arrow).Figure 2.: Endoscopic view of gallstone impacted at the pylorus. Fluoroscopic image of the endoscope position (inset).Figure 3.: Gallstone fragments.Figure 4.: Fluoroscopic visualization of bilioenteric fistula postretrieval. Contrast opacifies the gallbladder (black arrow), bilioenteric fistula (arrowhead), and flow passing into the distal duodenum (white arrow). LT, left. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Electrohydraulic lithotripsy and stone basket retrieval of gallstone.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_0a2xr50q"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} DISCLOSURES Author contributions: All authors fulfil the ICMJE criteria for authorship, including the following: substantial contributions to the conception or design of the work; the acquisition, analysis, or interpretation of data for the work; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. C. O'Leary is the article guarantor. Financial disclosure: Dr Eran Shlomovitz is a consultant for Boston Scientific. Informed consent was obtained for this case report.