Bouveret's syndrome--case report

Bouveret Syndrome: A Systematic Review of Endoscopic Therapy and a Novel Predictive Tool to Aid in Management

BACKGROUND AND GOALS

Bouveret syndrome is characterized by gastroduodenal obstruction caused by an impacted gallstone. Current literature recommends endoscopic therapy as the first line of intervention despite significantly lower success rates compared with surgery. The lack of treatment efficacy studies and the paucity of clinical guidelines contribute to current practices being arbitrary. The aim of this systematic review was to identify factors that predict outcomes of endoscopic therapy. Subsequently, a predictive tool was devised to predict the success of endoscopic therapy and recommendations were proposed to improve current management strategies of impacted gallstones in the upper gastrointestinal tract.

METHODS

A systematic search of PubMed, Medline, Cochrane, and Scopus was performed for articles that contained the terms "Bouveret syndrome," "Bouveret's syndrome," "gallstone" AND "gastric obstruction" and "gallstone" AND "duodenal obstruction" that were published between January 1, 1950 to April 15, 2018. Articles were reviewed by 3 reviewers and raw data collated. χ and Kolmogorov-Smirnov tests were used to test associations between predictors and endoscopic outcomes. A logistic regression model was then used to create a predictive tool which was cross validated.

RESULTS

Failure of endoscopic therapy is associated with increasing gallstone length (P<0.0001) and impaction in the distal duodenum (P<0.05). Using multiple endoscopic modalities is associated with better success rates (P<0.05). The novel predictive tool predicted success of endoscopic therapy with an area under the receiver operating characteristic score of 0.86 (95% confidence interval: 0.79-0.94).

CONCLUSION

In Bouveret syndrome, a selective approach to endoscopic therapy can expedite definitive treatment and improve current management strategies.

Uncommon presentation of a common disease - Bouveret's syndrome: A case report and systematic literature review

AIM

To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).

METHODS

A MEDLINE search was performed for the BS. The search was conducted independently by two clinicians (Yahya AL-Habbal and Matthew Ng) in April 2016. A case of BS is also described.

RESULTS

A total of 315 articles, published from 1967 to 2016, were found. For a clinically meaningful clinical review, articles published before 01/01/1990 and were excluded, leaving 235 unique articles to review. Twenty-seven articles were not available (neither by direct communication nor through inter-library transfer). These were also excluded. The final number of articles reviewed was 208. There were 161 case reports, 13 reviews, 23 images (radiological and clinical images), and 11 letters to editor. Female to male ratio was 1.82. Mean age was 74 years. Treatment modalities included laparotomy in the majority of cases, laparoscopic surgery, endoscopic surgery and shockwave lithotripsy.

CONCLUSION

There is limited evidence in the literature about the appropriate approach. We suggest an algorithm for management of BS.

Novel treatment options for Bouveret's syndrome: a comprehensive review of 61 cases of successful endoscopic treatment

In Bouveret's syndrome, a biliary stone obstructs the duodenum. Surgical treatment is plagued by high morbidity and mortality. Therefore, endoscopic treatment has become a first-line approach. Areas covered: A literature search of Medline and Google Scholar databases was performed using the terms endoscopic treatment, non-operative treatment, Bouveret's syndrome, and gallstone ileus. Sixty-one cases of successful endoscopic treatment were found over the period 1978-2016 and are summarized herein. Therapeutic modalities used in 52 patients with complete success included mechanical lithotripsy (40% of cases), electrohydraulic lithotripsy (21% of cases), extraction of the intact stone and laser lithotripsy (15% of cases each), extracorporeal shockwave lithotripsy and duodenal stenting (4% of cases each). In the remaining 9 patients, stone fragments migrated distally and required surgical removal. Cholecystectomy was performed in five (8.2%) of 61 patients and gallbladder cancer was detected in three (4.9%) patients. Expert commentary: Meticulous preparation, including that of instruments, personnel, patient anesthesia, and X-ray availability, is key to success in this unusual situation. Partial success (stone fragmentation and mobilization to another location) may render surgery easier as these patients present with dense adherences in the right upper quadrant. Cholecystectomy is reserved for highly selected patients (e.g. relapsing ileus, gallbladder cancer).

Laparoscopic treatment of an upper gastrointestinal obstruction due to Bouveret’s syndrome

Bouveret’s syndrome is an extremely rare type of gallstone-induced ileus with atypical clinical manifestations, such as abdominal distension and pain, nausea and vomiting, fever or even gastrointestinal bleeding, which may easily be misdiagnosed. In the present case, a 55-year-old male was admitted to the hospital with upper gastrointestinal obstructive symptoms but without pain, fever, jaundice or melena. At first, gastrolithiasis and peptic ulcer combined with pyloric obstruction were suspected after gastroscopy revealed a large, hard stone in the duodenal bulb. A revised diagnosis of Bouveret’s syndrome was made following abdominal computed tomography. Subsequently, the patient exhibited a good postoperative recovery after laparoscopic duodenotomy for gallstone removal and subtotal cholecystectomy. The condition of the patient remained stable after being followed up for 6 mo. The successful application of laparoscopic therapy to treat Bouveret’s syndrome has seldom been reported. Laparoscopic enterolithotomy is safe and effective, with good patient tolerability, rapid postoperative recovery and few wound-related complications. The laparoscopic treatment of Bouveret’s syndrome is worth exploring.