Combined laser and mechanical lithotripsy for endoscopic management of Bouveret’s syndrome: A case report

Abstract

Bouveret’s syndrome (BS) represents an exceedingly rare clinical entity characterized by gastric outlet obstruction induced by a gallstone passing through a cholecystoduodenal, cholecystogastric or choledochoduodenal fistula and impacting in the duodenum or pylorus. Endoscopy is the preferred first-line therapy. It has a favorable safety profile, but requires high level of expertise to achieve stone clearance. We report here the case of a 75-year-old Caucasian male who presented with vomiting and upper gastrointestinal bleeding and was diagnosed with BS by upper endoscopy. A single session stone extraction utilizing mechanical lithotripsy and laser lithotripsy was executed. Complete clearance of the duodenum and gallbladder was achieved, extracting successfully all fragments larger than 5 mm. The rarity of BS and its non-specific presentation makes it largely overlooked leading commonly to delayed diagnosis, which results in a high mortality rate of 12-30%. Computer tomography is the diagnostic method of choice. Upper endoscopy can establish the presence of obstruction, but fails to visualize a stone in up to 1/3 of the cases. Management is either endoscopic or surgical. Endoscopic treatment has a good safety profile (mortality 1.6% vs. 17.5-25% for surgery) but poor success rate – 43% vs. 94.1%. To achieve higher success rate, more advanced techniques are required such as mechanical or laser lithotripsy. Laser lithotripsy is a feasible option for endoscopic treatment of BS, but the duration of the procedure might be an issue in frail patients.