The first experience in the treatment of small bowel biliary obstruction using tulium laser (Tm:YAG) in a patient with Bouveret syndrome

Abstract

Cholelithiasis complicated with a bilioenteral fistula and small bowel biliary obstruction is an absolute indication for surgical treatment. To date, modern capabilities of high-tech specialized intra-luminal operative endoscopy with laser lithotripsy can prevent the routine surgical intervention, thus reducing the risk of adverse events and length of hospital stay. This clinical case describes diagnostics of the pathology and the first experience in treating the Bouveret syndrome with lithotripsy and thulium laser (Tm:YAG) light.Purpose: to improve outcomes in patients with small bowel biliary obstruction and a bilioenteral fistula using thulium laser (Tm:YAG) light as the first and final method of surgical (endoscopic) treatment.Material and methods: a patient with pains in the upper abdomen, weakness, vomiting after eating was admitted to the Botkin Hospital. Complete blood analysis, biochemical blood analysis, transabdominal ultrasound and X-ray examination of abdominal organs were made at the reception department. After that, she was transferred to the surgical department where computed tomography, magnetic resonance cholangiopancreatography and esophagogastroduodenoscopy were performed.Results: The performed instrumental diagnostics revealed a large calculus with diameter up to 4.5 cm in the bulb of the duodenum and a fistula passage connecting to the gallbladder with diameter of up 2.0 cm. Because of long disease duration and a formed internal fistula the patient was simultaneously made esophagogastroduodenoscopy and lithotripsy to resolve small bowel obstruction. The calculus was removed using thulum laser (Tm:YAG) technique, a lithotriptor basket and an endoscopic loop for fragments extraction. The performed endoscopic procedure with thulium laser light has showed its high efficiencyConclusion: The effectiveness of laser medical technique with Tm:YA in patients with Bouveret syndrome has been proven by the authors