Bouveret’s syndrome: presentation of two cases with review of the literature and development of a surgical treatment strategy

Abstract

BackgroundBouveret’s syndrome causes gastric outlet obstruction when a gallstone is impacted in the duodenum or stomach via a bilioenteric fistula. It is a rare condition that causes significant morbidity and mortality and often occurs in the elderly with significant comorbidities. Individual diagnostic and treatment strategies are required for optimal management and outcome. The purpose of this paper is to develop a surgical strategy for optimized individual treatment of Bouveret’s syndrome based on the available literature and motivated by our own experience.Case presentationTwo cases of Bouveret’s syndrome are presented with individual management and restrictive surgical approaches tailored to the condition of the patients and intraoperative findings.ConclusionsImproved diagnostics and restrictive individual surgical approaches have shown to lower the mortality rates of Bouveret’s syndrome. For optimized outcome of the individual patient: The medical and perioperative management and time of surgery are tailored to the condition of the patient. CT-scan is most often required to secure the diagnosis. The surgical approach includes enterolithotomy alone or in combination with simultaneous or subsequent cholecystectomy and fistula repair. Lower overall morbidity and mortality are in favor of restrictive surgical approaches. The surgical strategy is adapted to the intraoperative findings and to the risk for secondary complications vs. the age and comorbidities of the patient.

Rare cause of gastric outlet obstruction

“…It is a variant of gallstone ileus resulting in gastroduodenal obstruction secondary to gallstone impaction in the duodenum. The stones enter the small bowel via cholecysto-enteric fistula which is created by chronic inflammation of the adherent biliary system and bowel walls causing necrosis [2]. Bouveret’s syndrome is usually caused by stones that are larger than stones that cause gallstone ileus.…”

“…Bouveret’s syndrome is usually caused by stones that are larger than stones that cause gallstone ileus. The average size is 4.6 cm compared to 2.5 cm [2]. It complicates 0.3%–5% of cholelithiasis [2,3].…”

“…Rigler’s triad of pneumobilia, an ectopic gallstone, and dilated small bowel on abdominal x-ray is classic but is only seen in 30%–35% of cases [6]. Classic CT scan findings are pneumobilia, cholecystoduodenal fistula and a gallstone in the duodenum [2,3,15]. Although, 15%–25% of gallstones cannot be visualized on CT scan as they can be isoattenuating.…”

“…Although the gastric outlet obstruction is almost always seen on EGD, the obstructing gallstone is seen only in 69% of cases [2]. …”

Surgical Strategy in Bouveret's Syndrome. A Case Report

“…It is a rather rare form of bowel obstruction, representing 1-3% of all cases [1]. Bouveret's syndrome, a rare condition, appears when the site of the gallstone obstruction is high in the duodenum and causes gastric outlet obstruction with high morbidity and mortality [2]. This condition is possible because of the creation of a fistula between the inflamed gallbladder and the adjacent part of the intestine.…”