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

Abstract

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).

Management of Bouveret's syndrome

“…5 In a comprehensive review of 128 patients The management of patients with Bouveret's syndrome is complex, and many endoscopic, surgical, or combination techniques can be used, with varying success rates. 2,4,7 The choice of a treatment modality depends on many factors, including the patient's age and comorbidities, the location of the obstruction, the resources availability, and the clinicians' level of expertise. 7 Here we propose an approach based on some of these factors that can guide the selection of the appropriate treatment strategy ( Figure 5).…”

“…2,4,7 The choice of a treatment modality depends on many factors, including the patient's age and comorbidities, the location of the obstruction, the resources availability, and the clinicians' level of expertise. 7 Here we propose an approach based on some of these factors that can guide the selection of the appropriate treatment strategy ( Figure 5). This should be utilized only to assist Endoscopic retrieval is the approach recommended initially, given the low morbidity and mortality that is associated with it.…”

“…However, success rates significantly drop significantly if the impacted stones are larger than 3 cm in size. 2,4,7 If this fails other endoscopic techniques can be considered before surgery. 4,7 While an endoscopy is an ideal option in stable patients wishing to avoid surgery, it has its limitations.…”

“…2,4,7 If this fails other endoscopic techniques can be considered before surgery. 4,7 While an endoscopy is an ideal option in stable patients wishing to avoid surgery, it has its limitations. Its failure to retrieve stones (the success rate is reported to be less than 20%), the need for more than one procedure, complications such as esophageal perforation, hemorrhage, the distal migration of stones with the subsequent development of gallstone ileus, and an inability to repair fistulas during endoscopy are among the many well-described limitations of endoscopic intervention.…”

“…Its failure to retrieve stones (the success rate is reported to be less than 20%), the need for more than one procedure, complications such as esophageal perforation, hemorrhage, the distal migration of stones with the subsequent development of gallstone ileus, and an inability to repair fistulas during endoscopy are among the many well-described limitations of endoscopic intervention. 4,7 Historically, surgery has been the mainstay of treatment for Bouveret's syndrome, with 91% of patients eventually requiring surgery at some point. Its success rate has been reported to be as high as 84% in some case series.…”