749 Bouveret Syndrome: A Challenging Case of Impacted Gallstone Within the Fourth Part of the Duodenum. (19th August 2022)

• Record Type: Journal Article
• Authors: Smith, E; Zhao, S; El-Boghdady, M; Sabato-Ceraldi, S
• Is Part Of: British journal of surgery. Volume 109(2022)Supplement 6
• Publication Date: 2022-08-19
• Subjects: Surgery -- Periodicals; 617.005
• DOI: 10.1093/bjs/znac269.156
• Languages: English
• ISSNs: 0007-1323

Abstract

Abstract: Aim: Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. In this report, we present a case of Bouveret syndrome in a 68-year-old requiring an atypical approach to surgical retrieval. Method: The patient presented acutely with abdominal pain and vomiting. This was on a background of recent admission for gallstone ileus managed conservatively. Initially, due to high anaesthetic risk (P POSSUM score = 14% mortality, 60% morbidity), the patient was managed conservatively with nasogastric drainage and total parenteral nutrition. On day 6 of admission, emergency laparotomy was performed after identifying radiological signs of impending perforation related to a large gallstone impacted in the fourth part of the duodenum and a cholecysto-duodenal fistula. Endoscopic management was not available locally. Unsuccessful attempt was made to milk the stone proximally for retrieval via pyloroplasty. Subsequently, high pressure water flushes were delivered via the gastrostomy which expelled the stone distally. The stone was then retrieved via jejunotomy at the DJ flexure. Results: The patient required a 2-day high dependency unit admission, and she was discharged 3 weeks post-operatively at her functional baseline. She was clinically well and asymptomatic when reviewed at the four-month post-operative surgical follow up appointment. Conclusions: This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. Enterolithotomy can be considered in case of large, impacted stone and can be a safe option in patients with multiple co-morbidities.