Minimally invasive treatment of gallstone ileus

Gallstone ileus, a rare complication of cholelithiasis (about 1%–3% of all intestinal ileus cases), is characterized by mechanical obstruction of the gastrointestinal tract caused by a dislodged gallstone (typically >2 cm in size) migrating from the gallbladder via the cholecystoenteric fistula. Bouveret syndrome, a variant of gallstone ileus, refers to gastric outlet obstruction caused by a gallstone entering the duodenum via the bilioduodenal fistula.¹ The literature on Bouveret syndrome is scarce, and thus far, there have been no uniform treatment guidelines.² This report presents a case of Bouveret syndrome successfully managed with endoscopic surgery.

In November 2020, a 75-year-old woman with a history of chronic cholecystitis presented to the Surgical Department of the Wolski Hospital, Warsaw, Poland, with a 4-day history of upper abdominal pain, vomiting, and retention of gases and stool. Laboratory tests revealed the following: leucocyte count of 21 × 10⁹/l (reference range [RR], 4.5–11 × 10⁹/l), C-reactive protein level of 224.67 nmol/l (RR <⁠47.6 nmol/l), potassium level of 2.8 mmol/l (RR, 3.5–5.1 mmol/l), and creatinine level of 386.4 μmol/l (RR, 50.4–98.15 μmol/l). Abdominal computed tomography (CT) revealed dilated stomach filled with gas and fluid, distended gallbladder with a thickened wall, gas-filled common bile duct 10 mm in diameter, and a 3-cm gallstone stuck in the duodenal bulb (Figure 1A and 1B). We decided to endoscopically remove the gallstone under general anesthesia. Initially, we intended to crush the stone with a lithotripter, as forcible stone extraction may have caused duodenal wall rupture; however, we could not access the gallstone using this approach (Figure 1C). Eventually, the stone was removed with an endoscopic basket, crushed in the gastric lumen, and extracted piece by piece via the esophagus (Figure 1D). The procedure took 70 minutes (Figure 1E). Within the following days, the ileus symptoms disappeared, and the laboratory results returned to normal.

Since Bouveret syndrome presents with nonspecific symptoms, such as abdominal pain, nausea, vomiting, and biliary colic,³ a history of chronic cholecystitis may help raise suspicion. CT is a diagnostic tool of choice, and a characteristic radiologic sign, that is, Rigler triad (pneumobilia, gastrointestinal tract obstruction, and ectopic localization of a gallstone), is crucial for diagnosis.⁴ Surgery is a treatment of choice for gallstone ileus; it is aimed at removing the ectopic intestinal gallstone and closing the fistula. Endoscopic extraction is feasible in the case of a duodenal stone.⁵ Based on our patient’s advanced age, comorbidities, and wasting caused by prolonged ileus, we chose endoscopic gallstone removal and refrained from the fistula repair, although a persisting fistula may cause retrograde cholecystitis and increase a risk of gallbladder cancer. Magnetic resonance imaging was used to visualize the biliary fistula and exclude residual cholelithiasis (Figure 1F). During 40-month follow-up, our patient did not develop any symptoms suggestive of a persistent fistula. Therefore, endoscopic treatment without the fistula closure may be preferred over high-risk open surgery in the elderly and high-risk patients owing to their shorter life expectancy, which is associated with a low risk of cholelithiasis recurrence and neoplastic transformation.