One-stage procedure for the management of Bouveret's syndrome: A case report and operative video.

INTRODUCTION AND

IMPORTANCE

Bouveret's syndrome is a rare condition that causes gastric outlet obstruction, due to migrating gallbladder stone (s). It occurs more commonly in elderly female patients with multiple comorbidities and presents with non-specific symptoms. This may lead to delayed definitive management and an increase in morbidity and mortality rate.

CASE PRESENTATION: We report a case of a 60-year-old female who presented with five days history of upper abdominal pain, nausea and vomiting. She was initially diagnosed as acute cholecystitis, then with further investigation a diagnosis of Bouveret's syndrome was established. An initial attempt at endoscopic stone extraction with mechanical instruments as well as laser lithotripsy was unsuccessful. The patient then underwent a successful one-stage operation for stone extraction and repair of the fistula.

CLINICAL DISCUSSION: There is still a controversy in the decision of treatment of choice. Less invasive options like endoscopy and laser lithotripsy have a low success rate. Therefore, surgical management remains the mainstay of treatment. A one-stage procedure is typically recommended for younger, healthier patients as it reduces the risk of recurrent complications and the need for repeated anesthesia. A two-stage approach may be more appropriate for older, more comorbid patients because of less operative time and lower mortality risks.

CONCLUSION

Currently, there are no clear management guidelines. Although endoscopic modalities should be considered first, surgical option is the main treatment. We advocate for a one-stage procedure unless the patient is critically ill or if there is no backup hepatopancreaticobiliary surgeon in the healthcare institution.