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

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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.

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