Intrastone tunneling endoscopic lithotripsy technique for the treatment of Bouveret syndrome

An 89-year-old woman presented with acute abdominal pain and vomiting. Computed tomography revealed a gas-filled gallbladder and a 38 × 29 mm gallstone inside the duodenal bulb, compatible with Bouveret syndrome ([Fig. 1]). After multidisciplinary discussion, endoscopic treatment was pursued ([Video 1]).

Fig. 1 Computed tomography revealed a gas-filled gallbladder and a 38 × 29 mm gallstone inside the duodenal bulb, compatible with Bouveret syndrome.

Video 1 Multistep approach using a triangle tip knife to expose the gallstone inner core was followed by electrohydraulic lithotripsy, which achieved complete stone fragmentation in a case of Bouveret syndrome.

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Upper endoscopy confirmed a gallstone impacted in the duodenal bulb ([Fig. 2]). Initial removal attempt with snare and lithotripsy extraction basket was unsuccessful. Subsequent attempt at gallstone fragmentation with argon plasma coagulation was ineffective. After team discussion, a triangle tip (TT) electrosurgical knife, with spray coagulation (effect 3, 60 watts), was used, creating a tunnel to the gallstone inner core ([Fig. 3]). Due to time limitation the procedure was interrupted.

Fig. 2 Upper endoscopy confirmed a gallstone impacted in the duodenal bulb.

Fig. 3 Use of a triangle tip knife allowed the creation of a tunnel to the gallstone inner core.

A second upper endoscopy was performed the next day. Tunnel widening, using the TT knife, further exposed the inner core. Electrohydraulic lithotripsy of the inner core was then performed, after water instillation, resulting in complete stone fragmentation ([Fig. 4]). The fragments were then removed using a net basket. Final inspection revealed superficial ulceration of the pylorus and anterosuperior wall of the bulb ([Fig. 5]). No fistulous orifice was identified. The combined time of the two procedures was 120 minutes. The patient needed no further treatment and remains well.

Fig. 4 Complete stone fragmentation using electrohydraulic lithotripsy.

Fig. 5 Ulceration of the pylorus and anterosuperior wall of the bulb.

Gallstones have a hard inner core and soft outer shell [1]. From our experience, electrohydraulic lithotripsy is less successful in achieving fragmentation of the soft outer shell of large gallstones, making it a laborious procedure [2]. Despite previous reports of use of an electrosurgical endoscopy knife for the endoscopic treatment of bezoars [3], to our knowledge, this is the first report of its use in the management of Bouveret syndrome. In our case, the use of the TT knife allowed access to the inner core of the gallstone, which was subsequently fragmented using electrohydraulic lithotripsy. This multistep approach should be considered for large gallstones.

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Competing Interest

The authors declare that they have no conflict of interest.

• References

• 1 Futai R, Iemoto T, Inoue Y. et al. Successful treatment of Bouveret syndrome by electrohydraulic lithotripsy and double balloon endoscopy. Am J Case Rep 2019; 20: 1320-1324
• 2 Rafael MA, Figueiredo L, Horta D. et al. Treatment of Bouveret syndrome with electrohydraulic lithotripsy. Clin Endosc 2020; 53: 241-242
• 3 Maehata T, Kiyokawa H, Nakahara K. et al. Successfully combined therapy of Coca-Cola and endoscopic treatment for a giant diospyrobezoar in the duodenum using the electrosurgical endo-knife and ileus tube. VideoGIE 2021; 6: 475-477

Publication History

Article published online:
14 October 2022