Limits...
Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome).

Rogart JN, Perkal M, Nagar A - Diagn Ther Endosc (2008)

Bottom Line: Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery.After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful.We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

View Article: PubMed Central - PubMed

Affiliation: Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, West Haven VAMC, CT 06510, USA.

ABSTRACT
Bouveret's syndrome is a rare condition of gastric outlet obstruction resulting from the migration of a gallstone through a choledochoduodenal fistula. Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery. We report the case of an elderly male who presented with nausea and hematemesis, and was found on CT scan and endoscopy to have an obstructing gallstone in his duodenal bulb. After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful. We believe this to be the first case of Bouveret's syndrome successfully treated by endoscopy alone in the United States. We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

No MeSH data available.


Related in: MedlinePlus

Double-snare extraction technique. Two overlapping jumbo polypectomy snares (arrows) were used to grasp the stone at different angles, providing adequate leverage for extraction into the stomach.
© Copyright Policy - open-access
Related In: Results  -  Collection


getmorefigures.php?uid=PMC2239211&req=5

fig4: Double-snare extraction technique. Two overlapping jumbo polypectomy snares (arrows) were used to grasp the stone at different angles, providing adequate leverage for extraction into the stomach.

Mentions: Three days later endoscopy wasrepeated, and an intracorporeal electrohydraulic lithotripter (IEHL; NorthgateTechnologies, Ill, USA), which was previously unavailable, was employed, asworking with the Holmium: YAG laser had been only partially successful. Using a 1.9F fiber (power of 1, increased to40; frequency of 10, increased to 30) under constant saline irrigation, IEHLwas successful at shattering the outer “shell” of the stone and breaking itinto two large pieces, leaving behind an extremely hard, smaller core (see Figure 3(b)). Ultimately, the majority of thestone was fragmented (Figure 3(c)) though the largerpiece still could not be removed easily from the duodenal bulb. Using a“double-snare” technique, two jumbo polypectomy snares ( cm, Cook Endoscopy,Ind, USA) were used to grasp the still-impacted large stone fragment atdifferent angles and pull it into the stomach (see Figure 4). Examination of the remainder of the duodenumshowed no other stones. The largecholecystoduodenal fistula was visualized, and the gastroscope easily passedinto the lumen of the gallbladder (see Figure 5). Due to the length of the procedure, we choseto complete the endoscopy another day.


Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome).

Rogart JN, Perkal M, Nagar A - Diagn Ther Endosc (2008)

Double-snare extraction technique. Two overlapping jumbo polypectomy snares (arrows) were used to grasp the stone at different angles, providing adequate leverage for extraction into the stomach.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2239211&req=5

fig4: Double-snare extraction technique. Two overlapping jumbo polypectomy snares (arrows) were used to grasp the stone at different angles, providing adequate leverage for extraction into the stomach.
Mentions: Three days later endoscopy wasrepeated, and an intracorporeal electrohydraulic lithotripter (IEHL; NorthgateTechnologies, Ill, USA), which was previously unavailable, was employed, asworking with the Holmium: YAG laser had been only partially successful. Using a 1.9F fiber (power of 1, increased to40; frequency of 10, increased to 30) under constant saline irrigation, IEHLwas successful at shattering the outer “shell” of the stone and breaking itinto two large pieces, leaving behind an extremely hard, smaller core (see Figure 3(b)). Ultimately, the majority of thestone was fragmented (Figure 3(c)) though the largerpiece still could not be removed easily from the duodenal bulb. Using a“double-snare” technique, two jumbo polypectomy snares ( cm, Cook Endoscopy,Ind, USA) were used to grasp the still-impacted large stone fragment atdifferent angles and pull it into the stomach (see Figure 4). Examination of the remainder of the duodenumshowed no other stones. The largecholecystoduodenal fistula was visualized, and the gastroscope easily passedinto the lumen of the gallbladder (see Figure 5). Due to the length of the procedure, we choseto complete the endoscopy another day.

Bottom Line: Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery.After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful.We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

View Article: PubMed Central - PubMed

Affiliation: Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, West Haven VAMC, CT 06510, USA.

ABSTRACT
Bouveret's syndrome is a rare condition of gastric outlet obstruction resulting from the migration of a gallstone through a choledochoduodenal fistula. Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery. We report the case of an elderly male who presented with nausea and hematemesis, and was found on CT scan and endoscopy to have an obstructing gallstone in his duodenal bulb. After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful. We believe this to be the first case of Bouveret's syndrome successfully treated by endoscopy alone in the United States. We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

No MeSH data available.


Related in: MedlinePlus