Smith Emma, Zhao Sarah, El Boghdady Michael, Sabato-Ceraldi Serena
General Surgery Department, Croydon University Hospital, London CR7 7YE, United Kingdom.
General Surgery Department, Croydon University Hospital, London CR7 7YE, United Kingdom; University of Edinburgh, Scotland, United Kingdom.
Int J Surg Case Rep. 2022 May;94:107084. doi: 10.1016/j.ijscr.2022.107084. Epub 2022 Apr 14.
Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. Although rare, this condition carries a high mortality rate and no current standardised guidelines for management.
We present a case of a patient in their 60s with recurrent small bowel obstruction secondary to a cholecysto-duodenal fistula and large gallstone which became impacted in the fourth part of the duodenum. The patient had a P-POSSUM Score of 14% mortality and 60% morbidity risk, had multiple co-morbidities, was bedbound, BMI 59 and had been deemed high risk for general anaesthetic at oncology centre for a 10 × 10 cm likely gynaecological malignancy a month prior to this admission.
In contrast to existing literature, endoscopic lithotripsy was considered but not attempted due to unavailability of this service locally. Surgical intervention was decided based on radiological features of impending duodenal perforation on CT imaging and multiple disciplinary team discussion. The patient was managed with open enterolithotomy at the duodeno-jejunal (DJ) flexure and discharged 3 weeks post-operatively at her pre-operative baseline.
This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. In cases where anatomical location of impaction precludes retrieval via simple gastrostomy, we suggest using high pressure flush to mobilise the stone to more favourable location distally. We emphasise that stone size should be considered when planning surgical management.
布韦雷综合征是一种罕见病症，其特征为胆结石瘘入十二指肠近端或幽门导致胃出口梗阻。尽管罕见，但该病症死亡率高，目前尚无标准化的治疗指南。
我们报告一例60多岁的患者，因胆囊十二指肠瘘和大的胆结石导致反复小肠梗阻，结石嵌顿于十二指肠第四部。该患者的P-POSSUM评分为死亡率14%、发病率风险60%，有多种合并症，长期卧床，体重指数59，在本次入院前一个月，在肿瘤中心因可能为10×10 cm的妇科恶性肿瘤被认为全身麻醉风险高。
与现有文献不同，考虑过内镜碎石术，但因当地无法提供此项服务而未尝试。基于CT成像上十二指肠即将穿孔的影像学特征以及多学科团队讨论，决定进行手术干预。患者在十二指肠空肠（DJ）曲处接受了开放式肠石切除术，术后3周出院，恢复到术前基线状态。
据我们所知，这是第一份描述成功手术治疗嵌顿于十二指肠第四部胆结石的报告。在结石嵌顿的解剖位置无法通过简单的胃造口术取出的情况下，我们建议使用高压冲洗将结石移动到更有利的远端位置。我们强调，在规划手术治疗时应考虑结石大小。
