==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2792041810.5144/0256-4947.2016.436asm-6-436Case ReportEndoscopic treatment of Bouveret’s syndrome in an extremely elderly patient with Holmium: YAG laser Chang Kao-Chi Chen Wei-Ming Wei Kuo-Liang From the Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, TaiwanCorrespondence: Dr. Kuo-Liang Wei, Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, 6 Section West, Chia-Po Road, Putz City, Chia-Yi 613, Puzi 61363, Taiwan, T: 886-5-362-1000 F: 886-5-362-3002, gwogi@adm.cgmh.org.twNov-Dec 2016 36 6 436 439 Copyright © 2016, Annals of Saudi Medicine2016This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Bouveret’s syndrome is a rare presentation of duodenal obstruction or gastric outlet obstruction caused by a large gallstone migrating through a cholecystoduodenal or choledochoduodenal fistula. Most patients are elderly and often have underlying comorbidities, complicating surgery. Endoscopic therapy should be used as first-line treatment for these patients who are not good surgical candidates. We report a case of a 98-year-old Chinese female who presented with vomiting for three days. Esophagogastroduodenoscopy and computed tomography confirmed the diagnosis of Bouveret’s syndrome. The patient successfully underwent endoscopic lithotripsy with the Holmium: Yttrium–Aluminum–Garnet (Ho: YAG) laser. Ho: YAG laser lithotripsy has been used to treat Bouveret’s syndrome in four case reports. It can be recommended in patients with Bouveret’s syndrome who are poor candidates for surgery. ==== Body Bouveret’s syndrome is a rare presentation of duodenal obstruction or gastric outlet obstruction caused by a large gallstone migrating through a cholecystoduodenal or choledochoduodenal fistula. In the majority of reported cases, surgical intervention was performed. However, the major complication and mortality rates for surgical treatment are approximately 13%–22.7%.1–3,9 Moreover, most patients are elderly and often have underlying comorbidities, complicating surgery. Previous reports have shown the effectiveness of minimal invasive treatment modalities such as extracorporeal shock wave lithotripsy, mechanical lithotripsy, electrohydraulic lithotripsy, and laser lithotripsy for treating Bouveret’s syndrome. Although the success rates of these non-surgical therapies are unsatisfactory, endoscopic treatment with laser lithotripsy seems to be more promising than other non-surgical methods.3 In recent years, there have been some reports on using endoscopy alone for successfully treating Bouveret’s syndrome. We describe an extremely elderly patient with high surgical risk treated using the Ho: YAG laser for endoscopic lithotripsy. CASE A 98-year-old Chinese female with cryptogenic liver cirrhosis, Child-Pugh A, presented with complaints of nausea, vomiting, abdominal pain, abdominal fullness, and anorexia for three days. She denied constipation, fever, or chills. Her vital signs were stable, and no peritoneal signs were noted on physical examination. Laboratory findings of the patient were as follows: white blood cell count, 13000/μL (80.7% segmented neutrophils); total bilirubin, 2.1 mg/dL; albumin, 3.4 g/dL; and normal creatinine level. Esophagogastroduodenoscopy showed a lot of fluid in the stomach, fistulous orifice on the proximal second portion of the duodenum near the bulb, and a large gallstone obstructing the second portion of the duodenum (Figure 1A and 1B). Abdominal computed tomography (CT) revealed an obstructed duodenum with a distended stomach, containing a lot of fluid, air in the biliary tree and gallbladder, a cholecystoduodenal fistula, and a 3.2×3.0-cm gallstone within the second portion of the duodenum (Figure 2A, 2B, 2C). Because of old age and underlying liver cirrhosis, the patient was a poor candidate for surgical intervention. Endoscopic mechanical lithotripsy was attempted to fragment and remove the stone. However, the large and firm stone broke two sets of our mechanical lithotripters, and the first therapeutic endoscopy failed. Therefore, the AURIGA Ho: YAG laser system (Lynton Surgical, UK) was used during the second attempt of therapeutic endoscopy. A 365-μ flexible quartz laser fiber was passed through the Glo-Tip catheter first, and the Glo-tip catheter was inserted through the working channel of the upper gastrointestinal endoscope to the duodenum. The force and frequency of laser pulses were 1.8 J and 12 Hz, respectively. Adequate water irrigation was performed during the procedure, and the stone was fragmented gradually using Ho: YAG laser lithotripsy under direct endoscopic view (Figure 3A, 3B, 3C). After complete fragmentation, the large piece of stone was removed readily with a Dormia basket. The patient’s condition improved rapidly without further discomfort associated with cholelithiasis. Cholecystoduodenal fistula was not repaired, and the patient presented with no complaints due to the gallstone at the six-month follow up. DISCUSSION Gallstone ileus is an uncommon but serious complication of cholelithiasis following migration of a large gallstone to the intestine through a cholecystoduodenal fistula, and it comprises only 1%–4% cases of intestinal obstruction.1 The stone can obstruct any site in the gastrointestinal tract, but the most common site of obstruction is the distal small intestine where the lumen is the narrowest. Most investigators believe that stones must be more than 2–2.5 cm in diameter to obstruct the intestine. 4,5 In a review of 1001 reported cases by Reisner and Cohen,6 impaction of the stone occurs in the ileum (60.5%), jejunum (16.1%), stomach (14.2%), colon (4.1%), and duodenum (3.5%). A gallstone impacting the duodenum and resulting in gastric outlet obstruction or duodenal obstruction is known as Bouveret’s syndrome and was first described in 1896 by Leon Bouveret (1850–1929), a French physician who played an important role in studying gastric diseases.7 Base on the above description and the review of 128 cases by Mitchell et al,3 Bouveret’s syndrome is categorized as a rare disease. The mean patient age was 74.1 years, and the female-to-male sex ratio was 1.86. Common symptoms included nausea/vomiting (86%) and abdominal pain or discomfort (71%), and common signs included abdominal tenderness (44%), dehydration (31%), and abdominal distention (27%). All cases had gastroduodenal obstruction on esophagogastroduodenoscopy, but the obstructing stone could be detected in only 69% cases during endoscopic examination. Fistulous stoma was seen in only 13% esophagogastroduodenoscopies. Plain abdominal radiography may show pneumobilia, calcified right upper quadrant mass or gallstone, gastric distention, and dilated small bowel loops in some cases, but the sensitivity is low. Abdominal CT is the preferred imaging modality to evaluate biliary complications and to reveal the classical Rigler’s triad of pneumobilia, ectopic gallstone, and gastroduodenal obstruction.8 Most patients with Bouveret’s syndrome have been treated by surgery, but the major complications and mortality rates are high despite modern surgical techniques.1–3,9 Thus endoscopic treatments have been popular because of the advanced age and comorbidities seen in this patient group. Endoscopic laser lithotripsy seems to be more promising than other endoscopic treatment.3 The Ho: YAG laser lithotripsy was reported only in four cases.10–13 One of these cases was complicated with distal gallstone ileus after Ho: YAG laser lithotripsy; hence, surgical enterotomy was performed.11 Another case was treated using Ho: YAG laser lithotripsy with electrohydraulic lithotripter,13 and the remaining two cases were successfully treated using Ho: YAG laser lithotripsy.10,12 Our case was a characteristic Bouveret’s syndrome patient who was extremely old, showing characteristic features and poor risk factors for surgery. Initial endoscopic mechanical lithotripsy failed because the stone was too large and firm. We chose the Ho: YAG laser lithotripsy because of its wide use in the surgical management of urinary lithiasis and prior success rates in treating Bouveret’s syndrome. The Ho: YAG laser is a solid-state pulsed-wave laser with a wavelength of 2140 nm and a pulse duration of 350–700 μs.14 It is capable of disintegrating urinary stones of all compositions while maintaining a wide margin of safety.15 A previous study also demonstrated the safety and efficacy of the Ho: YAG laser lithotripsy in the management of complex biliary tract stones.16 The laser deploys via a flexible optical fiber, and we can work with the laser through the working channel of the endoscope. The laser fiber can be placed under endoscopic view and makes the treatment technically easy and safe. The mechanism of stone fragmentation with the Ho: YAG laser mainly includes superheating the surrounding water and forming vaporization bubbles, which create a thermal effect in the localized area within 3 mm of the probe.17 Some investigators have commented that Ho: YAG laser lithotripsy occurs through a “drilling effect”, whereby small bits of stone are vaporized, emitting a fine stone dust, which obscures visualization. 18 For endoscopic use, an effective irrigation system would be essential. In our case, the large and firm gallstone was fixed in the duodenum and it broke two sets of our mechanical lithotripters. Hence, the fact that it could be fragmented in one session using Ho: YAG laser lithotripsy shows the superior fragmentation power of this device. The rhodamine-6 G dye laser system also has been used successfully for endoscopic treatment of Bouveret’s syndrome, but multiple sessions are needed to achieve complete fragmentation.19,20 A potential complication of endoscopic treatment is that partial fragmentation or dislocation of the stone can cause distal gallstone ileus, often requiring surgical intervention.11,21 Although surgery ultimately is necessary in these cases, endoscopic lithotripsy helps to avoid the potentially high-risk duodenotomy and change to easier distal enterotomy.22 Direct endoscopic lithotomy of the complete gallstone and mechanical lithotripsy or electrohydraulic lithotripsy in cases of Bouveret’s syndrome with high failure rates have been demonstrated in previous reports. 3 Ho: YAG laser lithotripsy has been used successfully and safely in patients with Bouveret’s syndrome, so it should be considered as first-line treatment for patients with poor surgical risk. There are no procedure-related complications or long-term adverse outcomes in these four case reports.10–13 The limitation of the Ho: YAG laser lithotripsy is the inability to close the fistula or do further cholecystectomy as surgery. Therefore, it has potential for recurrence, if there are residual stones in gallbladder. Further systematic study might reveal more experience and make it possible to make better recommendations, but this may be unavailable because of the rarity of Bouveret’s syndrome. A special endoscopic suite of Ho: YAG laser for a rare disease is not cost-effective. However, the Ho: YAG laser is very popular in urology, and is used for urolithiasis. In our hospital, instead of possessing a special Ho: YAG laser system in gastroenterology division, we borrow it from the urology division when needed. In conclusion, we believe that Ho: YAG laser lithotripsy can be recommended in patients with Bouveret’s syndrome who are poor candidates for surgery. Thus, endoscopists should be familiar with Ho: YAG laser lithotripsy which is available in many hospitals for efficient treatment of these difficult cases. SIMILAR CASES PUBLISHED: 4 Conflicts of interest The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article. Figure 1 A) Cholecystoduodenal fistula B) Gallstone in duodenum. Figure 2 A) Pneumobilia and distended stomach B) Gallstone obstructs the duodenum C) CT scan confirmed Bouveret’s syndrome. Figure 3 A) Start of laser lithotripsy B) Partial fragmentation of the gallstone C) Complete fragmentation of the gallstone. ==== Refs REFERENCES 1 Clavien PA Richon J Burgan S Rohner A Gallstone ileus Br J Surg 1990 7 77 7 737 42 2200556 2 Ayantunde AA Agrawal A Gallstone Ileus: Diagnosis and Management World J Surg 2007 31 1292 1297 17436117 3 Cappell MS Davis M Characterization of Bouveret’s syndrome: a comprehensive review of 128 cases Am J Gastroenterol 2006 101 9 2139 2146 16817848 4 Abou-Saif A Al-Kawas FH Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula and gallstone ileus (clinical reviews) Am J Gastroenetrol 2002 97 249 254 5 Dai Xin-Zheng Li Guo-Qiang Zhang Feng Wang Xue-Hao Zhang Chuan-Yong Gallstone ileus: Case report and literature review World J Gastroenterol 2013 9 7 19 33 5586 5589 24023505 6 Reisner RM Cohen JR Gallstone ileus: a review of 1001 reported cases Am Surg 1994 60 441 446 8198337 7 Bouveret L Sténose du pylore adhérent à la vésicule Rev Med (Paris) 1896 16 1 16 8 Gan S More than meets the eye: subtle but important CT findings in Bouveret’s syndrome AJR Am J Roentgenol 2008 191 1 182 185 18562743 9 Lowe AS Stephenson S Kay CL May J Duodenal obstruction by gallstone (Bouveret’s syndrome): a review of the literature Endoscopy 2005 37 1 82 87 15657864 10 Sinha Anubha Nazareth Michelle Shah AN Eurtuk Etal Uma Sundaram MD Successful endoscopic therapy of Bouveret’s syndrome using holmium laser lithotripsy: A case report Am J Gastroeterol 2002 97 S146 11 Alsolaiman MM Reitz C Nawras AT Bouveret’s syndrome complicated by distal gallstone ileus after laser lithotripsy using Holmium: YAG laser BMC Gastroenterol 2002 2 15 12086587 12 Goldstein EB Savel RH Pachter HL Cohen J Shamamian P Successful treatment of Bouveret syndrome using holmium: YAG laser lithotripsy Am Surg 2005 10 71 10 882 5 16468542 13 Rogart JN Perkal M Nagar A Successful multimodality endoscopic treatment of gastric outlet obstruction caused by an impacted gallstone (Bouveret’s Syndrome) Diagn Ther Endosc 2008 47 1512 14 Marks AJ Teichman JM Lasers in clinical urology: state of the art and new horizons World J Urol 2007 25 3 227 33 17393172 15 Patel Abhishek P Knudsen Bodo E Optimizing Use of the Holmium:YAG Laser for Surgical Management of Urinary Lithiasis Curr Urol Rep 2014 15 397 24532341 16 Shamamiam P Grasso M Management of complex biliary tract caculi with a holmium laser J Gastrointest Surg 2004 8 191 9 15036195 17 Blomley MJK Nicholson DA Bartal G Foster C Bradley A Myers M Man W Li S Banks LM Holmium-YAG laser for gall stone fragmentation: an endoscopic tool Gut 1995 36 442 445 7698706 18 Razvi HA Denstedt JD Chun SS Sales JL Intracarporeal lithotripsy with the holmium: YAG laser J Urol 1996 156 912 4 8709362 19 Maiss J Successful treatment of Bouveret’s syndrome by endoscopic laserlithotripsy Endoscopy 1999 31 S4 5 10223382 20 Langhorst J Schumacher B Deselaers T Neuhaus H Successful endoscopic therapy of a gastric outlet obstruction due to gallstone with intracorporal laser lithotripsy: a case of Bouveret’s syndrome Gastrointest Endosc 2000 5 209 213 21 Reinhardt SW Bouveret’s syndrome complicated by classic gallstone ileus: progression of disease or iatrogenic? 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