Complex endoscopic management of gallbladder cancer patient with Bouveret syndrome.
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ABSTRACT:
SUBMITTER: Vanek P
PROVIDER: S-EPMC7805016 | biostudies-literature | 2021 Jan
REPOSITORIES: biostudies-literature
Publications
Complex endoscopic management of gallbladder cancer patient with Bouveret syndrome.
Vanek Petr P Freeman Martin L ML Trikudanathan Guru G
VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy 20201213 1
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Project description:Video 1Endoscopic management of Bouveret syndrome with electrohydraulic lithotripsy.
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Project description:Video 1Endoscopic treatment of a Bouveret syndrome showing and describing the techniques and procedures involved.
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Project description:Video 1Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife. A 61-year-old man with a 3-decade history of recurrent cholecystitis presented to the community emergency department with severe right upper quadrant pain. A CT scan was performed and revealed gangrenous cholecystitis with likely cholecystoduodenal fistulous communication.After discussion with the patient and the HPB team, the plan was made to attempt endoscopic extraction of the obstructing stone. This would be performed in the operating room, such that if endoscopic extraction was not possible, surgical management would proceed.During the endoscopy, 1 L of liquid material was suctioned and the retained solids were cleared as best as possible. The large obstructing stone was then seen in the duodenal cap. In the cap, we could appreciate the obstructing stone and the fistulous tract.We then passed a guidewire distal to the stone and advanced a 15- to 20-mm extraction balloon over the guidewire. The balloon was passed distal to the stone and inflated to 20 mm. We then applied firm, steady traction in an attempt to extract the stone.With the double-channel gastroscope, we passed a second wire and extraction balloon distal to the stone to increase the amount of traction that could be applied. Both balloons were inflated distal to the stone, and steady, firm traction was again applied. Unfortunately, this was not successful either.We then decided to use a regular ERCP needle knife to incise the stone. Because the knife was delicate, it was easily deformable, so we decided to switch to a triangle-tip knife.Using the "PreciseSECT" mode on the electrosurgical unit, the stone was repeatedly incised. Particular care was taken to avoid flinging the knife and damaging the duodenal wall.Saline was used as the irrigation solution to ensure electrosurgical conductivity when the current was applied.At this point, we could appreciate fragmentation of the stones after repeated incision.After about 3 hours of stone incision and fragmentation, the guidewire was passed beyond the stone; the extraction balloon was advanced over the wire; and the balloon was again inflated with steady traction applied. This time, the stone was successfully extracted from the stomach.The duodenum was then examined. There were no remaining large pieces of stone or any significant mucosal damage or perforation.Using a mechanical lithotripter, the remaining larger fragments of stone were fragmented and extracted. However, because the stone had a large diameter, lithotripsy at the center was not initially possible, and the smaller lateral aspects had to be performed until the stone was completely fragmented.This case demonstrates the incision and fragmentation of a massive gallstone with the use of an endoscopic submucosal dissection knife and electrosurgical unit.With cautious application of this technique, successful endoscopic management of a large gallstone causing Bouveret syndrome was achieved. This technique avoided open surgical management and allowed for elective cholecystectomy at a later date with less morbidity.
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Project description:Acute cholecystitis is a common and frequently occurring disease, and laparoscopic cholecystectomy is the preferred treatment method. Percutaneous transhepatic gallbladder drainage is regarded as the first-line palliative procedure for elderly patients with poor cardiopulmonary function who cannot tolerate general anesthesia. However, for patients with acute cholecystitis who are undergoing treatment with oral antithrombotics or who have abnormal coagulation mechanisms, endoscopic transpapillary gallbladder drainage may be a good choice. Endoscopic transpapillary gallbladder drainage is an endoscopic retrograde cholangiopancreatography-based technique that drains the gallbladder by placing a tube into the cavity of the gallbladder though the cystic gall duct. It is the application of the concept of natural orifice transluminal endoscopic surgery in the biliary system. This technique can not only achieve gallbladder drainage but can also minimize the risk of procedure-induced bleeding. In this paper, we describe a representative case to introduce the key points of this procedure and the associated clinical care, hoping to provide useful information for clinicians and nurses.
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Project description: Not available
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Project description:BackgroundBouveret syndrome is characterized by gallstone impaction in the upper gastrointestinal tract causing gastric outlet obstruction. In Bouveret syndrome, endoscopic gallstone removal can avert the need for surgery. However, in cases in which endoscopic therapy is unlikely to succeed, endoscopic attempts delay definitive treatment and compound patient risks. We previously developed a model that predicts endoscopic outcomes from data derived through a systematic review. This tool uses gallstone length, site of impaction, and the number of planned methods of lithotripsy to predict the likelihood of endoscopic success with an accuracy of 81.0%. This study aimed to evaluate our tool performance in an independent, non-training data set and assess endoscopic and surgical outcomes.MethodsSystematic searches of the PubMed, Scopus, and Cochrane databases were performed for articles published between 16 April 2018 and 1 June 2021. The data reported after our previous study were harvested and inputted into the tool to evaluate their ability to accurately predict outcomes when compared with actual outcomes.ResultsNewly collated data in fields of interest showed no significant statistical differences compared with previous training data sets. Endoscopic therapy was successful in 41.9% of cases. Gallstones of ≤4 cm had a higher chance of successful endoscopic intervention (odds ratio 6.7, 95% confidence interval 1.7-25.8, P < 0.01). Complications of surgery were reported in 29.5%; there was one fatality reported. Post hoc evaluation of our predictive tool demonstrated an AUROC score of 0.80.ConclusionsWe have demonstrated in an independent data set that the tool can be used to accurately predict outcomes of endoscopic therapy. Patients in whom endoscopic therapy is most likely to fail should be offered an early surgical opinion.
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Project description:Given the ubiquity of laparoscopic cholecystectomy in the modern era, the incidence of incidentally diagnosed gallbladder cancers (GBCs) is rising. This unique clinical scenario poses specific challenges regarding the role of staging, re-resection, and adjuvant treatment for patients with this disease. This review will address these controversies with the latest published data.
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Project description:Biliary-enteric fistula is a rare complication of cholelithiasis that can lead to gallstone ileus. Gallstone impaction in the duodenum and pylorus is extremely rare and can lead to gastric outlet obstruction, a condition known as Bouveret syndrome. Bouveret syndrome needs to be diagnosed and managed in a timely fashion, as it has a high mortality rate. We describe a case of an elderly patient who presented with Bouveret syndrome secondary to impaction of the biliary calculus in the first part of duodenum.
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