Bouveret Syndrome Associated with Acute Gangrenous Cholecystitis

Bouveret Syndrome Associated with Acute Gangrenous
Cholecystitis
Cornel Iancu, Raluca Bodea, Nadim Al Hajjar, Dana Todea-Iancu, Ovidiu Bălă, Iurie Acalovschi
3rd Surgical Clinic Cluj-Napoca, University of Medicine and Pharmacy, Cluj-Napoca, Romania
Abstract
An 89-year-old patient was hospitalized with signs of
acute lithiasic cholecystitis and gastric emptying failure. The
decision for surgery was taken and a subhepatic block was
evidenced, caused by a perforated gangrenous cholecystitis
with pericholecystic abscess, a cholecysto-antroduodenal
fistula with two gallstones, 9/5 and 4/3 cm in size, impacted
in the duodenum. It was necessary to perform an Y-en-Roux
antroduodenojejunal anastomosis because an antroduodenal
parietal defect resulted after the removal of the gangrenous
gallbladder. The immediate and long term postoperative
evolution in terms of anastomosis functionality was good.
Key words
Gangrenous cholecystitis – Bouveret syndrome – Y-enRoux antroduodenojejunal anastomosis
Introduction
The Bouveret syndrome, described for the first time
in 1896 by Leon Bouveret, is defined as a high intestinal
obstruction caused by the impaction of one or more gallstones
in the duodenum, consecutive to a biliodigestive fistula [1,
2]. It is a particular form of biliary ileus, occurring in 3% of
all cases of gallstone impaction in the digestive tract, which
represent 1-3% of all intestinal obstruction causes [3].
This fact is also evidenced by the relatively few cases
reported in the literature, up to 300 published cases [4, 5].
In a patient suspected of Bouveret syndrome, it is essential
to establish a positive diagnosis and to perform an emergency
therapeutic intervention for the subsequent good evolution.
J Gastrointestin Liver Dis
March 2008 Vol. 17 No 1, 87-90
Address for correspondence:
Assoc. Prof. Dr. Cornel Iancu
Clinica Chirurgie III
Str. Croitorilor, Nr. 19-21
400162, Cluj-Napoca, Romania
Email: dr_cornel_iancu@yahoo.com
These are the most important factors which contribute to the
decrease of mortality, estimated at 15-25% [1].
Case Report
An 89-year-old female patient, with no significant
personal history, was admitted to the 3rd Surgical Clinic
Cluj, complaining of pain in the right hypochondrium, fever,
nausea, loss of appetite and abdominal distension.
The patient was in a good condition, but with pale skin
and mucosae, had hemodynamic and respiratory stability,
diuresis and intestinal transit were present. The abdominal
examination evidenced an inflammatory subhepatic block
and sensitivity to right upper quadrant palpation.
Laboratory examinations, except a slight increase in
amylasemia (315 U/l)(normal values up to 200 U/l) and
leucocytosis (11,700 K/uL), were within normal limits.
Abdominal ultrasound examination revealed the liver at
the upper limit of normal, an enlarged gallbladder, filled with
gallstones, and a 5 mm transonic area around the gallbladder.
The ascending colon was adherent to the liver, aerocolia
and aeroenteria were present. The surgical intervention
Fig.1 Macroscopic appearance of the gallstone
causing the bilio-antroduodenal fistula.
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Iancu et al
was decided.
Intraoperatively, a subhepatic block was evidenced. Its
dissection showed a perforated gangrenous gallbladder, with
a pericholecystic abscess, a cholecysto-antroduodenal fistula,
with two gallstones, 9/5 and 4/3 cm in size (Fig. 1), impacted
at the antroduodenal level. After removal of the gangrenous
gallbladder, a parietal defect with a length of about 11 cm was
found at the level of the antrum and duodenum. The preferred
solution was a side-to-side Roux-en-Y antroduodenojejunal
anastomosis (Figs. 2, 3).
Fig.2 Posterior cross-section of the Roux-en-Y
antroduodenal jejunal anastomosis.
Fig.3 Closure of the antroduodenal parietal
defect by a L-L Roux-en-Y antroduodenal jejunal
anastomosis; final appearance of anastomosis.
The patient was discharged on postoperative day 8. The
immediate postoperative evolution, as well as the long term
evolution were favorable. Barium examination at 6 months
showed a functional anastomosis (Fig. 4).
Discussion
One of the rarest complications of biliary lithiasis is
biliodigestive fistula, with a frequency of less than 1%
(6). The factors favoring the fistula formation are: size of
the gallstone (2-8 cm) [2], long history of biliary disease,
repeated episodes of acute cholecystitis, female sex and
advanced age (over 60 years) [1]. The fistula can be
cholecystoduodenal (in 60% of cases), cholecystocolic (in
17%), cholecystogastric (in 5%), and choledocoduodenal
(in 5%) [7].
Once in the intestinal lumen, the gallstone will manifest
differently, depending on its size, the digestive tract segment
Fig.4 Radiological follow-up at 6 months;
good passage of barium substance through the
antroduodenal jejunal anastomosis.
involved by the fistula and the pre-existence of stenotic
areas at this level. Thus, the gallstone can be asymptomatic
and can be eliminated with faeces or by vomiting, or it can
become impacted somewhere along its digestive tract course,
resulting in obstruction (15% of cases) [8]. In decreasing
order of frequency, the obstruction can be located in the
terminal ileum (50-75% of cases), the proximal ileum and the
jejunum (20-40%), the colon, and more rarely, the stomach
or the duodenum [9].
The therapeutic strategy is chosen taking into consideration
several aspects: the patient’s age, comorbidities, the effect of
obstruction on the general condition, the size of the gallstone
and fistula, local inflammatory changes, the location of the
obstruction. It has been demonstrated that the duration of
the surgical intervention does not influence subsequent
evolution, but evolution can be influenced by the delay in
establishing the correct diagnosis and the unjustified delay
in intervention [10].
The ideal treatment is to solve the obstruction by
removing the gallstone, to close the fistula and prevent
recurrences, and this can be achieved by open surgery.
If the extraction of gallstones whether by classic or
laparoscopic duodenotomy or by an endoscopic procedure
is compulsory at first, cholecystectomy and the solution of
the fistula at another time or in serial interventions [5] are
decided by the operative team. The approach will be mainly
oriented by the general state of the patient and by the skills
of the surgical team.
The preference of some surgeons for the intervention
limited to duodenotomy with the extraction of gallstones
should not be generalized. This approach will only be adopted
for patients in an extremely poor state or in cases in which
local inflammatory changes make the intervention extremely
Bouveret syndrome
difficult, predisposing to intraoperative complications. The
supporters of simple interventions justify their decision by
an increase in mortality when cholecystectomy and closure
of fistula are associated, in 20-30% [11] compared to 12%
in simple duodenotomy cases [9] and also by the fact that a
cholecystoduodenal fistula may function as a biliodigestive
anastomosis in the presence of a permeable cyst. The
persistence of the fistula orifice favors stasis at the level of the
terminal common bile duct and, secondary to it, cholangitis
and lithiasis of the main bile duct [12, 13]. The closure
of the fistula orifice leaves a dysfunctional scleroatrophic
gallbladder, which favors the recurrence of lithiasis, acute
cholecystitis or gallbladder cancer [14, 15]. In 1961, Bossart
et al reported a 15% incidence of gallbladder carcinoma in
patients with biliary fistula, as compared with only 0.8% in
cholecystectomy samples at that time [16]. This group of
patients at high risk also includes patients with Bouveret
syndrome, in whom the fistula has not been closed. The
postoperative persistence of symptoms in the majority of
patients with duodenotomy and extraction of gallstones is
another argument for performing cholecystectomy [15] in
patients with a good general state.
The first intervention with the concomitant achievement
of the three treatment objectives was performed in 1929,
when Holz, trying to mobilize a gallstone impacted in the
duodenum, involuntarily penetrated through the fistula orifice
in the gallbladder and, after removing the gallstone, had to
close the fistula tract and perform a cholecystectomy [17].
Sometimes, the solution of the parietal defect at duodenal
level consists of a simple rupture, but it can also be a
challenge to the surgeon, who may be obliged by the local
situation to use other methods. The morbidity and mortality
rates are determined to a large extent by the quality of the
solution of the duodenal parietal defect.
Most authors report the suture of the fistula orifice
[13]. In 1972, Redding et al performed vagotomy and
Jaboulay gastroduodenostomy forced by the intense local
inflammation, in a case of high intestinal obstruction due to
impaction of two gallstones, one of 25 mm in the antrum
and the other of 20 mm in the duodenal bulb [12].
With the accumulation of experience and the acquisition
of adequate equipment, the laparoscopic approach, although
difficult, has become possible. Sica et al [5] report the first
case of Bouveret syndrome solved by laparoscopic route.
In well selected patients with important comorbidities
and major surgical risk, less aggressive methods can
be attempted, such as endoscopic procedures, which
however will not correct the fistula and will not prevent
recurrences. At endoscopy, the gallstone can be removed
mechanically, electrohydraulically or by laser lithotripsy.
Dumonceau et al have reported two cases treated with
combined extracorporeal shock wave lithotripsy (ESWL)
and electrohydraulic lithotripsy [18]. Maiss et al published
two Bouveret syndrome patients successfully treated by
laser lithotripsy, of whom the last one with a small sized
fistula identified at bulbar level was followed up until its
closure [19, 20].
89
In our patient, the association of Bouveret syndrome
with a gangrenous fistula prompted us to perform
cholecystectomy. The antroduodenal parietal defect, 11 cm in
length, with the absence of the anterior duodenal wall, made
the simple suture impossible, and therefore we chose a sideto-side Y-en-Roux antroduodenojejunal anastomosis. The
control by barium examination at 6 months postoperatively
showed good passage through the Roux loop, without barium
opacification of the proximal duodenum and jejunum. This
type of anastomosis was performed by our team in another
case of Bouveret syndrome and in five cases of colon cancer
with duodenal invasion, in all cases the anastomosis being
well tolerated.
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