EHL of Gallstones: Technique

Transcription

Bouveret-Syndrome with Gallbladder Fistula
Silke Resing, Doris Stiefenhöfer, Alexander Dechêne
Dept. of Gastroenterology and Hepatology, University Hospital Essen, Germany
Definition
Bouveret-Syndrome is a rare complication of cholecystolithiasis; a particular type of
obstruction, where a gallstone migrates from the gallbladder to the duodenum via a
fistula, and becomes impacted in the duodenal bulb.
Case Report
• 61y old woman with forceful vomiting + abdominal pain
• First EGD: empty stomach, obstruction in the duodenal bulb
► Gall stone migrated through gallbladder fistula (see Figure1)
• Insertion of a nasoduodenal tube for nutrition
• Second EGD: electrohydraulic lithotripsy (EHL) – 9 5F-probes used in a 2h session,
removal of half of the stone in fragments
•
(see Figure 2.)
• Third EGD: Repeat EHL (8 5F-probes) until fragmentation stone sufficient for removal
by forceps and Roth-net.
• Difficulties in retrieving the largest fragment: temporary impactation of the retrieval net
in the esophagogastric junction and the upper esophageal sphincter due to
anatomical reasons
• Large fistula between gall bladder and duodenal bulb due to stone perforation, slight
signs of inflammation and self-limiting bleeding after stone extraction
• Fourth EGD: two small stones in the duodenum and gallbladder, removed with
retrieval net.(Figure 3) Gallbladder-duodenum fistula with luminal diameter of approx.
25mm (Figure 4), minimal inflammation and no free abdominal perforation. Small
lacerations to the esophageal mucosa.
EHL of Gallstones: Technique
• Shock-wave generator and probes (5F
or 3F, depending on working channel)
• Water filling for optimal coupling
• Destruction of stone by shockwaves
• Removal of stone fragements
Synposis: Technique of electrohydraulic lithotripsy
Figure 1: Impacted gallstone in duodenal bulb,
seen from the stomach through the pylorus
Figure 2: Fragmentation of gallstone via EHL
Arrow: EHL-probe
EHL-Generator (Nortec, US)
Discussion
Traditionally, very large stones can be safely removed by surgery at the price of
relatively high invasiveness including duodenotomy and general anesthesia. In this
case, it was the patient´s preference to have the obstruction removed by minimally
invasive methods.
An increasing number of reports show that endoscopic lithotripsy and removal is a
viable alternative to a surgical duodenotomy with similar success rates. There are three
methods of endoscopic stone fragmentation apart from removal in tot (if possible):
• Laser lithotripsy;
• Mechanical lithotripsy;
• Electrohydraulic lithotripsy (EHL), as in our case.
These methods are most successful for small stones and/or stones that are mobile.
Duodenum
Figure 3: Large stone fragment in retrieval net
Conclusion
Fistula
The EHL procedure was carried out in step-by-step stages, without major difficulties and
without risk of creating further complications to the patient. During treatment, patient
nutrition was maintained via the use of a nasoduodenal tube passing the stone. The
large fistula required no treatment, and the patient was free of complaints one month
later, declining further examinations or therapies.
Figure 4: Orifice of fistula seen from
duodenal bulb
Learning outcome:
· The case report demonstrates the endoscopic treatment of the Bouveret's syndrome
with EHL.
· The described problem solving strategies during assistance and patient care will be
explained with imaging.
References:
Huebner ES, Dubois S, Lee SD et al. (2007) Successful endoscopic treatment of Bouveret's syndrome with intracorporeal electrohydraulic lithotripsy.
Gastrointest Endosc 66:183-184; discussion 184
Figure 5: Retrieved stone fragments after EHL
Hier ggf. Logo Klinik, Fachabteilung, Institut
Dies ist ein wissenschaftliches Poster –
Im Format DIN A1 quer.
Name Autor1, Name Autor2, Name Autor3
1 Klinik, Institut oder Fachabteilung des ersten Autors | 2 Klinik, Institut oder Fachabteilung des zweiten Autors
3 Klinik, Institut oder Fachabteilung des dritten Autors
Einleitung
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Material und Methoden
Ergebnisse
Zusammenfassung
Schlussfolgerung
Daten, Tabellen, Abb.
Können ggf. mit farbigen Flächen hinterlegt werden.

EHL of Gallstones: Technique

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