Slice and dice, endoscopic management of large abstracting intraduodenal stone using an electrosurgical knife. And these are our disclosures. Bouvier-Rey syndrome is a rare complication of choleidothiasis in which gallstone ileus occurs secondary to an acquired cholecystointeric fistula. The gallstone may migrate through the fistula into the gastrointestinal tract, therefore causing gastric alley obstruction. Given the rarity of the condition, there are no standardized treatment guidelines for the management of Bouvier-Rey syndrome. Potential treatment options would include endoscopic, laparoscopic, or open surgical management. We report a case of a 77-year-old male who presented to the emergency department with a 5-day history of gradual onset epigastric pain associated with nausea and vomiting after meals. The patient denied fevers, chills, or other infective symptoms. Laboratory investigation was significant for leukocytosis with our left shift. Liver biochemistries were within normal limits. CT imaging of the abdomen demonstrated a large 5-centimeter calculus impacted in the proximal duodenum with marked gastric distension as shown by the arrow. In addition, multiple gallstones were present with marked pericholecystic inflammation and stranding. The imaging finding confirmed the presence of a cholecystoduodenal fistula with associated gallstone ileus and gastric alley obstruction. After extensive discussions involving surgical colleagues and considering patient preference, we proceeded with endoscopic management of the impacted stone. During the index endoscopy procedure, a large calculus was found wedged in the duodenal bulb immediately distal to the pylorus with near-total obstruction of the duodenal lumen. Unfortunately, we were not able to achieve meaningful stone fragmentation despite an exhaustive range of maneuvers and tools including pyloric balloon dilatation followed by attempted sneer retrieval, occlusion balloon catheter, mechanical lithotripsy, and extensive electrohydraulic lithotripsy. A subsequent endoscopic procedure was then undertaken and we utilized a T-type submucosal dissection knife with a hydrosurgical dissection jet to fragment the large impacted stone using the precision water jet. However, the water jet was unable to fragment the stone efficiently. Therefore, the decision was made to utilize the submucosal dissection knife with electrosurgical energy. In a very cautious and systemic fashion, stone fragmentation was performed by grasping the stone with a knife tip and delivering electrosurgical energy while retracting the knife into a distal attachment fitted onto our endoscope. Great care was undertaken to avoid mucosal contact and resultant bleeding. This approach yielded large stone fragments which were grasped and withdrawn into the stomach using a retrieval net and large caliber sneer. The largest fragments were crushed further using mechanical lithotripsy to prevent future obstruction in the GI tract. After stone fragmentation and removal, a large cholecystodiodenal fistula was identified with additional multiple large pigmented stones visualized within the remaining gallbladder body. Fortunately, these stones were able to be retrieved into the stomach with a sneer. The large cholecystodiodenal fistula was then completely visualized. Given concerns over spontaneous fistula closure and lack of clarity regarding the patient's surgical candidacy, a 0.035 inch guide wire was advanced into the fistula and passed integrate through the cystic duct into the common bile duct and subsequently through the ampulla into the small bowel. We then placed a 0.007 inch by 0.012 inch double pigtail plastic stent integrately into the duodenal lumen where it was deployed successfully. The proximal end of the pigtail stent was placed within the gallbladder. Our patient developed transient and mild abdominal discomfort post-endoscopic procedure which quickly resolved. Reassuringly, the patient did not develop further gallstone ileus. The patient was then reviewed by the surgical service and underwent surgical intervention with laparoscopic cholecystectomy and successful fistula closure. In summary, our case highlights that Bouvierette syndrome and gallstone fragmentation can be effectively and successfully managed utilizing a submucosal dissection knife with electrosurgical energy. However, great care must be taken to prevent mucosal injury or injuries to adjacent structures of the distal stomach and proximal duodenum. Importantly, further case experience and evaluation is necessary before this approach can be widely accepted.

Bouvier-Rey syndrome

cholelithiasis

endoscopic management

duodenal obstruction

laparoscopic cholecystectomy

bouvier