Post written by Fiona Milne, MD, from Queen’s University, Kingston Health Sciences Centre, Kingston, Ontario, Canada.

Our case describes a 61-year-old man with a 3-decade history of recurrent cholecystitis who presented with Bouveret syndrome. A CT scan showed a 5-cm obstructing gallstone in the proximal duodenum. Surgery was considered to be high risk, given medical comorbidities.

After discussion with the general surgery team, endoscopic decompression and stone extraction were arranged in the operating room, with plans to convert to open procedure if unsuccessful. Guidewire—placed extraction balloons were inflated distal to the stone to attempt to pull the stone into the stomach, which was unsuccessful. Stone fragmentation initially with an ERCP needle knife and ultimately with a triangle-tip electrosurgical knife successfully incised around the stone.

Once the stone was fragmented, it was passed into the stomach with the aid of a guidewire—placed extraction balloon. Large stone fragments were then crushed with the mechanical lithotripter.

Currently described endoscopic methods for managing Bouveret syndrome include simple stone retrieval, mechanical lithotripsy, electrohydraulic lithotripsy, and laser lithotripsy. These therapies have varying rates of success but may offer therapeutic intervention as an alternative to surgery.

In our case, the stone was too large for the first 2 methods, and lithotripsy was unavailable at our center. The decision to feature this case was driven by the unique educational value; a literature review did not show previous description of using an electrosurgical knife to fragment a stone in this particular setting.

One of the aspects of my training that I have enjoyed is developing an approach to endoscopic dilemmas. This case was a salient reminder to think outside the box and use tools in innovative ways when conventional methods are infeasible or unavailable. Use of an electrosurgical knife in conjunction with other extraction methods helped the patient avoid a high-risk surgery.

Bouveret syndrome management with a needle knife. A, CT scan demonstrating gastric outlet obstruction due to 5-cm stone in duodenal cap. B, View of the stone and fistula in the duodenal cap. C, Incision of the stone with the triangle-tip knife with waterjet. D, Mechanical lithotripsy of the fragmented stone.

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