Successful surgical intervention of Bouveret's syndrome at a district general hospital: a case report and literature review.

Introduction: Bouveret's syndrome is a rare etiology of gastric outlet obstruction, comprising 3% of gallstone ileus (GI) cases. GI occurs with cholecystoenteric fistulating disease resulting in gallstone impaction within the gastrointestinal tract. There is a lack of unified guidance in GI management for surgeons. This, combined with its unpredictable symptomatology at presentation, results in delayed diagnoses and high mortality rates, despite advancements in surgical care. Presentation of case: A 71-year-old male with a 10-day history of abdominal pain and vomiting. Imaging revealed gallstone impaction in the proximal duodenum. The patient underwent an emergency laparotomy where a solitary gallstone was found at the pylorus. A gastrotomy for stone retrieval was done followed by an intraoperative esophagogastroduodenoscopy (EGD) ensuring repair integrity and complete stone retrieval. The patient recovered well post-operatively. Discussion: Surgical management of GI remains controversial, with dichotomy between simple enterolithotomy and combined procedures with fistula repair. In high risk, diagnostically challenging cases, such as this one, the use of intra-operative EGD to evaluate integrity of enterolithotomy repair was a critical step in management and prospective patient outcome. Though frequently used in upper-gastrointestinal surgery, its use in context of GI management is not well described in literature. Its use is valuable and may reduce post-operative morbidity. Conclusion: GI is clinically ambiguous at presentation. In absence of definitive guidelines, management for GI relies on a multidisciplinary approach and sound surgical judgment. For high-risk patients with Bouveret's syndrome, enterolithotomy alone, with intra-operative EGD and consistent post-operative follow-up provide the best patient outcomes.