Effective endoscopic holmium laser lithotripsy in the treatment of a large impacted gallstone in the duodenum

Gallstone ileus is caused by the passage of one or more large gallstones (at least 2.5cm in size) in the gastrointestinal tract through a bilioenteric fistula. It accounts for 1% to 4% of all cases of mechanical small-bowel obstruction [1,2]. The obstructing gallstone is usually impacted in the terminal ileum, rarely the duodenum [1]. Computed tomography generally reveals mechanical bowel obstruction, pneumobilia, and an ectopic stone in the intestinal lumen (Rigler’s triad) [3]. Although surgery is considered the gold standard treatment, a less invasive endoscopic approach is advisable in high risk patients [4]. An 87-year-old woman was admitted to the emergency department with abdominal pain and vomiting of 3 days’ duration. Computed tomography showed a large, calcified ring in the duodenum and aerobilia (●" Fig.1). Upper gastrointestinal endoscopy revealed a large obstructive stone in the duodenal bulb that could not be removed endoscopically, even after pyloric dilation. Because of the obstructive symptoms, a gastrojejunal anastomosis was created, which partially relieved the obstruction. To fragment the stone, we performed another endoscopic procedure. A holmium laser (HLS30WHolmium:YAG 30WLaser; Olympus America, Center Valley, Pennsylvania, USA) was applied for a total of approximately 200 minutes. This resulted in fragmentation of the stone into small parts, which were removed with an extraction basket and a retrieval device (●" Video 1). The patient was discharged after 15 days with complete resolution of the occlusive symptoms, and her scheduled cholecystectomy was canceled.