title: Bouveret's syndrome: presentation of two cases with review of the literature and development of a surgical treatment strategy.
abstract: BACKGROUND
  Bouveret's syndrome causes gastric outlet obstruction when a gallstone is impacted in the duodenum or stomach via a bilioenteric fistula. It is a rare condition that causes significant morbidity and mortality and often occurs in the elderly with significant comorbidities. Individual diagnostic and treatment strategies are required for optimal management and outcome. The purpose of this paper is to develop a surgical strategy for optimized individual treatment of Bouveret's syndrome based on the available literature and motivated by our own experience.
  
  
  METHODS
  Two cases of Bouveret's syndrome are presented with individual management and restrictive surgical approaches tailored to the condition of the patients and intraoperative findings.
  
  
  CONCLUSIONS
  Improved diagnostics and restrictive individual surgical approaches have shown to lower the mortality rates of Bouveret's syndrome. For optimized outcome of the individual patient: The medical and perioperative management and time of surgery are tailored to the condition of the patient. CT-scan is most often required to secure the diagnosis. The surgical approach includes enterolithotomy alone or in combination with simultaneous or subsequent cholecystectomy and fistula repair. Lower overall morbidity and mortality are in favor of restrictive surgical approaches. The surgical strategy is adapted to the intraoperative findings and to the risk for secondary complications vs. the age and comorbidities of the patient.
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany. beat.mueller@med.uni-heidelberg.de.
authors.forename: Felix
authors.initials: F
authors.lastname: Nickel
authors.forename: Matthias M
authors.initials: MM
authors.lastname: Müller-Eschner
authors.forename: Jackson
authors.initials: J
authors.lastname: Chu
authors.forename: Hendrik
authors.initials: H
authors.lastname: von Tengg-Kobligk
authors.forename: Beat P
authors.initials: BP
authors.lastname: Müller-Stich
mesh_terms: D000368:Aged; D002763:Cholecystectomy; D004378:Duodenal Diseases / Q000175:diagnosis / Q000601:surgery*; D042882:Gallstones / Q000175:diagnosis / Q000601:surgery*; D017219:Gastric Outlet Obstruction / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D007412:Intestinal Fistula / Q000175:diagnosis / Q000601:surgery*; D008297:Male; D013577:Syndrome