Bouveret's syndrome complicated by distal gallstone ileus after laser lithotropsy using Holmium: YAG laser

BACKGROUND: Bouveret's syndrome is an unusual presentation of duodenal obstruction caused by the passage of a large gallstone through a cholecystoduodenal fistula. Endoscopic therapy has been used as first-line treatment, especially in patients with high surgical risk. CASE PRESENTATION: We report a 67-year-old woman who underwent an endoscopic attempt to fragment and retrieve a duodenal stone using a Holmium: Yttrium-Aluminum-Garnet Laser (Ho:YAG) which resulted in small bowel obstruction. The patient successfully underwent enterolithotomy without cholecystectomy or closure of the fistula. CONCLUSION: We conclude that, distal gallstone obstruction, due to migration of partially fragmented stones, can occur as a possible complication of laser lithotripsy treatment of Bouveret's syndrome and might require urgent enterolithotomy

Should enteral feeding be the standard of care for acute pancreatitis?: Abou-Assi S, Craig K, O'Keefe SJD, Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Gastroenterol 2002;97:2255–62

This study was performed prospectively to define outcomes including length of hospital stay, duration of feeding, complications, hospital costs, and indications for nutritional support in patients admitted with acute pancreatitis (AP). Patients who failed to improve after 48 h of conservative treatment or who could not tolerate an oral diet were randomized to receive either nasojejunal (NJ) or total parenteral (TPN) feeding. The majority of cases were related to alcohol consumption or gallstones. The goal feeding rates were intended to provide 1.5 g protein/kg/day and 25–30 Kcal/kg/day. The two nutritionally supported groups were compared on an intention to treat basis. In all, 75% of patients admitted for AP improved after conventional therapy within 48 h and did not require nutritional support. Of the patients, 27 patients were randomized to TPN and 26 to NJ feeding. Three patients in the NJ group were switched to TPN (two needed surgery and one could not tolerate the NJ feeds), and two in the TPN group were converted to NJ feeding because of sepsis. The average length of hospital stay was shorter in the NJ group versus the TPN group (14 vs 18 days) but the difference was not significant. The introduction of oral feeding was tolerated better in the NJ group, with 80% advancing to an oral diet without difficulty in comparison to 63% in the TPN group. The average length of nutritional support was significantly shorter in the enteral nutrition (EN) patients who were fed by NJ tube than in patients on TPN (6.7 vs 10.8 days, p < 0.001). However, the EN group received fewer calories (49% vs 85%) and protein (42% vs 85%) in comparison to the TPN group ( p < 0.005). The disease severity as well as the serum pancreatic enzyme levels on admission and thereafter were comparable between the groups. Nutrition associated complications were significantly more common in the TPN group. These included hyperglycemia, septic complications, and catheter-related infections requiring prolonged therapy. The incidence of severe complication and death was similar in the two groups. A post hoc analysis of patients with severe pancreatitis showed similar results, with significantly more rapid resolution of the disease process in the NJ group. The average cost per hospital stay was considerably lower for patients who improved sufficiently to forgo nutritional support ($4,597) in comparison to patients who required nutritional support. Patients who received enteral feeding had a lower total average hospitalization cost of$26,464 versus $34,530 for those who required parenteral nutrition, based on intention to treat analysis. The significantly lower average nutritional costs in the enteral group of$394 per patient in comparison to $2,756 per patient in the parenteral group ( p = 0.0004) could be explained by the combination of the lower daily costs of enteral feeding ($23.3/day vs $222/day), and the shorter duration of feeding (6.7 vs 10.8 days). Consequently, the proportion of hospital costs resulting from enteral feeding was significantly lower than for parenteral feeding (1.8% vs 8.4%, p < 0.0001). The authors concluded that NJ feeding initiated 48 h postadmission for patients with AP was safer than TPN, and does not exacerbate the disease, is well tolerated and less costly than TPN