749 Bouveret Syndrome: A Challenging Case of Impacted Gallstone Within the Fourth Part of the Duodenum

Abstract Aim Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to gallstone fistulating into the proximal duodenum or pylorus. In this report, we present case of in 68-year-old requiring an atypical approach surgical retrieval. Method The patient presented acutely with abdominal pain and vomiting. This was on background recent admission for ileus managed conservatively. Initially, due high anaesthetic risk (P POSSUM score = 14% mortality, 60% morbidity), conservatively nasogastric drainage total parenteral nutrition. On day 6 admission, emergency laparotomy performed after identifying radiological signs impending perforation related large impacted fourth part cholecysto-duodenal fistula. Endoscopic management not available locally. Unsuccessful attempt made milk stone proximally retrieval via pyloroplasty. Subsequently, pressure water flushes were delivered gastrostomy which expelled distally. then retrieved jejunotomy at DJ flexure. Results required 2-day dependency unit she discharged 3 weeks post-operatively her functional baseline. She clinically well asymptomatic when reviewed four-month post-operative follow up appointment. Conclusions first report our knowledge describe successful duodenum. Enterolithotomy can be considered large, safe option patients multiple co-morbidities.