# Management of Complex Gallstone Disease With Bouveret’s and Mirizzi Syndrome: A Case Report With Literature Review

## TL;DR

This case report describes a rare and complex gallstone disease involving both Bouveret’s and Mirizzi syndromes, highlighting the challenges and multidisciplinary approach needed for successful management.

## Contribution

The paper presents a unique case of concurrent Bouveret’s and Mirizzi syndromes, emphasizing the importance of staged treatment and combined surgical and endoscopic strategies.

## Key findings

- A 64-year-old man presented with both Bouveret’s syndrome and Csendes Type Va Mirizzi syndrome.
- Robotic-assisted gastrotomy and subtotal cholecystectomy were used, followed by endoscopic stenting for complications.
- Multidisciplinary management led to recovery and stability at follow-up.

## Abstract

Gallstone disease affects up to 20% of adults, but rare complications include Bouveret’s syndrome, occurring in approximately 0.05% of patients with gallstones, and Mirizzi syndrome, with Type Va involving concurrent biliary and enteric fistulae. We report the case of a 64-year-old man with concurrent Bouveret’s syndrome and Csendes Type Va Mirizzi syndrome associated with a cholecystoduodenal fistula. An initial laparoscopic cholecystectomy was abandoned due to concern for malignancy. During the same admission, the patient developed gastric outlet obstruction, and imaging confirmed Bouveret’s syndrome caused by a large ectopic gallstone. This was managed with robotic-assisted gastrotomy and stone extraction as a damage-control procedure, with definitive biliary surgery deferred because of severe inflammation and unclear anatomy. Subsequent imaging demonstrated a residual Hartmann’s pouch stone with Type Va Mirizzi syndrome and a persistent cholecystoduodenal fistula. The patient underwent a robotic subtotal cholecystectomy with intraoperative indocyanine green assessment and endoscopic evaluation. His postoperative course was complicated by peritonitis, bilious and enteric leakage, and intra-abdominal collections, requiring laparoscopic washout, radiological drainage, total parenteral nutrition, and endoscopic retrograde cholangiopancreatography with placement of a covered metal stent for a cystic duct stump leak. The patient recovered with multidisciplinary management and remained well at follow-up. This case illustrates the complexity of managing dual fistula-related gallstone disease and highlights the importance of staged decision-making, detailed imaging, and combined surgical and endoscopic approaches.