Olfactory Dysfunction Predicts Frailty and Poor Postoperative Outcome in Older Patients Scheduled for Elective Non-Cardiac Surgery.

OBJECTIVES: Frailty has been suggested to take part in the recently demonstrated link between olfactory dysfunction and overall mortality risk. Preoperative assessment of frailty is essential to detect the most vulnerable patients scheduled for surgery. The aim of this study was to evaluate whether olfactory dysfunction is a reliable predictor of preoperative frailty and postoperative outcome. DESIGN: This was a single-center prospective observational study conducted between July and October 2020 in Brussels, Belgium. SETTING AND PARTICIPANTS: 155 preoperative patients aged from 65 years old and scheduled for elective non-cardiac surgery. MEASUREMENTS: Olfactory function was examined using the Sniffin' Sticks 12-item identification test. Frailty was assessed using the Edmonton Frail Scale (EFS) and handgrip strength. The clock drawing test (CDT) from the EFS was also analyzed separately to evaluate cognitive function. Patients were followed for postoperative complications and mortality over one year. RESULTS: Olfactory dysfunction was significantly associated with the EFS score, anosmic patients having a higher median EFS score than normosmic patients (6[4-7] vs 4[2-5], p = .025). Anosmic patients had an increased odds of being frail after adjusting for possible confounding factors (OR: 6.19, 95% CI: 1.65-23.20, p = .007) and were more at risk of poor postoperative outcome (including complications and death) (OR: 4.33, 95% CI: 1.28-14.67, p = .018). CONCLUSIONS: Olfactory dysfunction is associated with preoperative frailty determined by the EFS and with poor post-surgical outcome at one-year.

Characterization of passive dosimeters in proton pencil beam scanning - A EURADOS intercomparison for mailed dosimetry audits in proton therapy centres.

The lack of mailed dosimetry audits of proton therapy centres in Europe has encouraged researchers of EURADOS Working Group 9 (WG9) to compare response of several existing passive detector systems in therapeutic pencil beam scanning. Alanine Electron Paramagnetic Resonance dosimetry systems from 3 different institutes (ISS, Italy; UH, Belgium and IFJ PAN, Poland), natLiF:Mg, Ti (MTS-N) and natLiF:Mg, Cu, P (MCP-N) thermoluminescent dosimeters (TLDs), GD-352M radiophotoluminescent glass dosimeters (RPLGDs) and Al2O3:C optically stimulated dosimeters (OSLDs) were evaluate. Dosimeter repeatability, batch reproducibility and response in therapeutic Pencil Beam Scanning were verified for implementation as mail auditing system. Alanine detectors demonstrated the lowest linear energy transfer (LET) dependence with an agreement between measured and treatment planning system (TPS) dose below 1%. The OSLDs measured on average a 6.3% lower dose compared to TPS calculation, with no significant difference between varying modulations and ranges. Both GD-352M and MCP-N measured a lower dose than the TPS and luminescent response was dependent on the LET of the therapeutic proton beam. Thermoluminescent response of MTS-N was also found to be dependent on the LET and a higher dose than TPS was measured with the most pronounced increase of 11%. As alanine detectors are characterized by the lowest energy dependence for different parameters of therapeutic pencil beam scanning they are suitable candidates for mail auditing in proton therapy. The response of luminescence detector systems have shown promises even though more careful calibration and corrections are needed for its implementation as part of a mailed dosimetry audit system.

Out-of-field doses for scanning proton radiotherapy of shallowly located paediatric tumours-a comparison of range shifter and 3D printed compensator.

The lowest possible energy of proton scanning beam in cyclotron proton therapy facilities is typically between 60 and 100 MeV. Treatment of superficial lesions requires a pre-absorber to deliver doses to shallower volumes. In most of the cases a range shifter (RS) is used, but as an alternative solution, a patient-specific 3D printed proton beam compensator (BC) can be applied. A BC enables further reduction of the air gap and consequently reduction of beam scattering. Such pre-absorbers are additional sources of secondary radiation. The aim of this work was the comparison of RS and BC with respect to out-of-field doses for a simulated treatment of superficial paediatric brain tumours. EURADOS WG9 performed comparative measurements of scattered radiation in the Proteus C-235 IBA facility (Cyclotron Centre Bronowice at the Institute of Nuclear Physics, CCB IFJ PAN, Kraków, Poland) using two anthropomorphic phantoms-5 and 10 yr old-for a superficial target in the brain. Both active detectors located inside the therapy room, and passive detectors placed inside the phantoms were used. Measurements were supplemented by Monte Carlo simulation of the radiation transport. For the applied 3D printed pre-absorbers, out-of-field doses from both secondary photons and neutrons were lower than for RS. Measurements with active environmental dosimeters at five positions inside the therapy room indicated that the RS/BC ratio of the out-of-field dose was also higher than one, with a maximum of 1.7. Photon dose inside phantoms leads to higher out-of-field doses for RS than BC to almost all organs with the highest RS/BC ratio 12.5 and 13.2 for breasts for 5 and 10 yr old phantoms, respectively. For organs closest to the isocentre such as the thyroid, neutron doses were lower for BC than RS due to neutrons moderation in the target volume, but for more distant organs like bladder-conversely-lower doses for RS than BC were observed. The use of 3D printed BC as the pre-absorber placed in the near vicinity of patient in the treatment of superficial tumours does not result in the increase of secondary radiation compared to the treatment with RS, placed far from the patient.

Prevalence and Risk Factors of Postprandial Hypotension among Elderly People Admitted in a Geriatric Evaluation and Management Unit : An Observational Study.

OBJECTIVES: To explore the prevalence and potential risk factors of postprandial hypotension (PPH) among elderly patients in an acute geriatric ward. DESIGN: A prospective observational study. SETTING: Geriatric Unit in a Belgian tertiary-care University Hospital. PARTICIPANTS: Seventy-six hospitalized elderly patients after stabilization of their acute conditions. MEASUREMENTS: PPH and orthostatic hypotension (OH) measured by a non-invasive automated blood pressure device, demographic data, Katz's Basic Activities of Daily Living (ADL) and Lawton's instrumental ADL, Short Physical Performance Battery, Charlson Comorbidity Index, Mini Nutritional Assessment-Short Form, Timed Up and Go test, Get-up Early test, grip strength and 7 classes of drugs. RESULTS: Overall, the prevalence of PPH was 46% (n=35/76), and it was symptomatic in 31% of the patients (n=11/35). PPH is associated with OH in one-third of the cases (n=12/35). Two-thirds of the patients with HPP had a significant drop in systolic blood pressure within the first 75 minutes after a meal. In univariate analyses, risk factors of PPH were nursing home residence, alpha-blocker consumption, help needed for eating and a good level of global functional status. However, patients with a good functional status were at increased risk of alpha-blocker exposure. In multivariate analyses, only alpha-blocker consumption and help needed for eating remained statistically significant. CONCLUSION: PPH is frequent among hospitalized elderly people in a Geriatric Evaluation and Management Unit, affecting nearly one out of two people. The use of alpha-blockers is an important risk factor and may alert clinicians to the risk of PPH.

Exercise Interventions for the Prevention and Treatment of Sarcopenia. A Systematic Umbrella Review.

OBJECTIVES: The aim of this systematic review is to provide an overview of the efficacy of different exercise interventions to counter sarcopenia in older adults. This review will allow the Belgian Society of Gerontology and Geriatrics and other scientific societies to formulate specific exercise recommendations in their Clinical Guidelines for Sarcopenia. DESIGN: We used the method of a systematic umbrella-review. Based on the level of evidence, we formulated specific recommendations for clinical practice. METHODS: Two databases (Pubmed and Web Of Science) were searched systematically and methodological quality of the reviews was assessed. Extracted data was than mapped to an exercise category and an overall synthesis (bottom line statements) was formulated for each of these exercise categories. Subsequently, we assigned a rating of the quality of the evidence supporting each bottom line statement. RESULTS: We identified 14 systematic reviews or meta-analyses, encompassing four exercise categories: resistance training, resistance training + nutritional supplementation, multimodal exercise programmes and bloodflow restriction training. Importantly, very few systematic reviews or meta-analyses clearly mentioned baseline sarcopenia status. There is high quality evidence for a positive and significant effect of resistance training on muscle mass, muscle strength, and physical performance. The added effect of nutritional supplementation for resistance training on muscle function appears limited. Blood flow restriction training is a novel training method that has a significant impact on muscle strength. CONCLUSION: Since sarcopenia is affecting all skeletal muscles in the body, we recommend training the large muscle groups in a total body approach. Although low-intensity resistance training (≤50% 1RM) is sufficient to induce strength gains, we recommend a high-intensity resistance training program (i.e. 80% 1RM) to obtain maximal strength gains. Multimodal exercises and blood flow restriction resistance training may be considered as well.

SOI microdosimetry and modified MKM for evaluation of relative biological effectiveness for a passive proton therapy radiation field.

With more patients receiving external beam radiation therapy with protons, it becomes increasingly important to refine the clinical understanding of the relative biological effectiveness (RBE) for dose delivered during treatment. Treatment planning systems used in clinics typically implement a constant RBE of 1.1 for proton fields irrespective of their highly heterogeneous linear energy transfer (LET). Quality assurance tools that can measure beam characteristics and quantify or be indicative of biological outcomes become necessary in the transition towards more sophisticated RBE weighted treatment planning and for verification of the Monte Carlo and analytical based models they use. In this study the RBE for the CHO-K1 cell line in a passively delivered clinical proton spread out Bragg peak (SOBP) is determined both in vitro and using a silicon-on-insulator (SOI) microdosimetry method paired with the modified microdosimetric kinetic model. The RBE along the central axis of a SOBP with 2 Gy delivered at the middle of the treatment field was found to vary between 1.11-1.98 and the RBE for 10% cell survival between 1.07-1.58 with a 250 kVp x-ray reference radiation and between 1.19-2.34 and 0.95-1.41, respectively, for a Co60 reference. Good agreement was found between RBE values calculated from the SOI-microdosimetry-MKM approach and in vitro. A strong correlation between proton lineal energy and RBE was observed particularly in the distal end and falloff of the SOBP.

Spousal Caregiving Is Associated with an Increased Risk of Frailty: A Case-Control Study.

BACKGROUND: Evidence suggests that providing care for a disabled elderly person may have implications for the caregiver's own health (decreased immunity, hypertension, and depression). OBJECTIVE: Explore if older spousal caregivers are at greater risks of frailty compared to older people without a load of care. DESIGN: Case-control study. SETTING: Participants were assessed at home in Wallonia, Belgium. PARTICIPANTS: Cases: community-dwelling spousal caregivers of older patients, recruited mainly by the geriatric outpatient clinic. CONTROLS: people living at home with an independent spouse at the functional and cognitive level matched for age, gender and comorbidities. MEASUREMENTS: Mini nutritional assessment-short form (MNA-SF), short physical performance battery (SPPB), frailty phenotype (Fried), geriatric depression scale (GDS-15), clock drawing test, sleep quality, and medications. The multivariable analysis used a conditional logistic regression. RESULTS: Among 79 caregivers, 42 were women; mean age and Charlson comorbidity index were 79.4±5.3 and 4.0±1.2, respectively. Among care-receivers (mean age 81.4±5.2), 82% had cognitive impairment. Caregiving was associated with a risk of frailty (Odd Ratio (OR) 6.66; 95% confidence interval (CI) 2.20-20.16), the consumption of antidepressants (OR 4.74; 95% CI 1.32 -17.01), shorter nights of sleep (OR 3.53; 95% CI 1.37-9.13) and more difficulties maintaining a social network (OR 5.25; 95% CI 1.68-16.40). CONCLUSIONS: Spousal caregivers were at an increased risk of being frail, having shorter nights of sleep, taking antidepressants and having difficulties maintaining their social network, compared to non-caregiver controls. Older spousal caregivers deserve the full attention of professionals to prevent functional decline and anticipate a care breakdown.

MICRODOSIMETRIC MEASUREMENT OF SECONDARY RADIATION IN THE PASSIVE SCATTERED PROTON THERAPY ROOM OF iTHEMBA LABS USING A TISSUE-EQUIVALENT PROPORTIONAL COUNTER.

Measurements of the dose equivalent at different distances from the isocenter of the proton therapy center at iThemba LABS were previously performed with a tissue-equivalent proportional counter (TEPC). These measurements showed that the scattered radiation levels were one or two orders of magnitude higher in comparison to other passive scattering delivery systems. In order to reduce these radiation levels, additional shielding was installed shortly after the measurements were done. Therefore, the aim of this work is to quantify and assess the reduction of the secondary doses delivered in the proton therapy room at iThemba LABS after the installation of the additional shielding. This has been performed by measuring microdosimetric spectra with a TEPC at 11 locations around the isocenter when a clinical modulated beam of 200 MeV proton was impinging onto a water phantom placed at the isocenter.

Early diagnosis of dehydration in hospitalized geriatric patients using clinical and laboratory criteria.

CONTEXT: Dehydration is a common yet underdiagnosed condition, which is associated with poor prognosis in older patients. The clinical and laboratory criteria for assessing dehydration are of variable or poor diagnostic value in this population and require further validation. OBJECTIVES: To test different clinical and laboratory criteria for the early diagnosis of dehydration in hospitalized older patients as compared to the standard diagnosis based on a body weight gain ≥ 3% during the first week of admission. DESIGN: Prospective study using clinical and laboratory criteria for dehydration selected by an expert panel. SETTING: Acute geriatric unit. PARTICIPANTS: Geriatric patients (n = 112; aged 83 ± 6 years) admitted to the unit. MEASUREMENTS: Using selected criteria (skin fold, dry mouth, calf muscle consistency, systolic blood pressure < 90 mmHg, orthostatic blood pressure drop, postural dizziness, thirst, apathy or delirium, urea, creatinine, uric acid, proteins, hemoglobin), expert clinicians prospectively assessed the patients to make a clinical diagnosis of dehydration upon admission. Clinicians were asked to provide a yes/no answer for each criterion and a global yes/no answer for dehydration, along with its estimated probability. Body weight was measured at admission and at Day 7. Laboratory parameters were assessed at baseline and at Day 7. The clinical diagnosis made at admission was retrospectively compared to the standard diagnosis made at Day 7 (> 3% weight gain) to test the values of each criterion separately, the global diagnosis, and its estimated probability. RESULTS: In total, 100 patients with complete data (mean age 83 ± 6 years) were considered for analysis. Dehydration was the principal reason for admission in three patients only but was clinically diagnosed as part of the study in 39 patients, whereas the standard diagnosis of dehydration was ascertained in 20. Inter-rater agreement (kappa) was fair for the clinical criteria and clinical diagnosis, moderate to near perfect for the laboratory criteria, and substantial for the estimated probability of dehydration. When matched with the standard diagnosis, the final clinical diagnosis of dehydration had 70% sensitivity and 69% specificity, with a 90% negative predictive value. Individually, both clinical and laboratory criteria had good specificity (65-90%), but poor sensitivity (< 55%). CONCLUSIONS: Compared with the standard diagnosis, dehydration was overdiagnosed by systematic clinical assessment upon admission in this frail population. However, clinicians performed better at excluding dehydration. Clinical acumen seems better than any individual clinical symptom or sign.

COMPARISON OF RESPONSE OF PASSIVE DOSIMETRY SYSTEMS IN SCANNING PROTON RADIOTHERAPY-A STUDY USING PAEDIATRIC ANTHROPOMORPHIC PHANTOMS.

Proton beam therapy has advantages in comparison to conventional photon radiotherapy due to the physical properties of proton beams (e.g. sharp distal fall off, adjustable range and modulation). In proton therapy, there is the possibility of sparing healthy tissue close to the target volume. This is especially important when tumours are located next to critical organs and while treating cancer in paediatric patients. On the other hand, the interactions of protons with matter result in the production of secondary radiation, mostly neutrons and gamma radiation, which deposit their energy at a distance from the target. The aim of this study was to compare the response of different passive dosimetry systems in mixed radiation field induced by proton pencil beam inside anthropomorphic phantoms representing 5 and 10 years old children. Doses were measured in different organs with thermoluminescent (MTS-7, MTS-6 and MCP-N), radiophotoluminescent (GD-352 M and GD-302M), bubble and poly-allyl-diglycol carbonate (PADC) track detectors. Results show that RPL detectors are the less sensitive for neutrons than LiF TLDs and can be applied for in-phantom dosimetry of gamma component. Neutron doses determined using track detectors, bubble detectors and pairs of MTS-7/MTS-6 are consistent within the uncertainty range. This is the first study dealing with measurements on child anthropomorphic phantoms irradiated by a pencil scanning beam technique.

SECONDARY NEUTRON DOSES IN A PROTON THERAPY CENTRE.

The formation of secondary high-energy neutrons in proton therapy can be a concern for radiation protection of staff. In this joint intercomparative study (CERN, SCK•CEN and IBA/IRISIB/ULB), secondary neutron doses were assessed with different detectors in several positions in the Proton Therapy Centre, Essen (Germany). The ambient dose equivalent H(*)(10) was assessed with Berthold LB 6411, WENDI-2, tissue-equivalent proportional counter (TEPC) and Bonner spheres (BS). The personal dose equivalent Hp(10) was measured with two types of active detectors and with bubble detectors. Using spectral and basic angular information, the reference Hp(10) was estimated. Results concerning staff exposure show H(*)(10) doses between 0.5 and 1 nSv/monitoring unit in a technical room. The LB 6411 showed an underestimation of H(*)(10), while WENDI-2 and TEPC showed good agreement with the BS data. A large overestimation for Hp(10) was observed for the active personal dosemeters, while the bubble detectors showed only a slight overestimation.

Functional status and medium-term prognosis of very elderly patients after an ICU stay: a prospective observational study.

BACKGROUND: Because the proportion of elderly patients admitted to the intensive care unit (ICU) is increasing, the objective of this study was to test the hypothesis that very elderly patients with better preadmission functional status would have better medium-term survival and functional status after an ICU stay. METHODS: In this observational study, 96 patients (68% surgical and 32% medical) aged ≥80 years and admitted to the ICU between May 2008 and June 2009 were recruited. Functional status was assessed using a modified Katz Scale and the Lawton Scale. Primary outcomes were: one-year mortality and its independent predictive factors, one-year functional status and perceived quality of life. RESULTS: Multivariate analysis showed that type of admission (surgical vs. medical), existence of cancer, Sequential Organ Failure Assessment (SOFA) Score at ICU admission and occurrence of septic complications during the ICU stay were independent predictive factors for one-year mortality, but preadmission functional status was not. At one year, despite functional decline in 50% of survivors, 68% perceived their health status to be equivalent to or better than before and 82.6% would agree to a further ICU stay. CONCLUSION: One-year mortality of very elderly patients after an ICU stay is not related to preadmission functional status but to the type of admission, existence of cancer, SOFA Score at ICU admission and occurrence of septic complications during the ICU stay. Despite functional decline in half of these patients, one year after admission 82.6% would agree to another ICU stay.

[Screening for frailty: a benefit for both patients and physicians]. / Dépister la fragilité: un bénéfice pour le patient et pour le soignant.

Preventing the increasing number of depending persons is a novel priority in European Union health policy. One of the means to succeed relies on identifying, among elderly persons, those at risk of dependency, also named "the frail elderly". Screening for frailty is also useful to better assess the physiological reserves of the elderly before any therapeutic decision, as early as the first consultation. Researchers currently work on developing a new simple tool allowing a distinction between frail and robust persons. Since frailty is partly reversible, the global geriatric evaluation, in a one-day clinic, will lead to a personalized program to prevent or reverse frailty by a multidisciplinary approach.

In vivo molecular imaging of apoptosis and necrosis in atherosclerotic plaques using microSPECT-CT and microPET-CT imaging.

PURPOSE: The purpose of this paper is to study molecular imaging of apoptosis and necrosis, two key players in atherosclerosis instability, using a multimodal imaging approach combining single photon emission computed tomography (SPECT), positron emission tomography (PET), and computed tomography (CT). PROCEDURES: Collar-induced carotid atherosclerosis ApoE knockout mice were imaged with (99m)Tc-AnxAF568 SPECT-CT to study apoptosis and sequentially with PET-CT following (124)I-Hypericin ((124)I-Hyp) injection to visualize necrosis. RESULTS: SPECT depicted increased (99m)Tc-AnxAF568 uptake in both atherosclerotic carotid arteries, whereas our data suggest that this uptake is not merely apoptosis related. Although PET of (124)I-Hyp was hampered by the slow blood clearance in atherosclerotic mice, (124)I-Hyp was able to target necrosis in the atherosclerotic plaque. CONCLUSION: Both (99m)Tc-AnxAF568 and (124)I-Hyp uptake are increased in atherosclerotic carotid vasculature compared to control arteries. While apoptosis imaging remains challenging, necrosis imaging can be feasible after improving the biodistribution characteristics of the probe.

In vitro and in vivo comparison of 18F and 123I-labeled ML10 with 68Ga-Cys2-AnxA5 for molecular imaging of apoptosis.

AIM: Recently, 18F-labeled 2-(5-fluoropentyl)-2-methylmalonic acid or ML10 has been proposed as a promising PET tracer for imaging of apoptosis. In this study we compared 18F-ML10, the 123I labeled 5-iodo derivative (123I-ML10) and a 68Ga-labeled Annexin A5 (AnxA5) and evaluated them as apoptosis tracers in several distinct models. METHODS: In vivo stability and biodistribution were studied in healthy mice. Apoptosis imaging was evaluated in anti-Fas treated mice and mice with muscular apoptosis. Furthermore, 18F-ML10 and 68Ga-Cys2-AnxA5 were evaluated in a rat model with reperfused liver infarct and a rat model with cerebral infarct as well as in Daudi tumor bearing mice, before and after treatment with cyclophosphamide and/or radiotherapy. RESULTS: 18F-ML10 and 68Ga-Cys2-AnxA5 were both stable, while 123I-ML10 metabolized very quickly in vivo. All tracers showed a 3-4 times higher uptake in apoptotic muscular tissue in comparison to that in healthy muscular tissue. Animals with anti-Fas induced hepatic apoptosis showed an increased liver uptake which was most pronounced for 18F-ML10. The uptake of both 18F-ML10 and 68Ga-Cys2-AnxA5 increased in the apoptotic region surrounding the cerebral infarction and the reperfused liver infarction. Tumor uptake of 68Ga-Cys2-AnxA5, but not of 18F-ML10, was statistically significantly higher after therapy as measured with PET/MRI. CONCLUSION: All radiotracers were able to detect apoptosis in vitro and in vivo in each of the studied animal models of apoptosis. 68Ga-Cys2-AnxA5, but not 18F-ML10, allowed to visualize the effect of tumor therapy in a statistically significant way.

Predicting functional adverse outcomes in hospitalized older patients: a systematic review of screening tools.

BACKGROUND: Functional decline frequently occurs following hospitalisation in older people and may be prevented or minimized by specific management. Such care processes needs appropriate early screening of older hospitalized patients. OBJECTIVE: To identify instruments able to detect on admission older hospitalized patients at risk of functional decline at and after discharge. METHODS: Functional decline is defined as loss of independence in activities of daily living (functional decline) or admission in nursing home. The systematic search used Medline 1970-2007, Web of Science 1981-2007 and references list of relevant papers. An independent epidemiologist assessed methodological quality of the retained articles. RESULTS: We found 12 studies developing predictive tools, including 7145 patients. Functional outcomes were assessed at or after discharge. Preadmission functional status, cognition, and social support were major components for prediction of functional evolution. Few instruments are fully validated and data concerning reliability are often lacking. Operational characteristics are moderate (sensitivity 29-87%, negative likelihood ratio 0.2-0.8). CONCLUSIONS: Instruments predicting functional adverse outcomes are difficult to compare due to heterogeneity of functional outcomes and hospital settings. The reason why so many tools have been developed is probably because none gives full satisfaction: their general predictive validity and performances are insufficient. Further research is needed to improve the screening of frail older patients admitted to hospital with standardized and validated tools.

Risk factors predicting later functional decline in older hospitalized patients.

With the demographic and epidemiological changes, an increasing number of older subjects are admitted to hospital. These patients are at increased risk of adverse health outcomes, including functional decline, increased length of stay, institutionalization, geriatric syndromes (e.g. delirium), hospital readmissions and death. Age, basic demographic data, diagnosis and comorbidities are not sufficient to estimate the risk of a further negative evolution of the frail older patient during and after hospitalization. As functional decline begins soon after admission, it is important to screen vulnerable patients early in order to plan appropriate orientation to geriatric programmes and to target interventions.This narrative review analyses which appropriate parameters, available soon after admission, may help to identify the older patients at risk of functional decline and to stratify their risk. Functional decline was defined here as loss of independence in basic care or admission in nursing home. The main risk factors identified by this analysis are functional status before or at admission, cognitive performance and social characteristics.These data may be easily and quickly collected by the nursing staff on admission, and further assessed by the geriatric liaison team, in order to optimize care management in frail older patients.

Laparoscopic treatment of a gastric outlet obstruction caused by a gallstone (Bouveret's syndrome).

Duodenal impaction of a gallstone after its migration through a cholecystoduodenal fistula is an uncommon cause of gallstone ileus described as Bouveret's syndrome. Surgical treatment is recommended, but the morbidity and mortality rates are nearly 60% and 30%, respectively. To reduce these rates using improved endoluminal surgery, a laparoscopically assisted intraluminal gastric surgery could be considered. A 74 year-old woman was admitted with typical Bouveret's syndrome. An intraluminal gastric laparoscopy was performed. The large stone impacted in the first duodenum was removed through the pylorus and pulled into the stomach. After its mechanical fragmentation, the stone was extracted with a sterile retriever bag through the main trocar. In the case of Bouveret's syndrome, treatment of the duodenal obstruction is mandatory. Surgical treatment of the cholecystoduodenal fistula still is controversial. We never perform a one-stage procedure, and we reserve a biliary operation for the patient who remains symptomatic. In this way, laparoscopically assisted intraluminal gastric surgery with transpyloric extraction of the stone can be a safe and interesting approach for this type of pathology.