A Novel Endoscopic Retrograde Cholangiopancreatography Technique to Reduce Stone Size in Type IV Mirizzi Syndrome: Avoiding Cholangiojejunostomy
Mirizzi syndrome (MS) is a rare condition associated with gallstones, occurring in approximately 0.1% of all gallstone cases. It is characterized by obstruction of the common bile duct (CBD) due to an impacted gallstone in the cystic duct or Hartmann’s pouch, leading to inflammation and compression of the CBD. The syndrome is classified into four types based on the severity of bile duct involvement, with type IV being the most severe, often requiring complex surgical interventions such as cholangiojejunostomy. However, surgical procedures, particularly in elderly patients, carry significant risks and complications. This article presents a novel endoscopic approach to manage type IV MS, avoiding the need for cholangiojejunostomy while effectively alleviating biliary obstruction.
The case involves a 72-year-old male patient diagnosed with cholecystolithiasis and obstructive jaundice. Initial clinical biochemistry results revealed elevated levels of total bilirubin (TBIL) at 139.6 mmol/L (normal range: 3.4–17.1 mmol/L), direct bilirubin (DBIL) at 81.0 mmol/L (normal range: 0–6.8 mmol/L), aspartate aminotransferase (AST) at 586 U/L (normal range: 8–40 U/L), and alanine aminotransferase (ALT) at 765 U/L (normal range: 5–40 U/L). Magnetic resonance cholangiopancreatography (MRCP) confirmed the diagnosis of type IV MS, showing a gallstone impacted in the cystic duct and extending into the CBD.
Given the patient’s advanced age and the associated risks of major surgery, the medical team opted for an endoscopic approach. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to relieve the biliary obstruction. During the procedure, cholangiography revealed a filling defect measuring 20 mm by 12 mm in the upper CBD, with no contrast agent filling the intrahepatic bile ducts. However, the gallbladder was filled with contrast agent, consistent with the diagnosis of MS. The impacted stone could not be removed directly due to its size and location.
To address this challenge, the SpyGlass-DS system (Boston Scientific Corp., Natick, MA, USA) was employed. This advanced endoscopic tool allowed for direct visualization and lithotripsy of the stone. Under direct view, the portion of the stone located in the CBD was crushed using laser lithotripsy, and the resulting fragments were extracted. However, the section of the stone lodged in the cystic duct could not be removed, and the decision was made to leave it in place to avoid further complications. Post-lithotripsy, balloon-occluded cholangiography demonstrated that the intrahepatic bile ducts were now filled with contrast agent, and the previous filling defect in the CBD had disappeared.
Following the procedure, a plastic biliary stent was placed to ensure continued bile flow. The patient’s symptoms were completely alleviated, and follow-up biochemistry results three days post-ERCP showed significant improvement: TBIL decreased to 53.8 mmol/L, DBIL to 26.6 mmol/L, AST to 63 U/L, and ALT to 231 U/L. Four weeks later, the patient underwent laparoscopic cholecystectomy and CBD exploration, with a T-shaped drainage tube placed to facilitate postoperative recovery.
This case highlights the effectiveness of combining ERCP with the SpyGlass-DS system in managing type IV MS. By using laser lithotripsy to fragment the stone and restore bile duct patency, the procedure effectively downstaged the condition from type IV to type II MS. This approach avoided the need for cholangiojejunostomy, preserving the integrity of the biliary tract and reducing the surgical burden on the elderly patient. The biliary mucosa demonstrated self-repair capabilities after stone removal, further supporting the feasibility of this minimally invasive technique.
The success of this technique opens new possibilities for treating type IV MS using a combination of laparoscopic and endoscopic therapies. However, long-term outcomes, including the potential for biliary stricture or stone recurrence, remain to be observed. Continued follow-up and research are necessary to validate the durability and safety of this approach.
In conclusion, the novel endoscopic technique described in this case offers a promising alternative to traditional surgical interventions for type IV MS. By leveraging advanced endoscopic tools and lithotripsy, the procedure effectively reduces stone size and restores bile duct patency, minimizing the need for invasive surgeries. This approach is particularly beneficial for elderly patients or those at high surgical risk, providing a safer and less invasive treatment option.
doi.org/10.1097/CM9.0000000000001370
Was this helpful?
0 / 0