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DOI: 10.1055/a-1594-1515
Endoscopic management of cystic duct stones and Mirizzi’s syndrome: experience at an academic medical center
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Abstract
Background and study aims Cystic duct stones (CDS) are challenging to treat with conventional ERCP techniques due to the small diameter and tortuous nature of the cystic duct. There have been limited studies focused on endoscopic management of CDS. We present our experience managing CDS endoscopically and demonstrate that new advances in endoscopic technology have rendered CDS easier to manage.
Patients and methods From 2013 to 2020, we prospectively maintained a database of patients undergoing endoscopic management of CDS. ERCP was performed in all patients, and if unsuccessful in removing stones, cholangioscopy with electrohydraulic lithotripsy (EHL) was utilized. All patients were followed in clinic for outcomes.
Results Of 5,123 ERCPs performed at our institution during the study period, 21 patients were diagnosed with CDS. Six patients were successfully treated with conventional ERCP alone. Cholangioscopy with EHL was used in 15 patients undergoing 18 procedures to achieve stone clearance. CDS clearance was achieved in all patients. There was one adverse event (post-ERCP pancreatitis). Spyglass DS was associated with a significant decrease in average procedure time in comparison to first-generation SpyGlass (89.3 vs. 54.4 minutes, P = 0.004). Thirteen patients (87 %) were discharged from the hospital within 24 hours. The median follow-up duration was 23.2 months.
Conclusions Endoscopy should be the preferred management strategy for CDS, especially in patients with prior cholecystectomy. Surgical outcomes have been associated with high patient morbidity and hospital length of stay. Our case series is the largest cohort of CDS patients successfully managed with cholangioscopy and EHL in the United States.
Publication History
Received: 30 March 2021
Accepted: 10 August 2021
Article published online:
14 January 2022
© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
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References
- 1 Turner MA, Fulcher AS. The cystic duct: normal anatomy and disease processes. Radiographics 2001; 21: 3-22 ; questionnaire 288–294
- 2 Grönroos JM. Mirizzi syndrome: consider endoscopic stone removal. ANZ J Surg 2007; 77: 716-717
- 3 Gomez D, Rahman SH, Toogood GJ. et al. Mirizzi's syndrome--results from a large western experience. HPB (Oxford) 2006; 8: 474-479
- 4 Tsuyuguchi T, Saisho H, Ishihara T. et al. Long-term follow-up after treatment of Mirizzi syndrome by peroral cholangioscopy. Gastrointest Endosc 2000; 52: 639-644
- 5 Jones JD, Pawa R. Single-operator peroral cholangioscopy for extraction of cystic duct stones in postcholecystectomy Mirizzi syndrome. Case Rep Gastrointest Med 2017; 2017: 1710501
- 6 Cao J, Ding X, Wu H. et al. Classification of the cystic duct patterns and endoscopic transpapillary cannulation of the gallbladder to prevent post-ERCP cholecystitis. BMC Gastroenterol 2019; 19: 1-7
- 7 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
- 8 Monga A, Ramchandani M, Reddy DN. Per-oral cholangioscopy. J Interv Gastroenterol 2011; 1: 70-77
- 9 Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 2007; 65: 832-841
- 10 Ishida Y, Itoi T, Okabe Y. Types of peroral cholangioscopy: how to choose the most suitable type of cholangioscopy. Curr Treat Options Gastroenterol 2016; 14: 210-219
- 11 Dimas ID, Vardas E, Papastergiou V. et al. Comparison of digital versus fiberoptic cholangioscopy in patients requiring evaluation of bile duct disease or treatment of biliary stones. Ann Gastroenterol 2019; 32: 199-204
- 12 Menon S, Lekharaju V, Wadsworth C. et al. Single Operator Cholangioscopy. Cholangioscopy. 2020: 29-44
- 13 Minami H, Mukai S, Sofuni A. et al. Clinical outcomes of digital cholangioscopy-guided procedures for the diagnosis of biliary strictures and treatment of difficult bile duct stones: a single-center large cohort study. J Clin Med 2021; 10 DOI: 10.3390/jcm10081638.
- 14 Marya NB, Martin JA, Sawas T. et al. ERCP-directed electrohydraulic lithotripsy for treatment of cystic duct and remnant gallbladder stones. VideoGIE 2020; 5: 300-303
- 15 Li J, Guo SJ, Zhang JC. et al. Novel peroral cholangioscopy-directed lithotripsy using an ultraslim upper endoscope for refractory Mirizzi syndrome: A case report. Medicine 2020; 99: e22649
- 16 Chon HK, Park C, Kim TH. Minimally invasive approach using digital single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy and endoscopic nasogallbladder drainage for the management of highgrade Mirizzi syndrome. Clin Endosc 2021; DOI: 10.5946/ce.2021.015.
- 17 Park C, Chon HK, Park DE. Endoscopic treatment including a single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy and endoscopic nasogallbladder drainage combined laparoscopic cholecystectomy for Mirizzi syndrome. Ann Hepatobiliary Pancreat Surg 2021; 25: S313
- 18 Issa H, Bseiso B, Al-Salem AH. Successful laser lithotripsy using peroral SpyGlass cholangioscopy in a patient with Mirizzi syndrome. Endoscopy 2011; 43: E166-E167
- 19 Tsuyuguchi T, Sakai Y, Sugiyama H. et al. Long-term follow-up after peroral cholangioscopy-directed lithotripsy in patients with difficult bile duct stones, including Mirizzi syndrome: an analysis of risk factors predicting stone recurrence. Surg Endosc 2011; 25: 2179-2185
- 20 Issa H, Bseiso B, Almousa F. et al. Successful treatment of Mirizzi's Syndrome Using SpyGlass guided laser lithotripsy. Gastroenterology Res 2012; 5: 162-166
- 21 Sepe PS, Berzin TM, Sanaka S. et al. Single-operator cholangioscopy for the extraction of cystic duct stones (with video). Gastrointest Endosc 2012; 75: 206-210
- 22 Bhandari S, Bathini R, Sharma A. et al. Usefulness of single-operator cholangioscopy-guided laser lithotripsy in patients with Mirizzi syndrome and cystic duct stones: experience at a tertiary care center. Gastrointest Endosc 2016; 84: 56-61
- 23 Forbes N, Ishikawa T, Mohamed R. High resolution cholangioscopic electrohydraulic lithotripsy for fragmentation and extraction of impacted cystic duct stones. Endoscopy 2016; 48: E88-E89
- 24 Salgado-Garza G, Hernandez-Arriaga P, Gonzalez-Urquijo M. et al. Single-operator cholangioscopy and electrohydraulic lithotripsy for the treatment of Mirizzi syndrome. Ann Med Surg (Lond) 2021; 62: 274-277
- 25 Shim CS, Moon JH, Cho YD. et al. The role of extracorporeal shock wave lithotripsy combined with endoscopic management of impacted cystic duct stones in patients with high surgical risk. Hepatogastroenterology 2005; 52: 1026-1029
- 26 Walsh R, Ponsky J, Dumot J. Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain. Surgi Endosc Other Intervent Techniq 2002; 16: 981-984
- 27 Palanivelu C, Rangarajan M, Jategaonkar PA. et al. Laparoscopic management of remnant cystic duct calculi: a retrospective study. Annals Royal College Surgeons England 2009; 91: 25-29
- 28 Kar A, Gulati S, Mohammed S. et al. Surgical management of cystic duct stump stone or gall bladder remnant stone. Indian J Surg 2018; 80: 284-287
- 29 Moon JH, Cha SW, Ryu CB. et al. Endoscopic treatment of retained bile-duct stones by using a balloon catheter for electrohydraulic lithotripsy without cholangioscopy. Gastrointest Endosc 2004; 60: 562-566