Endoscopy 2011; 43: E166-E167
DOI: 10.1055/s-0030-1256269
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Successful laser lithotripsy using peroral SpyGlass cholangioscopy in a patient with Mirizzi syndrome

H.  Issa1 , B.  Bseiso1 , A.  H.  Al-Salem2
  • 1Department of Internal Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
  • 2Department of Pediatric Surgery, Maternity and Children Hospital, Dammam, Saudi Arabia
Further Information

A. H. Al-SalemMD 

Department of Pediatric Surgery, Maternity and Children Hospital, Dammam

P.O. Box 61015
Qatif 31911
Saudi Arabia

Fax: +966-3-8630009

Email: ahsalsalem@hotmail.com

Publication History

Publication Date:
11 May 2011 (online)

Table of Contents

Mirrizi syndrome is a rare cause of obstructive jaundice. Open surgery is the usual treatment, but laparoscopy has also been advocated, and in order to avoid bile duct injuries, subtotal cholecystectomy and/or leaving a long cystic duct has gained popularity [1] [2] [3]. A retained cystic duct stone (CDS) is seen in 16 % of patients with postcholecystectomy syndrome; several modalities of treatment have been suggested but are more valuable for retained common bile duct stones (CBDS), because CBDS are accessible [4]. Retained CDSs, as in Mirrizi syndrome, are not easily accessible. This report describes the successful treatment of a difficult retained CDS in a patient with Mirrizi syndrome type 1, using a peroral SpyGlass (Boston Scientific, Massachusetts, USA) and intraductal laser lithotripter.

A 25-year-old woman with obstructive jaundice had endoscopic retrograde cholangiopancreatography (ERCP) which showed Mirrizi syndrome type 1 ([Fig. 1]).

Zoom Image

Fig. 1 Endoscopic retrograde cholangiopancreatography (ERCP) showing Mirizzi syndrome. Note the gallstones (thick arrow), the long and low inserted cystic duct (arrow with tail), and the stone impacted in the cystic duct (thin arrow).

She underwent laparoscopic cholecystectomy, but her jaundice was not relieved. A second ERCP revealed three CDSs. Attempts to extract the CDSs were unsuccessful ([Fig. 2]).

Zoom Image

Fig. 2 Post-laparoscopic-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) showing residual cystic duct stones. Note the clip on the cystic duct (thin arrow), the guide wire in the cystic duct (medium arrow), and the residual stone impacted in the cystic duct (thick arrow).

The patient underwent open resection of the remaining gallbladder, with stone extraction. Later, 1 month postoperatively, a repeat ERCP showed dilated common bile duct (CBD) and common hepatic duct, and a remaining CDS. Several attempts to extract the CDS were unsuccessful ([Fig. 3]).

Zoom Image

Fig. 3 Post-open-surgery endoscopic retrograde cholangiopancreatography (ERCP) showing residual cystic duct stone (arrow).

A 10-Fr, 10-cm stent was inserted, and an ERCP plus SpyGlass and laser lithotripsy was performed. This showed a large yellowish stone in the mid cystic duct ([Fig. 4]).

Zoom Image

Fig. 4 Endoscopic retrograde cholangiopancreatography (ERCP) using the SpyGlass and showing the residual stone in the cystic duct.

Using the Holmium laser CALCULASE device (Karl Storz, Tuttlingen, Germany), and the probe with frequency 6, energy 1.2 – 1.7 was used to fragment the stone. The fragments were extracted, and the cholangiogram confirmed that the CBD and cystic ducts were stone free ([Fig. 5]).

Zoom Image

Fig. 5 Endoscopic retrograde cholangiopancreatography (ERCP) showing complete clearance of the cystic duct and normal caliber of the bile ducts. Note the residual cystic duct remnant (arrow).

Retained CBDS are not rare, and ERCP, endoscopic sphincterotomy, and CBDS extraction is the treatment of choice. This, however, is not successful for stones greater than 2 cm in diameter. These stones require mechanical lithotripsy, sphincterotomy, and balloon dilation, electrohydraulic, or laser lithotripsy [4]. Failure to do mechanical lithotripsy will necessitate either electrohydraulic or laser lithotripsy, which requires direct visual control. In our patient, this was achieved using the single-operator peroral SpyGlass cholangiopancreatoscope and intraductal laser lithotripter. SpyGlass provides direct visualization of all bile ducts, which enables a single physician to diagnose and perform therapeutic intervention in one procedure [5]. To the best of our knowledge, this is the first case in which the SpyGlass and laser lithotripsy were successfully used to treat a difficult retained CDS in a patient with Mirrizi syndrome type I.

Endoscopy_UCTN_Code_TTT_1AR_2AH

Competing interests: None

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References

  • 1 Chan C Y, Liau K H, Ho C K, Chew S P. Mirizzi syndrome: a diagnostic and operative challenge.  Surgeon. 2003;  1 273-278
  • 2 Yeh C N, Jan Y Y, Chen M F. Laparoscopic treatment for Mirizzi syndrome.  Surg Endosc. 2003;  17 1573-1578
  • 3 McSherry C K, Ferstenberg H, Virshup M. The Mirizzi syndrome: suggested classification and surgical treatment.  Surg Gastroenterol. 1982;  1 219-225
  • 4 Blind P J, Lundmark M. Management of bile duct stones: lithotripsy by laser, electrohydraulic, and ultrasonic techniques. Report of a series and clinical review.  Eur J Surg. 1998;  16 403-409
  • 5 Chen Y K, Pleskow D K. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study.  Gastrointest Endosc. 2007;  65 832-841

A. H. Al-SalemMD 

Department of Pediatric Surgery, Maternity and Children Hospital, Dammam

P.O. Box 61015
Qatif 31911
Saudi Arabia

Fax: +966-3-8630009

Email: ahsalsalem@hotmail.com

#

References

  • 1 Chan C Y, Liau K H, Ho C K, Chew S P. Mirizzi syndrome: a diagnostic and operative challenge.  Surgeon. 2003;  1 273-278
  • 2 Yeh C N, Jan Y Y, Chen M F. Laparoscopic treatment for Mirizzi syndrome.  Surg Endosc. 2003;  17 1573-1578
  • 3 McSherry C K, Ferstenberg H, Virshup M. The Mirizzi syndrome: suggested classification and surgical treatment.  Surg Gastroenterol. 1982;  1 219-225
  • 4 Blind P J, Lundmark M. Management of bile duct stones: lithotripsy by laser, electrohydraulic, and ultrasonic techniques. Report of a series and clinical review.  Eur J Surg. 1998;  16 403-409
  • 5 Chen Y K, Pleskow D K. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study.  Gastrointest Endosc. 2007;  65 832-841

A. H. Al-SalemMD 

Department of Pediatric Surgery, Maternity and Children Hospital, Dammam

P.O. Box 61015
Qatif 31911
Saudi Arabia

Fax: +966-3-8630009

Email: ahsalsalem@hotmail.com

Zoom Image

Fig. 1 Endoscopic retrograde cholangiopancreatography (ERCP) showing Mirizzi syndrome. Note the gallstones (thick arrow), the long and low inserted cystic duct (arrow with tail), and the stone impacted in the cystic duct (thin arrow).

Zoom Image

Fig. 2 Post-laparoscopic-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) showing residual cystic duct stones. Note the clip on the cystic duct (thin arrow), the guide wire in the cystic duct (medium arrow), and the residual stone impacted in the cystic duct (thick arrow).

Zoom Image

Fig. 3 Post-open-surgery endoscopic retrograde cholangiopancreatography (ERCP) showing residual cystic duct stone (arrow).

Zoom Image

Fig. 4 Endoscopic retrograde cholangiopancreatography (ERCP) using the SpyGlass and showing the residual stone in the cystic duct.

Zoom Image

Fig. 5 Endoscopic retrograde cholangiopancreatography (ERCP) showing complete clearance of the cystic duct and normal caliber of the bile ducts. Note the residual cystic duct remnant (arrow).