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]).
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]).
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]).
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]).
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]).
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.
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