A Novel Endoscopic Retrograde Cholangiopancreatography Technique for Type IV Mirizzi Syndrome: Avoiding Cholangiojejunostomy

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A Novel Endoscopic Retrograde Cholangiopancreatography Technique for Type IV Mirizzi Syndrome: Avoiding Cholangiojejunostomy

Introduction

Mirizzi syndrome (MS) is a rare form of cholelithiasis, affecting only 0.1% of all gallstone cases. It presents a diagnostic challenge as its symptoms and imaging features can mimic those of choledocholithiasis and biliary tumors. Traditionally, surgical intervention, including cholecystectomy, common bile duct exploration with T-tube drainage, and cholangiojejunostomy, has been the mainstay of treatment. However, recent years have seen the emergence of endoscopic therapies for MS, though they are technically demanding and often impractical when stones are lodged in the Hartmann pouch. This article presents a case where endoscopic modalities were used to downstage type IV MS, avoiding the need for cholangiojejunostomy.

Case Presentation

A 72-year-old male patient was diagnosed with cholecystolithiasis and obstructive jaundice. His clinical biochemistry results showed elevated levels of total bilirubin (TBIL, 139.6 mmol/L), direct bilirubin (DBIL, 81.0 mmol/L), aspartate aminotransferase (AST, 586 U/L), and alanine aminotransferase (ALT, 765 U/L). Magnetic resonance cholangiopancreatography (MRCP) indicated type IV MS. Given his advanced age and the potential challenges of choledochol-enteric anastomosis, endoscopic retrograde cholangiopancreatography (ERCP) was chosen to relieve biliary obstruction.

ERCP Findings

Cholangiography revealed a filling defect of 20 mm × 12 mm at the upper common bile duct. The intrahepatic bile duct was devoid of contrast agent, while the gallbladder was filled, consistent with the diagnosis of MS. The stone was stuck, making extraction impossible.

Endoscopic Intervention

The SpyGlass-DS system (Boston Scientific Corp., Natick, MA, USA) was employed to crush the portion of the stone in the common bile duct using lithotripsy. Stone fragments were then extracted under direct view. The section of the stone in the cystic duct could not be removed, and the decision was made not to crush the remnant. Balloon-occluded cholangiography showed that the intrahepatic bile duct was filled with contrast agent, and the previous filling defect in the common bile duct had disappeared. A plastic biliary stent was placed, and the patient’s symptoms were completely alleviated.

Post-ERCP Recovery

Three days after ERCP, the patient’s biochemistry results improved: TBIL (53.8 mmol/L), DBIL (26.6 mmol/L), AST (63 U/L), and ALT (231 U/L). Four weeks later, laparoscopic cholecystectomy and common bile duct exploration were performed, with a T-shaped drainage tube placed.

Discussion

Type IV MS, characterized by significant bile duct impairment, typically requires cholangiojejunostomy. In this case, ERCP combined with SpyGlass-DS was used to extract the common bile duct stone via laser lithotripsy, restoring duct patency. This downstaged type IV MS to type II. The biliary mucosa self-repaired after stone removal, obviating the need for cholangiojejunostomy and preserving biliary tract integrity. This approach represents an innovative combination of laparoscopic and endoscopic therapies for type IV MS. Long-term complications such as biliary stricture or stone recurrence remain to be observed.

Conclusion

This case highlights the potential of a novel ERCP technique in downstaging type IV MS and avoiding cholangiojejunostomy. Further research is needed to evaluate the long-term outcomes of this approach.

Authors and Affiliations:

  • Tian-Ya Li, Zi-Xian Chen, Yu-Dong Wang, Ying Liu, Jin-Duo Zhang, Ping Yue, Wen-Bo Meng: The First Clinical Medical School of Lanzhou University, Lanzhou, Gansu 730000, China; Department of Radiology, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, China; Foreign Languages Department of Lanzhou University, Lanzhou, Gansu 730000, China; Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, China.

Correspondence:

  • Dr. Wen-Bo Meng: E-Mail: mengwb@lzu.edu.cn
  • Ping Yue: E-Mail: dryueping@sina.com

Funding:

  • This study was supported by the grant from Bethune Charitable Foundation (No. HZB-20181119-34).

References:

  1. Clemente G, Tringali A, De Rose AM, Panettieri E, Murazio M, Nuzzo G, et al. Mirizzi syndrome: diagnosis and management of a challenging biliary disease. Can J Gastroenterol Hepatol 2018;2018:6962090. doi: 10.1155/2018/6962090.
  2. Reverdito R, Moricz AD, Campos TD, Pacheco AM, Silva RA. Mirizzi syndrome grades III and IV: surgical treatment. Rev Col Bras Cir 2016;43:243–247. doi: 10.1590/0100-69912016004005.
  3. England RE, Martin DF. Endoscopic management of Mirizzi’s syndrome. Gut 1997;40:272–276. doi: 10.1136/gut.40.2.272.

How to Cite: Li TY, Chen ZX, Wang YD, Liu Y, Zhang JD, Yue P, Meng WB. A novel endoscopic retrograde cholangiopancreatography technique to reduce stone size in type IV Mirizzi syndrome: avoiding cholangiojejunostomy. Chin Med J 2021;134:1004–1005. doi: 10.1097/CM9.0000000000001370

DOI: doi.org/10.1097/CM9.0000000000001370

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