TEMPORARY BILIARY METAL STENT PLACEMENT IN THE CYSTIC DUCT AS AN AID TO CHOLANGIOSCOPY-GUIDED LASER LITHOTRIPSY OF MIRIZZI SYNDROME (MS)

Introduction:

Cholangioscopy-guided lithotripsy is a minimally invasive alternative to surgical treatment of Mirizzi Syndrome (MS).

Procedure:

we present A 54 year-old man with type I MS. Endoscopic therapy was carried out in three sessions. At baseline ERCP, a 16-mm stone pressing on the CBD was noted and urgent decompression of the CBD was achieved with a 10F plastic stent. Two weeks later, elective single-operator cholangioscopy with successful Holmium laser lithotripsy (LL) fragmentation of the stone was performed. Larger stone fragments were individually removed under cholangioscopy using a tripod forceps. However, complete clearance using balloon catheters or Dormia baskets under fluoroscopy could not be achieved, because stone fragments became impacted into the narrow cystic duct. Eventually a 10 × 80 mm fully covered self-expandable metal stent (FC-SEMS) was placed into the cystic duct past stone fragments. A double pig-tail stent was placed through it in order to drain the gallbladder, and a standard plastic biliary stent was placed in the CBD. At follow-up 8-weeks later, the cystic duct stents were removed. Stone fragments could be cleared easily from the cystic duct, which had become enlarged by the FC-SEMS. The patient was scheduled for cholecystectomy.

Conclusion:

Cholangioscopic lithotripsy and cystic duct clearance is usually labor intensive and may require several treatment sessions. As an alternative to a repeat session of cholangioscopy-guided LL, FC-SEMS insertion into the cystic duct past the stone fragments was technically easy and proved eventually effective. According to this novel strategy, temporary expansion of the cystic duct using a FC-SEMS might be considered as an adjunct to LL in selected difficult cases of MS, similarly to what has been shown for CBD stones impacted above a biliary stricture.