A SINGLE-CENTRE RETROSPECTIVE STUDY INTO DIAGNOSIS AND MANAGEMENT OF MIRIZZI SYNDROME USING SINGLE-OPERATOR PERORAL CHOLANGIOSCOPY

Aims Mirizzi Syndrome was first described in 1948 and refers to obstruction of the bile duct by impacted gallstones in the cystic duct or gallbladder. Management with conventional ERCP is difficult. We report our single centre experience using single operator cholangioscopy and electrohydraulic lithotripsy.

Methods All patients with a diagnosis Mirizzi syndrome and at least one failed stone clearance at conventional ERCP underwent Spyglass DS cholangioscopy at our centre from 2013-2019 and were included for analysis. From clinical records and the endoscopy reporting tool; patient demographics, previous procedures, stone visualisation, procedure success, complications and ongoing management were assessed.

Results Data on 34 patients who had Mirizzi syndrome diagnosed either pre or post ERCP was analysed (64% female, mean age 59.9 years (range 24-88)). In 20/34 cases Mirizzi syndrome was diagnosed on prior imaging. Of the other 14 cases; 5/34 were referred for cystic duct stones, 8/34 had suspected difficult CBD/CHD stones and 1 had a suspicious stricture. At cholangioscopy, stone(s) causing Mirizzi syndrome were visualised in 33/34 cases (97.1%). 30/33 (90.9%) of those who had stones visualised had successful stone clearance.

2/34 (5.9%) patients needed 3 procedures (all with cholangioscopy) and 4/34 (11.8%) needed 2 procedures (6 with cholangioscopy and 2 without). Patients had undergone a mean of 2 ERCPs (range 1-9) prior to referral. One patient had self-limiting sepsis but otherwise there were no early complications. Of patients (n=4) who did not achieve clearance, 2 were referred for definitive surgery and 2 were managed with recurrent stenting.

Conclusions The management of Mirizzi syndrome is challenging using conventional ERCP, patients may undergo multiple procedures. Visualisation of the obstructing stone using cholangioscopy provides a high probability of stone clearance using direct lithotripsy. It may reduce the need for additional interventions or complex surgery; so, should be considered early in the management of Mirizzi syndrome.