Diagnosing and Treating a Patient with Mirizzi’s Syndrome using Cholangioscopy with EHL and SpyGlass™ Retrieval Basket

 

Patient History

A 51-year-old female underwent a laparoscopic cholecystectomy for symptomatic cholelithiasis. Her postoperative course was complicated by intermittent upper abdominal symptoms for a few months, with a severe attack four months later that prompted admission and further workup. The patient was found to have obstructive jaundice and elevated LFTs (total bilirubin 2.6, direct bilirubin 1.6, alkaline phosphate 584, ALT 427 and AST 110). Furthermore, an MRCP suggested a large ovoid filling-defect in the distal CBD (Figures 1 and 2). Gastroenterology consult was placed for further management.  

 

Procedure

An ERCP was performed with the use of a Dreamtome™ RX Cannulating Sphincterotome and guidewire cannulation. The cholangiogram revealed a dilated duct, and a definitive large ovoid filling-defect in the distal CBD. Prior cholecystectomy clips were intact with no signs of extravasation to suggest any leak. A large biliary sphincterotomy was performed with copious bile flow. Then, a SpyScope™ DS Catheter was exchanged and advanced into the biliary tree to the bifurcation of the hepatics. Surprisingly, the distal CBD actually showed a mass effect, with marked irregular, hypervascular and inflammatory mucosa. Direct biopsies were taken using SpyBite™ Biopsy Forceps (Figure 3). The SpyScope DS Catheter was then slowly withdrawn, and a brief glimpse into the low take-off cystic duct stump showed a filling defect. We then angulated up the stump. Therein, a 3cm stone was visualized, fully-impacted and causing extrinsic compression of the CBD (Figure 4). An EHL probe was then advanced through the SpyScope DS Catheter, and 1,800 shots were administered to the stone with subsequent breakdown into numerous, smaller fragments (Figure 5). A SpyGlass Retrieval Basket was used to extract the majority of the stones into the duodenum (Figure 6). A number of stones refluxed back into the CBD as irrigation was performed throughout the procedure. We then exchanged a 9-12 balloon catheter and swept out the residual stones. The final occlusion cholangiogram revealed no further filling-defects.  

 

Outcome

A follow-up view of the biliary tree showed immediate decompression of the CBD and the overall impression was that of Mirizzi’s Syndrome caused by a massive cystic-duct stump stone. Follow-up pathology on the biopsies confirmed inflammatory changes and no signs of malignancy. The patient’s LFTs normalized and she returned to her baseline health thereafter.