CHOLECYSTO-CHOLEDOCHAL FISTULA RESOLVED BY LAPAROSCOPIC BILE DUCT EXPLORATION + CHOLEDOCOPLASTY IN A PATIENT WITH MIRIZZI SYNDROME TYPE IV
EAES Academy. Vargas Ávila A. 07/05/22; 363043; P087
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Abstract
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Aim:
Mirizzi Syndrome (MZ) is an uncommon complication of chronic gallstone disease characterized for an extrinsic compression of the bile duct due to indirect pressure applied upon it by an impacted stone in gallbladder, detected from 0.06% to 5.7% of patients during cholecystectomy, and 1.07% undergoing endoscopic retrograde cholangiopancreatography (ERCP). The aim of the study was to show the management of the MZ type IV using a bile duct exploration + choledocoplasty in a patient with cholecysto-choledochal fistula.
Methods:
A healthy 46 years old woman with a history of 2 caesarean arrived to the Emergency Department of our hospital reporting 48-hours of severe abdominal pain irradiated from the epigastrium to the right upper quadrant. The pain was getting worse, with fever and jaundice, unrelieved by analgesics. Laboratories, ultrasound, and magnetic resonance cholangiopancreatography were performed with a result of an acute cholangitis secondary to choledocholithiasis. Thus, an ERCP and cholangioscopy were done giving the evidence of cholecysto-choledochal fistula that cannot be resolved by an ERCP. Therefore, a surgery was practiced.
Results:
The relevant findings were adhesions among duodenum, gallbladder, and omentum. The gallbladder dissection plane was not found. In contrast, the bile duct was identified, consequently, a choledocotomy and biliary duct exploration were attained. Three stones (three centimeters) were found and removed. A revision was carried out with a fogarty catheter without evidence of residues. A Kher probe was placed in the bile duct and a choledocoplasty was made. Finally, on the fifth day the patient was discharged from the hospital.
Conclusions:
The surgical management is the mainstay treatment for MZ. Although, the laparoscopic technique is associated with high conversion rates ranged from 11.1% to 80% and an increased incidence of bile duct injury, it possesses many advantages that included shorter hospital stay, reduced wasted of resources, and avoiding bilioenteric bypass reducing morbidity and mortality. Despite experts recommend laparoscopic approach to manage only MZ type I, there are evidences of a successful laparoscopic resolution in other types of MZ using optimal techniques performed by the expertise of specialized surgeons, as well as in the case described here.
Mirizzi Syndrome (MZ) is an uncommon complication of chronic gallstone disease characterized for an extrinsic compression of the bile duct due to indirect pressure applied upon it by an impacted stone in gallbladder, detected from 0.06% to 5.7% of patients during cholecystectomy, and 1.07% undergoing endoscopic retrograde cholangiopancreatography (ERCP). The aim of the study was to show the management of the MZ type IV using a bile duct exploration + choledocoplasty in a patient with cholecysto-choledochal fistula.
Methods:
A healthy 46 years old woman with a history of 2 caesarean arrived to the Emergency Department of our hospital reporting 48-hours of severe abdominal pain irradiated from the epigastrium to the right upper quadrant. The pain was getting worse, with fever and jaundice, unrelieved by analgesics. Laboratories, ultrasound, and magnetic resonance cholangiopancreatography were performed with a result of an acute cholangitis secondary to choledocholithiasis. Thus, an ERCP and cholangioscopy were done giving the evidence of cholecysto-choledochal fistula that cannot be resolved by an ERCP. Therefore, a surgery was practiced.
Results:
The relevant findings were adhesions among duodenum, gallbladder, and omentum. The gallbladder dissection plane was not found. In contrast, the bile duct was identified, consequently, a choledocotomy and biliary duct exploration were attained. Three stones (three centimeters) were found and removed. A revision was carried out with a fogarty catheter without evidence of residues. A Kher probe was placed in the bile duct and a choledocoplasty was made. Finally, on the fifth day the patient was discharged from the hospital.
Conclusions:
The surgical management is the mainstay treatment for MZ. Although, the laparoscopic technique is associated with high conversion rates ranged from 11.1% to 80% and an increased incidence of bile duct injury, it possesses many advantages that included shorter hospital stay, reduced wasted of resources, and avoiding bilioenteric bypass reducing morbidity and mortality. Despite experts recommend laparoscopic approach to manage only MZ type I, there are evidences of a successful laparoscopic resolution in other types of MZ using optimal techniques performed by the expertise of specialized surgeons, as well as in the case described here.
Aim:
Mirizzi Syndrome (MZ) is an uncommon complication of chronic gallstone disease characterized for an extrinsic compression of the bile duct due to indirect pressure applied upon it by an impacted stone in gallbladder, detected from 0.06% to 5.7% of patients during cholecystectomy, and 1.07% undergoing endoscopic retrograde cholangiopancreatography (ERCP). The aim of the study was to show the management of the MZ type IV using a bile duct exploration + choledocoplasty in a patient with cholecysto-choledochal fistula.
Methods:
A healthy 46 years old woman with a history of 2 caesarean arrived to the Emergency Department of our hospital reporting 48-hours of severe abdominal pain irradiated from the epigastrium to the right upper quadrant. The pain was getting worse, with fever and jaundice, unrelieved by analgesics. Laboratories, ultrasound, and magnetic resonance cholangiopancreatography were performed with a result of an acute cholangitis secondary to choledocholithiasis. Thus, an ERCP and cholangioscopy were done giving the evidence of cholecysto-choledochal fistula that cannot be resolved by an ERCP. Therefore, a surgery was practiced.
Results:
The relevant findings were adhesions among duodenum, gallbladder, and omentum. The gallbladder dissection plane was not found. In contrast, the bile duct was identified, consequently, a choledocotomy and biliary duct exploration were attained. Three stones (three centimeters) were found and removed. A revision was carried out with a fogarty catheter without evidence of residues. A Kher probe was placed in the bile duct and a choledocoplasty was made. Finally, on the fifth day the patient was discharged from the hospital.
Conclusions:
The surgical management is the mainstay treatment for MZ. Although, the laparoscopic technique is associated with high conversion rates ranged from 11.1% to 80% and an increased incidence of bile duct injury, it possesses many advantages that included shorter hospital stay, reduced wasted of resources, and avoiding bilioenteric bypass reducing morbidity and mortality. Despite experts recommend laparoscopic approach to manage only MZ type I, there are evidences of a successful laparoscopic resolution in other types of MZ using optimal techniques performed by the expertise of specialized surgeons, as well as in the case described here.
Mirizzi Syndrome (MZ) is an uncommon complication of chronic gallstone disease characterized for an extrinsic compression of the bile duct due to indirect pressure applied upon it by an impacted stone in gallbladder, detected from 0.06% to 5.7% of patients during cholecystectomy, and 1.07% undergoing endoscopic retrograde cholangiopancreatography (ERCP). The aim of the study was to show the management of the MZ type IV using a bile duct exploration + choledocoplasty in a patient with cholecysto-choledochal fistula.
Methods:
A healthy 46 years old woman with a history of 2 caesarean arrived to the Emergency Department of our hospital reporting 48-hours of severe abdominal pain irradiated from the epigastrium to the right upper quadrant. The pain was getting worse, with fever and jaundice, unrelieved by analgesics. Laboratories, ultrasound, and magnetic resonance cholangiopancreatography were performed with a result of an acute cholangitis secondary to choledocholithiasis. Thus, an ERCP and cholangioscopy were done giving the evidence of cholecysto-choledochal fistula that cannot be resolved by an ERCP. Therefore, a surgery was practiced.
Results:
The relevant findings were adhesions among duodenum, gallbladder, and omentum. The gallbladder dissection plane was not found. In contrast, the bile duct was identified, consequently, a choledocotomy and biliary duct exploration were attained. Three stones (three centimeters) were found and removed. A revision was carried out with a fogarty catheter without evidence of residues. A Kher probe was placed in the bile duct and a choledocoplasty was made. Finally, on the fifth day the patient was discharged from the hospital.
Conclusions:
The surgical management is the mainstay treatment for MZ. Although, the laparoscopic technique is associated with high conversion rates ranged from 11.1% to 80% and an increased incidence of bile duct injury, it possesses many advantages that included shorter hospital stay, reduced wasted of resources, and avoiding bilioenteric bypass reducing morbidity and mortality. Despite experts recommend laparoscopic approach to manage only MZ type I, there are evidences of a successful laparoscopic resolution in other types of MZ using optimal techniques performed by the expertise of specialized surgeons, as well as in the case described here.
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