One-session laparoscopic management of Mirizzi syndrome: feasible and safe in specialist units

Clinical Outcomes and Treatment Strategy of Mirizzi's Syndrome Treated With Surgery

BACKGROUND

There is currently no standardized treatment for Mirizzi's syndrome (MS). We aim to explore the surgical treatment strategy for MS by analyzing its clinical characteristics and treatment outcomes.

METHODS

This retrospective study analyzed the clinical data of 130 patients with MS who underwent surgery at our hospital from April 2013 to April 2020.

RESULTS

The study population comprised 130 patients with MS, with an approximately balanced sex ratio and a median age of 58.5 years. The preoperative diagnostic rate was 82.3%. The diagnostic accuracy of ERCP was 92.5%, higher than that of MRCP and ultrasound. All patients underwent surgical treatment, with 74 cases of laparoscopic surgery, 43 cases of laparotomy, and 13 cases of laparoscopic surgery converted to laparotomy. A total of 23 patients experienced short-term and long-term complications after surgery, with a complication rate of 17.7%. There was no statistical difference between laparoscopic surgery and open surgery in terms of intraoperative hemorrhage, operative time, and postoperative complication rate. However, the length of hospital stay was shorter in the laparoscopic surgery compared to the open surgery, which was statistically different from each other.

CONCLUSION

ERCP is the gold standard for the diagnosis of MS, especially for identifying the type of MS. ERCP plays an important role in both the preoperative and postoperative phases of MS. Our study demonstrated that laparoscopic surgery was a safe and feasible option for MS treatment, even requires less hospitalization than open surgery.

Mirizzi syndrome: Problems and strategies

Mirizzi syndrome is a serious complication of gallstone disease. It is caused by the impacted stones in the gallbladder neck or cystic duct. One of the features of Mirizzi syndrome is severe inflammation or dense fibrosis at the Calot's triangle. In our clinical practice, bile duct, branches of right hepatic artery and right portal vein clinging to gallbladder infundibulum are often observed due to gallbladder infundibulum adhered to right hepatic hilum. The intraoperative damage of branches of right hepatic artery occurs more easily than that of bile duct, all of which are hidden pitfalls for surgeons. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferable tools for the diagnosis of Mirizzi syndrome. Anterograde cholecystectomy in Mirizzi syndrome is easy to damage branches of right hepatic artery and bile duct due to gallbladder infundibulum adhered to right hepatic hilum. Subtotal cholecystectomy is an easy, safe and definitive approach to Mirizzi syndrome. When combined with the application of ERCP, a laparoscopic management of Mirizzi syndrome by well-trained surgeons is feasible and safe. The objective of this review was to highlight its existing problems: (1) low preoperative diagnostic rate, (2) easy to damage bile duct and branches of right hepatic artery, and (3) high concomitant gallbladder carcinoma. Meanwhile, the review aimed to discuss the possible therapeutic strategies: (1) to enhance its preoperative recognition by imaging findings, and (2) to avoid potential pitfalls during surgery.

Mirizzi Syndrome-The Past, Present, and Future

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

The "Basket-in-Catheter" technique: facilitating transcystic bile duct exploration and optimising the management of suspected ductal stones

The 'Basket-in-Catheter' (BIC) technique facilitates basket-only laparoscopic transcystic exploration (LTCE), increasing its success rate. Using the cholangiography catheter as a sheath is easier and safer than inserting the wire basket-alone. This study evaluates its benefits in confirmed and suspected ductal stones. Retrospective analysis of prospectively collected data on patients with pre-operative or operative suspicion of bile duct stones or with positive and equivocal intraoperative cholangiographies (IOC) who had LTCE attempted using blind basket trawling, without choledochoscopy, were reviewed. The incidence and outcomes of blind basket LTCEs attempted before and after introducing the BIC technique, whether or not stones were retrieved, were analysed. Blind basket LTCE was attempted in 732 patients. Of 377 (51.5%) patients undergoing successful stone retrieval, only 62% had pre-operative clinical and radiological risk factors for ductal stones, 25% had operative risk factors and 13% had silent stones discovered on IOC. Another 355 patients (48.5%) had negative trawling, although one half had pre-operative risk factors for ductal stones and 47.6% had operative risk factors, e.g. cystic duct stones or dilatation. This cohort had equivocal cholangiography in 25.9%. Following basket trawling, repeat IOC confirmed resolution of abnormalities. As no stones were retrieved, these were not considered duct explorations. The BIC technique facilitates safe and speedy bile duct clearance when stones are confirmed, avoiding choledochotomies, without significant complications. BIC duct trawling is also beneficial in patients with suspected ductal stones, helping to resolve equivocal IOCs. It helps surgeons to acquire and consolidate ductal exploration skills.

Laparoscopic treatment of Mirizzi syndrome with subtotal cholecystectomy and electrohydraulic lithotripsy: A case report

Mirizzi syndrome is a rare chronic cholecystitis complication. However, the current consensus on managing this condition remains controversial, especially through laparoscopic surgery. This report describes the feasibility of treating type I Mirizzi syndrome with laparoscopic subtotal cholecystectomy and electrohydraulic lithotripsic gallstone removal. A 53-year-old woman presented with dark urine and right upper quadrant pain for 1 month. On examination, she was jaundiced. Blood tests showed highly elevated liver and biliary enzyme levels. Abdominal ultrasound showed a slightly dilated common bile duct with suspicion of choledocholithiasis. However, endoscopic retrograde cholangiopancreatography showed a narrowed common bile duct extrinsically compressed by a gallstone in the cystic duct, establishing a Mirizzi syndrome diagnosis. Elective laparoscopic cholecystectomy was planned. At operation, the trans-infundibulum approach was used since dissection around the cystic duct was difficult due to severe local inflammation of Calot's triangle. The gallbladder's neck was opened, and the stone was removed by lithotripsy via a flexible choledochoscope. Common bile duct exploration through the cystic duct was normal. The fundus and body of the gallbladder were resected, followed by T-tube drainage and suturing of the gallbladder's neck. The patient's postoperative clinical course was uneventful. Treating Mirizzi syndrome remains a major challenge for hepatobiliary specialists even with open surgery due to high complication rates, including bile duct injuries. Treatment is primarily to clear out the responsible stone and necrotic tissue. Due to advances in endoscopic surgery and equipment, subtotal cholecystectomy with laparoscopic gallstone extraction provides a safe and effective option for patients with Mirizzi syndrome. Laparoscopic subtotal cholecystectomy with electrohydraulic lithotripsy is a feasible and useful approach for treating Mirizzi syndrome that avoids iatrogenic bile duct injury.

Achieving Critical View of Safety via a New Technique: The Triple One (111) Technique

BACKGROUND

Misidentification of anatomical structures is one of the most common causes of bile duct injury following laparoscopic cholecystectomy. Achieving Critical View of Safety (CVS) is a standard step in conducting safe cholecystectomy all over the world. In our institute, we achieve CVS via a unique technique called Triple One or 111 and find it very helpful and easy to achieve CVS. Moreover, the rate of conversion has also decreased while achieving CVS via this technique. The unique aspect of the Triple One technique is that by following this method, even new laparoscopic surgeons can achieve CVS very easily in difficult cases and, hence, it decreases the chances of vasculobiliary injury (VBI).

OBJECTIVE

This study aimed to determine how effective the Triple One technique is in achieving CVS as well as in lessening the chances of VBI.

MATERIAL AND METHODS

A total of 545 patients were admitted through the outpatient department, ranging in age from 30 to 70 years, with a mean of 50 years. The study comprised patients with American Society of Anaesthesiologists (ASA) I & II, acute and chronic cholecystitis, and symptomatic cholelithiasis. The study excluded patients with co-morbidities, prior abdominal procedures, and suspected complications. On the second postoperative day, all patients received their discharge papers and on the seventh postoperative day, follow-up was completed.

RESULTS

Successful gallbladder extraction using the Triple One technique was achieved in 540 (99%) cases. The other five (1%) cases converted to open cholecystectomy because of the difficult gallbladder anatomy and extensive scarring. No VBI or bile duct injury was noted. No mortality was recorded during the study period.

CONCLUSION

By incorporating CVS using the Triple One technique into our policies and curriculum, we may encourage safe cholecystectomy practices and prevent bile duct injuries.

Utilization of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Maneuver for Transcystic Intrahepatic Access

OBJECTIVE

This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy.

SUMMARY OF BACKGROUND DATA

Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particularly with the increasing role of transcystic exploration.

METHODS

The indications, techniques, and operative and postoperative data on choledochoscopy collected prospectively during transcystic and choledo- chotomy explorations were analyzed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochoscopes.

RESULTS

Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during 1320 bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilized more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts, and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. Twenty retained stones (2.1%) were encountered but no choledochoscopy related complications.

CONCLUSIONS

Choledochoscopy should always be performed during a chol- edochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilized in over 50% of explorations, increasing their rate of success. When attempted, the transcystic WBM achieves intrahepatic access in 70%-80%. It should be part of the training curriculum.

Single-incision versus four-incision laparoscopic transfistulous bile duct exploration for Mirizzi syndrome type II

BACKGROUND

We developed laparoscopic transfistulous bile duct exploration (LTBDE) for Mirizzi syndrome (MS) McSherry type II in September 2011. Then, single-incision LTBDE (SILTBDE) was adopted as a preferred technique since August 2013. This retrospective study aims to analyze the outcome of LTBDE in 7.7 years and to compare SILTBDE with four-incision LTBDE (4ILTBDE).

METHODS

Seventeen consecutive patients underwent LTBDE for MS McSherry type II from September 2011 to May 2019. Transfistulous removal of the impacted stone(s), choledochoscopic bile duct exploration, and primary closure of the gallbladder remnant were performed without biliary drainage.

RESULTS

The sex ratio is 12:5 (male: female) with an average age of 39.4 ± 10.3 (24-56) years. Ten patients (58.8%) had their diagnoses of MS established by preoperative imaging. According to the Csendes classification, three type II (17.6%), nine type III (52.9%), and five type IV (29.4%) were identified. The operative time was 264.8 ± 60.3 min (156-358 min). The stone clearance rate was 100%. The postoperative hospital stay was 4.7 ± 1.9 (2-10) days. No procedure was converted to an open operation. Two postoperative transient hyperamylasemia (11.8%) and one superficial wound infection (5.9%) occurred and all recovered well under conservative treatment (Clavien-Dindo grade I). During an average 2.2-year follow-up period, no biliary stricture or stone recurrence occurred. No significant difference exists between the SILTBDE and 4ILTBDE groups. Nevertheless, an insignificant trend of shorter postoperative hospital stay was observed in the former. A diagnosis of MS Csendes type IV implicates prolonged total and postoperative hospital stays (p < 0.01).

CONCLUSIONS

LTBDE is safe and efficacious for MS McSherry type II. It provides a simple solution for various types of MS and avoids undesirable complications following bilioenteric anastomosis. SILTBDE is comparable to 4ILTBDE for selected patients. Patients with MS Csendes type IV need more time to recover after surgery.

Type IV Mirizzi Syndrome: Brief Report and Review of Management Options

Mirizzi syndrome is a rare complication of chronic calculous cholecystitis. Preoperative diagnosis is challenging due to the absence of pathognomonic signs and symptoms and low sensitivity rates of imaging tests. Historically, laparotomy has been the preferred choice of surgical management. Endoscopic and laparoscopic approaches have been increasingly described as diagnostic and therapeutic options for Mirizzi type I and II, but data is limited regarding the management of more complex cases. We describe a staged endoscopic and laparoscopic approach for the management of type IV Mirizzi syndrome and review the management options.

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure

BACKGROUND

Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies.

AIMS AND METHODS

A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely.

RESULTS

The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions.

CONCLUSION

All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.

The Current Approach to the Diagnosis and Classification of Mirizzi Syndrome

Mirizzi syndrome occurs in up to 6% of patients with cholecystolithiasis. It is generally caused by external compression of the common hepatic duct by a gallstone impacted in the neck of the gallbladder or the cystic duct, which can lead to fistulisation. The aim of this review was to highlight the proposed classifications for Mirizzi syndrome (MS) and to provide an update on modern approaches to the diagnosis of this disease. We conducted research on various internet databases and the total number of records was 993, but after a gradual process of elimination our final review consisted of 21 articles. According to the literature, the Cesendes classification is the most commonly used, but many new suggestions have appeared. Our review shows that the ultrasonography (US) is the most frequently used method of initial diagnosis, despite still having only average sensitivity. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are good methods and are similarly effective, but only the latter can be simultaneously therapeutic. Some modern methods show very high sensitivity, but are not so commonly administered. Mirizzi syndrome is still a diagnostic challenge, despite the advancement of the available tools. Preoperative diagnosis is crucial to avoid complications during treatment. New research may bring a unification of classifications and diagnostic algorithms.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

Background

Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.

Methods

A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.

Results

Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.

Conclusion

This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.

Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates

Background

Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time.

Methods

Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature.

Results

28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%.

Conclusion

Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model

Aims

The rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning.

Methods

A prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data.

Results

Over five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%.

Conclusion

Index admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.