Combined Endoscopic and Laparoscopic Management of Postcholecystectomy Mirizzi Syndrome from a Remnant Cystic Duct Stone: Case Report and Review of the Literature

Abstract

Mirizzi syndrome has been defined in the literature as common bile duct obstruction resulting from calculi within Hartmann's pouch or cystic duct. We present a case of a 78-year-old female, who developed postcholecystectomy Mirizzi syndrome from a remnant cystic duct stone. Diagnosis of postcholecystectomy Mirizzi syndrome was made on endoscopic retrograde cholangiography (ERCP) performed postoperatively. The patient was treated with a novel strategy by combining advanced endoscopic and laparoscopic techniques in three stages as follows: Stage 1 (initial presentation): endoscopic sphincterotomy with common bile duct stent placement; Stage 2 (6 weeks after Stage 1): laparoscopic ultrasonography to locate the remnant cystic duct calculi followed by laparoscopic retrieval of the calculi and intracorporeal closure of cystic duct stump; Stage 3 (6 weeks after Stage 2): endoscopic removal of common bile duct stent along with performance of completion endoscopic retrograde cholangiogram. In addition, we have performed an extensive review of the various endoscopic and laparoscopic management techniques described in the literature for the treatment of postcholecystectomy syndrome occurring from retained cystic duct stones.

Late postcholecystectomy Mirizzi syndrome due to a sessile gall bladder remnant calculus managed by laparoscopic completion cholecystectomy: a feasible surgical option

“…Its overall incidence is 10%–40% with female preponderance (43% in women versus 28% in men) 2. It has been reported from 2 days to 32 years after cholecystectomy 3. The myriad symptoms and signs often hint toward the probable cause of PCS.…”

“…In one study involving 198 patients, the sensitivity of ultrasound for MS was as high as 77.8% 12. Though endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for MS, MRCP is a highly sensitive non-invasive diagnostic investigation with sensitivity approaching 100% and is preferred over ERCP 3. Heavily T2-weighted axial MR images can easily demonstrate the closely lying cystic duct and CHD which may sometimes be missed on MRCP 6.…”

“…For cystic duct stump calculus leading to PCMS, endoscopic management is feasible with options including sphincterotomy and balloon or basket use/holmium laser lithotripsy, electrohydraulic lithotripsy, mechanical extracorporeal shockwave lithotripsy for stone fragmentation or chemical dissolution followed by retrieval of stone fragments endoscopically 3 6. In remnant gall bladder after SC with calculus in the cystic duct, endoscopic manipulation of stone back into the gall bladder followed by LCC is also an option 6.…”

“…Biliary causes such as retained or recurrent biliary calculi with/out cholecystitis, biliary stricture, biliary dyskinesia and biliary leaks cause early or late PCS less frequently as compared with extrabiliary causes. Among all biliary causes of late PCS, postcholecystectomy Mirizzi syndrome (PCMS) is extremely rare 1–3. It is often misdiagnosed and difficult to manage.…”

“…PCMS can occur due to cystic duct stump calculus or gall bladder remnant calculus. The role of laparoscopy in its management is controversial 1–4. We present a case wherein, laparoscopic completion cholecystectomy (LCC) was performed for PCMS due to gall bladder remnant calculus, review the literature and summarise our algorithmic approach to the management of PCS.…”