1367 A Rare Feat: Successful ERCP Treatment of Mirrizi's Syndrome After Failed Surgery

Abstract

INTRODUCTION: Mirizzi's syndrome (MS) is a rare complication, occurring in around 1% of all cholecystectomies and affecting around 0.1% of all patients with gallstones (GS). MS occurs when an impacted GS in the neck of the gallbladder (GB) or cystic duct (CD) causes compression of the common bile duct (CBD) or common hepatic duct (CHD), resulting in obstruction and potential progression to a cholecystocholedochal fistula. MS is usually managed by surgery. We report a rare case of a critically ill patient who was successfully cleared of obstructing stones via ERCP after failed surgery, allowing the patient to undergo subsequent successful heart transplantation. CASE DESCRIPTION/METHODS: A 42-year-old male with a history of coronary artery disease and ischemic cardiomyopathy presented with cholangitis due to CBD obstruction. Despite successful ERCP duct clearance, he was deemed not to be a surgical candidate due to severe cardiac morbidities. Months later he represented with cholangitis and was found on ERCP to have a CBD/CHD obstruction due to a large stone, originating from the CD, which was filled with many large stones. He underwent an attempt of GB resection. However, safe GB resection was precluded due to profound adhesions, complete tissue plane loss, and extensive fibrosis. GB wall debridement and removal of multiple large gallstones was surgically attempted to alleviate the CBD/CHD obstruction. A follow-up ERCP for stent removal showed persistent MS, thereby precluding the patient from heart transplant listing due to persistent cholangitis risk. Three subsequent ERCPs with aggressive SpyScope exploration of the CBD/CHD and CD, electrohydraulic shockwave as well as mechanical basket lithotripsy within the CD, and basket and balloon stone fragment removal resulted in complete clearance of all CD and CBD/CHD stones. Shortly afterwards, the patient presented with decompensated heart failure and underwent successful heart transplantation. DISCUSSION: MS presents a significant challenge to clinicians. The treatment is surgical, although inflammation, adhesions, and associated tissue plane distortion pose a challenge to even the best surgeon with an increased risk of bile duct injury. ERCP allows for diagnostic confirmation and biliary drainage via stent placement to alleviate the obstruction and cholangitis. We describe the successful implementation of ERCP as definitive therapy by utilizing a multitude of tools to clear the CD, CBD/CHD stones after failed surgery.