Laparoscopic cholecystectomy combined with ERCP for treatment of Mirizzi syndrome

Abstract

Introduction: Since 1987, Laparoscopic cholecystectomy (LC) has been the standard treatment for gall bladder lesions. Complicated acute cholecystitis including associated with bile duct stones, acute cholangitis, biliary pancreatitis and Mirizzi Syndrome (MS) in patients were challenging to laparoscopic treatment. MS is characterized by gall stones impacting in the infundibulum, Hartmann’s pouch, or cystic duct and causing jaundice. Most common symptoms of this syndrome were jaundice, abdominal pain and fever. Pre-operative work-up including abdominal ultrasonography, CT scanning, MRCP and ERCP. Preoperative diagnosis of MS is often difficult but very important to confirm the diagnosis and to avoid intra-operative complications. Laparoscopic surgery as the primary treatment of MS is controversial and only reported in small case series. This study aims to clarify this challenging issue. Method: From Jan 2004 to Dec. 2017, 100 consecutive patients with MS were diagnosed by ERCP and then received surgical procedure at the Department of General Surgery, CGMH, Linkou, Taiwan. 60 patients were treated with LC 40 patients were treated with open cholecystectomy. The Clinical manifestations, pre-operative drainage, surgical treatment and post-operative outcome between these two groups will be compared. Result: The conversion rate of LC to open cholecystectomy for MS is 16.6%. The hospital stay is significantly shorter in the LC group patients than those converted to open cholecystectomy and traditional open cholecystectomy group patients. The risk factor for conversion and post-operative biliary complication is fistula type and low insertion of cystic duct, respectively. Conclusion: MS is still challenging to laparoscopic surgeon. However, pre-operative ERCP diagnosis and post-operative ERCP management is mandatory to decrease conversion rate and biliary complications.