Clinical Case of Radical Transpapillary Endoscopic Treatment of a Patient with Type IV Mirizzi Syndrome

Vollständiger Abstract

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Aim: to demonstrate the feasibility of intraductal contact lithotripsy using a holmium laser under peroral transpapillary cholangioscopy (POCS) guidance for radical endoscopic treatment of a patient with type IV Mirizzi syndrome. Key points. A 58-year-old female patient with a 5-year history of cholelithiasis was admitted on an emergency basis one year earlier with clinical signs of obstructive jaundice. At that time, endoscopic intervention was performed, including endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy, and biliary duodenal stenting. ERCP revealed a 4.0 × 2.0-cm calculus completely obstructing the common bile duct lumen, and a cholecystobiliary fistula was suspected. During the current hospitalization, the first stage of treatment consisted of balloon dilation of the previously performed endoscopic sphincterotomy followed by POCS using the SpyGlass DS II system. Complete obstruction of the common bile duct lumen by the calculus was confirmed, together with pronounced inflammatory changes in the bile duct wall at the site of the cholecystobiliary fistula. Contact lithotripsy of the biliary calculus was performed using a holmium laser, with fragmentation of both the intraductal and gallbladder portions of the calculus, followed by extraction of the fragments and placement of a nasobiliary drain. At the second stage, complete clearance of the main bile ducts and the gallbladder cavity was achieved under POCS guidance. A procedural complication — impaction and breakage of the extraction basket in the distal common bile duct — was also successfully managed by contact holmium laser lithotripsy performed through the basket mesh, followed by basket removal after fragmentation of the impacted biliary stone. Repeat stenting and cholecystectomy were not performed due to a shrunken gallbladder and complete clearance of the biliary tract, including the gallbladder. Conclusion. The endoscopic approach enabled radical treatment and obviated the need for surgery, demonstrating its potential in the management of complex forms of choledocholithiasis, including Mirizzi syndrome.