Successful endoscopic treatment for Mirizzi syndrome type II under direct peroral cholangioscopy using an ultraslim upper endoscope.

Surgery is standard management for patients with Mirizzi syndrome. In cases of Mirizzi syndrome type II, laparoscopic surgery is evenmore complicated because of the cholecystocholedochal fistula. Endoscopic treatment for Mirizzi syndrome is still controversial except to relieve a bile duct obstruction [1,2]. This report describes a successful endoscopic treatment for Mirizzi syndrome type II with laser lithotripsy under direct peroral cholangioscopy (POC) using an ultraslim upper endoscope. A 52-year-old woman presented with a 1-week history of epigastric pain and jaundice. Abdominal CT and magnetic resonance cholangiopancreatography showed diffuse bile duct dilation and stricture of the common hepatic duct with compression of a stone impacted in the cystic duct. Endoscopic retrograde cholangiopancreatography showed a large impacted stone at the level of the cystic duct (●" Fig.1). Intraductal ultrasonography revealed disappearance of the ductal wall between the stone and the bile duct, suggesting the presence of a cholecystocholedochal fistula, indicating the presence of type II Mirizzi syndrome. Conventional stone extraction, including mechanical lithotripsy, was unsuccessful. Intraductal laser lithotripsy under direct peroral cholangioscopy (POC) using an ultraslim endoscope (GIF-XP260N, outer diameter 5.5mm; Olympus, Tokyo, Japan) was performed. After a 0.025-inch guidewire (VisiGlide; Olympus) was placed into an intrahepatic duct, the slim endoscope was advanced into the bile duct over the anchored balloon catheter (MTW Endoskopie,Wesel, Germany) [3]. Intraductal stone fragmentation under direct endoscopic visualization using the FREDDY laser system (World ofMedicine, Berlin, Germany) (120mJ/pulse energyoutput and10Hz pulse rate) was successful (●" Fig.2, ●" Video 1) [4]. An automated CO2 insufflation system (Colosense Pro-500; Mirae Medics, Seoul, Korea) was used during the procedure. Then, the fragmented stones were extracted using a basket and balloon after changing to a duodenoscope. Followup direct POC revealed no stone remnants and complete closure of the cholecystocholedochal fistula (●" Fig.3). Subsequent abdominal CT showed the gallbladder to be contractedwith no remnant of stone. Direct POC using an ultraslim upper endoscope permits various intraductal endoscopic interventions through the 2.0-mm working channel. Developing accessories, such as an access balloon system and overtube, may be useful for endoscopic intraductal interventions under direct POC [5]. Fig.1 Cholangiogram showing a large impacted stone at the level of the cystic duct.