Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 28, 2020; 26(40): 6241-6249
Published online Oct 28, 2020. doi: 10.3748/wjg.v26.i40.6241
Predicting cholecystocholedochal fistulas in patients with Mirizzi syndrome undergoing endoscopic retrograde cholangiopancreatography
Chi-Huan Wu, Nai-Jen Liu, Chun-Nan Yeh, Shang-Yu Wang, Yi-Yin Jan
Chi-Huan Wu, Nai-Jen Liu, Department of Gastroenterology and Hepatology, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan 333, Taiwan
Chun-Nan Yeh, Shang-Yu Wang, Yi-Yin Jan, Department of General Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan 333, Taiwan
Author contributions: Jan YY designed the research protocol; Liu NJ and Wang SY conducted the research and contributed analytic tools; Wu CH wrote the paper and analyzed the data; Yeh CN reviewed and revised the paper.
Institutional review board statement: The study was approved by the Chang Gung Medical Foundation Institutional Review Board (IRB number: 201801210B0).
Informed consent statement: Due to the retrospective design of the study, consent was waived by the ethics committee for the entire study.
Conflict-of-interest statement: The authors have no financial disclosures to declare and no conflicts of interest to report.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at yehchunnan@gmail.com. Participants gave informed consent for data sharing.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Yi-Yin Jan, MD, Attending Doctor, Department of General Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, No. 5 Fu-Hsin Street, Queishan, Taoyuan 333, Taiwan. janyy@cgmh.org.tw
Received: May 16, 2020
Peer-review started: May 16, 2020
First decision: May 29, 2020
Revised: June 9, 2020
Accepted: October 1, 2020
Article in press: October 1, 2020
Published online: October 28, 2020
Abstract
BACKGROUND

Mirizzi syndrome (MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct (CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.

AIM

To evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.

METHODS

From 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed.

RESULTS

Gallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas (P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis (odds ratio 5.82, P = 0.002; 0.12, P = 0.008, respectively).

CONCLUSION

Gall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.

Keywords: Cholecystectomy, Cholecystocholedochal fistula, Common bile duct, Endoscopic retrograde cholangiopancreatography, Mirizzi syndrome

Core Tip: The diagnosis of Mirizzi syndrome (MS) and the presence or absence of a cholecystocholedochal fistula is important for surgical planning before cholecystectomy. Endoscopic retrograde cholangiopancreatography could serve diagnostic and therapeutic purposes in patients with MS and also help detect cholecystocholedochal fistulas before operation. Our study revealed that gall bladder opacification is more frequent in patients with cholecystocholedochal fistula. Pus in the common bile duct is predictive factor for the diagnosis of MS with cholecystocholedochal fistulas, and stricture length of the common bile duct longer than 2 cm is the protective factor for cholecystocholedochal fistulas in patients with MS.