title: Usefulness of single-operator cholangioscopy-guided laser lithotripsy in patients with Mirizzi syndrome and cystic duct stones: experience at a tertiary care center.
abstract: OBJECTIVE
  ERCP is an established technique for the management of bile duct stones. Large bile duct stones (>1.2 cm) require additional techniques such as mechanical lithotripsy and balloon sphincteroplasty for ductal clearance. The literature on endoscopic management of cystic duct stones (CDSs) and Mirizzi syndrome (MS) is limited. We report our experience with cholangioscopy-assisted extraction of CDSs and MS in patients in whom conventional endoscopic and surgical techniques failed.
  
  
  METHODS
  Between August 2011 and August 2014, 50 patients (15 males) diagnosed with MS (n = 40) and CDSs (n = 10) were recruited for the study. MRCP was the preferred diagnostic modality to outline the biliary anatomy. ERCP was performed by using an Olympus TJF 160/180 duodenoscope (Olympus, Tokyo, Japan). Cholangioscopy was performed by using the Spyglass system (Boston Scientific, Marlborough, Mass). Holmium laser lithotripsy (LL) was performed when conventional stone extraction techniques failed.
  
  
  RESULTS
  Cholangioscopy-guided LL was required in 34 of 50 patients (68%) with MS and CDSs. Stone extractions using conventional endoscopy techniques were successful in 8 patients and with surgery in another 8 patients, and these patients were excluded from the final statistical analysis. The mean stone size for MS was 21 mm (range 15-41 mm), and the CDS size was 8 mm (range 6-12 mm). Single-session ductal clearance could be achieved in 32 patients (94%). Adverse events were mild and included fever (2 patients), transient abdominal pain (2 patients), and self-limited pancreatitis (2 patients).
  
  
  CONCLUSIONS
  Cholangioscopy-guided LL is a useful technique for extraction of CDSs and in MS with high single-session success rates. It is also a rescue technique in patients in whom surgical stone extraction failed.
authors.affiliation: Baldota Institute of Digestive Sciences, Global Hospitals, Mumbai, India.
authors.forename: Suryaprakash
authors.initials: S
authors.lastname: Bhandari
authors.affiliation: Baldota Institute of Digestive Sciences, Global Hospitals, Mumbai, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Bathini
authors.affiliation: Baldota Institute of Digestive Sciences, Global Hospitals, Mumbai, India.
authors.forename: Atul
authors.initials: A
authors.lastname: Sharma
authors.affiliation: Baldota Institute of Digestive Sciences, Global Hospitals, Mumbai, India.
authors.forename: Amit
authors.initials: A
authors.lastname: Maydeo
mesh_terms: D000328:Adult; D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D049448:Cholangiopancreatography, Magnetic Resonance; D002769:Cholelithiasis / Q000150:complications / Q000628:therapy*; D003549:Cystic Duct / Q000601:surgery*; D016145:Endoscopy, Digestive System / Q000379:methods; D005260:Female; D006801:Humans; D053844:Lasers, Solid-State / Q000627:therapeutic use; D017602:Lithotripsy, Laser / Q000379:methods*; D008297:Male; D008875:Middle Aged; D057792:Mirizzi Syndrome / Q000209:etiology / Q000628:therapy*; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D016896:Treatment Outcome; D055815:Young Adult