Surg Endosc DOI 10.1007/s00464-014-3529-3

and Other Interventional Techniques

A minimally invasive strategy for Mirizzi syndrome: the combined endoscopic and robotic approach Kit-fai Lee • Ching-ning Chong • Ka-wing Ma Eric Cheung • John Wong • Sunny Cheung • Paul Lai



Received: 12 November 2013 / Accepted: 27 March 2014 Ó Springer Science+Business Media New York 2014

Abstract Background Mirizzi syndrome (MS) is a rare complication of gallstone disease. Despite the fact that successful laparoscopic treatments have been reported, open surgery remains the gold standard approach for this disease due to technical difficulties involved. Methods A minimally invasive strategy combining endoscopic retrograde cholangiopancreatography (ERCP) and robotic surgery for the management of MS was implemented in early 2012. This consisted of a preoperative ERCP for definitive diagnosis and endoscopic stent insertion. Robotic surgical approach was used during operation to facilitate gall bladder removal and suture of defect over common duct. ERCP was repeated postoperatively for stent removal. Patient demographics and treatment outcomes were collected prospectively. A historical cohort of patients with MS who underwent conventional surgery between 1999 and 2011 was identified for comparison of treatment outcomes. Results Five patients with MS were managed with this strategy. Robotic subtotal cholecystectomy was successfully performed in all the patients without conversion or morbidity. When compared with a historical cohort of 17 patients who underwent surgery for MS, this group of patients had significantly less conversion and shorter hospital stay though the operation time was longer. It also K. Lee (&)  C. Chong  E. Cheung  J. Wong  S. Cheung  P. Lai Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong e-mail: [email protected] K. Ma Department of Surgery, Queen Elizabeth Hospital, Kowloon, Hong Kong

showed less blood loss and less postoperative complications but these were not statistically significant. Conclusion Mirizzi syndrome can be effectively managed with a minimally invasive approach by adopting a robot-assisted surgery together with a planned pre- and postoperative ERCP. Keywords Mirizzi syndrome  ERCP  Robotic surgery  Cholecystectomy

Mirizzi Syndrome (MS) is a rare complication of gallstone disease in which the common hepatic duct is obstructed by a stone impacted at Hartmann’s pouch or cystic duct [1]. It is commonly classified as McSherry Type I when there is external compression only and Type II if a fistula is formed between gall bladder and common duct due to inflammation and erosion by the impacted stone [2]. Its incidence was reported between 0.06 and 5.7% [3, 4]. Difficulty in management of MS lies on inadequate pre-operative diagnosis and operative difficulties as a result of dense adhesion and altered anatomy. Despite the success of laparoscopic cholecystectomy as a minimally invasive approach for gall stone disease, MS remains a big challenge for laparoscopic approach. The current consensus is still to recommend open cholecystectomy for MS [5, 6], while some authors recommended laparoscopic approach for Type I MS only [7–9]. Nevertheless, MS remains the type of disease most suitable for minimally invasive approach in view of its benign nature (no need for radical resection and oncological clearance), and the specimen is usually small which does not require large wound for retrieval. On the other hand, the big incision associated with open surgery invites problems of

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wound infection or even wound dehiscence, given the underlying infective nature of the disease. With the recent introduction of surgical robot, the dexterity of robotic instruments should be able to overcome many obstacles that conventional laparoscopic approach has faced. Together with the latest advanced endoscopic retrograde cholangiopancreatography (ERCP) skill, precise pre-operative diagnosis and endoscopic therapeutic procedures can facilitate a lot on management of MS.

Materials and methods A minimally invasive strategy combining ERCP and robot for the management of MS was implemented in our institution in early 2012. Patients with MS usually presented with jaundice or cholangitis. In addition to ultrasound (US) which was the preliminary routine investigation for biliary disease, computed tomography (CT) or magnetic resonance cholangiopancreatography (MRCP) was performed for patients with suspected MS. CT and MRCP were also helpful to exclude gall bladder cancer or cholangiocarcinoma which might give rise to similar clinical picture and US finding. ERCP would be performed for suspected or confirmed MS. ERCP not only provided a confirmative diagnosis of MS but also enabled clearance of any concomitant common duct stone and placement of a plastic stent (Fig. 1A, B). This restored bile flow and allowed cholangitis to subside before definitive surgical treatment. Operation could be performed once liver function returned to normal and sepsis subsided. Operation was performed with the use of the da Vinci robotic system [10]. One 12-mm port for the robotic camera and three 8-mm ports for robotic instruments were placed. Besides, two 5-mm or one 5-mm plus one 10-mm assistant ports were inserted for suction, stone removal and passage of suture. (Fig. 2). The intended operation was a subtotal cholecystectomy. However, bile duct resection and hepaticojejunostomy was prepared for more extensive disease. The aim of operation was to remove most part of gall bladder and to leave a cuff of tissue near common duct for primary closure. During operation, omental adhesion around gall bladder was taken down first. Sometimes duodenum or transverse colon also adhered to gallbladder. This should be taken down carefully and any fistula to colon or duodenum should be identified and defect sutured. No attempt was made to dissect the Calot’s triangle as this area was usually inflamed and densely adherent. Fundusfirst approach was used routinely, and gall bladder was usually opened proximal to Hartmann’s pouch for clarification of anatomy from inside gall bladder. Laparoscopic USG was performed by the assistant surgeon at operation table. This could aid to identify stones and the biliary stent.

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Fig. 1 A ERCP confirmed the diagnosis of Mirizzi syndrome. B A plastic stent was placed across the obstructing stone to intrahepatic duct

Fig. 2 Sites of ports placement for operation

Stones were removed, and these could be retrieved within cut fingertip of a glove through assistant port. The plastic stent served as the landmark where the common duct was

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located. All gallstones including the index one that caused common hepatic duct obstruction were removed (Fig. 3A). Choledochoscopy through the right 8-mm robotic port was performed by assistant surgeon to confirm clearance before closure of bile duct. The defect over bile duct was closed by approximating the gall bladder cuff tissue with single layer continuous 3/0 or 4/0 absorbable suture (Fig. 3B). Intracorporeal suturing was much facilitated by robotic instruments. The plastic stent was deliberately left behind to promote bile flow to duodenum, and such strategy obviated the need of T-tube insertion and speeded up patient’s postoperative recovery. Specimen was usually small and could be easily retrieved through the 12-mm port, with small extension of wound if necessary. A drain was placed in right subhepatic space and brought out through the 8-mm port over the right. It could be removed early if there was no evidence of bile leakage. Patients could be discharged once they were fully mobilised and had adequate intake orally. They were readmitted 4–6

Fig. 3 A Stone was removed from inside common duct with robotic forceps. B Bile duct defect was being closed by intracorporeal suture using robotic instruments

weeks post-operatively for repeat ERCP as day procedure for stent removal and final check on bile duct patency. Patients were at least followed up once after ERCP. Patients who underwent operation for MS before the introduction of this combined endoscopic and robotic approach were identified from database. The demographic data and operative outcomes for these two groups of patients were compared. Mann-Whitney U test was used for comparing continuous variables while Fisher’s Exact Test was used for comparing categorical variables. A P value of less than 0.05 was considered statistically significant.

Results From January 2012 to September 2013, five patients with MS were managed with the combined endoscopic and robotic approach. Four were female, and one was male. The median age was 67 years. Three of them presented with jaundice, while two presented with acute cholangitis. CT was performed in 3 patients, MRCP in one patient and CT plus MRCP in one patient. ERCP with a French size 10 plastic stent insertion was successfully performed in all patients. In addition, common bile duct stones were detected and removed in one of the patients. The median size of stone that caused bile duct obstruction was 1.5 cm (range 1.2–3 cm). Subtotal cholecystectomy was successfully performed with the use of robot in all cases. There was no need for bile duct resection and hepaticojejunostomy. There was no conversion. Median operation time was 273 min (range 215–470 min), and median blood loss was 100 ml (range 20–300 ml). No patient required transfusion. There was no postoperative complication. Drains were removed between day 1 and day 3. Median postoperative hospital stay was 4 days (range 3–5 days). Pathology of resected specimens revealed acute on chronic cholecystitis in 3 patients and chronic cholecystits in 2 patients. ERCP were repeated 5–7 weeks after operation and all showed no residual stone or biliary stricture. All patients had normal liver function and were symptom free on follow-up. A historical cohort of 17 patients who underwent operative treatment for MS between 1999 and 2011 was identified. All but one patient received ERCP before surgery. Fifteen patients had sphincterotomy, nasobiliary drain insertion, or plastic stent insertion for bile duct decompression. Fourteen patients underwent open operation. Laparoscopic dissection was attempted in the remaining three patients but all were converted to open surgery due to uncertain anatomy and difficult dissection. T-tube was inserted in 11 patients (64.7%). Median duration of T-tube placement was 13 days (range 10–48 days). Two patients

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Surg Endosc Table 1 Comparison of the new treatment strategy and historical cohort for Mirizzi syndrome Combined endoscopic and robotic approach (N=5)

Historical cohort (N=17)

P value

Age

67 (46–80)

58 (38–72)

0.446

Female

4 (80.0%)

3 (17.6%)

0.021*

McSherry type I/II

2/3

6/11

[0.995

Bilirubin on presentation (lmol/L)

102 (57–255)

79 (8–264)

0.283

Causative stone size (cm)

1.5 (1.2–3)

2 (1–4.5)

0.548

Conversion for robotic or laparoscopic approach

0 (0%)

3 (100%)

0.018*

Operation time (min)

273 (215–470)

193 (90–465)

0.006*

Operative blood loss (ml)

100 (20–300)

200 (40–1600)a

0.075

T-tube placement

0 (0%)

11 (64.7%)

0.035*

Mortality

0

0

NA

Morbidity

0

5 (29.4%)

0.290

Length of hospital stay (days)

4(3–5)

9(5–22)

\0.005*

Values in median (range) or number of patients (percentage) a

Data only available in 13 patients

* Statistical significance

required hepaticojejunostomy in addition to cholecystectomy for extensive erosion of common duct by gall stone. The data of this group of patients were compared with the 5 patients using the combined ERCP and robotic approach in Table 1. The two groups were comparable in age, bilirubin level on presentation, size of causative stone and McSherry type except the combined approach group had significantly more female patients. There was no difference in blood loss or complication rate. The five complications in the historical cohort included four wound infections and one bile leak which was managed successfully with percutaneous drainage. The combined approach resulted in significant shorter hospital stay but the operation time was significantly longer.

Discussion A recent systemic review on laparoscopic treatment of MS identified 10 series each of which consisted of at least 4 patients between 1989 and 2008 [6]. Laparoscopic approach was attempted in 124 patients. The overall conversion, complication and reoperation rates were 41, 20

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and 6 %, respectively. Mortality due to biliary peritonitis occurred in 1 patient (0.8%). Details on length of hospital stay was available in 8 studies, the median stay was 8 days (range 3–13 days). It was concluded that laparoscopic management of MS could not be recommended as a standard procedure and open surgery remained the gold standard treatment for MS. Among the 10 series, the largest series contained 39 patients [11]. Its conversion rate was as high as 74% for Type I MS and 100% for Type II. The overall complication rate was 18%, and there was no operation-related death. On the other hand, the use of robot for operative treatment of MS was rarely reported. To our knowledge, only one series reported the use of robot in two cases of MS in the English literature [12]. In that series, the common bile duct was dissected out, and anterior longitudinal choledochotomy was made. T-tube was usually not inserted. We believe that such manoeuvre is not necessary as far as the gall bladder is dissected medial enough to take out the index stone and previously placed stent identified within common duct. This can avoid unnecessary injury to structures lying in Calot’s triangle including the right hepatic artery and right or left hepatic ducts. Certainly, if the disease is found to be more extensive, more liberal dissection and even reconstruction with hepaticojejunostomy is feasible with the use of robotic instruments. This is also the potential advantage of using robot. Our strategy demands an expertise on both ERCP and robotic surgery skills. While in some countries ERCP is only performed by physicians, the advantage for us is that ERCP is also performed by surgeons in our locality. This facilitates the overall planning of management of patients with suspected MS. The aim of ERCP is to confirm the diagnosis, clear any common duct stone and insert a biliary stent. The planned operation will be carried out when sepsis, if any, has settled and liver function normalised. Aim of operation is to remove all gallstones, to remove most of the gallbladder and to close the defect over the stented common duct primarily. The last step is to repeat ERCP for removal of stent when the repair site has completely healed up. Hazzan et al applied a similar approach in a patient with MS performing ERCP before and after an open subtotal cholecystectomy in as early as 1999 [13]. Chowbey et al described a similar treatment strategy in tackling MS but applied conventional laparoscopic approach in surgery at that time [14]. The conversion rate was still as high as 22%. A more recent series on laparoscopic treatment for MS achieved a lower conversion rate of 14% in 50 patients [15]. However, the authors concluded that laparoscopic primary suture of the defect on the wall of common bile duct was difficult and recommended it to be performed in experienced hands only. We believe that with the use of robot, primary closure of bile duct defect is no longer an obstacle for laparoscopic approach.

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As shown in this series, our strategy is safe and feasible. There was no conversion to open surgery. There was no operative morbidity and all patients could be discharged with a median hospital stay of only 4 days. When experience is further accumulated, we believe that the use of drain is not necessary, and the hospital stay can be further shortened. All patients were shown to have clear bile duct and normal liver function on follow-up. In contrast, for the 17 patients in the historical cohort, no attempt for minimally invasive approach was made for 14 patients while in the remaining three patients conversion to open surgery was all needed. They had significantly longer hospital stay (median 9 vs. 4 days). They also showed more blood loss and more post-operative complications although not statistically significant. In addition, the median T-tube placement period of 13 days in the historical group might also jeopardise the quality of life of patients even they had returned home. The only drawback was longer operation time with the new approach. It was related to the steeplearning curve for robotic surgery and the technical difficulty related to adhesion and altered anatomy. With time and experience, the operation time could be shortened. Thus, the new treatment strategy is very promising to make a minimally invasive approach for MS achievable and effective. The limitations of this study include the small number of patients included and the lack of more extensive form of MS that requires bile duct resection and reconstruction. Comparison with a historical cohort is not ideal as operative skill, and diagnostic technique have advanced throughout the years. Given the rarity of the disease, we would recommend this treatment strategy for other centres so that its efficacy can be verified. Certainly a direct comparison of robotic and laparoscopic approach was warranted to further evaluate the role of robot in such treatment strategy.

Conclusion Mirizzi syndrome can be effectively managed with a minimally invasive approach by adopting a robot-assisted surgery together with a planned pre- and post-operative ERCP. Such strategy conveys all the benefits of minimally invasive surgery for this complicated gall bladder disease including shorter hospital stay, smaller wounds, better

cosmesis and possibly decreased blood loss and less postoperative complication. Acknowledgements The authors thank Mr Philip Ip for his assistance with data processing and statistical analysis. Disclosure Drs. KF Lee, CN Chong, KW Ma, EY Cheung, J Wong, SY Cheung and PB Lai have no conflicts of interest or financial ties to disclose.

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A minimally invasive strategy for Mirizzi syndrome: the combined endoscopic and robotic approach.

Mirizzi syndrome (MS) is a rare complication of gallstone disease. Despite the fact that successful laparoscopic treatments have been reported, open s...
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