Balloon-assisted peroral cholangioscopy by using an 8.8-mm gastroscope for the diagnosis of Mirizzi syndrome

 CommentaryIn 1948, 17 years after he described intraoperative cholangiography, the Argentine physician Pablo Luis Mirizzi detailed obstructive jaundice resulting from compression of the common hepatic duct by gallstones impacted in the cystic duct or neck (Hartmann pouch) of the gallbladder. Cholecystocholedochal fistula formation may result from direct pressure necrosis of the stone against the duct wall, and Mirizzi syndrome subsequently was classified into several types based on whether or not such a fistula is demonstrated: In type I, no fistula is present, and the cystic duct is present (type IA) or obliterated (type IB). In types II to IV, a fistula is present, and the types reflect the size of the defect with respect to the diameter of the common bile duct: II, <33%; III, 33% to 66%; IV, >66%. The presence of a long cystic duct in parallel with the common hepatic duct or a low insertion of the cystic duct into the common bile duct increases the likelihood of this syndrome. It is critical to demonstrate the anatomy of the biliary tract and the obstruction to be able to plan a safe, operative approach. We all have seen bile duct injury as a result of unexpected intraoperative occurrences as Calot's triangle is entered. Sigmund Freud said “anatomy is destiny,” but lack of knowledge of anatomy also is destiny.Lawrence J. Brandt, MDAssociate Editor for Focal Points

PII: S0016-5107(09)02267-6

doi:10.1016/j.gie.2009.07.025

© 2010 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.