Background:
The management of Mirizzi syndrome has been primarily surgical, ranging from cholecystectomy to en-bloc resection with hepatico-jejunostomy for advanced Csendes III and IV types. The introduction of digital single-operator cholangioscopy (dSOC) allows for ductal clearance in patients with Mirizzi syndrome. Although small series have highlighted the feasibility of an endoscopic approach, there is a lack of comparisons between surgical and endoscopic treatments. The objective of the current study is to compare the outcomes and safety of dSOC-guided lithotripsy with the surgical approach.

Methods:
A multicenter international retrospective analysis was conducted on dSOC and surgical procedures in patients with type II-IV Mirizzi syndrome between 2005 and June 2022. Patients with postsurgical anatomy, Mirizzi type I, or a history of pre-dSOC cholecystectomy were excluded. Technical success was defined as the successful and complete clearance of the duct using either dSOC or surgery. The AGREE classification was employed for adverse event (AE) grading.

Results:
In total, 290 patients were included, with 176 undergoing treatment with dSOC and 114 undergoing surgery. At baseline, patients undergoing dSOC were older (61.3 years [SD16.4] vs. 56.0 [SD14.8]), experienced jaundice more frequently (79.4% vs. 61.9%, p=0.001), and had higher scores on the Charlson Comorbidity Index (3 [IQR 1-9] vs. 1 [0-3], p<0.001) and ASA scores (p<0.001).

While technical success was lower in the dSOC group compared to surgery (89.2% vs. 96.5%, p=0.025), the need for reinterventions and the median number of interventions were similar after a median follow-up duration of 741.5 days (IQR 320-1781) vs. 346 (IQR 67-1220) days (p=0.009). Overall adverse events (AE) occurred less frequently in the dSOC group (10.2% vs. 41.2%, p<0.001), including mild AE (4.0% vs. 13.1%, p=0.008), and severe AE (1.7% vs. 15.8%, p<0.001). Three fatal complications occurred in the surgical group (0.0% vs. 2.6%, p=0.060).
During follow-up, cholecystectomy was avoided in 115 out of 175 dSOC patients (65.3%), without resulting in statistically significant differences in long-term outcomes. When comparing patients from the primary surgery group with patients in whom elective cholecystectomy following dSOC was performed, a lower need for hepaticojejunostomy was observed (6.6% vs. 26.1%, p=0.002).

Conclusion:
Our study demonstrates that the use of dSOC for the removal of intraductal stones in Mirizzi syndrome is highly effective, showing superior safety despite treating patients with more underlying comorbidity. dSOC seems valuable in downgrading the extent of subsequent surgery, by potentially reducing the need for a HJ, and furthermore seems to prevent the need for cholecystectomy in two thirds of patients. Consequently, we advocate for dSOC as the primary modality in the management of Mirizzi syndrome

Willem Lammers

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