Surgery versus endoscopy with digital single-operator cholangioscopy-guided therapy for Mirizzi syndrome: The SEIZE study

Background: The management of Mirizzi syndrome has been primarily surgical, but there are no comparisons between surgical and digital single-operator cholangioscopy (dSOC)-guided treatment. The objective of this study was to compare the safety and other outcomes of the two approaches. Methods: A large multicenter international retrospective analysis was conducted comparing dSOC and surgery in patients with type II-IV Mirizzi syndrome between January 2005 and June 2023. Patients with postsurgical anatomy, Mirizzi type I or V, or previous cholecystectomy were excluded. Results: 290 patients were included (dSOC, n = 176; surgery, n = 114). At baseline, patients undergoing dSOC were older P = 0.006) and exhibited more co-morbidities. While technical success was lower with dSOC (89.8 % vs. 96.5 %; P = 0.04), the need for reintervention was comparable after a median follow-up duration of 741.5 days (interquartile range [IQR] 320-1781) vs. 346 days (IQR 67-1220; P = 0.009). Overall adverse events (10.2 % vs. 41.2 %; P < 0.001) and severe adverse events (1.7 % vs. 15.8 %; P < 0.001) occurred less frequently with dSOC, findings that were confirmed with propensity score-matching. A lower need for hepaticojejunostomy (8.2 % vs. 25.4 %; P = 0.006) and lower rate of conversion to open surgery (6.0 % vs. 22.8 %; P = 0.009) were observed in patients undergoing elective cholecystectomy following dSOC compared with the primary surgery group. Conclusions: Our study demonstrates that the use of dSOC for Mirizzi syndrome is effective, showing superior safety despite being used to treat patients with more underlying co-morbidities. dSOC seems valuable in downgrading the extent of subsequent surgery, by potentially reducing the need for hepaticojejunostomy and conversion to open surgery.