During a 48 month period to December

BACKGROUND Mirizzi's syndrome is a rare condition caused by the obstruction of the common bile duct or common hepatic duct by external compression from multiple impacted gallstones or a single large impacted gallstone in Hartman's pouch. Presenting symptoms are similar to cholecystitis but may be confused with other obstructing conditions such as common bile duct stones and ascending cholangitis due to presence of jaundice. Preoperative diagnosis is often difficult and usually missed. We wanted to analyse the clinical presentation, pre-operative diagnostic strategies, pre-operative bile duct stenting with ERCP, operative management and outcome of patients operated for Mirizzi's syndrome in a tertiary care center. METHODS This is retrospective study. Patients operated for Mirizzi's syndrome between May 2015 and August 2018 were included in the study. Their pre-operative demographics, pre-operative diagnostic strategies, operative management and outcome were recorded and analysed. RESULTS A total of 6 patients was identified out of 350 laparoscopic cholecystectomies performed during study period giving an incidence of 1.7 %. There were 5 males and 1 female with a mean age of 50 years. abdominal pain and jaundice were predominant symptoms and altered liver function tests were seen in all patients. Magnetic resonance cholangiopancreatography (MRCP) was the main stay of diagnosis and diagnostic of Mirizzi's syndrome in all patients. All patients in this study were having type III Mirizzi's syndrome. Pre-operative endoscopic retrograde cholangiopancreatography (ERCP), bile duct stenting, and laparoscopic choledochoplasty sufficed in all patients and none required Hepaticojejunostomy. CONCLUSIONS Mirizzi's syndrome a rare complication of cholelithiasis is a formidable diagnostic and therapeutic challenge. Pre-operative Magnetic Resonance Cholangiopancreatography (MRCP) is the main diagnostic strategy. Preoperative Endoscopic Retrograde Cholangiopancreatography (ERCP), bile duct stenting enable the surgeon to identify and minimize duct injury, and laparoscopic choledochoplasty is feasible and safe in most cases as well.

Nineteen biliary strictures were dilated using a modified angioplasty balloon catheter to allow insertion of a IOF prosthesis. In each instance biliary strictures were successfully dilated which had previously been too tight to widen with standard endoscopic biliary dilating catheters. Eleven patients had malignant hilar strictures, four malignant distal common bile duct strictures, and four benign strictures. There were no complications as a result of the procedure and satisfactory biliary drainage was established in all patients. We conclude that tight biliary strictures can be successfully dilated using a modified angioplasty balloon catheter.Endoscopic insertion of a prosthesis to drain a malignant biliary obstruction appears to be just as effective as a surgical bypass procedure.' In addition a recent trial indicates that the endoscopic approach may be safer.' In addition to the usual endoscopic difficulties experienced in selectively cannulating the biliary tree,4 we have found that one of the major obstacles to successful insertion of a biliary prosthesis is the resistance to dilatation of very tight biliary strictures despite the use of standard biliary dilators. In the past year we have investigated the value of the Olbert endoscopic balloon dilating catheter* for dilating biliary strictures which we found impossible to dilate using standard biliary dilators. Methods PATIENTSOver a 12 month period we dilated very tight biliary strictures in 19 patients (13 women). The mean age was 68 years, range 31 to 93. All patients were shown to have mechanical obstruction of the biliary tree by ultrasound examination. The nature and the site of the obstruction were further clarified by detailed cholangiography during endoscopic retrograde cholangiopancreatography (ERCP). Of the 15 patients with malignant biliary obstruction 11 had hilar lesions and the remaining four had lower common bile duct strictures. Four patients had benign strictures.The patients were admitted the day before the procedure. After obtaining informed consent from each patient, the platelet count, white cell count, and prothrombin time were measured and 2 U blood were cross matched. Ampicillin

Objectives: Intra-peritoneal bile leak and gallstones spillage is a commonevent, during laparoscopic cholecystectomy. Some time it is not possible to retrieve all spiltgallstones, these unretrieved intra-peritoneal gallstones, initially considered harmless, with timea number of complications have been reported. Our aim was to study, factors predisposing togallbladder perforation during laparoscopic cholecystectomy, and the incidence and adverseconsequences of intra-peritoneal spilt gallstone. Period: November 2008 to December 2011.Setting: Liaquat University Hospital were studied. Method: Patients who underwent successfullaparoscopic cholecystectomy for biliary colic and cholelitiasis. Patients who had intraperitonealbile and gallstones spillage during laparoscopic cholecystectomy were follow upfor long period, and all patients studied for risk of perforation and complications. Results:1038 patient underwent successful laparoscopic cholecystectomy, among them in 812(78.23%)patient intact gallbladder were removed, and in 226 (21.77%) patient gallbladder perforationoccurred. Patients had gallbladder perforations in 129(12.43) patients only bile leak was noted,and in 97(9.34%) patients bile and gallstones spillage occurred. Conclusion: We concludedthe outcome and incidence of serious complications after intra-operative spillage of gallstonesand bile, during laparoscopic cholecystectomy, is low and avoidable.