Mirizzi's syndrome: lessons learnt from 169 patients at a single center

Abstract

Backgrounds/AimsMirizzi's syndrome (MS) poses great diagnostic and management challenge to the treating physician. We presented our experience of MS cases with respect to clinical presentation, diagnostic difficulties, surgical procedures and outcome.MethodsProspectively maintained data of all surgically treated MS patients were analyzed.ResultsA total of 169 MS patients were surgically managed between 1989 and 2011. Presenting symptoms were jaundice (84%), pain (75%) and cholangitis (56%). Median symptom duration s was 8 months (range, <1 to 240 months). Preoperative diagnosis was possible only in 32% (54/169) of patients based on imaging study. Csendes Type II was the most common diagnosis (57%). Fistulization to the surrounding organs (bilio-enteric fistulization) were found in 14% of patients (24/169) during surgery. Gall bladder histopathology revealed xanthogranulomatous cholecystitis in 33% of patients (55/169). No significant difference in perioperative morbidity was found between choledochoplasty (use of gallbladder patch) (15/89, 17%) and bilio-enteric anastomosis (4/28, 14%) (p=0.748). Bile leak was more common with choledochoplasty (5/89, 5.6%) than bilio-enteric anastomosis (1/28, 3.5%), without statistical significance (p=0.669).ConclusionsPreoperative diagnosis of MS was possible in only one-third of patients in our series. Significant number of patients had associated fistulae to the surrounding organs, making the surgical procedure more complicated. Awareness of this entity is important for intraoperative diagnosis and consequently, for optimal surgical strategy and good outcome.

Mirizzi Syndrome: Four Case Reports and a Review of the Literature

“…The classification further grades the severity based on the degree of CBD destruction [6]. As might be expected, the more severe forms of Mirizzi syndrome are less common [7][8][9][10] The first two cases were presumed to have CBD stones. It is typically managed with laparoscopic cholecystectomy and ERCP either preoperatively or postoperatively.…”

Novel treatment for type III Mirizzi syndrome

“…Type II denotes a fistula involving one‐third of the diameter, type III involves two‐thirds of the diameter, and type IV is a fistula that involves the entire CHD. Whilst surgical management of Csendes type I (with total or subtotal cholecystectomy) and type IV (with bilio‐enteric anastomosis) is largely agreed upon, the procedure of choice for types II and III is still disputed . Choledochoplasty is well reported for the management of MS, with some proponents favouring it above other perhaps more recognized methods .…”

“…On the contrary, some surgeons contend the use of choledochoplasty, arguing that it has a greater chance of failure due to ongoing inflammation in the pedicle flap and higher rate of post‐operative bile leak . We understood these concerns and considered repair of the defect with the same flap around a T‐tube.…”

“…Whilst surgical management of Csendes type I (with total or subtotal cholecystectomy) and type IV (with bilio-enteric anastomosis) is largely agreed upon, the procedure of choice for types II and III is still disputed. 2 Choledochoplasty is well reported for the management of MS, with some proponents favouring it above other perhaps more recognized methods. [3][4][5][6] The gallbladder flap's independent blood supply, bile tolerant mucosa and nearby location, lends itself as the favoured flap material to repair such defects.…”

“…3 On the contrary, some surgeons contend the use of choledochoplasty, arguing that it has a greater chance of failure due to ongoing inflammation in the pedicle flap and higher rate of postoperative bile leak. 2,5 We understood these concerns and considered repair of the defect with the same flap around a T-tube. As this requires external biliary drainage for a minimum of 6 weeks postoperatively, we decided that internal biliary drainage with a plastic stent placed antegrade through the existing biliary defect would be the less morbid option.…”