Mirizzi Syndrome Classification, Are We Missing Something?

Abstract

INTRODUCTION: Resectable T1b-T3 Gallbladder Carcinoma (GBC) is optimally treated with oncologic extended R0 resection that includes gallbladder fossa resection or bisegmentectomy IVb/ V, portal/retroperitoneal lymphadenectomy. However, such surgery for GBC is infrequently practiced thus this study identified factors associated with optimal surgery. METHODS:The National Cancer Database was queried for patients diagnosed with Stage 1-3 (T1b-T3) GBC undergoing high quality surgery (HQS) between 2004-2016. HQS was defined as partial hepatectomy with cholecystectomy, lymph node harvest 6 and negative margins. Logistic regression was used to assess factors associated with HQS. Kaplan-Meier survival analyses were performed.RESULTS: 3867 patients were included; 368 (9.5%) had HQS and 3499 (90.5%) had inadequate surgery. HQS was associated with improved median overall survival (55.1 vs 25.4 months, P<.001). Factors associated with HQS included private insurance (OR 1.832, P<.001), median income >$40,227 (OR 1.400, P¼.030), urban/rural residence (OR 1.604, P¼.001), Medicaid Expansion state (OR 1.402, P¼.005), and increased distance to reporting hospital (OR 1.001, P¼.048). Inadequate surgery was associated with older age (OR 0.974, P<.001), Charleson-Deyo Comorbidity Score 1 (OR 0.707, P¼.004), and laparoscopic approach (OR 0.576, P<.001). Facility type incrementally improved HQS rate (integrated cancer network vs comprehensive community, 9.8% vs 6.1%, OR 1.664, P¼.004; academic/research center vs integrated cancer network, 14.7% vs 9.8%, OR 1.587, P¼.004). CONCLUSION:The impact of low-quality surgery for GBC on survival and the high frequency of which it is practiced, calls for intervening on modifiable factors to improve survival for GBC, such as centralization of surgery, open approach, and insurance status.

Type IV Mirizzi Syndrome: Brief Report and Review of Management Options

“…The available evidence is mostly limited to case series and retrospective reviews. 3,4,7,9,[11][12][13][14][15][16][17][18][19][20][21][22][23][24] Specifically in type IV Mirizzi syndrome, there tends to be extensive destruction of the bile duct wall with possible complete section of the common hepatic duct and Roux-en-Y hepaticojejunostomy is advocated instead of end-to-end bile duct anastomosis to prevent early biliary stricture. 3,11,17,25 To date, there are very few reported type IV Mirizzi syndrome cases managed laparoscopically.…”