Our experiencies with 27 cases. Int Semin Surg Oncol. Beltran MA. Mirizzi syndrome and gallstone ileus: an unusual presentation of gallstone disease. J Gastrointest Surg.
|Published (Last):||24 November 2013|
|PDF File Size:||4.78 Mb|
|ePub File Size:||17.81 Mb|
|Price:||Free* [*Free Regsitration Required]|
The disease can mimic cancer of the gallbladder, causing considerable diagnostic difficulties. Furthermore, it increases the risk of intraoperative biliary injury during cholecystectomy. The aim of this study is to point out some particular aspects of diagnosis and treatment of this condition.
The clinical records of patients with Mirizzi syndrome, treated in the last five years, were reviewed. Clinical data, cholangiograms, preoperative diagnosis, operative procedures, and early and late results were examined.
Eighteen consecutive patients were treated in the last five years. Presenting symptoms were jaundice, pain, and cholangitis. Preoperative diagnosis of Mirizzi syndrome was achieved in 11 patients, while 6 had a diagnosis of gallbladder cancer and 1 of Klatskin tumor. Seventeen patients underwent surgery, including cholecystectomy in 8 cases, bile duct repair over T-tube in 3 cases, and hepaticojejunostomy in 4 cases.
Two cases The overall morbidity rate was There was no postoperative mortality. An ERCP with stent insertion was required in three cases after surgery. Sixteen patients were asymptomatic at a mean distance of 24 months range: after surgery. Mirizzi syndrome requires being treated by an experienced biliary surgeon after a careful assessment of the local situation and anatomy. The preoperative placement of a stent via ERCP can simplify the surgical procedure. Mirizzi syndrome was firstly reported by Pablo Luis Mirizzi , one of the major biliary surgeons in the past century.
Mirizzi was born in Cordoba Argentina from Italian parents. He spent all his academic career in his hometown, where he left a deep mark [ 1 , 2 ]. He is mainly known for conceiving and performing the first intraoperative cholangiography in , a procedure that had a strong impact on biliary surgery of the XX century.
Mirizzi first described his syndrome in [ 3 ], presenting the case of a patient with a big stone impacted in the gallbladder infundibulum, causing jaundice by extrinsic compression of the common bile duct CBD with a productive inflammation extending from the gallbladder to the CBD. This condition is an important complication of gallbladder stones and requires a differential diagnosis from gallbladder cancer involving the CBD.
In McSherry et al. Type II represents the possible evolution of the properly mentioned Mirizzi syndrome type I. In Csendes et al. However, many authors continue to use the first classification of Csendes [ 5 ] which, by allowing a better distinction about the entity of the CBD wall involved in the fistula, could be useful to establish the right preoperative workup and surgical management.
Mirizzi syndrome is a condition difficult to diagnose and treat, representing a particular challenge for the biliary surgeon aware of the risk for the patient. The syndrome can mimic gallbladder cancer, but it also represents a precancerous condition, consequently causing considerable diagnostic difficulties. At the same time, because of the significant increase in the risk of intraoperative biliary injury during cholecystectomy, it is a very dangerous condition.
At present, a standard treatment of Mirizzi syndrome is not yet well defined, due to the heterogeneous clinical presentation. Surgical treatment should be planned after a careful assessment of the local situation and anatomy. During the past five years we observed some consecutive cases of Mirizzi syndrome, which led us to review this field in an attempt to point out some particular aspects of diagnosis and treatment of this challenging condition.
Detailed clinical records of patients with diagnosis at discharge of Mirizzi syndrome, treated in our unit between January 1st, , and December 31st, , were reviewed. The following data were considered: sex and age of the patients; presenting symptoms and previous treatments; preoperative radiological investigations; preoperative diagnosis; surgical procedures performed; postoperative course morbidity and mortality ; findings at pathological examination.
Follow-up data, obtained by direct clinical observation, laboratory findings liver function tests , and need for further treatment, were also recorded. In the last 5 years, 18 consecutive cases of Mirizzi syndrome were treated in our unit and they represented 1. Eleven patients were male and 7 were female with a mean age of Presenting symptoms were obstructive jaundice in 14 patients, colic pain in 3 patients, and acute cholangitis in one patient.
Fourteen patients underwent a preoperative ERCP; in all cases a stricture was found and, consequently, one or more stents were positioned in the CBD. Percutaneous cholangiography was performed in 2 patients and a percutaneous drainage was placed preoperatively.
After diagnostic investigations, a diagnosis of Mirizzi syndrome was achieved in 11 patients, a diagnosis of gallbladder cancer was achieved in 6 patients, and a Klatskin tumor was diagnosed in one patient.
Seventeen patients underwent surgery. Eight patients with type I Mirizzi syndrome underwent a simple cholecystectomy, leaving in place the portion of the infundibulum adherent to the CBD. In three cases of Mirizzi type II, after cholecystectomy, a bile duct repair over T-tube was made. The patient with type II Mirizzi presenting with acute colangitis was treated urgently with biliary drainage by ERCP and two months later underwent cholecystectomy and hepatico-jejunostomy.
On the contrary, an unexpected gallbladder cancer associated with the Mirizzi syndrome was diagnosed intraoperatively in two patients: a year-old man who received an explorative laparotomy for an unresectable cancer with peritoneal carcinomatosis and a year-old female who underwent right hepatectomy with CBD excision for gallbladder cancer involving the CBD.
Finally, a year old man, who had initially received a diagnosis of gallbladder cancer, was re-evaluated with CT scan and MRI eighteen months later and was diagnosed as Mirizzi type-I syndrome.
This patient did not undergo surgery and was treated by percutaneous drainage. The 8 patients who underwent simple cholecystectomy enjoy good health with normal liver function tests.
The three patients with CBD reconstruction over T-tube developed cholestasis after T-tube removal, due to the occurrence of a postoperative stricture: all cases were successfully treated with ERCP and multiple plastic stents insertions.
The 4 patients who had undergone hepaticojejunostomy enjoy good health with normal liver function tests. The patient with unexpected finding of gallbladder cancer died three months after surgery. The patient who underwent right hepatectomy is alive six months after surgery and is being treated with chemotherapy.
The patient with incorrect initial diagnosis of gallbladder cancer enjoys good health and replaces his percutaneous drainage at three month intervals. Clinical data are summarized in Table 1. All patients were monitored every six months after surgery mean follow-up: 24 months, range: by clinical evaluation, blood tests, and ultrasounds.
The review of this clinical experience on Mirizzi syndrome allows some considerations regarding the diagnosis and treatment of the disease. However, there is a complex relationship between Mirizzi syndrome and cancer: the high incidence of unexpected cancer is confirmed by the literature, as well as the erroneous preoperative diagnosis of cancer consequent to the particular clinical presentation [ 12 , 13 ].
The risk of bile duct injury during cholecystectomy for Mirizzi syndrome is increased according to the literature [ 14 ]. Diagnostic difficulties are explained by the different clinical presentations of the disease. The classic presentation is obstructive jaundice without painful symptoms and with evidence, at ultrasonography, of a gallstone impacted in the gallbladder infundibulum and determining an external obstruction of the CBD with consequent dilation of the intrahepatic biliary tree.
The diagnosis needs to be confirmed by CT or MRI and, finally, by surgery with histological examination. Simple nasobiliary drainage does not eliminate this necessity.
In addition, direct cholangiography obtained by ERCP provides a significant contribution to the correct diagnosis Figures 2 , 3 , 4 , and 5. In type I Mirizzi syndrome, surgical treatment involves removal of the gallbladder leaving in place the portion of the infundibulum adherent to the CBD.
In this way, the patency of the CBD is ensured by the presence of the stents. In type IIa Mirizzi syndrome the gallbladder is partially removed and part of the infundibular wall is used for the closure of the CBD. After surgery, stents can be eliminated spontaneously or subsequently removed. This modality of treatment is preferable to the CBD reconstruction over T-tube.
In fact, after the removal of the T-tube, a stricture can appear requiring further endoscopic treatment, as in three cases of this series. The 4 cases of Mirizzi type IIb in our series received hepaticojejunostomy with an uneventful clinical outcome at follow-up. Regarding laparoscopic surgical approach, there are different opinions in the literature.
Although laparotomy is considered a safer approach in the management of patients with Mirizzi syndrome, some authors [ 15 , 16 ] report satisfactory results with laparoscopic technique, performing a subtotal cholecystectomy. However, the laparoscopic approach is recommended only to very experienced surgeons. Another frequent clinical picture of the Mirizzi syndrome is that of a stricture mimicking biliary cancer.
When the associated inflammatory process is predominant, it involves the CBD and mimics a neoplastic stricture at the MR-cholangiography Figure 6. Patients usually undergo preoperative ERCP with placement of one or more stents. Endobiliary biopsies are obviously negative, taking into account the high frequency of false-negative findings. The diagnosis is clarified during surgical exploration by personal experience of the surgeon and analysis of the frozen-sections specimens.
In these cases, the clinical onset and MRI findings can justify the preoperative diagnostic error. A clinical onset with acute cholangitis is typical of type II Mirizzi syndrome: in these cases, diagnosis is facilitated by ERCP that allows to reduce the pressure in the CBD by positioning of nasobiliary drains or stents. In some cases, the Mirizzi syndrome can represent an unexpected intraoperative finding and the main risk is accidental bile duct injury.
On the contrary, the main goal must be to avoid any injury to the bile ducts and, therefore, the placement of a cholecystostomy may be an appropriate and justified measure as a bridge solution before referring the patient to a hepatobiliary center. Alternatively, it may be carried out a subtotal cholecystectomy, leaving in place a portion of the infundibulum adherent to the CBD, after removing the stones. Testini and coworkers suggested a decision algorithm for emergency in nonspecialized centers [ 18 ].
Mirizzi syndrome continues to be a disease of difficult diagnosis and treatment. The general surgeon without long experience in hepatobiliary surgery should refer the patient to a specialized hepatobiliary surgical center. It is difficult to standardize the treatment of the disease since clinical presentation and anatomical situations are very variable types I or II, suspected carcinoma.
It is important, however, for surgeons to know the disease and the possible intraoperative challenging situations. In patients with Mirizzi syndrome type I, the best management seems to be the preliminary placement of one or more stents by ERCP, followed by cholecystectomy leaving in place a small portion of the gallbladder adherent to the CBD. It is advisable to leave the stent in the postoperative period and remove it after nearly 2 months. In the occurrence of a postoperative stricture, endoscopic treatment with positioning of multiple plastic stents is recommended until resolution.
In type IIb, the definitive solution appears to be hepaticojejunostomy. As for the type of surgical approach laparoscopy or laparotomy , laparoscopy is reserved to a very experienced surgeon. However, in our opinion, laparotomy allows better evaluation of biliary anatomy, avoiding any risk of bile duct injury and with the advantage of a more accurate surgical procedure. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We will be providing unlimited waivers of publication charges for accepted articles related to COVID Sign up here as a reviewer to help fast-track new submissions. Journal overview.
Mirizzi syndrome: a new insight provided by a novel classification
Mirizzi's syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common hepatic duct, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis inflammation. A cholecystocholedochal fistula can occur. Mirizzi's syndrome has no consistent or unique clinical features that distinguish it from other more common forms of obstructive jaundice.
Mirizzi Syndrome: Diagnosis and Management of a Challenging Biliary Disease
Mirizzi syndrome refers to an uncommon phenomenon that results in extrinsic compression of an extrahepatic biliary duct from one or more calculi within the cystic duct or gallbladder. It is a functional hepatic syndrome but can often present with biliary duct dilatation and can mimic other hepatobiliary pathologies such as cholangiocarcinoma 2. It can be associated with acute cholecystitis. Fistulae can develop between the gallbladder and the common duct, and the stone may pass into the common duct.
[Mirizzi Syndrome: Experience at Spanish Hospital of Veracruz]
Background: Mirizzi syndrome is a complication of gallbladder stones impacted in Hartmann's pouch or cystic duct with compression of the bile duct. The diagnosis is made by imaging studies, although most of them are found through intraoperative surgical findings. Treatment is cholecystectomy and bile duct restoration when needed. Objective: to analyze a series of cases of Mirizzi syndrome and compare the results with those published in the literature. Results: In our series the frequency of Mirizzi syndrome was 0.
Benign obstruction of the common hepatic duct Mirizzi syndrome : diagnosis and operative management. The following items were evaluated: clinical presentation, laboratory results, preoperative evaluation, operative findings, presence of choledocholithiasis, type of Mirizzi syndrome according to the classification by Csendes, choice of operative procedures, and complications. All the patients presented altered hepatic function tests. The diagnosis of Mirizzi syndrome was intra-operative in seven Cholecystocholedochal fistula associated with choledocholithiasis was observed in three Mirizzi syndrome was classified as Csendes type I in five Cholecystectomy, as an isolated surgical procedure, was performed in four