Benign obstruction of the common hepatic duct (Mirizzi syndrome): diagnosis and operative management.
ABSTRACT Mirizzi syndrome is a rare complication of prolonged cholelithiasis, characterized by narrowing of the common hepatic duct due to mechanical compression and/or inflammation due to biliary calculus impacted in the infundibula of the gallbladder or in the cystic duct.
To describe a series of eight consecutive patients with Mirizzi syndrome, at a single institution, submitted to surgical treatment and to comment on their aspects with emphasis on the diagnosis and treatment.
Four women and four men, with a mean age of 61.6 years (42 to 82 years), presenting Mirizzi syndrome were operated between 1997 and 2003. 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.
The most frequent symptoms were abdominal pain (87.5%) and jaundice (87.5%). All the patients presented altered hepatic function tests. The diagnosis of Mirizzi syndrome was intra-operative in seven (87.5%) patients, and preoperative in one (12.5%). Cholecystocholedochal fistula associated with choledocholithiasis was observed in three (37.5%) cases. Mirizzi syndrome was classified as Csendes type I in five (62.5%) patients, type II in one (12.5%), type III in one (12,5%) and type IV in another (12.5%). Cholecystectomy, as an isolated surgical procedure, was performed in four (50.0%) patients. One (12.5%) patient was submitted to partial cholecystectomy and closure of the fistulous orifice with the central part of the infundibula. Two (25.0%) patients were submitted to cholecystectomy and side-to-side choledochoduodenostomy and another (12.5%) to side-to-side choledochoduodenostomy remaining the gallbladder in situ. Seven (87.5%) patients had an uneventful recovery and were discharged in good conditions. One (12.5%) patient presented a postoperative sepsis due to a sub-hepatic abscess, and was reoperated. There was no operative mortality.
The preoperative diagnosis of Mirizzi syndrome is difficult and an awarded suspicion is necessary to avoid lesions of the biliary tree. The problem may only become evident during the operation due to firm adherences around Calot's triangle. The success of the treatment is related to a precocious recognition of the condition, even at the time of surgery, and adapting the management considering to the individual characteristics of each case.
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ABSTRACT: To determine the diagnostic accuracy of combined magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) for preoperative diagnosis of Mirizzi syndrome. Fifty-two patients with surgically proven Mirizzi syndrome (n = 13) and cholecystitis without evidence for Mirizzi syndrome (n = 39) underwent both MRCP using single-shot turbo spin echo and 3-dimensional turbo spin echo sequences and CT. Two blinded observers independently and retrospectively reviewed the combination of MRCP and CT images and CT images alone. Diagnostic accuracy for a combined protocol and CT was evaluated. The overall sensitivity, specificity, positive and negative predictive values, and accuracy of the combination of MRCP and CT were 96.0%, 93.5%, 83.5%, 98.5%, and 94.0%, respectively. Corresponding values of CT were 42.0%, 98.5%, 93.0%, 83.5%, and 85.0%, respectively. The sensitivity, negative predictive value, and accuracy of combined protocol were significantly higher than those of CT alone (P = 0.000, 0.001, and 0.042, respectively). Interobserver agreement was better for combined images (kappa = 0.906) than for CT images alone (kappa = 0.812). A combination of MRCP and CT is useful for preoperative diagnosis of Mirizzi syndrome.Journal of computer assisted tomography 06/2009; 33(4):636-40. · 1.38 Impact Factor
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ABSTRACT: Mirizzi syndrome is an unusual presentation of prolonged cholelithiasis. This study aimed to analyze the diagnostic methods, operative strategies, and outcome of the surgical treatment of patients with Mirizzi syndrome. We retrospectively evaluated the patients with Mirizzi syndrome treated in our General Surgery Clinic. The data collected included demographic variables, clinical presentation, diagnostic methods, surgical procedures, and postoperative complications. The study included 13 male and 21 female patients, with a mean age of 67.2 years. The incidence of Mirizzi syndrome was determined as 0.6% (34/5632), and type II was more frequently observed (52.9%); no patient was determined as type IV. The incidences of types I and III were 35.2% and 11.7%, respectively. Among the preoperative diagnostic evaluations, ultrasonography was the initial imaging study that was performed in all patients. Computerized tomography, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography were the other radiological studies. Surgical procedures included cholecystectomy for 83% of the patients with type I. The remaining cases and 14 of the type II patients (77.7%) underwent choledochotomy and T-tube insertion following cholecystectomy. Four of the patients with type II variety and all of the type III patients underwent cholecystectomy and roux-en-Y hepaticojejunostomy. All of the patients had complete recovery, with a morbidity rate of 5.8%, and there was no hospital mortality. The essential part of the management of patients with Mirizzi syndrome is to determine the best surgical procedure in the preoperative period. In type I patients, simple cholecystectomy is generally enough, but sometimes T-tube insertion may be required, while the cases with types II-IV require more complex surgical approach, such as cholecystectomy and bilioenteric anastomosis. Roux-en-Y hepaticojejunostomy is an appropriate procedure with good outcome.The Turkish journal of gastroenterology: the official journal of Turkish Society of Gastroenterology 01/2009; 19(4):258-63. · 0.48 Impact Factor
- Southern medical journal 02/2009; 102(2):130. · 0.92 Impact Factor