The Mirizzi Syndrome: Multidisciplinary Management Promotes Optimal Outcomes

Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
Journal of Gastrointestinal Surgery (Impact Factor: 2.8). 07/2008; 12(6):1022-8. DOI: 10.1007/s11605-007-0305-x
Source: PubMed


The Mirizzi syndrome (MS) is a rare cause of obstructive jaundice produced by the impaction of a gallstone either in the cystic duct or in the gallbladder, resulting in stenosis of the extrahepatic bile duct and, in severe cases, direct cholecystocholedochal fistula formation. Sixteen patients were treated for MS in our center over the 12-year period 1993--2005 for a prevalence of 0.35% of all cholecystectomies performed. One patient was diagnosed only at the time of cholecystectomy. The other 15 patients presented with laboratory and imaging findings consistent with choledocholithiasis and underwent preoperative endoscopic retrograde cholangiopancreatography, which established the diagnosis in all but one patient. All patients underwent cholecystectomy. An initial laparoscopic approach was attempted in 14 patients, of whom 11 were converted to open procedures. MS was recognized operatively in 15 patients with definitive stone extraction and relief of obstruction in 13 patients. T-tubes were placed in 10 patients and 1 patient required a choledochoduodenostomy. Two patients required postoperative laser lithotripsy via a T-tube tract to clear their stones; and in another patient, MS was detected and treated via postoperative endoscopic retrograde cholangiopancreatography (ERCP). MS remains a serious diagnostic and therapeutic challenge for endoscopists and biliary surgeons.

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    • "Mirizzi’s syndrome is a rare condition characterized by presence of a common hepatic duct obstruction caused by an extrinsic compression of an impacted stone in Hartmann’s pouch or the cystic duct. It presents in approximately 0.35% of cholecystectomies performed [4]. Predisposing factors include a long intra-mural cystic duct or a low insertion of the cystic duct into the common bile duct. "
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    ABSTRACT: Mirizzi's syndrome is a rarely observed disorder that presents with obstructive jaundice. The condition is caused by a stone impacted in the gall bladder neck or cystic duct that impinges on the common hepatic duct, with or without a cholecystocholedochal fistula. The condition is often confused with other serious conditions such as hilar cholangiocarcinoma, which present with similar clinical and imaging findings, and a pre-operative diagnosis may be a serious challenge. We present the case of a 44-year-old Asian man with Mirizzi's syndrome who was initially diagnosed as having cholangiocarcinoma based on his clinical presentation, raised cancer antigen 19-9 levels and radiological findings. Our patient was diagnosed as having Mirizzi's syndrome intra-operatively and subsequently a cholecystectomy was performed with restoration of biliary drainage. Careful clinical assessment during surgery with the help of intra-operative frozen section helped in establishing the definitive diagnosis and altered the surgical procedure for our patient. Pre-operative diagnosis of Mirizzi's syndrome could be challenging as the clinical, biochemical and radiological presentation is similar to other conditions causing obstructive jaundice such as choledocholithiasis, bile duct stricture or cholangiocarcinoma. A high index of suspicion and careful surgical assessment may help in establishing a diagnosis and alter the clinical course for our patient.
    Full-text · Article · Jun 2012 · Journal of Medical Case Reports
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    • "MS is a rare cause of jaundice due to extrinsic compression of the CHD and is present in approximately 0.35% of cholecystectomies.4 Many series report much higher rates; however, this may represent differing views on what constitutes a case of MS. "
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    ABSTRACT: Mirizzi syndrome is a rare complication of cholecystolithiasis characterized by jaundice due to compression of the common hepatic duct. The diagnosis may not be immediately apparent, and management is controversial with open surgery still recommended by some authors. A case is detailed herein of a 67-year-old man who presented with abdominal pain, fever, and jaundice. A dilated bile duct was found on ultrasound, but the gallbladder could not be seen. The diagnosis of Mirizzi syndrome was made at ERCP, and a stent was placed through the papilla. Laparoscopic retrograde (fundus first) cholecystectomy was carried out utilizing a laparoscopic liver retractor. In this particular case, it was not possible at ERCP to get a guidewire and stent past the obstruction. A stent was left through the papilla, below the obstruction and this allowed primary duct closure during surgery. Acute Mirizzi syndrome should be suspected when a patient presents with acute cholecystitis and jaundice with dilated intrahepatic ducts on ultrasound. ERCP is useful to confirm the diagnosis and allows stenting to alleviate the jaundice and facilitate the subsequent operation. Laparoscopic ultrasound is useful to locate the impacted stone and to partially replicate the touch of the surgeon's hand, which is not available in laparoscopic surgery.
    Full-text · Article · Apr 2009 · JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons
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    ABSTRACT: We discuss the case of a man with an unusual complication of gallstone disease. An 85-year-old patient presented to the emergency department with a 3-week history of abdominal pain in the right upper abdominal quadrant. Thoracoabdominal radiography demonstrated that the whole extrahepatic biliary tree, including the common bile duct, common hepatic duct, gallbladder, and left and right hepatic ducts, were visibly delineated by air. The operative findings revealed a small shrunken gallbladder, a fistula between the gallbladder fundus and the gastric antrum, and a cholecystohepatic fistula, corresponding to Mirizzi syndrome, type II. A large gallstone was found impacted in the jejunum. This patient seems to have developed initially a cholecystohepatic fistula. Due to the acute inflammatory process, the stone eroded through the gallbladder wall and into the gastric antrum, passing from the antrum into the small bowel, where it became impacted. We suggest that the natural history of Mirizzi syndrome does not end with a cholecystobiliary fistula but that the continuous inflammation in the triangle of Calot may result in a complex fistula involving not only the biliary tract but also the adjacent viscera.
    Full-text · Article · May 2005 · Journal of Gastrointestinal Surgery
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