Benign obstruction of the common hepatic duct (Mirizzi syndrome): Diagnosis and operative management

General Surgery Department, Hospital do Servidor Público Estadual de São Paulo Francisco Morato de Oliveira, São Paulo, SP, Brazil.
Arquivos de Gastroenterologia 03/2005; 42(1):13-8. DOI: 10.1590/S0004-28032005000100005
Source: PubMed


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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    • "The intraoperative confirmation of Mirizzi syndrome was made after the extraction of the large gallstone. The contracted gallbladder, the inflammatory wall and the subsequent adherence with the common bile duct (CBD) resulted to the wide communication (fistulas diameter: = 3.5 cm) [4]. After temporary stenting of the CBD through the fistula opening we classified the condition as Mirizzi syndrome type IV which represents the most uncommon type [8]. "
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    ABSTRACT: Mirizzi syndrome is a rare complication of prolonged cholelithiasis with presence of large, impacted gallstone into the Hartman's pouch, causing chronic extrinsic compression of common bile duct (CBD). Fistula formation between the CBD and the gallbladder may represent an outcome of that condition. According to Mirizzi's classification and Csendes's subclassification, Mirizzi syndrome type IV represents the most uncommon type (4%). Spontaneous biliary-enteric fistulas have also been rarely reported (1.2-5%) in a large series of cholecystectomies. Cholecystocolic fistula is the most infrequent biliary enteric fistula, causing significant morbidity and representing a diagnostic challenge. We describe a very rare, to our knowledge, combination of Mirizzi syndrome type IV and cholecystocolic fistula. A 52 year old male, presented to our clinic complaining of episodic diarrhea (monthly episodes lasting 16 days), high temperature (38 degrees C-39 degrees C), right upper quadrant pain without jaundice. The definitive diagnosis was made intraoperatively. Magnetic Resonance Imaging (MRI) and Endoscopic Retrograde Cholangiopancreatography (ERCP) demonstrated the presence of Mirizzi syndrome with cholecystocolic fistula formation. The patient was operated upon, and cholecystectomy, cholecystocolic fistula excision and Roux-en-Y biliary-enteric anastomosis were undertaken with excellent post-operative course. Appropriate biliary tree imaging with ERCP and MRI/MRCP is essential for the diagnosis of Mirizzi syndrome and its complications. Cholecystectomy, fistula excision and biliary-enteric anastomosis with Roux-en-Y loop appears to be the most appropriate surgical intervention in order to avoid damage to Calot's triangle anatomic elements. Particularly in our case, ERCP was a valuable diagnostic tool that Mirizzi syndrome type IV and cholecystocolic fistula.
    Full-text · Article · Feb 2007 · BMC Surgery
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    ABSTRACT: Mirizzi syndrome is a rare cause of obstructive jaundice. This entity should be considered in the d i ff e rential diagnosis of all patients with obstru c t i v e jaundice. Failure to recognize the condition preoperatively can result in a major bile duct injury, particularly during laparoscopic surg e r y [ 1 ] . The syndrome refers to obstruction of the common hepatic duct by extrinsic compression usually from a gallstone impacted in Hartmann's pouch or the cystic duct. Large gallstones that become impacted in this area produce common hepatic duct o b s t ruction by two mechanisms: mechanical obstruction by direct compression of the common hepatic duct, or they can cause obstru c t i o n secondary to repeated bouts of local inflammation. In 1948, A rgentinean surgeon Pablo Luis Mirizzi, first described a syndrome of common hepatic duct obstruction in the setting of longstanding cholelithiasis and cholecystitis [2] . The classic description of the disease includes four components: (a) a close parallel course of the cystic duct and the common hepatic duct, (b) an impacted stone in the cystic duct or the neck of the gallbladder, (c) common hepatic duct obstruction secondary to external compression by the cystic duct stone (and the surrounding inflammation), and (d) jaundice, with or without cholangitis. Mirizzi's syndrome is a rare complication of cholelithiasis, with an estimated incidence of 0.05-2.7% [1,3,4] . It presents as a spectrum of disease that varies from extrinsic compression of the common hepatic duct to the presence of a cholecystobiliary fistula. Often, this dangerous alteration to anatomy is not recognized pre o p e r a t i v e l y, and has the potential to lead to significant morbidity and biliary injury, particularly in the laparoscopic era. CLASSIFICATION There are three classifications which have been proposed to describe variants of Mirizzi syndrome, and to aid in selecting the appropriate therapeutic procedure. The original classification, by McSherry et al [5] , described two types. Type I referred to compression of the common hepatic duct by a stone impacted in the cystic duct or Hartmann's pouch. Type II referred to erosion of the calculus from the cystic duct into the common hepatic duct, producing a cholecystocholedochal fistula. Csendes et al [6] created a second classification taking into account the extent of fistula. Type I remained the same, external compression of the common hepatic duct due to a stone impacted at the neck of the gallbladder or at the cystic duct. Types II to IV lesion referred to the presence and extent of a cholecystobiliary (cholecystohepatic or cholecystocholedochal) fistula, due to erosion of the anterior or lateral wall of the common hepatic duct by impacted stones. The fistula involved less than one-third of the circumference of the common hepatic duct in type II. Involvement of between one-third and two-thirds of the circumference of the common hepatic duct was called a type III lesion, while destruction of the entire wall of the common hepatic duct was called a type IV lesion. In their original paper, a total of 219 patients were identified with Mirizzi's syndrome. The incidence of type I lesions was 11 per cent, type II, 41 per cent, type III, 44 per cent and type IV, four per cent. The majority had obstructive jaundice. The third classification, proposed by Nagakawa and colleagues [7] , expanded upon the definition of the Mirizzi syndrome. Type I referred to a stone impacted in the cystic duct or gallbladder neck. Type II was characterized by a fistula of the common duct. Type III was defined by hepatic duct stenosis due to a stone at the confluence of the hepatic and cystic ducts. Type IV was characterized by hepatic duct stenosis as a complication of cholecystitis in the absence of calculi impacted in the cystic duct or gallbladder neck. In one series of 30 patients, the frequency of these four types as described by Nagakawa et al was 14, 2, 6, and 8%, respectively [8] .
    Full-text · Article · Jan 2006
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