Mirizzi syndrome grades III and IV: surgical treatment / Síndrome de Mirizzi graus III e IV: tratamento cirúrgico

ABSTRACT Objective : to evaluate the epidemiology and outcomes of surgical treatment of patients with Mirizzi Syndrome (MS) grades III and IV, the most advanced according to Csendes classification. Methods : we conducted a retrospective, cross-sectional study by reviewing records of thirteen patients with grades III and IV MS operated from December 2001 to September 2013, among the 3,691 cholecystectomies performed in the period. Results : the incidence of MS was 0.6% (23 cases) and grades III and IV amounted to 0.35% of this number. There was a predominance of type IV (12 cases). The preoperative diagnosis was possible in 53.8% of cases. The preferred approach was biliary-digestive derivation (10 cases), and "T" tube drainage with suture of the bile duct was the choice in three special occasions. Three patients had biliary fistula resolved with clinical management, and one coliperitoneum case required reoperation. In the outpatient follow-up of patients who underwent biliodigestive anastomosis (eight), 50% are asymptomatic, 25% had anastomotic stricture and 25% lost follow-up. The mean follow-up was 41.8 months. Conclusion : MS in advanced degrees has low incidence, preoperative diagnosis in only half of cases, and has the biliodigestive anastomosis as the best conduct, but not without morbidity.

RESUMO Objetivo: avaliar a epidemiologia e os resultados do tratamento cirúrgico de doentes portadores de graus III e IV, mais avançados, da Síndrome de Mirizzi (SM) de acordo com a classificação de Csendes. Métodos: estudo retrospectivo, de corte transversal através da revisão de prontuários de 13 pacientes portadores de graus III e IV da SM operados de dezembro de 2001 a setembro de 2013, entre 3691 colecistectomias realizadas neste período. Resultados: a incidência da SM foi 0,6% (23 casos) e os graus III e IV perfizeram 0,35% deste número. Houve um predomínio de tipo IV (12 casos). O diagnóstico pré-operatório foi possível em 53,8% dos casos. A conduta preferencial foi derivação biliodigestiva (10 casos) e foi optado por drenagem com tubo "T" e sutura da via biliar em três ocasiões especiais. Três pacientes apresentaram fístula biliar resolvida com conduta expectante e um caso de coleperitônio necessitou reoperação. No seguimento ambulatorial dos pacientes que realizaram a anastomose biliodigestiva (oito), 50% estão assintomáticos, 25% apresentaram estenose da anastomose e 25% perderam seguimento. O tempo médio de acompanhamento foi 41,8 meses. Conclusão: de incidência baixa e de diagnóstico pré-operatório em apenas metade dos casos, a SM em graus avançados tem na anastomose biliodigestiva sua melhor conduta, porém não isenta de morbimortalidade.

El síndrome de Mirizzi, un desafío para el cirujano / Mirizzi syndrome, a challenge for the surgeon

El síndrome de Mirizzi es una inflamación poco frecuente y crónica ocasionada por un cálculo impactado en la bolsa de Hartmann con obstrucción parcial o completa del conducto biliar principal. Es una complicación prolongada de la enfermedad litiásica biliar e infiere un diagnóstico preoperatorio difícil, así como una compleja conducción terapéutica. El objetivo de este trabajo es realizar una actualización del tema sobre el diagnóstico y tratamiento de esta entidad. Se realizó una revisión de las bases de datos Pubmed, Dynamed y Conchrane (idioma inglés y español) en busca de los artículos relacionados con el síndrome de Mirizzi. Trabajos adicionales fueron identificados mediante búsqueda manual de las referencias de artículos relevantes. Se presentó una actualización detallada acerca del diagnóstico y tratamiento de esta entidad teniendo en cuenta la experiencia del autor y los hallazgos de la revisión realizada. Para lograr un diagnóstico preoperatorio e intraoperatorio certero se requiere un alto índice de sospecha, llevando a una óptima proyección quirúrgica para tratar esta entidad(AU)

Mirizzi syndrome is a rare and chronic inflammation, caused by a calculus stuck to the Hartmann bag, with partial or complete obstruction of the main bile duct. It is a lengthened complication of lithiasic biliary disease and effects a difficult preoperative diagnosis and a therapeutic complex treatment. To perform an updating about the of subject and to present the "state of art" diagnosis and treatment for this entity. A review of PubMed, Dynamed and Conchrane data was made (in both English and Spanish), looking for articles about Mirizzi syndrome. Additional papers were identified by manual search for references of relevant articles. A detailed updating on the diagnosis and treatment of this entity was presented, taking into account the experience of the author and the findings from the review. High suspicion index is required for an accurate preoperative and intraoperative surgical diagnoses leading to an optimal approach to treat this condition(AU)

Síndrome de Mirizzi tipo IV: diagnóstico y manejo mediante colangiopancreatografía retrógrada endoscópica: reporte de caso / Mirizzi Syndrome Type IV: diagnosis and management through retrograde endoscopic cholangiopancreatography: case report

El síndrome de Mirizzi es una rara complicación de la colelitiasis, caracterizado por obstrucción mecánica del conducto hepatocolédoco por un cálculo impactado en el cístico o en el cuello vesicular. Después de un período de tiempo puede desarrollarse una fístula colecistobiliar por destrucción de la pared del colédoco. Según la clasificación de Csendes, el tipo IV es el menos frecuente. Se presentó un caso con antecedente de colelitiasis que ingresa con cuadro clínico compatible con colangitis aguda. Se realiza CPRE electiva, diagnosticándose síndrome de Mirizzi tipo IV y se coloca prótesis como puente para el tratamiento quirúrgico. Ante un paciente con esas características, la CPRE resulta un método diagnóstico y terapéutico indispensable.

The Mirizzi syndrome is a cholelithiasis rare complication, characterized by the mechanical obstruction of the hepato choledocus duct by a calculus impacted in the cystic or in the vesicular neck. We presented a case with cholelithiasis antecedents entering the hospital with a clinical picture compatible with acute cholangitis. We made an elective cholangiopancreatography finding a big protraction of the intrahepatic biliary tracts, stretch of the supraduodenal choledoc with a common cystic-vesicular neck and choledocian environment, forming a great duct of near 20 mm diameter, having inside an ovoid filling mistake which bigger diameter is 15 mm, directed to the choledocus and to the vesicle. We diagnosed a Mirizzi syndrome Type IV. In a patient with those characteristics, the cholangiopancreatography is an unavoidable diagnostic and therapeutic method.

Síndrome de Mirizzi: estudo de 11 casos / Mirizzis syndrome: report of eleven cases

Objetivo: descrever série de onze pacientes com síndrome de Mirizzi, submetidos a tratamento cirúrgico, comentando os aspectos etiopatogênicos e apresentação clínica, com ênfase no diagnóstico e tratamento. Métodos: estudo retrospectivo de onze pacientes consecutivos submetidos a tratamento cirúrgico. Foram considerados para apreciação: aspectos demográfico, clínicos, laboratoriais, meios diagnósticos, achados intraoperatórios, classificação dos doentes de acordo com Csendes et al., tática cirúrgica empregada e evolução pós-operatória. Resultados: dez pacientes (91,0%) eram mulheres e um (9,0%) homem. Os seguintes sintomas foram observados: dor e icterícia em todos os pacientes, colúria em nove (81,0%), náuseas e vômitos em sete (63,0%), acolia fecal em cinco (45,0%) e tumor palpável em um (9,0%). Os exames de laboratório mostraram leucocitose igual ou superior a 15.000 /mm3 em 45,0%. A bilirrubina total variou de 3,1 a 19,0 mg/dl. A ultrassonografia feita em todos pacientes mostrou presença de colelitíase e dilatação de V.B. em 77,7% e vesícula escleroatrófica em 27,0%. A tomografia computadorizada abdominal foi realizada em 9,0% e colangiopancreatografia em 18,0%. Os casos foram classificados, segundo Csendes, em: tipo I (quatro), tipo II (dois), tipo III (três) e tipo IV (dois) pacientes. Todos foram operados por cirurgia convencional. Destes, quatro (36,0%) apresentavam colangite, sendo três (27,0%) operados na urgência e um outro evoluiu com colangite durante a investigação, sendo operado no 19 dia. Os demais foram internados e operados eletivamente. Realizou-se: colecistectomia e derivação biliodigestiva em seis pacientes (54,0%), colecistectomia e coledocotomia em três (27,0%) e colecistectomia simples em dois casos (18%). No pós-operatório, nove (82,0%) evoluíram bem e tiveram alta hospitalar. Dois pacientes (18,0%) foram a óbito. Conclusões: todos os pacientes apresentavam sinais e sintomas de icterícia obstrutiva e em quase metade o hemograma era infeccioso. Apenas em três casos houve suspeita diagnóstica no pré-operatório. Os pacientes estáveis, sem infecção, que permitiram melhor investigação evoluíram favoravelmente. O tratamento da síndrome de Mirizzi é cirúrgico, variando a tática de acordo com o tipo da lesão.

Objectives: to report a series of eleven patients with Mirizzis syndrome submitted to surgical treatment. The authors present the etiopathogenic and clinical aspects of the disease. Methods: retrospective study of the eleven patients consecutive submitted to surgical treatment. The authors analysed the demografic, clinical and laboratory data, as well as intraoperative findings. They also classified the lesion according to Csendes classification, and presented the surgical management and post-operative follow-up. Results: there were 10 female patients (91.0 %) and 1 male patient (9.0%). Symptoms and signs were diffuse upper abdominal pain and jaundice in all patients, choluria in 9 (81%), nausea and vomit in 7 (63%), fecal acholia in 5 (45.0%) and a palpable tumor in 1 patient (9.0%). The laboratory exams showed leucocytosis equal or superior to 15.000/mm³ (45%) and the plasma bilirrubin varied between 3.1 mg/dL and 19.0 mg/dL. Ultrasonography showed in all patients the presence of cholelithiasis. There was dilation of gallbladder in 77.5% of the cases and scleroatrophic gallbladder in 27.0% patients. CT scan was realized in 9.0% and cholangiopancreatography in 18% of patients. The cases were classified according to Csendes classification. There were four type I, two type II, three type III and two type IV. All eleven cases were managed by classical open technique. Four patients (36%) presented with cholangitis; three of these patients had emergency operations and one presented cholangitis during the workup investigation, being operated on day 19 of admission. The others had elective operations. The surgical operations were: cholecystectomy and biliodigestive deviation in 6 patients (54%), cholecystectomy and choledochotomy in 3 patients (27%) and only cholecystectomy in 2 patients (18%). The postoperative course was uneventful in 9 patients (82%), but 2 patients (18%) died. Conclusion: all patients presented symptoms and signs of obstructive jaundice, and nearly half of these had infectious hemogram. The diagnosis of Mirizzis syndrome was suspected in only three patients. A complete diagnostic investigation was possible only in stable patients without infection, and these patients had a favorable course. Treatment of Mirizzis syndrome is surgical and the choice of operative approach varies according to the type of lesion.

Mirizzi syndrome : a diagnostic and surgical problem

This study was conducted at King Saud Hospital [350 beds], Al-Qassim Region, Saudia Arabia; between December 2000 till May 2005. The aim of this work is to describe a series of 13 patients presented with obstructive jaundice and proved to have Mirizzi syndrome, at a single institution, submitted to surgical treatment and to comment on their aspects with emphasis on the diagnosis and treatment The following items were evaluated: clinical presentation, laboratory results, preoperative evaluation, operative findings, type of Mirizzi syndrome according to the classification of Csendes et al, 1989, choice of operative procedures, and complications. The study comprised 13 patients [5 males and 8 females with mean age 58.2+9.3 years] with MS detected out of 1834 patients [0.7%] treated for cholelithiasis during the period of the study. Preoperative radiological examination succeeded in the diagnosis of MS in 6 cases; 2 cases by ultrasonography [15.4%], 4 cases by ERCP [30.8%], one out of 4 cases by CT [25%] and one out of 4 cases by MRCP [25%] and failed to diagnose 7 cases with a success rate of 46.2%. Surgical exploration through a right subcostal incision detected the presence of impacted stone in the infundibulum of the gallbladder or in the cystic duct of the all patients; there were 4 patients [30.8%] with MS type I, 3 patients [23.1%] had MS type II, 2 patients [15.4%] had MS type III and 4 patients [30.8%] had MS type IV. The surgical procedure done was cholecystectomy for patients with type I MS, Cholecystectomy, primary closure of the cholecysto biliary fistula and T- tube drainage of CHD for patients with MS type II. Patients with MS type III underwent cholecystectomy and choledochoduo denostomy, while cholecystectomy and Roux-en-Y hepatic jejunostomy were done for patients with MS type IV. Liver function tests returned to normal values in all patients within 43.8+20.7 days [range 30-70 days postoperatively] and the mean duration of post-operative and follow-up was 20.7+12.8 months [range: 6-48 months] with no postoperative major procedure-related complications or mortality. It could be concluded that MS is an uncommon form of benign obstructive jaundice identified with a frequency of 0.7% of patients with cholelithiasis. The preoperative diagnosis of Mirizzi syndrome is difficult and an awarded suspicion is necessary to avoid injuries of the biliary tree. The problem may only become evident during the operation due to firm adhesions around Calot's triangle. The success of the treatment is relate precocious recognition of the condition during surgery, and adapting the. management according to the individual characteristics of each case