Mirizzi's syndrome: lessons learnt from 169 patients at a single center

BACKGROUNDS/AIMS: Mirizzi's syndrome (MS) poses great diagnostic and management challenge to the treating physician. We presented our experience of MS cases with respect to clinical presentation, diagnostic difficulties, surgical procedures and outcome. METHODS: Prospectively maintained data of all surgically treated MS patients were analyzed. RESULTS: A total of 169 MS patients were surgically managed between 1989 and 2011. Presenting symptoms were jaundice (84%), pain (75%) and cholangitis (56%). Median symptom duration s was 8 months (range, <1 to 240 months). Preoperative diagnosis was possible only in 32% (54/169) of patients based on imaging study. Csendes Type II was the most common diagnosis (57%). Fistulization to the surrounding organs (bilio-enteric fistulization) were found in 14% of patients (24/169) during surgery. Gall bladder histopathology revealed xanthogranulomatous cholecystitis in 33% of patients (55/169). No significant difference in perioperative morbidity was found between choledochoplasty (use of gallbladder patch) (15/89, 17%) and bilio-enteric anastomosis (4/28, 14%) (p=0.748). Bile leak was more common with choledochoplasty (5/89, 5.6%) than bilio-enteric anastomosis (1/28, 3.5%), without statistical significance (p=0.669). CONCLUSIONS: Preoperative diagnosis of MS was possible in only one-third of patients in our series. Significant number of patients had associated fistulae to the surrounding organs, making the surgical procedure more complicated. Awareness of this entity is important for intraoperative diagnosis and consequently, for optimal surgical strategy and good outcome.

Risk Factors for Development of Biliary Stricture in Patients Presenting with Bile Leak after Cholecystectomy

BACKGROUND/AIMS: This study was aimed at determining the factors associated with the development of benign biliary stricture (BBS) in patients who had sustained a bile duct injury (BDI) at cholecystectomy and developed bile leaks. METHODS: A retrospective analysis of 214 patients with BDI who were referred to our center between January 1989 and December 2009 was done. RESULTS: One hundred fifty-three (71%) patients developed BBS (group I), and 61 (29%) were normal (group II). By univariate analysis, female gender (p=0.02), open cholecystectomy as the index operation (p=0.0001), delay in the referral from identification of injury (p=0.04), persistence of an external biliary fistula (EBF) beyond 4 weeks (p=0.0001), EBF output >400 mL (p=0.01), presence of jaundice (p=0.0001), raised serum total bilirubin level (p=0.0001), raised serum alkaline phosphatase level (p=0.0001), and complete BDI (p=0.0001) were associated with the development of BBS. Furthermore, open cholecystectomy as the index operation (p=0.04), delayed referral (p=0.02), persistent EBF (p=0.03), and complete BDI (p=0.001) were found to predict patient outcome in the multivariate analysis. CONCLUSIONS: For the majority of patients with BDI, the risk of developing BBS could have been predicted at the initial presentation.

Tuberculosis of the Spleen as a Cause of Fever of Unknown Origin and Splenomegaly

BACKGROUND/AIMS: Splenic involvement of tuberculosis, which is rare, warrants better definition in the current era of resurgence of tuberculosis. METHODS: Out of 339 splenectomies performed between January 1989 and December 2008 for indications other than trauma, histopathologic analysis of the spleen revealed tuberculosis in 8 patients. RESULTS: All eight patients were referred for splenectomy due to fever of unknown origin (FUO). No patient was infected with HIV, and all had at least moderate splenomegaly and hepatomegaly. Three patients had hypersplenism with bleeding manifestations. Radiologic evaluations demonstrated that splenic lesions were present in five patients. Five patients had evidence of tuberculosis manifested as enlarged splenic hilar lymph nodes, cystic lymph nodes, or liver. Two patients exhibited tubercle bacilli in their sputum during the postoperative period. CONCLUSIONS: In areas where tuberculosis is prevalent, tuberculosis should be considered in the differential diagnosis of patients presenting with FUO and splenomegaly. Extrasplenic involvement is usually seen in splenic tuberculosis, although it may not be apparent at presentation. Splenic tuberculosis can present in isolation without extrasplenic involvement, and even in immunocompetent individuals.