Mirizzi syndrome: ten years experience from a teaching hospital in Riyadh.

OBJECTIVE: Mirizzi syndrome (MS) is an uncommon presentation of cholelithiasis. This study aims to find the incidence and analyze the outcome of management of this condition at Riyadh Medical Complex (RMC) with particular reference to diagnostic methods and outcome of surgical treatment. METHODS: Retrospective study on 17 consecutive patients of MS diagnosed and managed at RMC over ten year period. The records were reviewed for demography, clinical presentation, diagnostic methods, operative procedures, postoperative complication and follow up. RESULTS: The incidence of MS syndrome was 0.7% of 2415 cholecystectomies. There was preponderance of Type I variety (58.8%). Ultrasonography was able to diagnose 82% cases. ERCP suggested the diagnosis in all cases and helped further in classifying and management of these patients. All Type I cases were managed with partial cholecystectomy, two underwent laparoscopic surgery. Three Type II patients were managed by partial cholecystectomy alone. Three patients with Type III variety had choledochoplasty whereas one remaining patient with Type IV variety underwent hepatico-jejunostomy. All patients had complete recovery with 17.6% procedure-related morbidity and no hospital mortality. All patients are doing well over a mean follow up 6.5 years. CONCLUSION: Preoperative diagnosis of Mirizzi syndrome by ultrasound and ERCP is essential to prevent serious complications during surgery. Partial cholecystectomy is an adequate procedure for Types I & II MS. Choledochoplasty provides an effective surgical repair in Type III cases. Although laparoscopic cholecystectomy in MS may be hazardous, it may still be tried in preoperatively diagnosed type I cases, provided the surgeon is experienced and keeps a low threshold for conversion open surgery.

Role of preoperative endoscopic retrograde cholangio pancreaticography in the management of mild to moderate acute biliary pancreatitis.

BACKGROUND: Controversy still exists about the role and timing of endoscopic retrograde cholangiopancreaicotography (ERCP) in mild to moderate biliary pancreatitis. Routine preoperative ERCP detects persisting common bile duct stones but is associated with definite morbidity and may delay definitive care. AIM OF STUDY: The study aims to evaluate the role of ERCP in the management of mild to moderate acute biliary pancreatitis. PATIENTS AND METHODS: The records of 196 patients with diagnosis of mild to moderate acute biliary pancreatitis (ABP) were retrospectively reviewed over four-years period. The various parameters examined were age, sex, clinical presentation, laboratory values, radiological studies, and severity of the attack, preoperative ERCP, surgical intervention and length of hospital stay. Pre operative ERCP was performed in 136 (67%) patients. Indications of ERCP were presence of jaundice, dilated common bile duct on ultrasonography, persistent hyperamylasemia, and associated cholangitis. In 17 patients with old age and multiple medical problems, ERCP served as a definite procedure. RESULTS: Mild to moderate cases accounted for 91% of ABP. Liver function tests (bilirubin, ALP, AST, ALT) were raised in 64% of cases. persistent hyperamylasemia in 4%, dilated CBD was observed in 14% associated cholangitis was present in 11%. Preoperative ERCP was positive in 22 (16%) patients, only where a CBD stones could be found and an endoscopic sphincterotomy) (ES) was performed. Positive predictive values were 25% for the high bilirubin level, 22% for the high ALP level, 50% for the persistent hyperamylasemia, 57% for the dilated CBD, 45% for the associated cholangitis. ERCP was associated with a morbidity rate of 3.6% with no mortality. The procedure was regarded as unnecessary in 84% of cases, where it increased the length of hospital stay by a mean of 2, 3 days. CONCLUSION: Preoperative ERCP was therapeutic in only 16% in cases of mild to moderate ABP. It should be done only on selective basis. In elderly patients with multiple medical problems. ERCP and ES can serve as definitive treatment.