Síndrome de Mirizzi, complicación inusual de la colelitiasis / Mirizzi Syndrome, a Rare Complication of Cholelithiasis

Introducción: El síndrome de Mirizzi es una entidad clínica rara y difícil de tratar; sin embargo, los avances tecnológicos recientes han brindado a los cirujanos nuevas opciones para un diagnóstico y tratamiento más efectivos de esta afección. Objetivo: Presentar el caso de síndrome de Mirizzi, complicación inusual de la colelitiasis. Presentación del caso: Se presenta una paciente femenina, de 56 años de edad, que acude a nuestra institución por presentar ictericia intermitente, dolor en el hipocondrio derecho, coluria y acolia. Conclusiones: El síndrome de Mirizzi, complicación de la colelitiasis, es una entidad poco frecuente, de difícil diagnóstico preoperatorio, por lo que en un gran porcentaje de los casos se diagnostica intraoperatoriamente. Su tratamiento es quirúrgico(AU)

Introduction: Mirizzi syndrome is a rare condition, difficult to treat; however, recent technological advances have provided surgeons with new options for diagnosing and treating this condition more effectively. Objective: To present a case of Mirizzi syndrome, an unusual complication of cholelithiasis. Case presentation: The case is presented of a 56-year-old female patient, who comes to our institution with intermittent jaundice, right hypochondrium pain, choluria and acholia. Conclusions: Mirizzi syndrome, a complication of cholelithiasis, is a rare entity, difficult to diagnose preoperatively; therefore, a large percentage of it's cases are diagnosed intraoperatively. Its treatment is surgical(AU)

Laparoscopic management of type II Mirizzi syndrome.

BACKGROUND: Mirizzi syndrome is an uncommon complication of longstanding gallstone disease. Pre-operative diagnosis is challenging, and to date, there is no consensus on the standard management for this condition. Until recently open cholecystectomy was the standard of care for type II Mirizzi syndrome (McSherry classification). The objective of this study was to assess the incidence and management of type II Mirizzi syndrome in patients with proven or suspected choledocholithiasis undergoing laparoscopic common bile duct (CBD) exploration and present our experience in the laparoscopic management of this rare condition over the last 21 years. METHODS: Prospective data collection of eleven cases of type II Mirizzi syndrome amongst a series of 425 laparoscopic bile duct explorations was performed between 1998 and 2019. Demographic, clinical, diagnostic, intra-operative, and post-operative data were recorded. RESULTS: The incidence of type II Mirizzi syndrome was 2.6% in 425 laparoscopic CBD explorations. All operations were completed laparoscopically with closure of the defect over a decompressed CBD (T-tube n = 3, antegrade stent n = 5, transcystic drain n = 2), and in one case a non-drained duct was closed with Endoloop. Stone clearance rate was 100% (11 cases). In two patients the transinfundibular approach was used in conjunction with holmium laser lithotripsy to enable choledochoscopy and successful stone clearance. Three patients were complicated in the post-operative period with bile leak (n = 2) and lower respiratory tract infection (n = 1). An incidental gallbladder carcinoma was found in one patient. CONCLUSION: Laparoscopic management of type II Mirizzi syndrome is feasible and safe when performed by experienced laparoscopic foregut surgeons. Laparoscopy and choledochoscopy can be combined with novel approaches and techniques to increase the likelihood of treatment success.

Mirizzi syndrome grades III and IV: surgical treatment.

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. 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.

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.

Mirizzi Syndrome: How it could be a challenge.

BACKGROUND/AIMS: Mirizzi syndrome (MS) is a rare complication of cholelithiasis. This entity should be considered in the differential diagnosis of all patients with obstructive jaundice. Failure to recognize this condition preoperatively can result in a major bile duct injury. In this study, our aim is to describe the clinical presentations, investigations, operative details, endoscopic management and the complications of both procedures. METHODOLOGY: We performed a retrospective analysis on the records of 65 patients with MS. All patients had a cholangiogram; either magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). We used a McSherry classification to divide patients with MS into type I MS and type II MS. Those patients had undergone different types of management either ERCP and/or surgery. RESULTS: The incidence of MS was 0.98% from a total of 4600 patients who had undergone cholecystectomy. From 65 patients with MS, 20 patients underwent ERCP where it was the sole treatment (18 of which had stent while 2 had the stone extracted). The overall surgically treated patients were 45 (23 patients with preliminary ERCP with stent and 22 patients with primary surgical treatment), 18 patients had MS type I while 27 patients had MS type II. Patients with different types of MS underwent different types of surgical procedures.

[Mirizzi Syndrome: Prevalence, diagnosis and treatment]. / Síndrome de Mirizzi: Prevalencia, diagnóstico y tratamiento.

BACKGROUND: The Mirizzi syndrome was described by Pablo Luis Mirizzi in 1948, who emphasized this syndrome was characterized by the obstruction of the common hepatic duct due to mechanical compression caused by an impacted stone in the gallbladder neck or in the cystic duct. The incidence ranges from 0.05% to 4%. MATERIAL AND METHODS: We performed a retrospective cross-sectional study. Based on the database of the General Surgery Division of the Prof Alejandro Posadas National Hospital, between July 2007and June 2013, charts of all patients with biliary lithiasis disease operated in this period were analyzed. We analyzed the clinical features, the various diagnostic techniques and the treatment carried out in each of them. RESULTS: Surgery due to biliary lithiasis was performed in 2,160 patients. Fourteen patients, 8 females and 6 males, had Mirizzi syndrome (0.65%). The mean age was 55.3 years old (range 34-70 years old). Four patients were scheduled for elective surgery and 10 were operated during emergency. Preoperative differential diagnosis was: extrahepatic cholestasis 10, cholecystitis 3 and biliary duct stenosis vs gallbladder cancer 1. The treatments performed were: 3 conventional cholecystectomies with intraoperative dynamic cholangiography, 2 conventional cholecystectomies plus choledochoplasty with Kehr tube, 2 laparoscopic cholecystectomies plus choledochoplasty with Kehr tube, 1 partial cholecystectomy with Pezzer catheterization, 3 choledochoduodenostomy, 1 choledochoplasty with gallbladder remnant, 1 hepaticojejunostomy and 1 treatment in two steps (percutaneous biliary drainage and cholecystectomy). Regarding complications, we observed 1 autolimited leak from the choledocoduodenostomy, 1 death in an ederly patient, and 1 hepatic abscess treated by a minimaly invasive approach. CONCLUSIONS: Mirizzi syndrome is a disease with low prevalence, which must be taken into account in biliary surgery, because the treatment varies according to the intraoperative findings and the experience of the surgical team.

[Mirizzi syndrome: experience at Spanish Hospital of Veracruz]. / Síndrome de Mirizzi. Experiencia del Hospital Español de Veracruz.

BACKGROUND: Mirizzi syndrome is a complication of gallbladder stones impacted in Hartmann's pouch or cystic duct with compression of the bile duct. The diagnosis is made by imaging studies, although most of them are found through intraoperative surgical findings. Treatment is cholecystectomy and bile duct restoration when needed. OBJECTIVE: to analyze a series of cases of Mirizzi syndrome and compare the results with those published in the literature. CLINICAL CASE: We report 4 cases with Mirizzi syndrome in a cohort of 1,034 cases studied in the Hospital Español of Veracruz over 21 years. RESULTS: In our series the frequency of Mirizzi syndrome was 0.38%, the average age was 32.1 ± 58.4 years, 50% were male gender and 25% had jaundice with a demonstrable liver profile. In 1 case, ultrasound suggested Mirizzi syndrome and percutaneous cholangiography and computed tomography confirmed the diagnosis. All patients underwent laparoscopic cholecystectomy, and 2 transcystic cholangiographies were performed. One case was classified as Type I-A and three as type I-B. (Beltran and Csendes). The postoperative evolution was satisfactory in all and no mortality was presented. CONCLUSIONS: Mirizzi syndrome should be suspected in patients with gallstones who develop obstructive jaundice and it must be confirmed with imaging studies. The surgeon must take extreme precautions to avoid accidental injury to the bile ducts.

Antecedentes: el síndrome de Mirizzi es una complicación de la litiasis vesicular por cálculos impactados en la bolsa de Hartmann o conducto cístico que comprimen la vía biliar principal; el diagnóstico se establece mediante estudios de imagen, aunque la mayor parte son hallazgos transoperatorios; su tratamiento es la colecistectomía con restauración de la vía biliar. Objetivo: analizar una serie de casos de síndrome de Mirizzi y comparar los resultados con lo publicado en la bibliografía mundial. Casos clínicos: se comunican cuatro casos con síndrome de Mirizzi de una cohorte de 1,034 casos con enfermedad litiásica vesicular del Hospital Español de Veracruz, en 21 años. La frecuencia en esta muestra es de 0.38%, con edad promedio de 32.1 ± 58.4 años; 50% son hombres y 25% tuvo ictericia y coluria con perfil hepático demostrativo. En un caso el ultrasonido sugirió síndrome de Mirizzi; el diagnóstico se corroboró por colangiografía percutánea y tomografía computada. A todos los pacientes se les realizó colecistectomía laparoscópica, y en dos se efectuó colangiografía transcística. Un caso correspondió al tipo I-A y 3 al tipo I-B según la Clasificación de Beltrán y Csendes. La evolución postoperatoria fue satisfactoria y no hubo mortalidad. Conclusiones: el síndrome de Mirizzi debe sospecharse en pacientes con litiasis vesicular con ictericia obstructiva. El cirujano debe extremar las precauciones para evitar lesionar la vía biliar.

Appraisal of diagnosis and surgical approach for Mirizzi syndrome.

BACKGROUND: Mirizzi syndrome is an important and rare complication of gallstone disease. This study aims to evaluate the treatment approach by analysing the diagnostic method and the outcome of surgical treatment in our hospital. METHODS: We retrospectively analysed the data of 198 patients with Mirizzi syndrome between January 2004 and January 2010. The records were reviewed for demography, clinical presentation, diagnostic method, operative procedure, postoperative complication and follow-up. RESULTS: The incidence of Mirizzi syndrome was 0.66% of 29 875 patients who underwent cholecystectomy for cholelithiasis. The incidence of types I, II, III and IV was 59.1%, 24.7%, 13.1% and 3.1%, respectively. In this study, ultrasonography and magnetic resonance cholangiopancreatography (MRCP) could have the suspicion of Mirizzi syndrome in 77.8% and 82.3% of cases. Cholecystectomy also has been shown to be effective for type I Mirizzi syndrome. Our common surgical approach in Mirizzi syndrome types II and III was partial cholecystectomy without removal of the portion of gallbladder around the fistula margin. For some cases, choledochoplasty was needed. For Mirizzi syndrome type IV, we performed hepaticojejunostomy for all patients. CONCLUSION: Ultrasound, MRCP and endoscopic retrograde cholangiopancreatography in combination with choledochoscope procedure in operation could improve the diagnostic sensitivity of Mirizzi syndrome. Intraoperative choledochoscope is effective to confirm Mirizzi syndrome during operation. Open surgery is the current standard for managing patients with Mirizzi syndrome. Laparoscopic surgery should be confined to Mirizzi syndrome type I and patients should be selected very strictly.