Mirizzi syndrome:Problems and strategies

Mirizzi syndrome is a serious complication of gallstone disease.It is caused by the impacted stones in the gallbladder neck or cystic duct.One of the features of Mirizzi syndrome is severe inflammation or dense fibrosis at the Calot’s triangle.In our clinical practice,bile duct,branches of right hepatic artery and right portal vein clinging to gallbladder infundibulum are often observed due to gallbladder infundibulum adhered to right hepatic hilum.The intraoperative damage of branches of right hepatic artery occurs more easily than that of bile duct,all of which are hidden pitfalls for surgeons.Magnetic resonance cholangiopancreatography(MRCP)and endoscopic retrograde cholangiopancreatography(ERCP)are the preferable tools for the diagnosis of Mirizzi syndrome.Anterograde cholecystectomy in Mirizzi syndrome is easy to damage branches of right hepatic artery and bile duct due to gallbladder infundibulum adhered to right hepatic hilum.Subtotal cholecystectomy is an easy,safe and definitive approach to Mirizzi syndrome.When combined with the application of ERCP,a laparoscopic management of Mirizzi syndrome by well-trained surgeons is feasible and safe.The objective of this review was to highlight its existing problems:(1)low preoperative diagnostic rate,(2)easy to damage bile duct and branches of right hepatic artery,and(3)high concomitant gallbladder carcinoma.Meanwhile,the review aimed to discuss the possible therapeutic strategies:(1)to enhance its preoperative recognition by imaging findings,and(2)to avoid potential pitfalls during surgery.

Type I Mirizzi syndrome treated by electrohydraulic lithotripsy under the direct view of SpyGlass:A case report

BACKGROUND Mirizzi syndrome is an uncommon clinical complication for which the available treatment options mainly include open surgery,laparoscopic surgery,endoscopic retrograde cholangiopancreatography(ERCP),electrohydraulic lithotripsy,and laser lithotripsy.Here,a patient diagnosed with type I Mirizzi syndrome was treated with electrohydraulic lithotripsy under SpyGlass direct visualization,which may provide a reference to explore new treatments for Mirizzi syndrome.CASE SUMMARY This paper describes a middle-aged female patient with suspected choledocholithiasis who complained for over 1 mo of intermittent abdominal pain,dark yellow urine,jaundice,and was proposed to undergo ERCP lithotomy.Mirizzi syndrome was found during the operation and confirmed by SpyGlass.Electrohydraulic lithotripsy was performed under the direct vision of SpyGlass.After the lithotripsy,the stones were extracted using the stone extraction basket and balloon.After the operation,the patient developed transient hyperamylasemia.Through a series of symptomatic treatments(such as fasting,fluids and antiinflammation medications),the symptoms of the patient improved.Finally,laparoscopic cholecystectomy or open cholecystectomy was performed after a half-year post-operatively.CONCLUSION Direct visualization-guided laser or electrohydraulic lithotripsy with SpyGlass is feasible and minimally invasive for type I Mirizzi syndrome without apparent unsafe outcomes.

Mirizzi syndrome:History,current knowledge and proposal of a simplified classification

Chronic complications of symptomatic gallstone disease, such as Mirizzi syndrome, are rare in Western developed countries with an incidence of less than 1% a year. The importance and implications of this condition are related to their associated and potentially serious surgical complications such as bile duct injury, and to its modern management when encountered during laparoscopic cholecystectomy. The pathophysiological process leading to the subtypes of Mirizzi syndrome has been explained by means of a pressure ulcer caused by an impacted gallstone at the gallbladder infundibulum, leading to an inflammatory response causing first external obstruction of the bile duct, and eventually eroding into the bile duct and evolving to a cholecystocholedochal or cholecystohepatic fistula. This article reviews the life of Pablo Luis Mirizzi, describes the earlier and later descriptions of Mirizzi syndrome, discusses the pathophysiological process leading to the development of these uncommon fistulas, reviews the current diagnostic modalities and surgical approaches and finally proposes a simplified classification for Mirizzi syndrome intended to standardize the reports on this condition and to eventually develop a consensual surgical approach to this unexpected and seriously dangerous condition.

Coexistence of Mirizzi syndrome with adenomyomatosis in the gallbladder:report of a case

BACKGROUND: Mirizzi syndrome is a rare complication of cholelithiasis. Adenomyomatosis is a common tumor-like lesion of the gallbladder. METHODS: A 52-year-old man was admitted to our hospital complaining of right hypochondriac pain and jaundice. Ultrasonography and computed tomography revealed stones in the gallbladder and dilation of the intrahepatic bile ducts. Magnetic resonance cholangiopancreatography revealed narrowing of the common bile duct caused by compression of the gallbladder. Laparotomy revealed type II Mirizzi syndrome. RESULTS: Partial cholecystectomy with a Roux-en-Y hepaticojejunostomy reconstruction was performed. Histologically, Rokitansky-Aschoff sinus proliferation, hypertrophy of smooth muscles, and fibrosis were seen in the gallbladder. A segmental type of adenomyornatosis of the gallbladder was diagnosed. CONCLUSIONS: The pathogenic link between the two peculiar entities is unclear. A possible explanation is considered that the pathogenesis of Mirizzi syndrome is resulted from chronic inflammation due to adenomyomatosis.

The incidence of Mirizzi syndrome in patients undergoing endoscopic retrograde cholangiopancreatography

BACKGROUND:Mirizzi syndrome is a rare complication of cholelithiasis,characterized by the narrowing of the common hepatic duct as a result of mechanical compression and/or inflammation due to biliary calculus impacted in the infundibula of the gallbladder or in the cystic duct.In this study,we aimed to describe the clinical presentations,investigations,operative details,and complications of seven patients who underwent endoscopic retrograde cholangiopancreatography and were finally diagnosed with Mirizzi syndrome in our center. METHOD:We performed a retrospective analysis of the records of 7 patients with Mirizzi syndrome who underwent endoscopic retrograde cholangiopancreatography. RESULTS:The incidence of Mirizzi syndrome was 1.07% of 656 patients given endoscopic retrograde cholangiopan- creatography.Ultrasonography was able to diagnose one case.Endoscopic retrograde cholangiopancreatography suggested the diagnosis in five cases and helped further in the management of these patients.Four patients had cholecystectomy and T-tube placement,and two had cholecystectomy and choledochoduodenostomy.One patient with typeⅠMirizzi syndrome according to the Csendes classification successfully underwent laparoscopic cholecystectomy. CONCLUSIONS:In the study,the incidence of Mirizzi syndrome was 1.07%of patients who underwent endoscopic retrograde cholangiopancreatography. Preoperative diagnosis of Mirizzi syndrome by endoscopicretrograde cholangiopancreatography is important to prevent complications.

Mirizzi Syndrome: Our Experience with 27 Cases in PUMC Hospital

Objective To retrospectively evaluate the diagnosis and treatment of Mirizzi syndrome （MS）. Methods Patients who received elective or emergency cholecystectomies in our center during 23 years were retrospectively evaluated. The data reviewed included demography, clinical presentations, diagnostic methods, surgical procedures, postoperative complications, and follow-up.

Surgical strategies for Mirizzi syndrome:A ten-year single center experience

BACKGROUND Mirizzi syndrome(MS)remains a challenging biliary disease,and its low rate of preoperative diagnosis should be resolved.Moreover,technological advances have not resulted in decisive improvements in the surgical treatment of MS.Complex bile duct lesions due to MS make surgery difficult,especially when the laparoscopic approach is adopted.The safety and long-term effect of MS treatment need to be guaranteed in terms of preoperative diagnosis and surgical strategy.AIM To analyze preoperative diagnostic methods and the safety,effectiveness,prognosis and related factors of surgical strategies for different types of MS.METHODS The clinical data of MS patients who received surgical treatment from January 1,2010 to December 31,2020 were retrospectively reviewed.Patients with malignancies,choledochojejunal fistula,lack of data and lost to follow-up were excluded.According to preoperative imaging examination records and documented intraoperative findings,the clinical types of MS were determined using the Csendes classification.The safety,effectiveness and long-term prognosis of surgical treatment in different types of MS,and their interactions with the clinical characteristics of patients were summarized.RESULTS Sixty-six patients with MS were included(34 males and 32 females).Magnetic resonance imaging/magnetic resonance cholangiopancreatography(MRI/MRCP)showed specific imaging features of MS in 58 cases(87.9%),which was superior to ultrasound scan(USS)in the diagnosis of MS and more sensitive to subtle biliary lesions than USS.The overall laparoscopic surgery completion rate was 53.03%(35/66),where the completion rates of MS type I,II and III were 69.05%(29/42),42.86%(6/14)and zero(0/10),respectively.Thirty-one patients(46.97%)underwent laparotomy or conversion to laparotomy including 11 cases of iatrogenic bile duct injury which occurred in type I patients,and 25 of these patients underwent bile duct exploration,repair and T-tube drainage.In addition,25 patients underwent intraoperative choledochoscopy and T-tube cholangiography.Overall,21 cases(31.8%)were repaired by simple suturing,and 14 cases(21.2%)were repaired using the remaining gallbladder wall patch in the subtotal cholecystectomy.The ascendant of the Csendes classification types led to an increase in surgical complexity reflected by increased operation time,bleeding volume and cost.Gender,acute abdominal pain and measurable stone size had no effect on Csendes type of MS or final surgical approach.Age had no effect on the classification of MS,but it influenced the final surgical approach,hospital stay and cost.A total of 66 patients obtained a relatively high preoperative diagnostic rate and underwent surgery safely without serious complications,and no mortality was observed during the follow-up period of 36.5±26.5 mo(range 13-76,median 22 mo).CONCLUSION MRI/MRCP can improve the preoperative diagnosis of MS.The Csendes classification can reflect the difficulty of treatment.The surgical strategies including laparoscopic surgery for MS should be formulated based on full evaluation and selection.

Predicting cholecystocholedochal fistulas in patients with Mirizzi syndrome undergoing endoscopic retrograde cholangiopancreatography

BACKGROUND Mirizzi syndrome(MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography(ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct(CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.AIM To evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.METHODS From 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed.RESULTS Gallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas(P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis(odds ratio 5.82, P = 0.002;0.12, P = 0.008, respectively).CONCLUSION Gall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.

Multidisciplinary management of Mirizzi syndrome with cholecystobiliary fistula: the value of minimally invasive endoscopic surgery

Mirizzi syndrome, a rare complication of gallstones, is defined by obstruction of the main bile duct. This obstruction may worsen and thus result in cholecystobiliary fistula. Surgical management of Mirizzi syndrome is complicated by the presence of inflamed tissue around the hepatic pedicle, making it impossible to distinguish between the main bile duct and the gallbladder. The surgeon＇s first task is to perform subtotal cholecystotomy（from the fundus of the gallbladder to the neck） without trying to locate the cystic duct. In a second step, the gallstones are extracted and the main bile duct is then repaired. In most cases, a T-tube is used to drain the main bile duct, and abdominal drainage is left in place（in case a bile fistula forms）. This study concluded that preoperative drainage of the main bile duct in the treatment of Mirizzi syndrome types II and III is feasible and might help to decrease the postoperative complication rate.

Mirizzi Syndrome Complicating Acute Cholecystitis: CT Diagnosis

Mirizzi syndrome is a rare complication of gallstones with an incidence of less than 1% per year in Western countries. Imaging and endoscopy play a key role in its diagnosis. CT scan helps to eliminate any malignant lesion of the bile ducts or liver hence comes in handy in the confirmation of Mirizzi syndrome. We hereby report a case of a Mirizzi syndrome complicating acute cholecystitis in a 41-year-old patient without any history of disease.

Effect of endoscopic retrograde cholangiopancreatography combined with laparoscopy and choledochoscopy on the treatment of Mirizzi syndrome

Background Mirizzi syndrome is often difficult to diagnose before surgery, and is often accompanied by extensive adhesions in the cystohepatic （Calot＇s） triangle and the difficulty of separating tissue can lead to bile duct injury and other intraoperative and postoperative complications. The aim of this study is to investigate minimally invasive means of treating different types of Mirizzi syndrome. Methods Fifty-four patients diagnosed with Mirizzi syndrome were enrolled between July 2004 and May 2012. The diagnosis was further refined according to the Csendes classification. Twenty-seven patients were treated with a combination of endoscopic retrograde cholangiopancreatography （ERCP）, laparoscopy, and choledochoscopy （tripartite approach group）; type I in 16 cases, type II five cases, and type III in six cases. Twenty-seven patients were treated with laparotomy （routine approach group）; type I in 19 cases, type II in six cases, and type III in two cases. The operation time, blood loss during operation, initiation of intake time of food, postoperative complications, and hospital stays were compared between two groups. Results All patients were successfully cured in surgical operation. The operation time was （49.7±27.5） minutes, blood loss during operation was （21.1±15.9） ml, initiation of intake time of food was （6.3±2.7） hours, postoperative complications were with two cases （7%, 2/27）, and hospital stay was （6.7±1.8） days in the tripartite approach group. In the routine approach group, the operation time was （85.1±20.3） minutes, blood loss during operation was （150.3±20.5） ml, initiation of intake time of food was （36.6±10.3） hours, postoperative complications were with three cases （11%, 3/27）, and hospital stay was （10.9±3.4） days. Except for postoperative complications, there were significant differences in the operation time, blood loss during operation, initiation of intake time of food, and hospital stays between two groups （P 〈0.05）. Conclusions ERCP combined with laparoscopy and choledochoscopy is a safe and effective means of treating Mirizzi syndrome. The approach is minimally invasive and patients recover quickly requiring only brief hospitalization.