Mirizzi syndrome in a patient with carcinoma of the gallbladder

Epigenetic modifications: Key players in cancer heterogeneity and drug resistance

Cancer heterogeneity and drug resistance remain pivotal obstacles in effective cancer treatment and management. One major contributor to these challenges is epigenetic modifications - gene regulation that does not involve changes to the DNA sequence itself but significantly impacts gene expression. As we elucidate these phenomena, we underscore the pivotal role of epigenetic modifications in regulating gene expression, contributing to cellular diversity, and driving adaptive changes that can instigate therapeutic resistance. This review dissects essential epigenetic modifications - DNA methylation, histone modifications, and chromatin remodeling - illustrating their significant yet complex contributions to cancer biology. While these changes offer potential avenues for therapeutic intervention due to their reversible nature, the interplay of epigenetic and genetic changes in cancer cells presents unique challenges that must be addressed to harness their full potential. By critically analyzing the current research landscape, we identify knowledge gaps and propose future research directions, exploring the potential of epigenetic therapies and discussing the obstacles in translating these concepts into effective treatments. This comprehensive review aims to stimulate further research and aid in developing innovative, patient-centered cancer therapies. Understanding the role of epigenetic modifications in cancer heterogeneity and drug resistance is critical for scientific advancement and paves the way towards improving patient outcomes in the fight against this formidable disease.

Mirizzi syndrome type IV associated with cholecystocolic fistula: a very rare condition--report of a case

Background

Mirizzi syndrome is a rare complication of prolonged cholelithiasis with presence of large, impacted gallstone into the Hartman's pouch, causing chronic extrinsic compression of common bile duct (CBD). Fistula formation between the CBD and the gallbladder may represent an outcome of that condition. According to Mirizzi's classification and Csendes's subclassification, Mirizzi syndrome type IV represents the most uncommon type (4%).

Spontaneous biliary-enteric fistulas have also been rarely reported (1.2–5%) in a large series of cholecystectomies. Cholecystocolic fistula is the most infrequent biliary enteric fistula, causing significant morbidity and representing a diagnostic challenge.

Case presentation

We describe a very rare, to our knowledge, combination of Mirizzi syndrome type IV and cholecystocolic fistula. A 52 year old male, presented to our clinic complaining of episodic diarrhea (monthly episodes lasting 16 days), high temperature (38°C–39°C), right upper quadrant pain without jaundice. The definitive diagnosis was made intraoperatively. Magnetic Resonance Imaging (MRI) and Endoscopic Retrograde Cholangiopancreatography (ERCP) demonstrated the presence of Mirizzi syndrome with cholecystocolic fistula formation. The patient was operated upon, and cholecystectomy, cholecystocolic fistula excision and Roux-en-Y biliary-enteric anastomosis were undertaken with excellent post-operative course.

Conclusion

Appropriate biliary tree imaging with ERCP and MRI/MRCP is essential for the diagnosis of Mirizzi syndrome and its complications. Cholecystectomy, fistula excision and biliary-enteric anastomosis with Roux-en-Y loop appears to be the most appropriate surgical intervention in order to avoid damage to Calot's triangle anatomic elements. Particularly in our case, ERCP was a valuable diagnostic tool that Mirizzi syndrome type IV and cholecystocolic fistula.

Mirizzi syndrome and gallbladder cancer

BACKGROUND/PURPOSE

Mirizzi syndrome is a rare complication of gallstone disease (GSD). The association of Mirizzi syndrome and gallbladder carcinoma (GBC) is not well understood. We report our experience of gallbladder carcinoma in patients with Mirizzi syndrome.

METHODS

We performed a retrospective analysis of the records of patients with Mirizzi syndrome who underwent cholecystectomy at a tertiary care hospital with special emphasis on patients who were found to harbor GBC. Patients with Mirizzi syndrome with associated GBC were compared with those who had Mirizzi syndrome alone and those with uncomplicated GSD.

RESULTS

Out of 4,800 cholecystectomies, Mirizzi syndrome was found in 133 (2.8%). Seven (5.3%) patients with Mirizzi syndrome had associated GBC, as compared to only 1% in patients with GSD. GBC was detected on final histology after cholecystectomy in 5 patients, and was detected preoperatively and intraoperatively in 1 patient each. Patients with Mirizzi syndrome with associated GBC were older (60 vs 50 years; P <or= 0.0001) and had a longer duration of symptoms (59 vs 24 months; P = 0.002) as compared to those with Mirizzi syndrome alone. However, presenting clinical features were not different in these two groups.

CONCLUSIONS

There was a higher incidence of GBC in patients with Mirizzi syndrome than in patients with uncomplicated GSD. There were no clinical features to differentiate these patients with GBC from those with Mirizzi syndrome alone, except that they were a decade older and had longer duration of symptoms. In the majority, the diagnosis of GBC was made on final histology, after cholecystectomy; hence, this group of patients with GBC are to be treated like any other patients with incidental GBC.

Mirizzi syndrome: a diagnostic and operative challenge

INTRODUCTION

Mirizzi syndrome (MS) is an unusual complication of gallstone disease. The majority of cases are not identified pre-operatively, despite advances in imaging techniques.

MATERIALS AND METHODS

Eighteen cases of MS were treated between January 1997 and April 2002. The clinical presentation, modes of investigation, surgical management and outcome are retrospectively reviewed.

RESULTS

There were 13 female and 5 male patients, with a mean age of 60 years. Seven patients presented with the classical Charcot's triad. Ultrasonography (US) was the first imaging investigation in 13 patients and computerised tomography (CT) in the other five cases. Eleven patients had a successful endoscopic retrograde cholangio-pancreatography (ERCP) carried out. Diagnosis of MS was arrived at in seven patients following pre-operative imagings. Overall, 11 patients had Type 1 and seven patients had Type 2 MS. In the group with Type 1 MS, nine patients underwent open cholecystectomy, of whom six had concomitant common bile duct (CBD) exploration for stones and one patient with biliary stenosis had a hepaticojejunostomy bypass. Laparoscopic cholecystectomy was attempted in two patients, with successful completion in one case. In the group with Type 2 MS, four fistulas were closed surgically, the other three had biliary bypass procedures.

CONCLUSION

Mirizzi syndrome is an unusual condition that poses diagnostic and operative challenges to the surgeon. With a judicious approach during dissection and early recognition of its presence, bile duct injury can be avoided. Good outcome can be achieved with an appropriate surgical procedure.

Coexistent gallbladder carcinoma in Mirizzi syndrome

A 52-year-old woman presented with right upper quadrant pain and obstructive jaundice. Computed tomographic scan showed Mirizzi syndrome type 1 and a thickened and calcified gallbladder wall, raising the possibility of coexistent gallbladder carcinoma that was later confirmed on histology post-cholecystectomy.

Long-term follow-up after treatment of Mirizzi syndrome by peroral cholangioscopy

BACKGROUND

The standard treatment for Mirizzi syndrome is surgical, although endoscopic and percutaneous management have also been described. The aim of this study was to evaluate the usefulness of shock wave lithotripsy combined with peroral cholangioscopy and its long-term outcome in patients with Mirizzi syndrome.

METHODS

The records of 25 patients with Mirizzi syndrome who underwent endoscopic treatment between April 1990 and November 1998 were retrospectively reviewed. Shock wave lithotripsy was performed under direct vision with a "mother-baby" endoscope system in 2 patients with type I and 23 with type II Mirizzi syndrome (12 men and 13 women, mean age 60 years). Follow-up data were obtained from clinical records or through telephone interviews.

RESULTS

In the two patients with type I, the cholangioscopic approach failed and both patients underwent open cholecystectomy. The 23 patients with type II were all successfully treated with shock wave lithotripsy alone. The cholangioscopic approach was unsuccessful in the treatment of residual gallbladder stones. Follow-up data were obtained in all but one patient (mean 43.6 months, range 4 to 103 months). Of the 23 patients with type II, 12 with no gallbladder stones had remained asymptomatic during the follow-up period. Of the 6 patients with type II with large residual gallbladder stones, 4 had acute cholangitis due to stone migration 6, 9, 28, and 34 months after endoscopic treatment. Two patients died during the follow-up period, one of non-biliary causes and the other of coexistent gallbladder carcinoma.

CONCLUSIONS

Endoscopic treatment of Mirizzi syndrome using peroral cholangioscopy is a safe and effective alternative to surgery, especially in patients with the type II syndrome. A favorable long-term outcome depends on the absence of large residual gallbladder stones.

The Mirizzi syndrome

The Mirizzi syndrome is an unusual presentation of gallstones which occurs when a gallstone becomes impacted in either Hartmann's pouch of the gallbladder or the cystic duct, causing obstruction of the common hepatic duct by extrinsic compression. The diagnosis of this syndrome is of importance because surgery in its presence is associated with an increased incidence of bile duct injury. The pathology, clinical presentation and management of this syndrome are discussed, and several illustrative case reports presented.