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

The Multifaceted Impact of Gallstones: Understanding Complications and Management Strategies

Gallstones, or cholelithiasis, represent a prevalent gastrointestinal disorder characterized by the formation of calculi within the gallbladder. This review aims to provide a comprehensive analysis of the complications associated with gallstones, with a focus on their pathophysiology, clinical manifestations, diagnostic methodologies, and management strategies. Gallstone-related complications encompass a broad spectrum, including biliary colic, acute cholecystitis, choledocholithiasis, acute pancreatitis, and cholangitis. The pathogenesis of these complications primarily involves biliary obstruction and subsequent infection, leading to significant morbidity and potential mortality. Diagnostic evaluation of gallstone complications employs various imaging techniques, such as ultrasonography, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP), each with distinct advantages and limitations. Therapeutic approaches are discussed, ranging from conservative management with pharmacotherapy and bile acid dissolution agents to interventional procedures like extracorporeal shock wave lithotripsy (ESWL) and percutaneous cholecystostomy. Surgical management, particularly laparoscopic cholecystectomy, remains the gold standard for definitive treatment. Additionally, advancements in endoscopic techniques, including endoscopic sphincterotomy (EST) and cholangioscopy, are highlighted. This review synthesizes current research findings and clinical guidelines, aiming to enhance the understanding and management of gallstone-related complications among healthcare professionals, thereby improving patient outcomes and reducing the burden of this common ailment.

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.

Bouveret's syndrome: a rare presentation of a common surgical enigma

Bouveret syndrome, an uncommon complication of cholelithiasis, typically manifests with symptoms of gastric outlet obstruction. Despite its rarity, Bouveret syndrome carries significant morbidity and mortality. This paper presents a case study and explores diagnostic approaches and management options for this challenging condition.

Mirizzi syndrome: A case report emphasizing safe management strategies and literature review

INTRODUCTION AND IMPORTANCE

Mirizzi syndrome, a rare complication of cholelithiasis, involves gallstones causing common hepatic duct compression. It poses diagnostic challenges with nonspecific symptoms. Early recognition and surgical intervention are crucial, emphasizing a multidisciplinary approach for this complex condition with potential complications.

CASE REPORT

A 69-year-old woman presented with pruritus, jaundice, and a history of hepatic colics. Laboratory results showed no signs of inflammation but indicated cholestasis. Imaging suggested Mirizzi syndrome type 1, confirmed by MRI. The patient underwent surgery, revealing Mirizzi syndrome type II with the presence of a cholecystocholedochal fistula involving less than one-third of the circumference of the main bile duct. Subtotal cholecystectomy and suturing of the main bile duct onto a T-tube were performed, resulting in a favorable recovery and normalization of blood tests after 10 days.

CLINICAL DISCUSSION

Mirizzi syndrome, named after surgeon Pablo Luis Mirizzi, was first detailed in 1948. Clinical symptoms include jaundice, colic pain, and complications such as cholecystocholedochal fistula and gallstone ileus. Blood tests and imaging aid diagnosis. Surgical management targets obstruction relief and defect repair. Dissecting Calot's triangle carries risks. In complex cases, cholecysto-choledocus-duodenostomy may be considered.

CONCLUSION

Mirizzi syndrome, a rare but significant condition, demands careful clinical attention to prevent underdiagnosis. Timely and appropriate management, utilizing imaging tests alongside ERCP, is essential for optimal outcomes and complication prevention.

Mirizzi Syndrome-The Past, Present, and Future

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

Reverse Mirizzi Syndrome

A man in his 40s presented to our Hospital with abdominal pain, jaundice, and pruritus. He had a history of Alagille Syndrome treated with cholecystojejunostomy in the neonatal period because of initial misdiagnosis of biliary atresia. Laboratory investigations showed hyperbilirubinemia (total bilirubin 1.76 mg/dL [<1.2 mg/dL]; conjugated 1.06 mg/dL [<0.3 mg/dL]) and cholestasis (GGT 78 U/L [<50 U/L]; ALP 200 U/L [<50 U/L]). Transabdominal ultrasound was limited by aerobilia due to the cholecystojejuno-anastomosis. Subsequent basal CT scan revealed an impacted stone within the patient's native common bile duct (CBD). Aerobilia in intrahepatic bile ducts and gallbladder was reported. Magnetic Resonance cholangiopancreatography confirmed the gallstone in the CBD compressing cystic duct and common hepatic duct, with dilation of the upstream bile ducts. Furthermore, the native CBD was obstructed by other gallstones. In Mirizzi syndrome, gallstones impacted in gallbladder's Hartmann's pouch or cystic duct extrinsically compress CBD. We suggest naming the present condition "Reverse Mirizzi Syndrome" (Renzulli Matteo Syndrome, RMS) because it is the exact opposite of Mirizzi syndrome.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Laparoscopic treatment of Mirizzi syndrome with subtotal cholecystectomy and electrohydraulic lithotripsy: A case report

Mirizzi syndrome is a rare chronic cholecystitis complication. However, the current consensus on managing this condition remains controversial, especially through laparoscopic surgery. This report describes the feasibility of treating type I Mirizzi syndrome with laparoscopic subtotal cholecystectomy and electrohydraulic lithotripsic gallstone removal. A 53-year-old woman presented with dark urine and right upper quadrant pain for 1 month. On examination, she was jaundiced. Blood tests showed highly elevated liver and biliary enzyme levels. Abdominal ultrasound showed a slightly dilated common bile duct with suspicion of choledocholithiasis. However, endoscopic retrograde cholangiopancreatography showed a narrowed common bile duct extrinsically compressed by a gallstone in the cystic duct, establishing a Mirizzi syndrome diagnosis. Elective laparoscopic cholecystectomy was planned. At operation, the trans-infundibulum approach was used since dissection around the cystic duct was difficult due to severe local inflammation of Calot's triangle. The gallbladder's neck was opened, and the stone was removed by lithotripsy via a flexible choledochoscope. Common bile duct exploration through the cystic duct was normal. The fundus and body of the gallbladder were resected, followed by T-tube drainage and suturing of the gallbladder's neck. The patient's postoperative clinical course was uneventful. Treating Mirizzi syndrome remains a major challenge for hepatobiliary specialists even with open surgery due to high complication rates, including bile duct injuries. Treatment is primarily to clear out the responsible stone and necrotic tissue. Due to advances in endoscopic surgery and equipment, subtotal cholecystectomy with laparoscopic gallstone extraction provides a safe and effective option for patients with Mirizzi syndrome. Laparoscopic subtotal cholecystectomy with electrohydraulic lithotripsy is a feasible and useful approach for treating Mirizzi syndrome that avoids iatrogenic bile duct injury.

Biliary Anatomy 2.0 Quiz: Test Your Knowledge

Anatomy has remained an interest of physicians throughout the ages. The biliary tract spans from the liver to the hepatoduodenal mesentery, pancreas, and into the duodenum. Therefore, it is important for not only hepatobiliary surgeons but also general gastrointestinal surgeons, gastroenterologists, radiologists, and pathologists to be familiar with biliary anatomy and its variants. While surgery for hilar cholangiocarcinoma is one of the most challenging procedures, cholecystectomy is one of the most common procedures done from the beginning of surgical training. We hope that by answering the following questions, you will gain a comprehensive understanding of biliary anatomy and a greater appreciation for it.

Mirizzi syndrome type V complicated with triple fistula: a case report

BACKGROUND

Mirizzi syndrome (MS) is a complicated form of longstanding, symptomatic cholelithiasis. According to Beltran Classification MS Type V has been introduced to describe the cholecystoenteric fistula, with or without gallstone ileus. Mirizzi syndrome Type V with double fistula has been reported in the past; however, the triple fistula is an even rarer case, first described in the international literature so far.

CASE PRESENTATION

A 77-year-old male was admitted to our surgical department with recurrent episodes of abdominal pain, which initially presented in the last 6 months and was accompanied with jaundice. Computed tomography showed findings of cholelithiasis, pneumobilia and choledocholithiasis. We performed an ERCP, which showed two fistulas of the gallbladder with the pyloric antrum and the duodenum, respectively. Surgical treatment was immediately undergone and during laparotomy, we confirmed these findings. We ligated and dissected these communications. In addition, a third fistula between the gallbladder and the common bile duct was identified. An insertion of a Kehr T-tube into the common bile duct was performed via the gallbladder. After 3 months, the Kehr T-tube was removed and in the subsequent 2 years of follow-up the patient was presented without complications.

CONCLUSIONS

Mirizzi syndrome complicated with triple fistula, first described in the international literature, to the best of our knowledge, confirms the long natural history of inflammation.

Exploring the imaging features and treatment options of Mirizzi syndrome

The patient is a 54-year-old female who presented to the emergency department for episodic right biliary colic with nausea and vomiting over the past year. The patient's symptoms warranted multiple emergency department visits, but were self-limiting. During the most recent visit, the patient had a low-grade fever of 99.8°F (96.8°F-99.5°F) and a borderline elevated total bilirubin of 1.2 (0.2-1.2 mg/dL). Abdominal ultrasound revealed cholelithiasis, gallbladder wall thickening, and biliary ductal dilatation. Subsequent MRCP revealed an impacted stone within the gallbladder neck and a prominent common hepatic duct, compatible with Mirizzi syndrome Type I. The obtained imaging combined with clinical correlation in the setting of jaundice and right upper quadrant pain guided the patient's management. A laparoscopic cholecystectomy was performed and the patient was safely discharged the following day.

Endoscopic retrograde cholangiopancreatography-oriented surgery for accomplished treatment of Mirizzi syndrome: a single-center experience

BACKGROUND

Mirizzi syndrome is a gallstone disease characterized by compression of extrahepatic biliary duct with an impacted stone. Our aim is to identify and describe the incidence, clinical presentation, operative details and the association postoperative complication of Mirizzi syndrome in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

The ERCP procedures were held in Gastroenterology Endoscopy Unit and retrospectively evaluated. The patients were divided into two groups, the cholelithiasis + common bile duct (CBD) stone group and the Mirizzi syndrome group. These groups were compared with the demographic characteristics, ERCP procedures, types of Mirizzi syndrome and surgical technique.

RESULTS

A total of 1018 consecutive patients who underwent ERCP were scanned retrospectively. Of the 515 patients fulfilling the criteria for ERCP, 12 had Mirizzi syndrome and 503 had cholelithiasis and CBD stones. Half of the Mirizzi syndrome patients were diagnosed with pre-ERCP ultrasonography. The mean diameter of choledoc was found to be 10 mm in ERCP. ERCP-related complication rates (pancreatitis, bleeding and perforation) were the same in the two groups; 66.6% of the Mirizzi syndrome patients applied cholecystectomy and placement of T-tube surgical procedures, and there were no postoperative complications.

CONCLUSION

Surgery is the definitive treatment of Mirizzi syndrome. Thus patients should have a correct preoperative diagnosis for an appropriate and safe surgery. We think that ERCP could be the best guide for this. Also, we believe that intraoperative cholangiography with ERCP and hybrid procedures for guiding surgical treatment may become an advanced treatment option in the future.

Mirizzi syndrome complicated by type IV cholecystobiliary fistula to the right hepatic duct

Mirizzi syndrome is a rare complication of long-term chronic cholecystitis, characterized by extrinsic compression of the common hepatic duct that may progress to development of cholecystobiliary fistula. Here we report a case of a 38-year-old female patient who underwent laparoscopic cholecystectomy with intraoperative cholangiogram for acute cholecystitis and choledocholithiasis. Intraoperatively, the patient was found to have a Mirizzi syndrome complicated by cholecystobiliary fistula to the right hepatic duct. The gallbladder was successfully removed, cholelithiasis cleared and a ureteral stent was used in reconstruction. The patient was discharged on postoperative two and was doing well on routine follow-up. Ultimately, Mirizzi syndrome is a rare clinical entity that requires careful consideration during preoperative workup and a high suspicion when abnormal anatomy is encountered intraoperatively.

Mirizzi Syndrome: An Unusual Complication of Cholelithiasis

Mirizzi syndrome is a rare condition caused by the obstruction of the common bile duct or common hepatic duct by external compression from multiple impacted gallstones or a single large impacted gallstone in Hartman's pouch. The condition can easily be confused with choledocholithiasis, bile duct stricture or cholangiocarcinoma due to the presence of obstructive jaundice hence may be overlooked due to the rarity of the condition. The incidence of Mirizzi syndrome among patients with gallstones is reported to range from 0.63 to 5.7%. Furthermore, it poses a differential diagnosis dilemma for the physician as well as radiologists because there are no clinical features or diagnostic procedures that have a 100% specificity and sensitivity. Laparotomy is the preferred surgical technique of choice. For the patients who are poor surgical candidate, mainstay of treatment is biliary stent placement for the restoration of normal biliary drainage. Due to low incidence of the Mirizzi syndrome, an elevated index of suspicion is required to diagnose this condition. At present, there are no well-developed, internationally recognized clinical guidelines for the management of this syndrome. Furthermore, the diagnostic procedures available still pose a barrier in the ability to confirm the diagnosis prior to surgical treatment, even though the diagnostic rate has increased dramatically.

Mirizzi Syndrome: A Case Report

Mirizzi syndrome (MS) describes a rare complication of cholelithiasis resulting from extrinsic compression of the common hepatic duct by impacted gallstones in the cystic duct or Hartmann's pouch. MS is most commonly seen in adults and is more prevalent in the female population. Due to the pathophysiology of MS being similar to other causes of cholecystitis and biliary obstruction, the symptomatology is rather nonspecific. While ultrasound and magnetic resonance cholangiopancreatography are commonly used for diagnosis, treatment of this condition typically involves cholecystectomy. Identifying MS versus other more common causes of obstructive jaundice is paramount in limiting complications. In this report, we describe a case of MS diagnosed in a 32-year-old male who presented with nonspecific abdominal pain and other signs of obstructive jaundice. The goal of this study is to show how identifying a rare underlying cause of a common presentation can lead to improved patient outcomes.

Right Hepatic Artery Syndrome With Mirizzi Syndrome: A Case Report

Anatomical diversity is rather typical in the biliary region. However, it has only sometimes been documented that the arteries of a hepatobiliary origin compressed the extrahepatic bile duct. Biliary obstruction may be caused by a myriad of benign and malignant diseases. Right hepatic artery syndrome (RHAS) is described as the consequence of right hepatic artery compression of the extrahepatic bile duct. We report a case of a 22-year-old male who presented with a complaint of abdominal pain and was later admitted as a case of acute calculous cholecystitis with obstructive jaundice. Abdominal ultrasound showed a picture of the so-called Mirizzi. However, A magnetic resonance cholangiopancreatography showed a picture of RHAS, so the patient needed endoscopic retrograde cholangiopancreatography to decompress the biliary system which was later performed successfully followed by cholecystectomy. The diagnosis of RHAS is well established in the literature, and it depends on the facility of the institute, cholecystectomy versus hepaticojejunostomy or endoscopic treatment alone are the management options that have been utilized to manage such cases.

The increasing incidence and high body mass index-related burden of gallbladder and biliary diseases-A results from global burden of disease study 2019

BACKGROUND

Gallbladder and biliary diseases are common gastrointestinal conditions associated with huge socioeconomic costs and are considered risk factors for cardiovascular diseases and digestive system cancers. The prevalence and incidence of gallbladder and biliary diseases have not received enough attention from 1990 to 2019. Several non-communicable diseases were associated with the incidence of gallbladder and biliary diseases. It is necessary to clarify the change in the incidence and disability burden of gallbladder and biliary diseases worldwide.

METHODS

Data on high body mass index (BMI)-related disease burden and incidence, years of life lost prematurely, and years lived with disability (YLDs) due to gallbladder and biliary diseases were obtained from the Global Burden of Disease 2019. The estimated annual percentage change was calculated to qualify the gallbladder and biliary disease burden change.

RESULTS

The global age-standardized incidence rate has increased from 585.35 per 100,000 (95% UI: 506.05-679.86) in 1990 to 634.32 per 100,000 (95% UI: 540.21-742.93) in 2019. And the increase in incidence was positively correlated with rising high BMI-related summary exposure value. The high BMI-related YLDs of gallbladder and biliary diseases have increased worldwide over time. Globally, the 25-49 age group suffered a rapid rise in incidence and high BMI attributable to the YLDs rate of gallbladder and biliary diseases.

CONCLUSION

The global incidence and high BMI-related YLDs of gallbladder and biliary diseases remain prominent to increase over the past 30 years. Notably, the incidence and high BMI-related YLDs among people aged 25-49 years have rapidly increased over time. Therefore, high BMI should be emphasized in strategic priorities for controlling gallbladder and biliary diseases.

Mirizzi Syndrome Type IV Successfully Treated with Peroral Single-operator Cholangioscopy-guided Electrohydraulic Lithotripsy: A Case Report with Literature Review

A 76-year-old man presented with liver dysfunction and intrahepatic bile duct dilatation. Imaging studies showed two large stones that had become impacted in the common hepatic duct, which was fused with the gallbladder. The patient was diagnosed with Mirizzi syndrome type IV. Hepaticojejunostomy and stone removal failed due to dense gallbladder adhesions involving the right hepatic artery. The bile flow was temporarily restored; however, the patient experienced cholangitis 16 months later. The stones were extracted via peroral single-operator cholangioscopy (SOC)-guided electrohydraulic lithotripsy. This is the first case in which stones were completely removed by SOC-guided treatment in a patient with Mirizzi syndrome type IV.

Mirizzi Syndrome: Is There a Place for Minimally Invasive Surgery?

Objectives

Mirizzi syndrome (MS) is a condition when an impacted stone in the cystic duct or the Hartmann's pouch due to its extrinsic compression and concomitant inflammation causes an obstruction of the common bile duct. Laparotomy was the preferred surgical technique to treat this syndrome. However, with advances in technologies, an increasing number of surgeons are starting to choose minimally invasive surgery. The objective of this study is to review existing literature relating to minimally invasive surgery treatment of MS.

Methods

PubMed and ClinicalKey were used to search and identify relevant articles since January 2000 to December 2020. The following keywords were applied: Mirizzi syndrome, laparoscopy, minimally invasive. The criteria for exclusion were applied: case reports with less than 2 patients, nonsurgical treatments, and reviews were excluded from this study.

Results

Thirty-two articles were identified for analysis, 17 (540 patients in total) of these articles fulfilled the inclusion criteria: 8 retrospective studies, 4 case series, and 5 prospective studies. In the analyzed cohort, 295 patients were treated laparoscopically. Out of 17 articles included in the manuscript, 14 articles provided the information on minimally invasive surgery approach. There were 221 minimally invasive surgeries, out of which 143 (64.7%) were successful, thus according to the type of MS: MS I-175 (79.2%), successful 105 (60%); MS II-40 (18%), successful 32 (80%); MS III-6 (2.7%), successful 6 (100%). The mean conversion rate from laparoscopic to open surgery was 26.2% (range 0-67%), and the median complication rate in seventeen studies was 18.1% (range 0-40%), respectively. The female/male ratio was 1.2:1, and the median age in fifteen studies providing overall data on age was 57.4 years (range 40.1-70.1 years).

Conclusions

Current evidence presents that open surgery remains the main treatment for MS. Minimally invasive approaches are feasible, safe, and are associated with short-term recovery, significant differences in the operation time and blood loss during operation. However, minimally invasive approaches are mainly restricted to selected patients with type I MS.

Single-incision versus four-incision laparoscopic transfistulous bile duct exploration for Mirizzi syndrome type II

BACKGROUND

We developed laparoscopic transfistulous bile duct exploration (LTBDE) for Mirizzi syndrome (MS) McSherry type II in September 2011. Then, single-incision LTBDE (SILTBDE) was adopted as a preferred technique since August 2013. This retrospective study aims to analyze the outcome of LTBDE in 7.7 years and to compare SILTBDE with four-incision LTBDE (4ILTBDE).

METHODS

Seventeen consecutive patients underwent LTBDE for MS McSherry type II from September 2011 to May 2019. Transfistulous removal of the impacted stone(s), choledochoscopic bile duct exploration, and primary closure of the gallbladder remnant were performed without biliary drainage.

RESULTS

The sex ratio is 12:5 (male: female) with an average age of 39.4 ± 10.3 (24-56) years. Ten patients (58.8%) had their diagnoses of MS established by preoperative imaging. According to the Csendes classification, three type II (17.6%), nine type III (52.9%), and five type IV (29.4%) were identified. The operative time was 264.8 ± 60.3 min (156-358 min). The stone clearance rate was 100%. The postoperative hospital stay was 4.7 ± 1.9 (2-10) days. No procedure was converted to an open operation. Two postoperative transient hyperamylasemia (11.8%) and one superficial wound infection (5.9%) occurred and all recovered well under conservative treatment (Clavien-Dindo grade I). During an average 2.2-year follow-up period, no biliary stricture or stone recurrence occurred. No significant difference exists between the SILTBDE and 4ILTBDE groups. Nevertheless, an insignificant trend of shorter postoperative hospital stay was observed in the former. A diagnosis of MS Csendes type IV implicates prolonged total and postoperative hospital stays (p < 0.01).

CONCLUSIONS

LTBDE is safe and efficacious for MS McSherry type II. It provides a simple solution for various types of MS and avoids undesirable complications following bilioenteric anastomosis. SILTBDE is comparable to 4ILTBDE for selected patients. Patients with MS Csendes type IV need more time to recover after surgery.

Mirizzi SD caused a rare case of Angiocholitis ictero-uremigene with shock septic: Case report and review of literature

Introduction

Mirizzi syndrome is an obstructive jaundice caused by extrinsic compression of the common bile duct by a stone embedded in the cystic duct [1].

Cholangitis is a diagnostic and therapeutic emergency whose main risk is that of septic shock [1]. It can also progress to “Ictero-Uremigenic Angiocholitis” associated with sometimes extremely serious renal failure [2].

Case presentation

We reported the case of a 73-year-old patient admitted to the emergency room with septic shock on severe cholangitis. Given the presence of acute febrile cholangitis with criteria of septic shock on the one hand and acute renal failure on the other hand, the diagnosis of ictero-uremigenic Angiocholitis was made.

Discussion

Angiocholitis is an inflammation and infection of the bile ducts, the etiologies of which are diverse, among them: Mirizzi's syndrome [1].

The anatomical basis of Mirizzi syndrome has generally been attributed to an abnormal relationship between the cystic duct and the common hepatic duct [3]. Angiocholitis constitutes a diagnostic and therapeutic emergency, its complications threaten the vital prognosis [4]. Ictero-uremigenic Angiocholitis where the septic component dominates represents a real picture of sepsis, cholestatic jaundice, oliguria with renal failure [2].

Conclusion

fortunately rare, but always to be feared, the ictero-uremigenic Angiocholitis produces a typical picture of Angiocholitis, accompanied by a serious septic shock which passes largely to the fore associating in a very short period of time an organic renal insufficiency [2], the Age over 70 is a serious factor, it constitutes a therapeutic emergency requiring desobstruction of the main bile duct and possibly recourse to hemodialysis [4].

•

Angiocholitis is a diagnostic and therapeutic emergency. The main risk is that of septic shock.

•

Angiocholitis can also develop into “ictero-uremogenic cholangitis”, associated with renal failure which is sometimes extremely serious.

•

Age Over 70 years is considered as a severity factor.

•

It constitutes a therapeutic emergency requiring disobstruction of the main bile duct and possibly recourse to hemodialysis.

Laparoscopic subtotal reconstituting cholecystectomy in type II & III Mirizzi syndrome: Case series of 5 patients

BACKGROUND

Mirizzi syndrome Type II & III treatment is a true surgical challenge. The purpose was to determine whether the laparoscopic subtotal reconstituting cholecystectomy can be a safe and effective approach in our institution to treat Mirizzi Syndrome type II and III.

CASE PRESENTATION

We report a case series of 5 patients with Mirizzi syndrome type II and III who underwent laparoscopic subtotal reconstituting cholecystectomy.

DISCUSSION

We found only one patient had presurgical diagnosis, average surgical time of 218 min, average surgical bleeding of 230 ml and the mean hospital stay of 3.4 days; one patient presented low volume and auto limited biliary leak; no cases presented biliary injury, major complications, or reintervention.

CONCLUSIONS

Laparoscopic subtotal reconstituting cholecystectomy is a security and effective technique to treat type II and III Mirizzi syndrome in our context.

The Association of Preoperative Risk Factors for Laparoscopic Conversion to Open Surgery in Elective Cholecystectomy

Background

Laparoscopic cholecystectomy is a common operation worldwide, with low mortality (0.01%) and morbidity (2–8%). It has been reported 2.9 to 3.2% of elective laparoscopic cholecystectomies are converted to open surgery. Converted cases are associated with increased complications rates.

Method

Two thousand and seventy-five patients, 82.8% females and 17.2% males who underwent elective laparoscopic cholecystectomy in our hospital, between March 1, 2016, and February 28, 2018, were prospectively collected in a database. Pearson's Chi-squared and Fisher's exact tests were used to determine significance, with p <0.05 deemed statistically significant. We analyzed seven risk factors associated with conversion to open surgery; age, gender, body mass index (BMI), previous abdominal surgeries, the presence of contracted gallbladder, Mirizzi syndrome, or choledocholithiasis. Laparoscopic cholecystectomy was performed using a 3-port technique (73%) and a 4-port technique (27%).

Results

Finding associated “strong” factors to conversion: male patients, >60-years-old, previous upper abdominal surgery, contracted gallbladder, Mirizzi syndrome or choledocholithiasis. The presence of a higher or lower BMI did not influence the rate of conversion. The most impact association were males over 60 years, and males with an earlier upper abdominal surgery.

Conclusion

Laparoscopic cholecystectomy is the gold standard for gallstones and gallbladder disease; however, inflammation, adhesions, and anatomic difficulty continue to challenge the use and safety of this approach in a small number of patients. This study identifies predictors of choice for open cholecystectomy. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of conversion and address these factors preoperatively.

How to cite this article

Hanson-Viana E, Ayala-Moreno EA, Ortega-Leon LH, et al. The Association of Preoperative Risk Factors for Laparoscopic Conversion to Open Surgery in Elective Cholecystectomy. Euroasian J Hepato-Gastroenterol 2022;12(1):6–9.

Minimally invasive management of Mirizzi syndrome Va: Case series and narrative review of the literature

INTRODUCTION

Mirizzi's Syndrome (MS) is a rare pathology, known to be a challenge for the surgeon. In the surgical management, open approach vs laparoscopic is a topic of discussion due to anatomic variations. The aim of this study is to analyze our experience in the laparoscopic management of this condition in Type Va.

METHODS

We made a descriptive retrospective study of patients diagnosed with MS type Va and treated by laparoscopic approach from 2014 to 2019, in two high volume centers of Bogotá, Colombia.

RESULTS

1073 patients who presented complications from gallstones were evaluated, of which 16 were diagnosed with MS type Va. 75% were females and 25% males; 80% presented jaundice and 90% abdominal pain; 12 patients showed cholecystoduodenal fistula and 4 cholecystocolic fistula. All patients underwent laparoscopic management, total cholecystectomy and fistula resection with primary closure was possible on a 100% of the patients. Conversion rate was 0%. The follow up was 18 months.

CONCLUSION

Laparoscopic management of MS is feasible and safe; the experience of the surgery group and selection of the patients is the key to a successful outcome.

Setting up a surgical complex gallstone service in a non-HPB unit

Objective: Complex gallstone disease is associated with a higher risk of complication during laparoscopic cholecystectomy than biliary colic and simple cholecystitis. It is traditionally managed in a hepatopancreaticobiliary (HPB) unit where there is expertise for common bile duct exploration and repair. We developed a mentorship scheme for a busy upper gastro-intestinal (UGI) unit, with support from a specialist HPB unit to treat complex gallstone disease, to reduce the burden on the HPB unit and enable local treatment of patients.

Material and Methods: Through the creation of a service level agreement, the specialist HPB unit were commissioned to provide mentorship for two surgeons at a large UGI unit with an interest in providing a complex gallstone service to their local population. Eight sessions of mentored operating were supported, with the provision for additional support if complications occurred.

Results: There were 14 patients included in the mentorship phase of the programme from November 2015 to May 2017. Cholecystectomies were performed on patients with previously complex histories, which included: previous cholecystostomy; CBD stones and multiple ERCPs; suspected choledochoduodenal fistula; suspected cholecystoduodenal fistula; suspected Mirrizzi’s syndrome; previous significant intra-abdominal operation; and significant medical co-morbidities. There was one post-operative complication requiring a return to theatre, and one minor wound infection associated with the complex gallstone lists.

Conclusion: We demonstrated a method to reduce the burden on specialist HPB unit for the operative management of complex gallstone disease and safely implement such a service at large UGI unit with an interest in providing a complex gallstone service.

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.

Beyond acute cholecystitis-gallstone-related complications and what the emergency radiologist should know

The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.

The Current Approach to the Diagnosis and Classification of Mirizzi Syndrome

Mirizzi syndrome occurs in up to 6% of patients with cholecystolithiasis. It is generally caused by external compression of the common hepatic duct by a gallstone impacted in the neck of the gallbladder or the cystic duct, which can lead to fistulisation. The aim of this review was to highlight the proposed classifications for Mirizzi syndrome (MS) and to provide an update on modern approaches to the diagnosis of this disease. We conducted research on various internet databases and the total number of records was 993, but after a gradual process of elimination our final review consisted of 21 articles. According to the literature, the Cesendes classification is the most commonly used, but many new suggestions have appeared. Our review shows that the ultrasonography (US) is the most frequently used method of initial diagnosis, despite still having only average sensitivity. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are good methods and are similarly effective, but only the latter can be simultaneously therapeutic. Some modern methods show very high sensitivity, but are not so commonly administered. Mirizzi syndrome is still a diagnostic challenge, despite the advancement of the available tools. Preoperative diagnosis is crucial to avoid complications during treatment. New research may bring a unification of classifications and diagnostic algorithms.

Emergency surgery for hemobilia due to hepatic artery pseudoaneurysm rupture complicated by Mirizzi syndrome type II: a case report

Background

Hemobilia refers to bleeding into the biliary tract. Hepatic artery pseudoaneurysm (HAP) rupture is an uncommon cause of hemobilia, and cases of HAP associated with Mirizzi syndrome are extremely rare. Although transarterial embolization is recommended as the first-line treatment for hemobilia, surgery is sometimes required.

Case presentation

A 76-year-old woman was referred to our hospital with epigastric pain. She was febrile and had conjunctival icterus and epigastric tenderness. Laboratory tests revealed abnormal white blood cell count and liver function. An abdominal computed tomography (CT) revealed multiple calculi in the gallbladder, an incarcerated calculus in the cystic duct, and a slightly dilated common hepatic duct. Based on examination findings, she was diagnosed with Mirizzi syndrome type I, complicated by cholangitis. Intravenous antibiotics were administered, and we performed endoscopic retrograde cholangiopancreatography (ERCP) to place a drainage tube. The fever persisted; therefore, contrast-enhanced CT (CECT) was performed. This revealed portal vein thrombosis and hepatic abscesses; therefore, heparin infusion was administered. The following day, she complained of melena, and laboratory tests showed that she was anemic. ERCP was performed to change the drainage tube in the bile duct; however, bleeding from the papilla of Vater was observed. CECT demonstrated a right HAP with high-density fluid in the gallbladder and gallbladder perforation. Finally, she was diagnosed with hemobilia caused by HAP rupture, and emergency surgery was performed to secure hemostasis and control the infection. During laparotomy, we found that a right HAP had ruptured into the gallbladder. The gallbladder made a cholecystobiliary fistula, which indicated Mirizzi syndrome type II. Although we tried to repair the right hepatic artery, we later ligated it due to arterial wall vulnerability. Then, we performed subtotal cholecystectomy and inserted a T-tube into the common bile duct. There were no postoperative complications except for minor leakage from the T-tube insertion site. The patient was discharged after a total hospital stay of 7 weeks.

Conclusions

We experienced an extremely rare case of emergency definitive surgery for hemobilia due to HAP rupture complicated by Mirizzi syndrome type II. Surgery might be indicated when controlling underlying infections was required.

Elevation of CA 19-9 in Mirizzi Syndrome in the Absence of Malignancy: A Case Report

Patient: Male, 71-year-old

Final Diagnosis: Mirizzi syndrome

Symptoms: Epigastric pain • fatigue • jaundice

Medication: —

Clinical Procedure: Laparoscopic cholecystectomy

Specialty: Surgery

Surgical outcome of Mirizzi syndrome: Value of endoscopic retrograde cholangiopancreatography and laparoscopic procedures

BACKGROUND

Laparoscopic cholecystectomy (LC) with associated procedures and endoscopic retrograde cholangiopancreatography (ERCP) have been the standard treatments for both common and rare biliary diseases. Mirizzi syndrome (MS) is a rare and complex biliary condition. We report our experience with MS treatment and investigate the value of laparoscopic procedures and ERCP in patient management.

METHODS

From 2004 to 2017, 100 consecutive patients with MS were diagnosed by ERCP and underwent surgery in a referral center. Sixty patients were treated with intended LC, and 40 patients were treated with open cholecystectomy (OC). The clinical manifestations, ERCP and associated procedures, surgical procedures, and postoperative outcomes were investigated.

RESULTS

The surgical mortality rate was 1%, while the surgical morbidity rate was 15%. The patients treated with intended LC suffered from less morbidity (5%). The percentage of postoperative residual biliary stones was 32% (n = 32), and only three patients underwent re-operation (laparotomy) for stone removal. The laparotomy conversion rate in the intended LC group was 16.7% (10/60). The length of hospitalization for the patients with successful LC was significantly shorter than that for the patients with conversion and intended OC. Csendes classification was a risk factor for conversion from LC to OC (type I vs types II to V, P < .0001).

CONCLUSIONS

A combination of a laparoscopic procedure and ERCP may provide therapeutic benefits for patients with MS.

Mirizzi syndrome type V complicated with both cholecystobiliary and cholecystocolic fistula: a case report

Mirizzi syndrome (MS) is a common bile duct (CBD) obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Patients affected by MS may present abdominal pain and jaundice. A 37-year-old male with neurologic residuals post-encephalitis arrived at the emergency department reporting abdominal pain, jaundice and fever. An ultrasound of the abdomen identified cholecystolithiasis with a dilated CBD. He did not undergo CT or MRI due to poor compliance and parents’ disagreement. Eventually, they accepted to perform endoscopic retrograde cholangiopancreatography, which diagnosed MS with both cholecystobiliary and cholecystocolonic fistula without gallstone ileum (type Va). Therefore, patient underwent cholecystectomy, wedge resection of the colon and choledochoplasty with ‘Kehr's T-tube’ insertion. A plastic biliary stent was successively placed and removed after 4 month. Ultimately, he did neither complain any other biliary symptoms nor alteration in laboratory tests after 4-years of follow-up.

Gastric outlet obstruction - looking for a syndrome: Bouveret or Mirizzi?

Introduction and importance

Gastric outlet obstruction can result from any pathological process that causes intrinsic blockage or extrinsic pressure on the distal stomach and duodenum. Gallstone related gastric outlet obstruction is a well-known entity classically due to a cholecystoenteric fistula formation.

Case presentation

We present here a case of a 36-year-old man who presented with right upper quadrant abdominal pain associated with marked nausea and vomiting. Abdominal CT scan done in the emergency department revealed a large impacted infundibular gallstone with signs of acute cholecystitis, associated with prominent gastric distention. Gastric outlet obstruction was due to stenosis at the duodenal level from external compression by the large impacted stone with no evidence of fistula. Laparoscopic cholecystectomy was performed with total resolution of symptoms.

Clinical discussion

Gastric outlet obstruction can be secondary to many etiologies, and notably gallstone disease. Classically this is due to formation of a cholecystoenteric fistula and intrinsic obstruction by the migrated stone. Our case is unique in that a large impacted infundibular gallstone caused gastric outlet obstruction with absence of any fistula or gallstone migration.

Conclusion

Gastric outlet obstruction due to external compression by a non-migrated gallstone is a rare undescribed entity. Surgical treatment should not be delayed to prevent complications and fistula formation.

•

Gallstone-related gastric outlet obstruction (GOO) is classically caused by the formation of a cholecystoenteric fistula.

•

We report a rare case of gastric outlet obstruction due to an impacted infundibular gallstone in the absence of any fistula.

•

Laparoscopic cholecystectomy may resolve gastric outlet obstruction when an impacted infundibular gallstone is the cause.

Minimally invasive management of Mirizzi syndrome Va: Case series and narrative review of the literature

INTRODUCTION

Mirizzi's Syndrome (MS) is a rare pathology, known to be a challenge for the surgeon. In the surgical management, open approach vs laparoscopic is a topic of discussion due to anatomic variations. The aim of this study is to analyze our experience in the laparoscopic management of this condition in Type Va.

METHODS

We made a descriptive retrospective study of patients diagnosed with MS type Va and treated by laparoscopic approach from 2014 to 2019, in two high volume centers of Bogotá, Colombia.

RESULTS

1073 patients who presented complications from gallstones were evaluated, of which 16 were diagnosed with MS type Va. 75% were females and 25% males; 80% presented jaundice and 90% abdominal pain; 12 patients showed cholecystoduodenal fistula and 4 cholecystocolic fistula. All patients underwent laparoscopic management, total cholecystectomy and fistula resection with primary closure was possible on a 100% of the patients. Conversion rate was 0%. The follow up was 18 months.

CONCLUSION

Laparoscopic management of MS is feasible and safe; the experience of the surgery group and selection of the patients is the key to a successful outcome.

Role of laparoscopy in the treatment of internal biliary fistulas in a high-volume center and a review of the literature

BACKGROUND

Biliary fistulas may result as a complication of gallstone disease. According to their tract, abdominal internal biliary fistulas may be classified into cholecystobiliary and bilioenteric fistulas. Surgical treatment is challenging and requires highly trained surgeons with high preoperative suspicion. Conventional surgery is still of choice by most of the authors. However, laparoscopy is emerging as a minimally invasive alternative. We investigated the surgical approach, conversion rate, and outcomes according to the type of biliary fistula.

METHODS

We retrospectively reviewed 11,130 laparoscopic cholecystectomies, 31 open cholecystectomies, and 31 surgeries for gallstone ileus at our institution from May 2007 to May 2020. We diagnosed internal biliary fistula in 73 patients and divided them into two groups according to their fistulous tract: cholecystobiliary fistula and bilioenteric fistula. We described demographic characteristics, preoperative imaging modalities, surgical approach, conversion rates, surgical procedures, and outcomes. We additionally revised the literature and compared our results with 13 studies from the past 10 years.

RESULTS

There were 22 and 51 patients in the cholecystobiliary and bilioenteric groups, respectively. Our preoperative suspicion of a fistula was 80%. We started 88% of procedures by laparoscopic approach. The effectiveness of laparoscopy in the resolution of internal biliary fistula was 40% for cholecystobiliary fistula and 55% for bilioenteric fistulas. The most frequent cause for conversion to laparotomy was the difficulty to identify anatomical features, in addition to the need to perform a Roux en-Y hepaticojejunostomy. Choledocholithiasis was not associated with an increase in conversion rates.

CONCLUSIONS

Laparoscopic resolution of a biliary fistula is still a matter of controversy. Despite the high conversion rates, we believe that a great number of patients benefit from this minimally invasive technique. A high preoperative suspicion and trained surgeons are vital in the treatment of internal biliary fistulas.

Obstructive jaundice due to acute acalculous cholecystitis: 'Mirizzi-like syndrome'

A 78 year-old female status post subarachnoid haemorrhage developed abdominal pain and obstructive jaundice. CT scan showed acute cholecystitis and dilation of the intrahepatic ducts. Endoscopic retrograde cholangiography revealed hepatic duct stenosis due to compression by an enlarged gallbladder. No stones were seen in the common hepatic duct and the cystic duct was patent. An endoscopic retrograde biliary drain was placed to relieve the obstructive jaundice due to acute acalculous cholecystitis. Percutaneous transhepatic drainage was performed to treat the acute acalculous cholecystitis. Hepatic duct stenosis was improved on endoscopic retrograde cholangiography performed 19 days after percutaneous transhepatic drainage. It may be reasonable to treat 'Mirizzi-like syndrome' non-operatively.

Role of magnetic resonance imaging in Bouveret's syndrome: A case report with review of the literature

Bouveret's syndrome is a rare form of gallstone ileus occurring due to obstructing gallstone into the proximal duodenum through a cholecystoduodenal fistula. We report the case of a 72-year-old female presenting with abdominal pain secondary to a large gallstone in the region of the duodenal bulb, causing the upstream gastric obstruction. Here we discuss the clinical features, imaging technologies, and surgical management of Bouveret's syndrome.

Minimally Invasive Approach Using Digital Single-Operator Peroral Cholangioscopy-Guided Electrohydraulic Lithotripsy and Endoscopic Nasogallbladder Drainage for the Management of HighGrade Mirizzi Syndrome

Mirizzi syndrome is a rare complication of gallbladder disease that can be difficult to treat. In particular, endoscopic treatment often fails because of the inability to access or to capture the impacted cystic duct stone. We report a case of Mirizzi syndrome grade III that was successfully managed by digital single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy with endoscopic nasogallbladder drainage and interval laparoscopic cholecystectomy. Based on our experience, digital single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy with endoscopic nasogallbladder drainage is a feasible minimally invasive approach for the management of high-grade Mirizzi syndrome.

Gallbladder Disorders: A Comprehensive Review

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

Mirizzi syndrome from type I to Vb: a single center experience

OBJECTIVES

The present study describes a cohort of patients diagnosed with Mirizzi syndrome from type I to Vb, over a period of four years. It aimed to identify diagnostic and management pitfalls of Mirizzi syndrome, as well as their concomitant cholecystobiliary or cholecystoenteric fistulas.

MATERIAL AND METHODS

We retrospectively reviewed all electronic medical records of patients who underwent surgery for Mirizzi syndrome at a single institution.

RESULTS

Twenty-two patients (0.6%) were diagnosed with Mirizzi syndrome. Most of the patients were females (n=19, 86.3%). Mean age was 43.8 years (range: 21-71 years). Ultrasound was performed in all (100%) patients. Six (27.2%) patients had a CT scan and six (27.2%) patients had endoscopic retrograde cholangiopancreatography. Overall preoperative diagnosis was achieved on 36.6% (n=8) of the patients. There were the same total and partial cholecystectomies, accounting for ten (45.5%) cases each, one hepaticojejunostomy with cholecystectomy (4.5%), and one enterolithotomy (4.5%). Laparoscopic cholecystectomy was attempted in 15 (68.1%) patients, with conversion to open surgery in 93.3% (n=14) of the patients. An open approach was made in five (22.7%) cases. Four (18.1%) patients were reported as MS type I, both types II and III each account for 22.7% (n=5) of the cases, there was only one (4.5%) patient with type IV, and seven (31.8%) patients with type V.

CONCLUSION

There are limited studies of patients with Mirizzi syndrome, including type V classification, and when this syndrome is suspected, a preoperative diagnosis should be made to avoid bile duct injuries or lesions to adjacent organs.

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.

Type III Mirizzi, successfully treated with a free gallbladder flap, a case report

BACKGROUND

Mirizzi syndrome is a type of biliary obstruction caused by an impacted stone in the gallbladder neck or cystic duct that causes and extrinsic obstruction of the common bile duct, this condition if left untreated can lead to duct erosion, fistula, and cholangitis. Preoperative diagnosis is difficult since if not diagnosed correctly can elevate the risk of intraoperative bile duct injury.

CASE PRESENTATION

We present the case of a 61-year-old patient, she presented to our hospital with obstructive jaundice, and a type III Mirizzi syndrome was identified. Preoperative diagnosis was completed, and she was successfully treated using a gallbladder free flap. On follow-ups, the patient is doing well.

CONCLUSION

Mirizzi Syndrome is a rare syndrome that can lead to anatomical disturbances and surgical difficulties due to the hostile territory it creates. High clinical awareness, an emphasis on the preoperative diagnosis, and safe surgical techniques minimizing bile duct injury can improve patients outcome.

Síndrome de Mirizzi que simulaba una neoplasia biliar maligna

El síndrome de Mirizzi puede cursar con manifestaciones clínicas y hallazgos imagenológicos y de laboratorio, similares a los encontrados en las neoplasias biliares malignas. Se describe el caso de un paciente cuyo enfoque clínico inicial y estudios de imágenes aportaron datos sugerentes de neoplasia de las vías biliares. Los marcadores tumorales (CA 19-9, CEA) resultaron elevados. Una nueva evaluación clínica y la exploración endoscópica por laparotomía de las vías biliares, permitieron establecer el diagnóstico de síndrome de Mirizzi. Después de la extracción del cálculo biliar y de la anastomosis entre el conducto hepático y el yeyuno, el paciente permaneció asintomático. En este caso, la reevaluación clínica y el uso del protocolo adecuado de estudio, contribuyeron a orientar y confirmar el diagnóstico de síndrome de Mirizzi, lo cual determinó la conducta terapéutica más acertada.

Safety and feasibility of laparoscopic approaches for the management of Mirizzi syndrome: a systematic review

BACKGROUND

Laparoscopic approaches for the management of Mirizzi syndrome (MS) are controversial and challenging procedures for high conversion rate. This review aims at evaluating their safety and feasibility.

METHODS

We reviewed studies related to the laparoscopic approaches for the management of MS with detailed data of articles from January 2009 to December 2019 found in PubMed.

RESULTS

From 63 articles, we reviewed 17 articles detailing laparoscopic approaches for MS. There were 857 patients with MS; 432 of which were identified from 73,842 patients underwent cholecystectomy. Laparoscopic approaches were attempted in 440 patients and were successful in 290. The conversion rate was 34.09%. Various methods including laparoscopic cholecystectomy, laparoscopic subtotal cholecystectomy, laparoscopic common bile duct exploration (LCBDE) and (LTCBDE) were performed. The preoperative diagnosis of MS was made in 338 of 500 patients (67.60%). The mean operating time ranged from 49.7 ± 27.5 min to 270.5 ± 65.5 min, and the mean intraoperative bleeding varied from 21.1 ± 15.9 ml to 162.81 ± 40.83 ml. The mean hospital stay varied from 4.5 ± 3.7 to 7.21 ± 1.61 days. Postoperative complications occurred in 27 patients.

CONCLUSIONS

Various laparoscopic approaches are safe and feasible for the treatment of MS in the hands of experienced laparoscopic surgeons, especially for type I and II of Csendes classification. Definitive preoperative diagnosis and earlier management are essential.