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

Clinical Outcomes and Treatment Strategy of Mirizzi's Syndrome Treated With Surgery

BACKGROUND

There is currently no standardized treatment for Mirizzi's syndrome (MS). We aim to explore the surgical treatment strategy for MS by analyzing its clinical characteristics and treatment outcomes.

METHODS

This retrospective study analyzed the clinical data of 130 patients with MS who underwent surgery at our hospital from April 2013 to April 2020.

RESULTS

The study population comprised 130 patients with MS, with an approximately balanced sex ratio and a median age of 58.5 years. The preoperative diagnostic rate was 82.3%. The diagnostic accuracy of ERCP was 92.5%, higher than that of MRCP and ultrasound. All patients underwent surgical treatment, with 74 cases of laparoscopic surgery, 43 cases of laparotomy, and 13 cases of laparoscopic surgery converted to laparotomy. A total of 23 patients experienced short-term and long-term complications after surgery, with a complication rate of 17.7%. There was no statistical difference between laparoscopic surgery and open surgery in terms of intraoperative hemorrhage, operative time, and postoperative complication rate. However, the length of hospital stay was shorter in the laparoscopic surgery compared to the open surgery, which was statistically different from each other.

CONCLUSION

ERCP is the gold standard for the diagnosis of MS, especially for identifying the type of MS. ERCP plays an important role in both the preoperative and postoperative phases of MS. Our study demonstrated that laparoscopic surgery was a safe and feasible option for MS treatment, even requires less hospitalization than open surgery.

Mirizzi syndrome: The Trojan horse of gallbladder disease

Background

The incidence of Mirizzi Syndrome ranges from 0.05 to 5.7 % of patients who undergo cholecystectomy. The purpose of this study is to examine the preoperative workup and postoperative outcomes for patients diagnosed with Mirizzi Syndrome.

Methods

Retrospective chart review was conducted between January 2018 and January 2022 at a single institution. All adult patients who underwent cholecystectomy were included.

Results

1628 patients underwent cholecystectomy of which 47 were diagnosed with Mirizzi Syndrome. The majority of patients had type 1 Mirizzi Syndrome. Preoperative studies were often nondiagnostic and 81 % of cases were diagnosed intraoperatively. 66 % of cases were performed laparoscopically, an open approach was required for type V Mirizzi Syndrome. The complication rate was 25 %; most commonly a bile leak requiring ERCP.

Conclusion

Mirizzi syndrome is more common than previously expected and related to patient's ability to seek timely medical care. Most cases can be completed laparoscopically however there is a high rate of complications.

Key message

This study presents an additional cohort of patients found to have Mirizzi syndrome and supports the hypothesis that it is difficult to diagnose preoperatively. Cases should be attempted laparoscopically but there remains a high complication rate.

Operative timing and the safety of emergency laparoscopic cholecystectomy: A retrospective analysis

The ideal operative timing for laparoscopic cholecystectomy (LC) remains controversial, particularly in emergency patients. This study aimed to evaluate the necessity of operative timing for emergency LC. One hundred ninety-four patients who had undergone operative timings were classified into groups of <72h and >72h from the onset of symptoms to the operation. Baseline data, basic disease, operative bleeding, complications, and conversion rates were analyzed by Variance analysis and logistic regression analysis. The total morbidity of postoperative complication was 4.93% and 3.84% (P = .751) in the <72h and >72h groups respectively. The complication and conversion to LC were mainly influenced by age and gallbladder volume (odds ratio [OR] = 1.078, P = .013, and OR = 1.035, P = .031), but not by operative timing (P = .292). The intraoperative blood loss was closely correlated with the gallbladder volume (OR = 1.019, P = .025) by logit regression analysis, and correlation coefficient of R = 0.436, P < .01. Our results suggest that it is not necessary to confine the operative timing of LC to within 72h from the onset of symptoms, and gallbladder volume should be emphasized in the operative timing for emergency LC.

Mirizzi Syndrome Type I: A Case Presentation

Mirizzi syndrome (MS) is a rare complication of chronic cholelithiasis. The syndrome describes gallstone obstruction of Hartmann's pouch or the cystic duct that extrinsically compresses the common hepatic duct, causing obstructive jaundice. In advanced cases, the gallstones may erode into the biliary tree creating a fistula, requiring prompt diagnosis and careful surgical management. We present a case of an 82-year-old female who presented with upper abdominal pain and jaundice, later diagnosed with suspected MS type I, and managed surgically. We aim to highlight MS type I because of the potential progression and damage to the bile duct, creating complications that may affect overall patient outcome.

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.

Type IV Mirizzi Syndrome: Brief Report and Review of Management Options

Mirizzi syndrome is a rare complication of chronic calculous cholecystitis. Preoperative diagnosis is challenging due to the absence of pathognomonic signs and symptoms and low sensitivity rates of imaging tests. Historically, laparotomy has been the preferred choice of surgical management. Endoscopic and laparoscopic approaches have been increasingly described as diagnostic and therapeutic options for Mirizzi type I and II, but data is limited regarding the management of more complex cases. We describe a staged endoscopic and laparoscopic approach for the management of type IV Mirizzi syndrome and review the management options.

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.