Mirizzi syndrome: a new insight provided by a novel classification

Abstract

Backgrounds/Aims: Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis. The aim of this study is to evaluate our 15-year experience in this challenging entity and to propose a new classification for this disease. Methods: A retrospective study including patients diagnosed with Mirizzi syndrome and undergoing surgical procedures for Mirizzi syndrome between January 2000 and October 2015 was conducted. Data collected included clinical, surgical procedure, postoperative morbidity. Patients were evaluated according to the Csendes classification and the proposed system, in which patients were divided into three types and three subtypes. Results: 28 patients were included for analysis. They accounted as the 0.5% of a total of 4853 cholecystectomies performed in the study period. There were 21 women and 7 men. Initial laparotomic approach was performed in 12 patients and in 16 patients laparoscopic procedures were attempted. The procedure was completed in only 6 patients, 5 presenting type I and 1 type II Mirizzi syndrome. Mean postoperative stay was 15±9 days. Postoperative morbidity rate was 28%. Postoperative mortality was none. Conclusions: Laparoscopic surgery for Mirizzi syndrome has been shown succesful only in early stages. A novel classification is proposed, based on the types of common bile duct injuries and in the presence cholecystoenteric fistula. (Ann Hepatobiliary Pancreat Surg 2017;21:67-75)

Laparoscopic management of type II Mirizzi syndrome

“…Ultrasonography is the most commonly used imaging procedure in the diagnosis of gallstones. The sensitivity of US for the diagnosis of Mirizzi syndrome ranges 8.3-62.7% [6,8,13,26]. However, in our series, none of the pre-operative US scans performed yielded a positive diagnosis.…”

“…It is only achieved in 8-62.5% of cases [6]. In our series the [6,8,13,26]. It is considered a gold standard diagnostic tool, as it defines the cause, level and extent of biliary obstruction, as well as ductal abnormalities, including fistula [14,18].…”

“…The true incidence of Mirizzi syndrome is unknown, as most of the cases are diagnosed in symptomatic patients undergoing biliary surgery, while asymptomatic cases may go undetected [3]. Most of the large patient series estimate the incidence of types I and II Mirizzi syndrome between 0.05 and 2.7% among patients with symptomatic gallstone disease in western developed countries [8,24]. However, in Asia, Central and South America the incidence of Mirizzi syndrome is higher (4.7-5.7% of symptomatic gallstone disease) [6,11,12].…”

“…CT scan is useful in differentiating Mirizzi syndrome from a malignancy, especially when a cholecystobiliary fistula is present [14]. Pre-operative diagnosis improves outcomes of surgery, allowing better planning [5,6,8,[27][28][29] and referral to the appropriate surgeon. If pre-operative diagnosis is not achieved, intra-operative recognition and proper management are essential to improve outcomes, reduce morbidity (up to 17% bile duct injury) and mortality [5,13].…”

“…This compression causes pressure ulceration that produces local inflammation. The compression and subsequent inflammation will lead to first external obstruction of the bile duct and further erosion into the bile duct, evolving into a cholecystocholedochal or cholecystohepatic fistula with different degrees of communication between the gallbladder and bile duct [4][5][6][7][8].…”