Mirizzi syndrome and cholecystobiliary fistula: A unifying classification

Abstract

A new classification of patients with Mirizzi syndrome and cholecystobiliary fistula is presented. Type I lesions are those with external compression of the common bile duct. In type II lesions a cholecystobiliary fistula is present with erosion of less than one-third of the circumference of the bile duct. In type III lesions the fistula involves up to two-thirds of the duct circumference and in type IV lesions there is complete destruction of the bile duct. A total of 219 patients were identified with these lesions from 17,395 patients with benign biliary tract diseases undergoing surgery. The incidence of type I lesions was 11 per cent, type II 41 per cent, type III 44 per cent and type IV 4 per cent. The majority had obstructive jaundice. In type I lesions, cholecystectomy plus choledochostomy is effective. In type II lesions, suture of the fistula with absorbable material or choledochoplasty with the remnant of gallbladder can be performed. In type III lesions suture is not indicated and choledochoplasty is recommended. In type IV lesions, bilioenteric anastomosis is preferred. Operative mortality rate increases according to the severity of the lesion, as does postoperative morbidity. During cholecystectomy, partial resection is recommended in order to extract the stones, visualize the common bile duct and define the type and location of the fistula. T tubes should be placed distal to the fistula.

Mirizzi Syndrome Complicating Acute Cholecystitis: CT Diagnosis

“…Csendes in 1989 [7], after carefully studying 219 cases, described 4 types -Type 1: external compression of the common bile duct; -Type 2: cholecystobiliary fistula affecting less than one-third of the circumference of the bile duct; -Type 3: fistula involving up to two-thirds of the circumference of the bile duct; -Type 4: fistula with complete destruction of the wall of the bile duct.…”

Manejo cirúrgico da síndrome de Mirizzi

“…Csendes et al 5 sugeriram nova classificação baseada no tamanho da fístula biliar. As lesões do tipo I seriam aquelas devido à compressão externa da via biliar principal; as do tipo II, onde a fístula colecistobiliar erodiu menos do que 1/3 da circunferência do ducto biliar; as do tipo III, onde a fístula envolveu mais do que 2/3 da circunferência do ducto biliar e as do tipo IV quando existisse destruição completa do ducto biliar.…”

“…É importante reconhecer a presença da fistula colecistobiliar para não permanecer dissecando entre o espaço inexistente entre vesícula e ducto hepático comum. Csendes et al 5 , estudando série de 219 pacientes recomenda como manejo cirúrgico colecistectomia parcial e retirada dos cálculos para ver o ducto biliar comum e definir o tipo e a localização da fístula com colangiografia intra-operatória. Esse autor aconselha colocar tubo-T se o processo inflamatório/fibrótico for intenso e a colangiografia não for realizada.…”

“…Foram avaliados a apresentação clínica; os resultados de laboratório e exames de imagem; os achados operatórios; a presença de coledocolitíase; a classificação de acordo com Csendes et al 5 (Tabela 1, Figura 1); a escolha do procedimento operatório; e as complicações pré-operatórias.…”

Mirizzi syndrome

“…The condition was classified by McSherry and colleagues in 1982 and the modification of the same by Csendes and colleagues 4 …”