The Mirizzi Syndrome: Multidisciplinary Management Promotes Optimal Outcomes

Abstract

The Mirizzi syndrome (MS) is a rare cause of obstructive jaundice produced by the impaction of a gallstone either in the cystic duct or in the gallbladder, resulting in stenosis of the extrahepatic bile duct and, in severe cases, direct cholecystocholedochal fistula formation. Sixteen patients were treated for MS in our center over the 12-year period 1993--2005 for a prevalence of 0.35% of all cholecystectomies performed. One patient was diagnosed only at the time of cholecystectomy. The other 15 patients presented with laboratory and imaging findings consistent with choledocholithiasis and underwent preoperative endoscopic retrograde cholangiopancreatography, which established the diagnosis in all but one patient. All patients underwent cholecystectomy. An initial laparoscopic approach was attempted in 14 patients, of whom 11 were converted to open procedures. MS was recognized operatively in 15 patients with definitive stone extraction and relief of obstruction in 13 patients. T-tubes were placed in 10 patients and 1 patient required a choledochoduodenostomy. Two patients required postoperative laser lithotripsy via a T-tube tract to clear their stones; and in another patient, MS was detected and treated via postoperative endoscopic retrograde cholangiopancreatography (ERCP). MS remains a serious diagnostic and therapeutic challenge for endoscopists and biliary surgeons.

The role of endoscopy in the management of choledocholithiasis

“…It is an uncommon complication of gallstone disease, reported in approximately 0.3% of large series of cholecystectomies. 167,168 Historically, the role of ERC was to diagnose Mirizzi syndrome and relieve biliary obstruction via stenting before definitive surgical management. However, case series also describe successful endoscopic stone removal in Mirizzi syndrome, usually after some form of intraductal lithotripsy or ESWL, both preand postoperatively.…”

Update on the Diagnosis and Treatment of Mirizzi Syndrome in Laparoscopic Era

“…These signs can also be detected by endoscopic ultrasound. 14 MCR has demonstrated high specificity and sensitivity in detecting gallstones and bile duct stenosis. It can describe typical findings of this entity like external narrowing of the common hepatic duct, impacted stone at the junction with the cystic duct, and dilatation of intrahepatic and extrahepatic duct.…”

Evidence-based clinical practice guidelines for cholelithiasis 2016

“…Other studies have concluded that ESWL could be considered in highrisk surgery patients or in patients with Mirizzi syndrome [94,95] [97,98]. The proficiency of surgeons treating patients with this disease also differs by region.…”