A Retrospective Review of the Diagnostic and Management Challenges of Mirizzi Syndrome at the Singapore General Hospital

Abstract

Background: Mirizzi syndrome (MS) occurs when gallstone impaction in Hartmann’s pouch results in extrinsic obstruction of the common bile duct, and fistulation may occur. Methods: We retrospectively reviewed electronic records of patients surgically treated for MS from November 2001 to June 2012. Patient presentations, diagnostic methods, treatments and complications were recorded. Results: Sixty-four patients were grouped according to a classification proposed by Beltran et al. [World J Surg 2008; 32: 2237–2243]. Forty-three (66.2%), 18 (27.7%) and 3 (4.6%) patients were classified as types I, II, and III respectively. Magnetic-resonance-cholangiopancreaticography was the most sensitive imaging modality, suggesting MS in 24 (88.9%), followed by CT scan (40%) and ultrasonography (11.4%). Forty-four underwent Endoscopic-retrograde-cholangiopancreaticography and 29 (65.9%) suggested the presence of MS. MS was accurately diagnosed pre-operatively in 48 (73.8%) patients. In type I, 40 (93.0%) patients underwent cholecystectomy, while 3 required hepaticojejunostomy. In type II, 12 (66.7%) underwent cholecystectomy and 5 (27.8%) required hepatico-enteric anastomosis. In type III, 1 underwent cholecystectomy and 2 (66.7%) required hepatico-enteric anastomosis. Laparoscopic cholecystectomy was attempted in 20 (30.8%) patients and 13 (65.0%) required conversion. Twenty-nine (44.6%) underwent intra-operative-cholangioscopy, 30 (46.2%) underwent intra-operative-cholangiogram and 41 (63.1%) underwent intra-operative T-tube placement. Six (9.2%) experienced intra-operative complications, 12 (18.5%) experienced post-operative complications and 10 (15.4%) experienced late complications. Conclusion: MS is a challenging condition and multimodal diagnostic approach has the greatest yield in achieving accurate pre-operative diagnosis. If suspicion is high, a trial of laparoscopic dissection with low threshold for open conversion is recommended.