Surgical management of Mirizzi syndrome during the pandemic in a COVID 19 referral center: Report of a case from a developing country

Anthony R Perez,Brent Andrew G Viray,Crisostomo E Arcilla,Emmanuel T Limpin

doi:10.5348/100093z04bv2020cr

Abstract

>Mirizzi syndrome (MS) is a rare complication of gallstone disease. Surgical management may be complex, depending on the type of Mirizzi, and may range from simple cholecystectomy to a hepaticojejunostomy. A 39-year-old female diagnosed previously to have gallstones was admitted in the Philippine General Hospital (PGH), a tertiary COVID 19 referral center presenting with obstructive jaundice, right upper quadrant pain and fever. Hepatobiliary ultrasonography demonstrated a markedly distended gallbladder with a stone at the Hartmann's pouch. A diagnosis of Mirizzi syndrome with cholangitis was made. The patient was managed with broad spectrum antibiotics and scheduled for surgery. No further imaging or endoscopy was requested due to the limitations brought about by the pandemic. Upon a negative COVID 19 polymerase chain reaction (COVID 19 PCR) test result she underwent surgery, subtotal cholecystectomy, intraoperative cholangiography, and choledochoplasty. No perioperative complications were noted. This patient was managed with the goal of providing excellent patient care while limiting risks from COVID 19 both to the patient and the health care team. This case demonstrates the need to address issues brought about by the pandemic resulting in limitations in resources, added risk of morbidity to patients, and increased level of technical difficulty particularly in biliary surgery.

Highlights

While there is no actual data yet nor a mathematical model to express the number of surgical cases that have been compromised, a surge of backlogs awaits as we pass the fourth week of enhanced community quarantine (ECQ)
Whether bile can generate a high amount of viral aerosolization is still under investigation[12] All these herald emergent GI surgery as high risk aerosol generating procedures (AGP)
Where resources are available, zoning of work spaces and designating dedicated COVID and NON-COVID health care teams may be beneficial to allow continuation of services in your respective institutions. This allows access to the usual process leading them to surgery or other treatment options appropriate for non-COVID patients without compromise

Summary

Please see PAHPBS Recommendation on Rational Use of PPE

This set of recommendation does not focus on specific HPB conditions due to the wide spectrum of clinical presentation, risk factors, available treatment strategies in each local unit of practice, availability of resources and expertise; and financial capability of our Filipino patients. Where resources are available, zoning of work spaces and designating dedicated COVID and NON-COVID health care teams may be beneficial to allow continuation of services in your respective institutions This allows access to the usual process leading them to surgery or other treatment options appropriate for non-COVID patients without compromise. 33-34 Delaying essential cancer surgeries for a few weeks maybe necessary as the risk of COVID-19 infection reported a higher mortality rate especially those who were pre-symptomatic during the time of surgery. Diagnostics including CT chest[38] in all patients especially undergoing liver, biliary, pancreatic resection and emergency procedures should be practiced This will serve as a good metastatic work up but may detect beginning or subtle changes in the lung parenchyma necessitating further examination or tests to exclude or confirm the presence of Covid-19.

Procedures with

Always remember hand hygiene in between steps

Findings

Highest Priority