Diagnosis Of Mirizzi Syndrome Research Articles

FPre-Operative Ultrasound Diagnostics of Mirizzi Syndrome

Background. Mirizzi syndrome (MS) is one of the most severe complications of the gastrointestinal tract and the most complex pathological process in biliary surgery in general. The issue of ultrasound diagnostics (USD) of MS in patients with gallstone disease (GLC) at the preoperative stage for planning the scope of surgical intervention and warning the patient about possible complications is acute. The goal. Determine the sensitivity of preoperative ultrasound in the diagnosis of MS and finding the most significant echo pattern of MS during ultrasound. Materials and Methods. The results of 9126 cholecystectomies performed in the Kharkiv Clinical Hospital on railway transport No. 2 for the period from 1997 to 2023 were analyzed, while MS was suspected in 159 (1.7%) patients by ultrasound. Out of 159 in whom signs of MS were detected by ultrasound, MS was reliably confirmed intraoperatively in 116 (72,9%) patients, and no SM was detected in 43 (27,1%) patients. MS I type was detected in 98 (84.49%) patients, MS II type – 18 (15.51%). Among them there were 87 (75) women, 29 (25) men, the age of the patients ranged from 37 to 80 years (on average – 66.4 years). To analyze the sensitivity of certain echo characteristics during preoperative ultrasound in case of suspicion of SM, the diagnostic sensitivity index (DS) was used. Results. It was established that the most sensitive echocardiogram is the absence of a clear border between the back wall of the gallbladder and the hepaticocholedochus, the frequency is 75.40%. The next sign of sensitivity, which was confirmed intraoperatively, is a shrunken gall bladder, the DS indicator is 54.55%. It was also established that the combination of such echo features as: a shrunken gallbladder and the absence of a clear border between the back wall of the gallbladder and hepatic choledochal, which was detected in 25, in 23 of them, MS was confirmed intraoperatively, the DS rate was 92%. Conclusions. Ultrasound allows with a high (72,9%) degree of probability to establish the presence of SM at the preoperative stage. A reliable ultrasound sign of the presence of SM is the visualization of the common wall between the gallbladder and the hepaticocholedochus – DS 75.40%. With a combination of echo signs: shrunken gallbladder and deformation of the wall of the hepaticocholedochus in the place of attachment of the gallbladder, it is possible to assume MS with a high percentage of reliability (92%) with the help of ultrasound at the preoperative stage. The received information about the high probability of the presence of MS before the operation allows you to correctly plan possible options for the volume and tactics of surgical intervention.

Surgical strategies for Mirizzi syndrome: A ten-year single center experience.

BACKGROUNDMirizzi syndrome (MS) remains a challenging biliary disease, and its low rate of preoperative diagnosis should be resolved. Moreover, technological advances have not resulted in decisive improvements in the surgical treatment of MS. Complex bile duct lesions due to MS make surgery difficult, especially when the laparoscopic approach is adopted. The safety and long-term effect of MS treatment need to be guaranteed in terms of preoperative diagnosis and surgical strategy.AIMTo analyze preoperative diagnostic methods and the safety, effectiveness, prognosis and related factors of surgical strategies for different types of MS.METHODSThe clinical data of MS patients who received surgical treatment from January 1, 2010 to December 31, 2020 were retrospectively reviewed. Patients with malignancies, choledochojejunal fistula, lack of data and lost to follow-up were excluded. According to preoperative imaging examination records and documented intraoperative findings, the clinical types of MS were determined using the Csendes classification. The safety, effectiveness and long-term prognosis of surgical treatment in different types of MS, and their interactions with the clinical characteristics of patients were summarized.RESULTSSixty-six patients with MS were included (34 males and 32 females). Magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) showed specific imaging features of MS in 58 cases (87.9%), which was superior to ultrasound scan (USS) in the diagnosis of MS and more sensitive to subtle biliary lesions than USS. The overall laparoscopic surgery completion rate was 53.03% (35/66), where the completion rates of MS type I, II and III were 69.05% (29/42), 42.86% (6/14) and zero (0/10), respectively. Thirty-one patients (46.97%) underwent laparotomy or conversion to laparotomy including 11 cases of iatrogenic bile duct injury which occurred in type I patients, and 25 of these patients underwent bile duct exploration, repair and T-tube drainage. In addition, 25 patients underwent intraoperative choledochoscopy and T-tube cholangiography. Overall, 21 cases (31.8%) were repaired by simple suturing, and 14 cases (21.2%) were repaired using the remaining gallbladder wall patch in the subtotal cholecystectomy. The ascendant of the Csendes classification types led to an increase in surgical complexity reflected by increased operation time, bleeding volume and cost. Gender, acute abdominal pain and measurable stone size had no effect on Csendes type of MS or final surgical approach. Age had no effect on the classification of MS, but it influenced the final surgical approach, hospital stay and cost. A total of 66 patients obtained a relatively high preoperative diagnostic rate and underwent surgery safely without serious complications, and no mortality was observed during the follow-up period of 36.5 ± 26.5 mo (range 13-76, median 22 mo).CONCLUSIONMRI/MRCP can improve the preoperative diagnosis of MS. The Csendes classification can reflect the difficulty of treatment. The surgical strategies including laparoscopic surgery for MS should be formulated based on full evaluation and selection.

Predicting cholecystocholedochal fistulas in patients with Mirizzi syndrome undergoing endoscopic retrograde cholangiopancreatography.

BACKGROUNDMirizzi syndrome (MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct (CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.AIMTo evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.METHODSFrom 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed. RESULTSGallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas (P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis (odds ratio 5.82, P = 0.002; 0.12, P = 0.008, respectively).CONCLUSIONGall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.

Safety and feasibility of laparoscopic approaches for the management of Mirizzi syndrome: a systematic review.

Laparoscopic approaches for the management of Mirizzi syndrome (MS) are controversial and challenging procedures for high conversion rate. This review aims at evaluating their safety and feasibility. We reviewed studies related to the laparoscopic approaches for the management of MS with detailed data of articles from January 2009 to December 2019 found in PubMed. From 63 articles, we reviewed 17 articles detailing laparoscopic approaches for MS. There were 857 patients with MS; 432 of which were identified from 73,842 patients underwent cholecystectomy. Laparoscopic approaches were attempted in 440 patients and were successful in 290. The conversion rate was 34.09%. Various methods including laparoscopic cholecystectomy, laparoscopic subtotal cholecystectomy, laparoscopic common bile duct exploration (LCBDE) and (LTCBDE) were performed. The preoperative diagnosis of MS was made in 338 of 500 patients (67.60%). The mean operating time ranged from 49.7 ± 27.5min to 270.5 ± 65.5min, and the mean intraoperative bleeding varied from 21.1 ± 15.9ml to 162.81 ± 40.83ml. The mean hospital stay varied from 4.5 ± 3.7 to 7.21 ± 1.61days. Postoperative complications occurred in 27 patients. Various laparoscopic approaches are safe and feasible for the treatment of MS in the hands of experienced laparoscopic surgeons, especially for type I and II of Csendes classification. Definitive preoperative diagnosis and earlier management are essential.

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

&gt;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.

Laparoscopic cholecystectomy combined with ERCP for treatment of Mirizzi syndrome

Introduction: Since 1987, Laparoscopic cholecystectomy (LC) has been the standard treatment for gall bladder lesions. Complicated acute cholecystitis including associated with bile duct stones, acute cholangitis, biliary pancreatitis and Mirizzi Syndrome (MS) in patients were challenging to laparoscopic treatment. MS is characterized by gall stones impacting in the infundibulum, Hartmann’s pouch, or cystic duct and causing jaundice. Most common symptoms of this syndrome were jaundice, abdominal pain and fever. Pre-operative work-up including abdominal ultrasonography, CT scanning, MRCP and ERCP. Preoperative diagnosis of MS is often difficult but very important to confirm the diagnosis and to avoid intra-operative complications. Laparoscopic surgery as the primary treatment of MS is controversial and only reported in small case series. This study aims to clarify this challenging issue. Method: From Jan 2004 to Dec. 2017, 100 consecutive patients with MS were diagnosed by ERCP and then received surgical procedure at the Department of General Surgery, CGMH, Linkou, Taiwan. 60 patients were treated with LC 40 patients were treated with open cholecystectomy. The Clinical manifestations, pre-operative drainage, surgical treatment and post-operative outcome between these two groups will be compared. Result: The conversion rate of LC to open cholecystectomy for MS is 16.6%. The hospital stay is significantly shorter in the LC group patients than those converted to open cholecystectomy and traditional open cholecystectomy group patients. The risk factor for conversion and post-operative biliary complication is fistula type and low insertion of cystic duct, respectively. Conclusion: MS is still challenging to laparoscopic surgeon. However, pre-operative ERCP diagnosis and post-operative ERCP management is mandatory to decrease conversion rate and biliary complications.

Role of Laparoscopic Surgery in the Current Management of Mirizzi Syndrome

Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis caused by extrinsic biliary compression by stones in the gallbladder infundibulum or cystic duct. The purpose of this study was to evaluate the outcomes associated with a laparoscopic approach to this disease process. This is a 10-year, retrospective study conducted at two academic medical centers with established acute care surgery practices. Patients with a diagnosis of MS confirmed intraoperatively were included. Eighty-eight patients with MS were identified with 55 (62.5%) being type 1. Twenty six (29.5%) patients, all type 1, underwent successful laparoscopic cholecystectomy. Of the 62 patients that underwent open cholecystectomy, 27.3 per cent had a laparoscopy converted to open procedure. There was no significant difference in overall complications (19.2 vs 29%) among those undergoing laparoscopic versus open cholecystectomy. Length of stay was lower in patients that had a laparoscopic approach (P = 0.001). Laparoscopic cholecystectomy can safely be attempted in type 1 MS and seems to be associated with fewer overall complications and shorter length of stay compared with an open approach.

Complicated gallstone disease: diagnosis and management of Mirizzi syndrome

Mirizzi syndrome (MS) is characterized by an obstruction of the proximal bile duct due to extrinsic compression by either an impacted stone in the gallbladder neck or local inflammatory changes. Although this is a rare syndrome in developed countries (0.7-1.4%), preoperative diagnosis and careful surgical management are essential to avoid bilio-vascular injuries and misdiagnosed malignancy. The purpose of this study was to review our experience in the diagnosis and management of MS, assess the role of laparoscopy and the risk of concomitant gallbladder carcinoma. This study took place in a large county hospital which serves indigent and undocumented immigrants without easy access to healthcare. Data were collected through a retrospective chart review of 4939 patients that underwent cholecystectomy over 6years. Patient demographics, preoperative, intraoperative, postoperative data and outcomes were analyzed. MS was identified in 60 of 4939 patients (1.21%) who underwent cholecystectomy. The mean age at presentation was 47years, and 35 patients were females. The most common symptom at presentation was abdominal pain (100%) followed by nausea/vomiting (87%) and jaundice (43%). Type I MS was diagnosed in 16 patients and 44 had type II MS. Preoperative diagnosis was achieved in 43 patients (71%). Magnetic resonance cholangiopancreatography was the best diagnostic modality. Laparoscopic cholecystectomy was successful in 4 out of 16 patients with type I MS. Three patients (5.26%) had simultaneous gallbladder cancer. Overall morbidity was 27% and mortality was 0. Clavien grade ≥3 complications were seen in six patients (10%). The mean length of follow-up was 2.3months (range 0-5) for type I MS patients and 5.4months (range 0-46) for type II patients. MS is rare, but preoperative diagnosis or intraoperative suspicion is important. Laparoscopic cholecystectomy may be possible in selected type I cases. Open cholecystectomy is the standard of care for type II MS.

Laparoscopic transfistulous bile duct exploration for Mirizzi syndrome type II: a simplified standardized technique.

Laparoscopic treatment is a viable option for Mirizzi syndrome (MS) type I, but it is not recommended for MS type II (McSherry classification). We introduce laparoscopic transfistulous bile duct exploration (LTBDE) as a simplified standardized technique for MS type II. Eleven consecutive LTBDEs performed by a surgeon for MS type II were analyzed retrospectively, including three successful single-incision LTBDEs (SILTBDEs). Transfistulous stone removal followed by primary closure of gallbladder remnant and partial cholecystectomy was performed. An additional choledochotomy was required in one patient. Preoperative endoscopic retrograde cholangiopancreatography and operative findings confirmed the diagnosis of MS in five and five patients, respectively. Preoperative ultrasound implied the remaining diagnosis. The operative time was 270.5±65.5min. The stone clearance rate was 100%. The postoperative length of hospital stay was 5.1±2.2days. There was no open conversion. Overall complications comprised two postoperative transient hyperamylasemia (18.2%) and one superficial wound infection (9.1%). Compared with the other group of 92 patients who underwent laparoscopic bile duct exploration, the MS type II group had a significantly younger age, a higher jaundice rate, a lower single-incision laparoscopic approach rate, a lower choledochotomy rate, longer operative time, a lower postoperative pethidine dose, and a longer total length of hospital stay. The average follow-up period was 12.1months. LTBDE is safe and efficacious for MS type II including Csendes type IV. A high suspicion of MS is critical. SILTBDE is feasible in selected cases. Long-term follow-up is mandatory.

Update on the diagnosis and treatment of mirizzi syndrome in laparoscopic era: our experience in 7 years.

Mirizzi syndrome (MS) is a rare complication of cholelithiasis. The objective of this study was to assess the current incidence of MS in our area and present our experience in the clinical, diagnostic, and therapeutic management, focussing in laparoscopic approach. We prospectively analyzed 35 cases of MS between January 2006 and November 2012, collecting information regarding demographics, clinical management, diagnostic methods, surgical procedure, postoperative morbidity, and follow-up. All patients underwent abdominal ultrasonography. In patients with suspected obstructive jaundice, magnetic cholangiography resonance and endoscopic retrograde cholangiopancreatogram were performed preoperatively, detecting MS in 68.5% of patients. The incidence of MS was 2.8% in 1168 cholecystectomies for cholelithiasis. There were 13 men and 22 women, with a mean age of 70.1 years. Nineteen patients had MS type I (54.2%). Fourteen were treated with laparoscopic cholecystectomy (LC) successfully, whereas 3 conversions were performed because of difficult surgical dissection. In the remaining 2, subtotal cholecystectomy was performed. Seven patients had type II MS (20%). In 5 cases cholecystectomy and bile duct repair were performed with T-tube placement (in 4 by laparoscopic approach), in another one subtotal cholecystectomy with primary biliary choledochorrhaphy was performed, because of dilated bile duct. Finally, the remaining patients with type III and IV SM (14.2% and 11.4%, respectively) were treated with Roux-en-Y hepaticojejunostomy.We observed 14.5% morbidity, highlighting 2 cases of postoperative collection and 1 case of biliary fistula. There was no postoperative mortality. The mean follow-up of patients was 13.4±4 months. Preoperative diagnosis of MS is difficult, but it is essential in the proper management of the disease. Investigations as magnetic cholangiography resonance and endoscopic retrograde cholangiopancreatogram contribute to the success of preoperative identification. LC should be reserved to MS type I and type II highly selected cases. This pathology should be treated by experienced surgeons to decrease the risk of iatrogenia.

Mirizzi Syndrome: Experience in Diagnosis and Treatment of 25 Cases

The objective of this study is to summarize the experience in diagnosis and treatment of Mirizzi syndrome (MS) and reduce the incidence of operative complications. Twenty-five cases of Mirizzi syndrome from January 2005 to January 2010 were retrospectively analyzed. There were 11 male patients and 14 female patients, ranging in ages from 26 to 80 years with a median age of 51.3. Preoperative radiological diagnosis was achieved in 10 patients: ultrasonography (n = 5) and magnetic resonance cholangiopancreatography (n = 10). The others were diagnosed intraoperatively. Fifteen patients had Type I MS. Two were treated with laparoscopic cholecystectomy successfully. The laparoscopic procedure had to be converted to open procedure in one patient. Seven patients had open complete cholecystectomy, three had subtotal cholecystectomy, and two had removal of stones from the gall bladder and choledochostomy after cholecystostomy was performed, with secondary cholecystectomy 3 months later. Six patients had Type II MS. Five underwent cholecystectomy, common bile duct (CBD) repair, and T-tube insertion. One was managed with transection of CBD and Roux-en-Y hepaticojejunostomy. Two patients with Type III MS underwent cholecystectomy, CBD repair, and T-tube insertion. Cholecystectomy and Roux-en-Y hepaticojejunostomy was performed in the two patients with Type IV MS. All the patients recovered from the operation. The follow-up period ranged from 5 years to 5 months. One patient developed obstructive jaundice more than 2 years after the operation, and recovered after the secondary operation. The follow-up of others were uneventful. Preoperative diagnosis of MS is very difficult. Magnetic resonance cholangiopancreatography is very helpful in preoperative diagnosis, and a high index of clinical suspicion is required to make a preoperative or intraoperative diagnosis, which can lead to correct operative strategy to manage Mirizzi syndrome.

Mirizzi syndrome

Mirizzi syndrome is an important complication of gallstone disease. If not recognized preoperatively, it can result in significant morbidity and mortality. Preoperative diagnosis may be difficult despite the availability of multiple imaging modalities. Ultrasonography (US), CT, and magnetic resonance cholangiopancreatography (MRCP) are common initial tests for suspected Mirizzi syndrome. Typical findings on US suggestive of Mirizzi syndrome are a shrunken gallbladder, impacted stone(s) in the cystic duct, a dilated intrahepatic tree, and common hepatic duct with a normal-sized common bile duct. The main role of CT is to differentiate Mirizzi syndrome from a malignancy in the area of porta hepatis or in the liver. MRI and MRCP are increasingly playing an important role and have the additional advantage of showing the extent of inflammation around the gallbladder that can help in the differentiation of Mirizzi syndrome from other gallbladder pathologies such as gallbladder malignancy. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the diagnosis of Mirizzi syndrome. It delineates the cause, level, and extent of biliary obstruction, as well as ductal abnormalities, including fistula. ERCP also offers a variety of therapeutic options, such as stone extraction and biliary stent placement. Percutaneous cholangiogram can provide information similar to ERCP; however, ERCP has an additional advantage of identifying a low-lying cystic duct that may be missed on percutaneous cholangiogram. Wire-guided intraductal US can provide high-resolution images of the biliary tract and adjacent structures. Treatment is primarily surgical. Open surgery is the current standard for managing patients with Mirizzi syndrome. Good short- and long-term results with low mortality and morbidity have been reported with open surgical management. Laparoscopic management is contraindicated in many patients because of the increased risk of morbidity and mortality associated with this approach. Endoscopic treatment may serve as an alternative in patients who are poor surgical candidates, such as elderly patients or those with multiple comorbidities. Endoscopic treatment also can serve as a temporizing measure to provide biliary drainage in preparation for an elective surgery.

Mirizzi's syndrome – results from a large western experience

Background. This paper reports a series of patients with Mirizzi's syndrome (MS) who were managed at our institution over an 11-year (1994–2005) period. Methods. Retrospective case note study of patients with a definitive or possible diagnosis of MS stated in radiology reports were identified using the hospital's radiology computer coding system. Results. 33 patients were identified with a median age of diagnosis of 70 (35–90) years and male to female ratio of 15:18. Liver function tests were deranged in all patients. Pre-operative radiological diagnosis was achieved in 28 patients: ultrasound scan (n = 4), computer tomography (n = 3), magnetic resonance cholangiopancreatography (n = 10) and endoscopic retrograde cholangiopancreatography (n = 11). Five patients were diagnosed intra-operatively. Type I MS was reported in 27 patients. Laparoscopic cholecystectomy was attempted in 18 patients with 6 being converted to open cholecystectomy. Six patients had biliary stent insertion only and 3 were conservatively managed. Six patients had type II MS, 4 were treated with open cholecystectomy and Roux-en-Y hepaticojejunostomy, 1 underwent an open subtotal cholecystectomy with fistula closure and 1 had percutaneous biliary stent insertion only. The median follow-up period was 2 (1–7) months (n = 18). 10 patients are currently under follow-up. Overall morbidity was 27% (n = 8) and mortality was 7% (n = 2). Conclusion. Pre-operative diagnosis of MS can be achieved using MRCP. Laparoscopic cholecystectomy for type I MS is a safe option and type II MS can be treated with Roux-en-Y hepaticojejunostomy or subtotal cholecystectomy with fistula closure.

Mirizzi syndrome: a diagnostic and operative challenge

Mirizzi syndrome (MS) is an unusual complication of gallstone disease. The majority of cases are not identified pre-operatively, despite advances in imaging techniques. Eighteen cases of MS were treated between January 1997 and April 2002. The clinical presentation, modes of investigation, surgical management and outcome are retrospectively reviewed. There were 13 female and 5 male patients, with a mean age of 60 years. Seven patients presented with the classical Charcot's triad. Ultrasonography (US) was the first imaging investigation in 13 patients and computerised tomography (CT) in the other five cases. Eleven patients had a successful endoscopic retrograde cholangio-pancreatography (ERCP) carried out. Diagnosis of MS was arrived at in seven patients following pre-operative imagings. Overall, 11 patients had Type 1 and seven patients had Type 2 MS. In the group with Type 1 MS, nine patients underwent open cholecystectomy, of whom six had concomitant common bile duct (CBD) exploration for stones and one patient with biliary stenosis had a hepaticojejunostomy bypass. Laparoscopic cholecystectomy was attempted in two patients, with successful completion in one case. In the group with Type 2 MS, four fistulas were closed surgically, the other three had biliary bypass procedures. Mirizzi syndrome is an unusual condition that poses diagnostic and operative challenges to the surgeon. With a judicious approach during dissection and early recognition of its presence, bile duct injury can be avoided. Good outcome can be achieved with an appropriate surgical procedure.

Mirizzi syndrome: an extra hazard for laparoscopic surgery.

Mirizzi Syndrome (MS) is an important but uncommon complication of gallstones characterized by narrowing of the common hepatic duct (CHD) due to mechanical compression or inflammation. This study aimed to assess the impact of preoperative and intraoperative diagnosis of MS on the performance, safety and efficacy of laparoscopic cholecystectomy. From a consecutive series of 1,281 patients having surgery for gall bladder disease between 1990 and 1998, nine patients with MS were identified from a prospective database and their clinical progress examined. Five out of the nine patients with MS presented with pain (2/5 were also jaundiced), and four presented with acute cholecystitis. Liver function tests were abnormal in all patients. Preoperative diagnosis of MS based on ultrasound was made in only two patients, and in a third on findings of a nasobiliary cholangiogram. In six patients, the diagnosis was intraoperative. In seven patients cholecystectomy was completed by laparoscopy. Two patients needed conversion to open cholecystectomy. In two patients the common bile duct was mistaken for the cystic duct and the error was recognized on relaxation of traction on the gall bladder in one, but in the other a duct injury occurred that was not recognized until the postoperative period. Preoperative diagnosis of MS is difficult, and a high index of suspicion is necessary to avoid serious complications. Once the diagnosis is known, successful laparoscopic management is possible but care should be taken to avoid duct injury.

Diagnostic du syndrome de mirizzi par la C.R.E.

Out of 9 648 endoscopic retrograde cholangio-pancreatographies (ERCP), in 48 (0.5 %) cases was Mirizzi syndrome diagnosed. These patients were investigated because of cholestasis. The basic question in the diagnosis of Mirizzi syndrome is the differentiation from other conditions causing similar morphological changes in the biliary tract. Among them choledochus carcinoma has a great importance with regards to its localisation and radiomorphology. The radiomorphological characteristics of Mirizzi syndrome are: dislocation, half-shaded or incomplete fillings and rarely obstruction of the common hepatic duct. ERCP gets the priority in the diagnosis of this syndrome because it exhibits the morphology of the biliary tract in greater details than other procedures and because it simultaneously gives informations about the morphology of the papilla of Vater and of the pancreatic ducts.