Mirizzi Syndrome Research Articles

Mirizzi syndrome: A retrospective analysis of 84 patients from a single center

Mirizzi syndrome: A retrospective analysis of 84 patients from a single center

Management of Mirizzi Syndrome in a Tertiary Care Centre of Southern IndiaA Series of 10 Cases

Mirizzi syndrome is a rare condition characterised by obstructive jaundice due to compression of Common Hepatic Duct (CHD) by a stone impacted in the neck of gall bladder. Incidence is around 1-2% in patients with symptomatic cholelithiasis. Preoperative diagnosis and management is challenging. Authors have retrospectively analysed the records of patients undergoing cholecystectomy in our institute for the past 5 years and selected those patients who had final diagnosis of Mirizzi syndrome were reviewed and following results were arrived. From January 2016 to February 2021, 446 patients underwent cholecystectomy. Out of these, 10 (2.24%) patients had final diagnosis of Mirizzi syndrome. Male:Female ratio was 3:7. Mean age at presentation was 49.5 years. Most common presenting symptoms were pain abdomen and jaundice. Mirizzi syndrome was preoperatively diagnosed only in 3 (30%) patients. Others were diagnosed during surgery. Type I in four patients, type II in three patients, type III in two patients and type IV in one patient. These patients were treated with either total or subtotal cholecystectomy. Open approach was used in 8 (80%) patients and Laparoscopic approach in 2 (20%) patients. Biliary drainage procedure was done in all patients, T-tube drainage in 5 (50%); Roux en Y Hepaticojejunostomy in 3 (30%) and Hepaticoduodenostomy in 2 (20%) patients. Thus, we conclude Mirizzi syndrome being one of rare complication of long standing cholelithiasis, pose a challenging task for diagnosis and management. High index of suspicion is required to identify and treat Mirizzi syndrome in order to avoid bile duct injuries.

A combined endoscopic and robotic approach for Mirizzi syndrome: the short- and long-term outcomes

Aims: We present the technique of a combined endoscopic and robotic approach for Mirizzi syndrome (MS) and report the short- and long-term results. Methods: Between July 2012 and August 2020, all patients with suspected MS underwent endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic confirmation and placement of the biliary stent. Subtotal cholecystectomy was then performed with the assistance of a surgical robot. The common bile duct was closed with a cuff of the gallbladder over a biliary stent. ERCP was repeated 6-8 weeks after surgery to remove the biliary stent and confirm the patency of common bile duct. The operative outcomes and long-term results were prospectively collected. Results: Twenty-two patients (10 males and 12 females) were included in the study. All patients underwent the planned robotic subtotal cholecystectomy and pre- and postoperative ERCP. The median age was 65.5 years (range 16-89 years). The median operative time was 212.5 min (range 125-510 min), and the median blood loss was 35 mL (range 7-700 mL). The median postoperative hospital stay was four days (range 3-15 days). Four patients (18.2%) developed postoperative complications including two intra-abdominal collections (9.1%), one wound infection (4.5%), and one atrial fibrillation with pneumonia (4.5%). The last patient also represented the only operative mortality. The median follow-up was 45.6 months; none developed recurrent cholangitis or jaundice, but one patient (4.5%) had a recurrent common bile duct stone which was successfully removed by ERCP. Conclusion: The proposed combined endoscopic and robotic approach can provide favorable short- and long-term outcomes for patients with MS.

Endoscopic management of cystic duct stones and Mirizzi's syndrome: experience at an academic medical center.

Background and study aims Cystic duct stones (CDS) are challenging to treat with conventional ERCP techniques due to the small diameter and tortuous nature of the cystic duct. There have been limited studies focused on endoscopic management of CDS. We present our experience managing CDS endoscopically and demonstrate that new advances in endoscopic technology have rendered CDS easier to manage. Patients and methods From 2013 to 2020, we prospectively maintained a database of patients undergoing endoscopic management of CDS. ERCP was performed in all patients, and if unsuccessful in removing stones, cholangioscopy with electrohydraulic lithotripsy (EHL) was utilized. All patients were followed in clinic for outcomes. Results Of 5,123 ERCPs performed at our institution during the study period, 21 patients were diagnosed with CDS. Six patients were successfully treated with conventional ERCP alone. Cholangioscopy with EHL was used in 15 patients undergoing 18 procedures to achieve stone clearance. CDS clearance was achieved in all patients. There was one adverse event (post-ERCP pancreatitis). Spyglass DS was associated with a significant decrease in average procedure time in comparison to first-generation SpyGlass (89.3 vs. 54.4 minutes, P = 0.004). Thirteen patients (87 %) were discharged from the hospital within 24 hours. The median follow-up duration was 23.2 months. Conclusions Endoscopy should be the preferred management strategy for CDS, especially in patients with prior cholecystectomy. Surgical outcomes have been associated with high patient morbidity and hospital length of stay. Our case series is the largest cohort of CDS patients successfully managed with cholangioscopy and EHL in the United States.

The second 'gallbladder operation'.

Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy. Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information. There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22-63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2-175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis (n = 4, 30.7%), acute cholecystitis (n = 2, one with empyema and GB perforation) and Mirizzi syndrome (n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3-7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients. Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most patients. A pre-operative roadmap is provided by the MRCP. For patients with residual GB, laparoscopic completion cholecystectomy is a feasible and safe option.

Laparoscopic modified subtotal cholecystectomy is a safe method in the management of mirizzi syndrome type I

Background: Efforts to reveal the cystic duct and the cystic artery during standard cholecystectomy in Mirizzi Syndrome (MS) without preoperative or intraoperative diagnosis increase the risk of biliary and vascular injury due to intense fibrosis in the Calot’s triangle. We aim to evaluate the postoperative results of a group of MS type I patients who were diagnosed by video scope intraoperatively and underwent laparoscopic modified subtotal cholecystectomy (LMSC) in the same session since safe dissection of Calot’s triangle could not be performed. Methods: Ten out of 1680 patients who underwent conventional laparoscopic cholecystectomy for acute or chronic cholecystitis between 2017 and 2019 were diagnosed with MS type I intraoperatively. These 10 patients underwent LMSC and their demographic characteristics, preoperative clinical histories, radiological images, intraoperative and postoperative findings were evaluated retrospectively. Intraoperative MS type determination and LMSC technique are explained. Results: The diagnoses of MS type I in all our cases were made laparoscopically with the help of a videoscope during the operation where safe dissection of the Calot’s triangle could not be performed in either elective or emergency cholecystectomy. LMSC was performed without leaving any cavity behind, and there was no need for any intervention at the operation site (suture, staple closure) since the cystic duct orifice was already obstructed due to fibrosis as visually verified by the camera. There were no intraoperative bile duct injuries or postoperative biliary fistula. None of our patients developed postcholecystectomy syndrome (range 1-38 months) Conclusion: The LMSC is a safe procedure in the diagnosis and surgery of MS type I where safe dissection of Calot’s triangle could not be performed

Robotic Management of Mirizzi Syndrome Type IV with Cholecystocolic Fistula: A Rare Case Report

Introduction: Mirizzi syndrome (MS) is a rare complication of prolonged cholelithiasis, with presence of a large gallstone impacted in Hartmann’s pouch, causing chronic extrinsic compression of the common bile duct, and potentially leading to fistula formation between the gallbladder and the common bile duct and/or bowel. Laparoscopic management is widely accepted for MS type I/II, whereas open surgery is the preferred approach for MS type III/IV and presence of a cholecystoenteric fistula. Robotic surgery has the advantage of 3D visualization and endowrist technology, helping to operate more accurately compared to laparoscopy, and could provide an appropriate alternative surgical approach. This report describes the robotic management of a MS type IV with cholecystocolic fistula. Method: The surgical procedure involved a robotic cholecystectomy with a small wedge excision of segment 4B/5 junction, extrahepatic bile duct resection, evacuation of major choledocholithiasis, and wedge excision of a cholecystocolic fistula at the transverse colon. Biliary enteric anastomosis was realized by Roux-en-Y hepaticojejunostomy. The colon was closed using a Heineke-Mikulicz plasty. Dissection was done by monopolar scissors, fenestrated bipolar forceps and robotic sealing device. Results: Operative time was 240 minutes and blood loss 30 cc. Pathology showed chronic cholecystitis without underlying malignance. No intraoperative complications were encountered and the postoperative course was uneventful. Discharged happened on postoperative day 5. Conclusions: Robotic surgery is a safe and feasible technique for MS type IV with cholecystocolic fistula.

O-BN06 A Proposed Difficulty Grading System for Laparoscopic Bile Duct Exploration. Benefits to Practice and Research

Abstract Background A gap remains between the mounting evidence for single session management of bile duct stones and the obstacles to wider adoption of this approach. The practice of laparoscopic bile duct exploration (LCBDE) is limited not only by the availability of training opportunities and adequate equipment but also by the perception that the technique is difficult and requires a high skill-set. The aim of this analysis is to compare the preoperative and operative characteristics and the postoperative outcomes in easy vs. difficult LCBDE in a large consecutive series, according to a proposed 5 grade classification. Methods 1326 LCBDEs were graded according to the location, number and size of ductal stones, retrieval techniques used, utilisation of choledochoscopy and specific biliary pathologies encountered. The cohort was divided into two groups: easy (Grades I A&B, and Grade II A&B, requiring transcystic or transductal exploration for up to 15 stones the largest being 15mm) and difficult (Grades III A&B, for over 15 stones or intrahepatic stones of any size needing transcystic choledochoscopy, IV and V with Mirizzi Syndrome, impacted stones, and ducts needing stenting, conversion or bilioenteric anastomosis). Various outcome parameters were compared. Results Age, sex, obesity and previous biliary admissions had no effect on operative difficulty. Emergency admission, obstructive jaundice, previous ERCP and dilated CBD were predictive of difficult explorations. 78.3% of patients with acute cholecystitis or pancreatitis, 37 % of jaundice and 46% of cholangitis had easy explorations. Transcystic stone retrieval was possible in 77.7% of easy explorations and choledochotomy required in 62.3% of difficult explorations (vs. 33.6% in the whole series). Choledochoscopy was utilised in 23.4% of Grades I&II vs. 98% in difficult explorations. As expected more biliary drains, stenting, bilio-enteric anastomosis, conversions, operative time, biliary-related complications, hospital stay, readmissions and retained stones increased with difficulty. Grades I&II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V, the median presentation to resolution interval increasing from 1 to 3 weeks. There were 2 deaths in difficulty Grade V and one in Grade IIB. Conclusions Difficulty grading of LCBDE is a useful tool of predicting outcomes. It facilitates comparison between studies and fair assessment of training. LCBDEs are easy in 72% and of these 77% can be completed transcystically. It is hoped this will encourage more units to adopt single session management of bile duct stones through establishing referral protocols, developing and refining the skills through training and acquiring the necessary equipment.

Laparoscopic Treatment оf Mirizzi Syndrome

Background. Mirizzi syndrome (MS) is a relatively rare complication of cholelithiasis, which occurs in a wide range from 0.2 to 5% according to different authors. Today, the surgical treatment of MS remains a challenge.Aim of study. To determine the possibilities of laparoscopic interventions in the surgical correction of various types of MS.Material AND methods. The work is based on a prospective analysis of cases of laparoscopic treatment of 19 patients with MS who were treated in the emergency surgery departments of the Republican Scientific Center for Emergency Medical Care in 2017–2019. This is 22.9% of all admitted patients (83) with MS during this period. Type 1 MS was diagnosed in 3 patients (15.7%), type 2 was diagnosed in 16 patients (84.2%).Results. In all cases of type 1 MS, laparoscopic cholecystectomy was performed. A new method for the correction of type 2 MS by forming a sleeve from the gallbladder wall was suggested, which was performed in 10 patients with good results. In the postoperative period, no nonspecific complications were observed in patients undergoing laparoscopic interventions. One patient had residual choledocholithiasis, which was managed by day 5 after the surgery with endoscopic retrograde cholangiopancreatography and endoscopic papillosphincterotomy and the removal of the calculus from the common bile duct. The average duration of stay of patients in a hospital bed was 10.8 days. Fatal outcome was observed in 1 case (5.3%).Conclusion. 1. The inclusion of endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and magnetic resonance imaging cholangiography in the diagnostic scheme improves the accuracy and quality of recognition of Mirizzi syndrome and allows the indications for the use of video laparoscopy to be evaluated. 2. Indication for laparocopic treatment of type 2 Mirizzi syndrome is the presence of a single calculus in the supraduodenal part of the common bile duct, which makes it possible to reduce the number of conversion to laparotomy. 3. In cases of type 1 Mirizzi syndrome, the operation of choice is laparoscopic cholecystectomy. 4. The operation of choice in patients with type 2 Mirizzi syndrome is laparoscopic subtotal cholecystectomy, fistula plasty with a gallbladder flap on the Kehr’s T-tube drain with the formation of a “cystic duct”-type sleeve.

Beyond acute cholecystitis—gallstone-related complications and what the emergency radiologist should know

The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.

Mirizzi Syndrome: The classic presentation

We recently cared for two children with Mirizzi Syndrome. Our first patient was a 12-year-old girl who had an unusual variant of Mirizzi syndrome: a cholecystohepatic fistula, which we stumbled upon during laparoscopic cholecystectomy [ 1 ]. The subject of this report is a 14-year-old young lady whose presentation was more typical (textbook). Cystic duct obstruction by an impacted stone caused acute cholecystitis. Because of the proximity of the ducts, the attendant inflammation “spilled over” onto the common bile duct (CBD) and caused partial obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement was followed by a laparoscopic cholecystectomy.

Percutaneous Stone Removal in the Setting of Mirizzi Syndrome: An Alternative Approach

Percutaneous Stone Removal in the Setting of Mirizzi Syndrome: An Alternative Approach

Mirizzi Syndrome Classification, Are We Missing Something?

Mirizzi Syndrome Classification, Are We Missing Something?

Mirizzi Syndrome: An Experience in Laparoscopic Era

Objective:To assess the presentation and surgical management of Mirrizi syndrome patients who underwent LaparoscopicCholecystectomy. Study Design and Setting:Retrospective Descriptive Study was conducted at Surgical Department Combined MilitaryHospital Rawalpindi and Combined Military Hospital Quetta from 1st Jan 2010 to 20th Jan 2016. Methodology:Patients undergoing laparoscopic cholecystectomy during this period were retrospectively reviewed. Allcases of Mirizzi Syndrome (MS) were identified and data analysed. Results:A total of 5500 patients underwent laparoscopic cholecystectomy during this period. Approximately 26(0.47%)cases were identified to be having MS. Out of these 26 cases only 8 (30%) were males while 18 (70%) were females. Ageranged from 25 to 80 years. Three patients (11%) had an endoscopic retrograde cholangiopancreaticography (ERCP) done.Type-I MS was found in 19 cases (73 %), Type-II in 3 cases (11%), Type-III and Type-IV in 2 cases each (7.69 %).Conversion to open surgery was carried out in 15 cases (57.6 %). All type-I MS had cholecystectomy except one casewhere partial cholecystectomy was done. T-tube closure of common bile duct was done in all Type-II MS. Similarly T-tube closure was possible in two cases of type-III while one hadRoux-en-Y hepaticojejunostomy. All cases of type-IV MS had Roux-en-Y hepaticojejunostomy. One patient out of 26 (3.8 %) had carcinoma gallbladder. There was no mortality. Conclusion:Type-I MS can be managed with laparoscopic cholecystectomy in selected patients.Type-II and type-III MS may need placement of T-tube while most of type-IV MS are managed with Roux-en-Y hepaticojejunostomy.

S1543 The Role of Mirizzi Syndrome in Diagnosis of Malignancy

Introduction: Mirizzi syndrome is an uncommon presentation of gallstone disease and refers to an obstruction of the common hepatic duct secondary to a stone wedged into the cystic duct. Many cases are not diagnosed prior to cholecystectomy, and the incidence in the developed world is approximately 1-2%.1 Case Description/Methods: An active 70-year-old male with a medical history significant for hypertension, hyperlipidemia, and well-controlled type 2 diabetes presented to his primary care physician for postprandial right upper quadrant (RUQ) abdominal pain and nausea. Outpatient RUQ ultrasound was concerning for choledocholithiasis with common bile duct dilation (8 mm) and cholelithiasis. He was referred to surgery for a cholecystectomy. However, prior to this consult, he presented to the Emergency Department for worsening RUQ pain and jaundice. At this time, he was afebrile and hemodynamically stable. Overall, he was well-appearing with scleral icterus and jaundice. Abdominal exam was non-revealing, with a soft, non-distended, non-tender abdomen and a negative Murphy’s sign. Labs showed no leukocytosis, total bilirubin 10.2, alkaline phosphatase 1450, AST 743, ALT 848, and normal lipase. CT scan showed cholelithiasis, a thickened gallbladder neck suggesting cholecystitis, and high-grade obstruction of the cystic duct and common hepatic duct consistent with Mirizzi syndrome (Figure 1, A-B). Patient underwent EUS and ERCP, which showed an 8.4x11.6mm ill-defined mass in the mid common bile duct (Figure 1, C). Biopsies were obtained and a plastic biliary stent was placed. Total bilirubin trended down while in the hospital, and pathology revealed adenocarcinoma. Discussion: Those with Mirizzi syndrome have a 5.3% to 28% incidence of developing gallbladder cancer.1 Therefore, providers should have a high suspicion for cancer in patients with signs of Mirizzi syndrome, especially in the elderly population. Further testing, including CA 19-9 and more definitive imaging, should be obtained prior to cholecystectomy in those with suspected malignancy, as subsequent surgery is associated with a worse prognosis.1Figure 1.: (A) Axial view shows abnormal enhancement at the cystic duct as it empties into the common hepatic duct. (B) Coronal view shows abrupt luminal transition in the mid common bile duct. (C) EUS shows mass in the mid common bile duct.

S1676 The Great Escape: The Rare Type V Mirizzi Syndrome

Introduction: Mirizzi syndrome is a rare complication of chronic gallstone disease, defined as the obstruction of the common bile duct (CBD) or common hepatic duct (CHD) secondary to compression from gallstone impaction Hartmann’s pouch. It is categorized based on the presence and degree of cholecystobiliary fistula formation; however resultant cholocystoenteric fistulas are rare. We discuss the case of a patient who presented to the outpatient clinic with evidence of painless jaundice and on further evaluation, was found to have type Vb Mirizzi syndrome. Case Description/Methods: A 44-year-old male currently on suboxone for previous opioid use disorder presented for evaluation of painless jaundice. He denied fevers, chills, abdominal pain, nausea, or vomiting. Laboratory investigations noted AST 65 IU/L, ALT 46 IU/L, ALP 347 IU/L, total bilirubin 16.9 mg/dL (direct bilirubin 13 mg/dL), albumin 3.4 g/dL, INR 1.1, negative viral serologies and acetaminophen level < 5 mcg/mL. CT abdomen with contrast showed pneumobilia, smooth hepatic contour, and splenomegaly [Figure 1A]. Endoscopic retrograde cholangiopancreatography (ERCP) showed spontaneous air in the biliary tree with bile emanating from a fistulous tract in the duodenal bulb [Figure 1B]. Contrast dye injection filled up the gallbladder thus confirming the presence of cholecystoduodenal fistula. Cholangiogram demonstrated an obstruction in the mid-CBD caused by a 22 mm stone in the gallbladder, protruding into the bile duct [Figure 1C]. The bile duct was stented and the patient underwent open cholecystectomy with CBD stone removal and repair, along with cholecsytoduodenal fistula disconnection and closure. Discussion: Mirizzi syndrome is uncommon with an incidence of < 1% per year. While previously classified as type I (extrinsic compression of the CHD or CBD without a cholecystobiliary fistula) or type II-IV (including a cholecystobiliary fistula), more recently, an extended classification has introduced type V Mirizzi syndrome encompassing types I-IV with the concomitant identification of a cholecystoenteric fistula. It is further subclassified as type Va and Vb (i.e., without and with gallstone ileus, respectively). Given that it encompasses the other subtypes, the treatment option primarily depends on the obstructing biliary lesion type. It is crucial to carefully evaluate and correctly identify patients' chronic gallstone disease complications as they can affect further endoscopic and surgical management.Figure 1.: Figure 1A: CT abdomen with contrast showing pneumobilia (red arrows); Figure 1B: Fistulous tract noted in the duodenal bulb on direct visualization (yellow arrow); Figure 1C: Cholangiogram demonstrating an obstruction in the mid common bile duct consistent with a large, approximately 22 mm bile duct stone in the gallbladder, protruding into the bile duct (red circle).

S3622 Endoscopic Management in a Rare Case of Type I Mirizzi's Syndrome

S3622 Endoscopic Management in a Rare Case of Type I Mirizzi's Syndrome

S1682 Malignancy Masquerading as Mirizzi Syndrome

S1682 Malignancy Masquerading as Mirizzi Syndrome

S3488 Mirizzi Syndrome: Diagnostic and Therapeutic Challenges in Hospital Settings With Health Inequalities

S3488 Mirizzi Syndrome: Diagnostic and Therapeutic Challenges in Hospital Settings With Health Inequalities

A Stone in Remnant Cystic Duct Causing Mirizzi Syndrome Following Laparoscopic Cholecystectomy

A Stone in Remnant Cystic Duct Causing Mirizzi Syndrome Following Laparoscopic Cholecystectomy