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PO Box 2345, Beijing 100023, China World J Gastroenterol 2006
September 14: 12(34): 5579-5581
www.wjgnet.com World Journal of GastroenterologyISSN
1007-9327
[email protected] 2006 The WJG Press. All rights reserved.
An alternative surgical approach to a difficult case of
Mirizzi
syndrome: A case report and review of the literature
Michael Safioleas, Michael Stamatakos, Constantinos Revenas,
Constantinos Chatziconstantinou,
Constantinos Safioleas, Alkiviades Kostakis
Michael Safioleas, Michael Stamatakos, ConstantinosSafioleas,
Alkiviades Kostakis,2
ndDepartment of Propedeutic
Surgery, School of Medicine, Athens University, Laiko
Hospital,
Greece
Constantinos Revenas, Constantinos Chatziconstantinou,Department
of Radiology, Laiko Hospital, Athens, Greece
Correspondence to: Professor Michael Safioleas, MD, PhD,7Kyprou
Ave. Filothei, 15237 Athens,
Greece. [email protected]
Telephone:+30-210-6812188Received:2006-05-27
Accepted:2006-06-15
Abstract
Mirizzi syndrome (MS) is an uncommon complication ofgallstone
disease and occurs in approximately 1% of allpatients suffering
from cholelithiasis. The syndrome ischaracterized by extrinsic
compression of the common
hepatic duct frequently resulting in clinical presentationof
intermittent or constant jaundice. Most cases are notidentified
preoperatively. Surgery is the indicated treat-ment for patients
with MS. We report here a 71-year-old male patient referred to the
surgical outpatientdepartment for diffuse upper abdominal pain and
mildjaundice (bilirubin rate: 4.2 mg/dL). Ultrasound examina-tion
revealed a stone in the cystic duct compressing thecommon hepatic
duct. The patient had a history of gas-trectomy for gastric ulcer
30 years ago. MRCP revealed astone impacted in the cystic duct
causing obstruction ofthe common hepatic duct by extrinsic
compression. Withthese findings the preoperative diagnosis was
indicative
of MS. At laparotomy a moderately shrunken gallbladderwas found
embedded in adhesions containing a largestone which was palpable in
the common bile duct. Theanterior wall of the body of the
gallbladder was openedby an incision which extended longitudinally
along thegallbladder towards the common bile duct. The
stonemeasuring 3.0 cm in diameter, was then removed set-ting
astride a large communication with the common bileduct. A Roux-en-Y
cholecysto-choledocho-jejunostomywas performed. The subhepatic
region was drained. Thepatient had an uneventful recovery. He was
dischargedeleven days after operation and remained well after
a30-mo follow-up.
2006 The WJG Press. All rights reserved.
Key words:Benign jaundice; Hepatic duct obstruction;Impacted
gallstone; Cholecystobiliary fistula
Safioleas M, Stamatakos M, Revenas C, Chatziconstantinou
C, Safioleas C, Kostakis A. An alternative surgical approach
to a difficult case of Mirizzi syndrome: A case report and
review of the literature.World J Gastroenterol 2006; 12(34):
5579-5581
http://www.wjgnet.com/1007-9327/12/5579.asp
INTRODUCTION
Mirizzi syndrome (MS) is a rare complication of long-standing
cholelithiasis, which results from impaction of alarge calculus or
multiple small stones in the cystic duct orin the neck of the
gallbladder causing extrinsic narrowingof the common hepatic duct.
This condition may resultin the clinical presentation of
intermittent or constant
jaundice. MS occurs in approximately 1% of all patientswith
cholelithiasis. Although modern imaging techniquesare available,
the majority of cases are identified duringsurgery. During the last
two decades, 27 patients sufferingfrom MS have been treated in our
department [1,2], wepresent here a case of a 71-year-old male
patient with MSand a literature review.
CASE REPORT
A 71-year-old male patient was referred to the
surgicaloutpatient department for diffuse upper abdominalpain and
mild jaundice (bilirubin rate: 4.2 mg/dL).
Ultrasound examination revealed a stone in the cystic
ductcompressing the common hepatic duct (Figure 1). Thepatient had
a history of gastrectomy for gastric ulcer 30years ago, thus ERCP
was not feasibile. MRCP revealeda stone impacted in the cystic duct
causing obstructionof the common hepatic duct by extrinsic
compression.Wi th th es e fi nd in gs th e pr eo pe ra ti ve di ag
nosis wasindicative of MS. At laparotomy a moderately
shrunkengallbladder was found embedded in adhesions containinga
large stone which was palpable in the common bileduct (Figure 2A).
It was obvious that the local operativecircumstances required great
surgical care. Therefore the
anterior wall of the body of the gallbladder was openedby an
incision which extended longitudinally along thegallbladder towards
the common bile duct. The cysticduct could not be identified. The
stone measuring 3.0cm in diameter was then removed setting astride
a large
CASE REPORT
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communication with the common bile duct (Figure 2B).Based on
this finding and because the risk of stricture atthe site of
fistulae was significant, we decided to bypassthe
cholecystocholedochal fistulus defect rather than toclose it
directly or by using a gallbladder flap for closingthe opening of
the common bile duct around a T-tube.A Roux-en-Y
cholecysto-choledocho-jejunostomy wasperformed (Figure 2C). The
subhepatic region wasdrained. The patient had an uneventful
recovery. He wasdischarged on the 11th postoperative day and
remained
well after a 30-mo follow-up.
DISCUSSION
MS was first described in 1948 as obstructive jaundice dueto a
gallstone impacted in the cystic duct or Hartmannspouch compressing
the common hepatic duct[3]. McSherry et al[4] in 1982 suggested a
subclassificationof MS into two types. The first type concerns the
externalcompression of the common hepatic duct by a calculusin the
cystic duct or Hartmanns pouch, whereas in thesecond type the stone
has entered partly or completelyinto the common bile duct,
resulting in a cholecysto-choledochal fistula. Furthermore, in 1989
a new
classification of patients with MS and cholecystobiliaryfistulae
was presented by Csendes et al[5],which includesfour types: type I
lesion includes those with externalcompression of the common bile
duct; type lesion is acholecystobiliary fistula present with
erosion of less thanone third of the circumference of the bile
duct; type lesion is a fistula involving up to two-thirds of the
ductcircumference; typelesion is a complete destruction ofthe bile
duct. MS and cholecystobiliary fistulae therefore appear tobe
different, evolving stages of the same pathologicalcondition, thus
it is reasonable that Lubbers[6] proposes
that the term MS can now be abandoned, since it is onlythe first
stage of a more complex process. Gallstone erosion into the common
duct is neverthelessa rare complication of cholelithiasis with an
incidence rateranging from 0.7% to 1.4% of all patients
undergoing
cholecystectomy[7]. The clinical diagnosis of MS is difficult,
since there areno pathognomonic patterns of presentation.
Ultrasoundis diagnostically the best screening method, with
ERCP
and/or MRCP to confirm the diagnosis. MRCP canbe as good as ERCP
in the diagnosis and its ability todelineate details of biliary
structures, but its disadvantagecompared to ERCP is its inability
to confirm the presenceof fistulae and does not afford therapeutic
stenting. Onthe other hand, T2weighted sections can differentiate
aneoplastic mass from an inflammatory one, that cannot bedetected
by ultrasonogram or CT scan[8]. Finally intraductalultrasound, as
an adjunct to ERCP, can also be of help[9].Despite of all these
modern diagnostic tools, the problemmay become apparent only during
surgery. Surg i ca l t rea tmen t for type I MS is par t ia
lcholecystectomy leaving the neck of the gallbladder
in place[10]. In some cases, open or laparoscopic
totalcholecystectomy may be performed [11]. However someauthors
consider this a contraindication for
laparoscopiccholecystectomy[12-14]. Surgical treatment of typeMS is
less clearly defined.Corlette and Bismuth [15] have recommended
partialcholecystectomy, oversuturing of the gallbladder cuff
andinsertion of a T-tube through the fistula as an
adequatetreatment for typeMS. Choledochoplasty is an acceptable
therapeutic approachbut the amount of gallbladder tissue employed
for this hasnot yet been standardized[16].
Furthermore, cholecystoduodenostomy has beendescribed[17]and
hepaticojejunectomy[18]can also be used ifcomplete destruction of
the common hepatic duct occurs. Reconstruction of the extrahepatic
biliary tree in caseof MS type with bypass of the lesion using a
Roux-
Figure 1 Ultrasound showing a stone compressing the common
hepatic duct.
GE50.6
12
3
>>_
MI < 0.4
CN28 cmDR66G 72
1 Gall bladder
2 Cystic duct
3 Common hepatic duct
>> Stone
Figure 2 Schematic representation of the described technique
during laparotomy
(A, B) and Roux-en-Y cholecysto-choledocho-jejunostomy (C).
A
B
C
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en-Y cholecysto-choledochal-jejunostomy as in our casecan be
carried out. To our knowledge, this is the first casedescribed in
the literature. In conclusion, since the preoperative diagnosis of
MScannot be achieved, an awarded suspicion is necessary toavoid a
lesion of the biliary tree if firm adherence around
Carlots triangle is found. The success of treatment isrelated to
a precocious recognition of the condition evenat the time of
surgery when the individual characteristicsof each case are
considered[18].
REFERENCES
1 Safioleas M, Yiagos E, Doka P, Koskinas A, Stefanou J,Skalkeas
Gr. Mirizzi Syndrome. Medical Annals1990; 13 :863-866
2 Safioleas M, Evagelidakis E, Xypolitas N, Liossi A.
MirizziSyndrome.Medical Annals1999; 12: 545-547
3 Mirizzi PL. Syndrome del conducto hepatico. Jo ur na
lInternational de Chirurgie1948; 8: 731-737
4 McSherry CK, Ferstenberg H, Virshup M. The Mirizzisyndrome:
suggested classification and surgical therapy.
SurgGastroenterol1982; 1: 219-225
5 Csendes A, Diaz JC, Burdiles P, Maluenda F, Nava O.Mirizzi
syndrome and cholecystobiliary fistula: a unifyingclassification.
Br J Surg1989; 76: 1139-1143
6 Lubbers EJ. Mirizzi syndrome. World J Surg1983; 7: 780-7857
Pemberton M, Wells AD. The Mirizzi syndrome. Postgrad Med
J1997; 73: 487-4908 Choi BW, Kim MJ, Chung JJ, Chung JB, Yoo HS,
Lee JT.
Radiologic findings of Mirizzi syndrome with emphasis onMRI.
Yonsei Med J2000; 41: 144-146
9 Phatak N, Kochman ML. Biliary endoscopy. Curr
OpinGastroenterol2004; 20: 281-287
10 Abou-Saif A, Al-Kawas FH. Complications of gallstonedisease:
Mirizzi syndrome, cholecystocholedochal fistula, andgallstone
ileus.Am J Gastroenterol2002; 97: 249-254
11 Yeh CN, Jan YY, Chen MF. Laparoscopic treatment for
Mirizzisyndrome. Surg Endosc2003; 17: 1573-1578
12 Posta CG. Unexpected Mirizzi anatomy: a major hazard to
thecommon bile duct during laparoscopic cholecystectomy.
SurgLaparosc Endosc1995; 5: 412-414
13 Bagia JS, North L, Hunt DR. Mirizzi syndrome: an extrahazard
for laparoscopic surgery.ANZ J Surg2001; 71: 394-397
14 Tan KY, Chng HC, Chen CY, Tan SM, Poh BK, Hoe MN.Mirizzi
syndrome: noteworthy aspects of a retrospective studyin one
centre.ANZ J Surg2004; 74: 833-837
15 Corlette MB, Bismuth H. Biliobiliary fistula. A trap in
thesurgery of cholelithiasis.Arch Surg1975; 110: 377-383
16 Shah OJ, Dar MA, Wani MA, Wani NA. Management ofMirizzi
syndrome: a new surgical approach. ANZ J Surg 2001;71: 423-427
17 Baer HU, Matthews JB, Schweizer WP, Gertsch P, BlumgartLH.
Management of the Mirizzi syndrome and the surgicalimplications of
cholecystcholedochal fistula. Br J Surg1990; 77:743-745
18 Johnson LW, Sehon JK, Lee WC, Zibari GB, McDonald
JC.Mirizzi's syndrome: experience from a
multi-institutionalreview.Am Surg2001; 67: 11-14
S- Editor Wang J L- EditorWang XL E- Editor Bi L
Safioleas M et al. MS 5581
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