Treatment of Mirizzi Syndrome

César Antonio Solis-Caxaj, MD

Strasbourg, France

I read with great interest the article by Kwon and Inui.1

It is a timely and excellent article, but a few aspects needcomments. In fact, the syndrome was originally de-scribed as an obstruction of the proximal bile duct sec-ondary to external compression by a large stone locatedin the Hartman pouch of the gallbladder or secondary tolocal inflammatory changes. In recent years, extension ofMirizzi’s eponym has been used to define obstructivejaundice induced by different grades of compression anderosion of the bile duct wall by a stone contained in thegallbladder or the cystic duct, which can evolve to acomplete cholecystocholedocal fistula, with compres-sion and dilatation of the proximal bile duct. It must bepointed out that Kehr in 1905 and Ruge in 1908 and,later on, Levrat and Chayvialle in 1941 reported cases ofexternal compression of the bile duct after stone impac-tion in the cystic duct,2,3 and the first case of cholecys-tobiliary fistula was reported by Puestow in 1942.4 Thenatural history of Mirizzi syndrome cannot stop withthe compression or the cholecystobiliary fistula, but itmay result in a complex fistula with neighboring di-gestive organs.5 Csendes and colleagues stated that theso-called Mirizzi syndrome and the cholecystobiliaryfistula are different evolving stages of the same patho-logic process.6

Mirizzi syndrome usually occurs in elderly (meanage 62 years)6 and frail people in the setting of long-standing biliary symptoms; for this reason I agreewith authors that surgical treatment must be precededby a morphologic diagnosis to precise the operativestrategy (laparoscopic or open procedures), conse-quently, to avoid biliary duct injury, especially sectionof the common hepatic duct, because the Mirizzi syn-drome has been cited as a trap in the surgery gall-stones. In this particular instance, the IVC-SCT canbe a useful tool for the diagnosis with possibility ofthree-dimensional reconstruction images, but it is noteffective in patients with a serum bilirrubin � 2 mg/dL,7 and the CT often does not demonstrate biliarystone. The ERCP provides a most precise delineationof the anatomy and pathology of the bile ducts. Nev-ertheless, its cost is greater than other diagnosis meth-ods; it suffers from technical limitations, including

the inability to access the bile ducts in 5% to 10% ofcases and incomplete filling of the ducts because oftight strictures or intraductal debris; and it is notdevoid of complications: sepsis and pancreatitis.8 An-other preoperative imaging study is the magnetic res-onance cholangiography (MRC), with an excellentcontrast resolution and without invasive and radiantfindings; it shows the extent of inflammation, thedilatation of the intrahepatic bile ducts, the level ofobstruction, the location of gallstones, and may revealcomplication such as fistula.8 Also, in T2-weightedimage, it can differentiate a tumoral mass from aninflammatory lesion. Today, the preoperative diagno-sis of Mirizzi syndrome must be made either by IVC-SCT, ERCP, MRC, or the combination of the lasttwo;5 of course, they will be preceded by ultrasonog-raphy (USG), which may eventually show findingssuggestive of Mirizzi syndrome.

Because of the widespread introduction of laparo-scopic cholecystectomy, questions have been raisedabout treating Mirizzi syndrome with this method. Therole of minimally invasive surgery in the treatment ofthis syndrome remains controversial. Some authors re-gard this condition as inappropriate for laparoscopic ap-proach, because the dense adhesions around Calot’s tri-angle, if a cholecystobiliary or biliobiliary fistula ispresent, make doing the dissection more difficult andcompelling to effect a direct common duct repair orbilioenteric anastomosis.9

So, the recommendation to the surgical commu-nity at large is that laparoscopic surgery must be re-served to selected patients with Mirizzi syndrometype I, but it is technically demanding, with a highdegree of expertise, because the risk of bile duct injuryis increased. The article by Kwon and Inui1 demon-strates this assertion, because from 24 patients, 17patients presented with Mirizzi syndrome type I, ofwhich 14 underwent initial laparoscopic procedure,with 4 conversions to open procedure. There were twoiatrogenic lesions of CBD in the laparoscopic group.All Mirizzi syndrome II patients underwent open pro-cedures in this study.

REFERENCES

1. Kwon AH, Inui H. Preoperative diagnosis and efficacy of laparo-scopic procedures in the treatment of Mirizzi syndrome. J AmColl Surg 2007;204:409–415.

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2. Behrend A, Cullen ML. Cholecysto-choledochal fistula: an un-usual internal biliary fistula. Am Surg 1950;132:297–303.

3. Levrat M, Chayvialle P. Les calculs de l’extremité inférieure ducystique à symptomatologie choledocienne par compression de lavoie biliaire principale. J Med Lyon 1941;26:455–459.

4. Puestow CB. Spontaneous internal biliary fistula. Ann Surg 1942;115:1043–1054.

5. Solis-Caxaj CA, Ramanah R, Miguet M, et al. Mirizzi syndrometype II with a gastric antrum erosion: an atypical presentation.Gastroenterol Clin Biol 2007. In press.

6. Csendes A, Diaz JC, Burdiles P, et al. Mirizzi syndrome and chole-cystobiliary fistula: a unifying classification. Br J Surg 1989;76:1139–1143.

7. Memel DS, Balfe DM, Semelka RC. The biliary tract. In: LeeJKT, Sagel SS, Stanley RJ, et al, eds. Computed body tomographywith MRI correlation. 3rd ed. Philadelphia: Lippincott-Raven;1998:779–844.

8. Kim PN, Outwater EK, Mitchell DG. Mirizzi syndrome: eval-uation by MR imaging. Am J Gastroenterol 1999;94:2546–2550.

9. Posta CG. Unexpected Mirizzi anatomy: a major hazard to com-mon bile duct during laparoscopic cholecystectomy. Surg Lapa-rosc Endosc 1995;5:412–414.

Foreign-Trained Physiciansand US Residencies

James A Hallock, MD, Stephen S Seeling, JD

Philadelphia, PA

We read with interest the article by Leon and colleagues.1

We applaud the authors for summarizing the pathwayfor international medical graduates (IMGs) to graduatemedical education and for recognizing the significantrole that IMGs play in American medicine. There are anumber of assertions in the article that require a clarify-ing response.

In commenting on the difficulty of passing US Med-ical Licensure Examinations (USMLE) and, in particu-lar, USMLE Step 2 Clinical Skills, the authors claim,“the majority of medical students have little or no com-mand of the English language in countries sending for-eign medical graduates to the US.” In fact, English is thelanguage of instruction for the top 5 source countries forEducational Commission for Foreign Medical Gradu-ates (ECFMG) certification in 2006. These 5 countriesalone account for nearly 50% of all ECFMG in 2006.About IMG performance on USMLE Step 2 CS, thepass rate for first-time IMG takers between July 1, 2005,and June 30, 2006, was 85%.

The authors correctly note that an applicant must

show evidence of strong ties to the home country for atourist visa. But in claiming that “high income” is re-quired for a tourist visa, they oversimplify and mischar-acterize tourist visa requirements. Many factors are con-sidered in determining whether an applicant hasdemonstrated sufficient home ties; high income is not inand of itself a prerequisite.

Their claim that “IMGs do not favor states with rig-orous licensure requirements” is, in the absence of spe-cifics, impressionistic at best. It disparages a qualifiedand motivated group of physicians, suggesting that theyconsciously gravitate to states with lower standards.This, to the best of our understanding, is not the case.Examination requirements for initial licensure are con-sistent among the states, with all states requiring thepassing of USMLE. There are minor variations aboutthe length of graduate medical education required forIMGs (most states require 3 years), but we are unawareof any evidence that this influences where IMGs chooseto practice.

REFERENCE

1. Leon LR Jr, Villar H, Leon CR, et al. The journey of a foreign-trained physician to a US residency. J Am Coll Surg2007;204:486–494.

Reply

Luis R Leon Jr, MD, RVT, Christine R Leon, PT

Tucson, AZ

We thank Dr Hallock and Mr Seeling for reading our arti-cle, for their comments, and for their insightful criticism.We will be happy to clarify their valid remarks about someof our statements. The first assertion alluded to Englishproficiency in countries sending international medicalgraduates (IMGs) to the US. They correctly point out thatEnglish is the instruction language for the top five donorcountries, which, according to Mullan,1 are the US, Can-ada, India, Philippines, and Pakistan. The last 3 alone sup-ply between 40% to 45% of IMGs to the US. Most of theseIMGs receive their education in English, but English is nottheir native idiom, which does represent a handicap fortest-takers. We wrote that the “majority of students havelittle or no command of the English language in countriessending foreign medical graduates to the US.” We agree

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