Case report Br. J. Surg. 1992, Vol. 79, July, 647
Mirizzi syndrome managed by endoscopic stenting and laparoscopic cholecystectomy N. R. Binnie, S. J. Nixon and K.R. Palmer* Department of Surgery and *Gastro-intestinal Unit, Western General Hospital, Edinburgh EH4 2XU, UK Correspondence to: Mr S . J. Nixon
Mirizzi syndrome type I1 is an uncommon obstructive jaundice caused by external compression of the common hepatic duct by gallstones and formation of a cholecystocholedochal Most patients are elderly and frail. Preoperative diagnosis and careful surgical management are essential in avoiding bile duct i n j ~ r y ~This . ~ . paper describes successful treatment by endoscopic biliary stenting and laparoscopic subtotal cholecystectomy.
Case report An 81-year-oldman presented with acute cholecystitisand obstructive jaundice. Ultrasonographic examination confirmed gallstones and dilatation of the biliary system. Endoscopic retrograde cholangiopancreatography (ERCP) (Figure 1 ) showed appearances of type I1 Mirizzi syndrome. The patient suffered from depression, pulmonary fibrosis, ischaemic heart disease and peripheral vascular disease. He was considered unfit lor major surgery and was referred for endoscopic biliary drainage. A Wilson-Cook stent (14 cm, 12 Fr) was inserted. Jaundice improved but toxaemia persisted despite antibiotic treatment. Laparoscopic cholecystectomy was performed 48 h later. The pneumoperitoneum was established and four cannulae were inserted. The gallbladder was inflamed and packed with stones. There were few adhesions to the gallbladder itself, but the common bile duct (CBD) and cystic duct were obliterated by dense fibrous tissue, making dissectionin this area hazardous. Retrograde diathermy hook dissection was performed from the fundus to Hartmann’s pouch and the gallbladder was divided at this level. Stones impacted in Hartmann’s pouch were dislodged by blunt dissection revealing the fistula into the
CBD through which the stent was clearly visible. A T tube drain was placed into the fistula. Suction drains were positioned in the subhepatic and subphrenic spaces.The gallbladder and stone debris were removed. Copious saline lavage was performed. There was some initial bile drainage which ceased when the T tube was removed. The patient’s recovery was delayed by cardiac arrhythmia, cardiac failure, respiratory failure and an exacerbation of his depressive illness, all of which responded to appropriate medical therapy. He was discharged on the 19th day after operation. ERCP and stent removal were performed 6 weeks later without complication.
Discussion P. L. Mirizzi described a syndrome of obstructive jaundice from gallstones impacted in the cystic duct o r Hartmann’s pouch causing extrinsic compression of the common hepatic duct, Many surgical approaches of varying complexity have been advocated for treating this syndrome. Immediate surgery despite jaundice has been recommended3, but other workers suggest initial nasobiliary drainage4. Total cholecystectomy involves a high risk of bile duct injury’ because of the obliteration of Calot’s triangle and anomalous anatomy with a predominance of a low insertion of the cystic duct5. Subtotal retrograde cholecystectomy may reduce the risk of bile duct injury3v4. Laparoscopic cholecystectomy lends itself well to fundus-first dissection and gives excellent anatomical views. Dewar4 described T tube drainage of the common hepatic duct via the fistula, while Baer et aL3 recommended a biliary-enteric bypass, having abandoned previous attempts simply to close the fistula. The present authors placed a modified T tube in the common hepatic duct, but this merely encouraged leakage of bile from the fistula, prevented normal function of the stent and delayed natural closure ofthe fistula. Jaundice and acute inflammation are considered by some to be contraindications to laparoscopic surgery6. Percutaneous cholecystostomy or cholecystolithotomy might have been considered but we have no expertise in these procedures. Preoperative ERCP with stenting gave excellent appreciation of the anatomy and improved the jaundice if not the cholecystitis. We doubt that open operation would have been safer, particularly as we have considerable experience in endoscopic stenting and laparoscopic cholecystectomy. We therefore recommend this minimally invasive approach when appropriate endoscopic and surgical expertise is available.
Acknowledgements The authors thank Mr D. A. D. MacLeod, St John’s Hospital, Livingston for permission to report on this patient.
References 1.
2.
3.
4. 5. 6.
Figure 1 Extrinsic compression ofthe common hepatic duct caused by gallstones in Hartmann S pouch
0007-1323/92/07064741
0 1992 Butterworth-Heinemann
Ltd
McSherry CK, Ferstenberg H, Virshup M. The Mirizzi syndrome: suggested classification and surgical therapy. Surg Gastroenterol 1982; 1: 219-25. Blumgart LH. Surgery of the Liver andBiliury Tract. Edinburgh: Churchill Livingstone, 1988. Baer HU, Matthews JB, Schweizer WP, Gertsch P, Blumgart LH. Management of the Mirizzi syndrome and the surgical implications of cholecystcholedochalfistula. Er J Surg 1990; 77: 743-5. Dewar G. Operative strategy in Mirizzi syndrome. Surg Gynecol Obstet 1990; 171: 157-9. Starling JR, Matallana RH. Benign mechanical obstruction of the common hepatic duct (Mirizzi syndrome). Surgery 1990; 88: 737-40. Cuschieri A, Dubois F, Mouiel J et al. The European experience with laparoscopic cholecystectomy.Am JSurg 1991;161:385-7.
Paper accepted 27 January 1992
647
Mirizzi syndrome managed by endoscopic stenting and laparoscopic cholecystectomy N. R. Binnie, S. J. Nixon and K.R. Palmer* Department of Surgery and *Gastro-intestinal Unit, Western General Hospital, Edinburgh EH4 2XU, UK Correspondence to: Mr S . J. Nixon
Mirizzi syndrome type I1 is an uncommon obstructive jaundice caused by external compression of the common hepatic duct by gallstones and formation of a cholecystocholedochal Most patients are elderly and frail. Preoperative diagnosis and careful surgical management are essential in avoiding bile duct i n j ~ r y ~This . ~ . paper describes successful treatment by endoscopic biliary stenting and laparoscopic subtotal cholecystectomy.
Case report An 81-year-oldman presented with acute cholecystitisand obstructive jaundice. Ultrasonographic examination confirmed gallstones and dilatation of the biliary system. Endoscopic retrograde cholangiopancreatography (ERCP) (Figure 1 ) showed appearances of type I1 Mirizzi syndrome. The patient suffered from depression, pulmonary fibrosis, ischaemic heart disease and peripheral vascular disease. He was considered unfit lor major surgery and was referred for endoscopic biliary drainage. A Wilson-Cook stent (14 cm, 12 Fr) was inserted. Jaundice improved but toxaemia persisted despite antibiotic treatment. Laparoscopic cholecystectomy was performed 48 h later. The pneumoperitoneum was established and four cannulae were inserted. The gallbladder was inflamed and packed with stones. There were few adhesions to the gallbladder itself, but the common bile duct (CBD) and cystic duct were obliterated by dense fibrous tissue, making dissectionin this area hazardous. Retrograde diathermy hook dissection was performed from the fundus to Hartmann’s pouch and the gallbladder was divided at this level. Stones impacted in Hartmann’s pouch were dislodged by blunt dissection revealing the fistula into the
CBD through which the stent was clearly visible. A T tube drain was placed into the fistula. Suction drains were positioned in the subhepatic and subphrenic spaces.The gallbladder and stone debris were removed. Copious saline lavage was performed. There was some initial bile drainage which ceased when the T tube was removed. The patient’s recovery was delayed by cardiac arrhythmia, cardiac failure, respiratory failure and an exacerbation of his depressive illness, all of which responded to appropriate medical therapy. He was discharged on the 19th day after operation. ERCP and stent removal were performed 6 weeks later without complication.
Discussion P. L. Mirizzi described a syndrome of obstructive jaundice from gallstones impacted in the cystic duct o r Hartmann’s pouch causing extrinsic compression of the common hepatic duct, Many surgical approaches of varying complexity have been advocated for treating this syndrome. Immediate surgery despite jaundice has been recommended3, but other workers suggest initial nasobiliary drainage4. Total cholecystectomy involves a high risk of bile duct injury’ because of the obliteration of Calot’s triangle and anomalous anatomy with a predominance of a low insertion of the cystic duct5. Subtotal retrograde cholecystectomy may reduce the risk of bile duct injury3v4. Laparoscopic cholecystectomy lends itself well to fundus-first dissection and gives excellent anatomical views. Dewar4 described T tube drainage of the common hepatic duct via the fistula, while Baer et aL3 recommended a biliary-enteric bypass, having abandoned previous attempts simply to close the fistula. The present authors placed a modified T tube in the common hepatic duct, but this merely encouraged leakage of bile from the fistula, prevented normal function of the stent and delayed natural closure ofthe fistula. Jaundice and acute inflammation are considered by some to be contraindications to laparoscopic surgery6. Percutaneous cholecystostomy or cholecystolithotomy might have been considered but we have no expertise in these procedures. Preoperative ERCP with stenting gave excellent appreciation of the anatomy and improved the jaundice if not the cholecystitis. We doubt that open operation would have been safer, particularly as we have considerable experience in endoscopic stenting and laparoscopic cholecystectomy. We therefore recommend this minimally invasive approach when appropriate endoscopic and surgical expertise is available.
Acknowledgements The authors thank Mr D. A. D. MacLeod, St John’s Hospital, Livingston for permission to report on this patient.
References 1.
2.
3.
4. 5. 6.
Figure 1 Extrinsic compression ofthe common hepatic duct caused by gallstones in Hartmann S pouch
0007-1323/92/07064741
0 1992 Butterworth-Heinemann
Ltd
McSherry CK, Ferstenberg H, Virshup M. The Mirizzi syndrome: suggested classification and surgical therapy. Surg Gastroenterol 1982; 1: 219-25. Blumgart LH. Surgery of the Liver andBiliury Tract. Edinburgh: Churchill Livingstone, 1988. Baer HU, Matthews JB, Schweizer WP, Gertsch P, Blumgart LH. Management of the Mirizzi syndrome and the surgical implications of cholecystcholedochalfistula. Er J Surg 1990; 77: 743-5. Dewar G. Operative strategy in Mirizzi syndrome. Surg Gynecol Obstet 1990; 171: 157-9. Starling JR, Matallana RH. Benign mechanical obstruction of the common hepatic duct (Mirizzi syndrome). Surgery 1990; 88: 737-40. Cuschieri A, Dubois F, Mouiel J et al. The European experience with laparoscopic cholecystectomy.Am JSurg 1991;161:385-7.
Paper accepted 27 January 1992
647
