ORIGINAL ARTICLE

Update on the Diagnosis and Treatment of Mirizzi Syndrome in Laparoscopic Era: Our Experience in 7 Years Jose B. Lledo´, MD, PhD, Sebastian M. Barber, MD, Jose C. Iban˜ez, MD, Antonio G. Torregrosa, MD, and R. Lopez-Andujar, MD, PhD

Introduction: 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. Materials and Methods: 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. Results: 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. Conclusions: 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. Key Words: Mirizzi syndrome, cholelithiasis, cholecystitis

(Surg Laparosc Endosc Percutan Tech 2014;24:495–501)

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xtrinsic biliary compression syndrome or Mirizzi syndrome (MS), described by Pablo Luis Mirizzi in 1948 is caused by obstruction of the common hepatic duct by the

Received for publication January 17, 2014; accepted June 3, 2014. From the Hepatobiliary Unit, Department of General Surgery, Hospital Universitari y Politecnic “La Fe,” Valencia, Spain. The authors declare no conflicts of interest. Reprints: Jose B. Lledo´, MD, PhD, Department of General Surgery, Hospital Universitari y Politecnic “La Fe,” Calle Gabriel Miro´ 28, Valencia 12. 46008, Spain (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins

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compression of an impacted stone in the neck of the gallbladder or cystic duct.1 It represents a rare complication of cholelithiasis, present in 0.2% to 1.5% of patients with gallbladder disease and 0.7% to 2.9% of cholecystectomies.2 It is more common in women, probably reflecting the female preponderance in biliary lithiasis. There is also an increased incidence of gallbladder cancer (GC) in this syndrome (25%) compared with patients with isolated cholelithiasis.3 There are several classifications of MS. In 1982, McSherry et al4 classified it according to the findings of endoscopic retrograde cholangiopancreatogram (ERCP) as: type I, extrinsic compression of the bile duct and type II, when linked with cholecisto-bile duct fistula. Subsequently, Starling and Matallana5 subdivided type I in IA, if there is a long cystic duct that runs parallel to the bile duct and is obstructed by stones and IB, when cystic is short, completely obliterated by stones, and there is no fistula. Nowadays, the most currently used is Csendez classification, who in 1989 divided MS into 4 types (Fig. 1)6:  Type 1: compression of the common hepatic duct by an impacted stone in the neck of the gallbladder or in the cystic duct.  Type 2: presence of cholecistobiliary duct fistula, which affects a third of the circumference of the bile duct.  Type 3: presence of fistula, which affects two thirds of the maximum diameter of the common bile.  Type 4: presence of fistula with complete destruction of the wall of the common hepatic duct. The main objective of this study was to assess the current incidence of MS in our area and as secondary objectives, to evaluate the clinical, diagnostic, and therapeutic management, making a review of the literature.

MATERIALS AND METHODS We retrospectively studied the data included prospectively in the database of patients operated for biliary disease. The study period was from January 2006 to November 2012. During this time period 1168 cholecystectomies (97.3% laparoscopic) were operated. We registered a total of 35 patients with MS. Demographic, clinical, and laboratory data, diagnostic studies, surgical procedures, operative findings, postoperative complications, and patient follow-up were analyzed. Hepatobiliary ultrasound was performed in all patients. The protocol diagnosis of suspected MS included magnetic cholangiography resonance (MCR) and ERCP in case of signs of occupation of the bile duct because of compression or stones. If lithiasis was confirmed, endoscopic sphincterotomy (ES) was practiced.

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Type I

Type II



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Type IV

Type III

FIGURE 1. Csendez classification of Mirizzi syndrome.

We use the Csendez classification6 to identify the types of MS. Postoperative complications were analyzed by the Clavien classification.7 Postoperative follow-up was completed in all patients, with a mean of 13.4 ± 4 months, performing a postoperative check approximately 2 months after hospital discharge and successive visits 6 and 12 months after surgery, when patient was totally discharged if remained asymptomatic. Data using frequency measures (absolute and percentage) for categorical variables, and mean, SD, and range for quantitative measures are presented. To explore whether there were factors related to the success of conservative treatment, we used Student t test for quantitative variables evaluation, and w2 (or the Fisher test) if they were dichotomous. The significance level was P < 0.05.

RESULTS From January 2006 to November 2012, 35 patients had MS, a total of 1168 cholecystectomies, representing an incidence of 2.8% of MS in our area. Twenty-two patients were women and 13 were men. When we analyze the main symptom in the clinical debut, we confirm that the most frequent was obstructive jaundice in 29 cases (82.8%), followed by abdominal pain in 23 (65.7%). Other symptoms at initial presentation were nausea and vomiting (31%) and anorexia (27%). The mean age at presentation was 70.1 ± 22 years. Following complementary tests were performed preoperatively: hepatobiliary ultrasound (in all patients, sensitivity of 51%), MRC in 27 patients (test with greater diagnostic sensitivity, 76%), ERCP (n = 16), and finally abdominal computed tomography (CT) (n = 12). ES was performed in 6 patients with choledocholithiasis and in 3 of them, prosthesis was placed in the common bile duct as preoperative biliary drainage. Among the 35 patients with MS, the distribution by type of presentation was: type I in 19 cases (54.2%), type II in 7 cases (20%), type III in 5 cases (14.2%) and, finally, type IV in 4 (9.6%). Twenty-four patients were diagnosed preoperatively and the rest in surgery, representing 68.5% versus 31.5%, respectively. Cholecystectomy was performed in all of them. Four patients were operated urgently because of clinical suspicion and positive ultrasonography of acute cholecystitis.

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Cholecystectomy was initiated by laparoscopic approach in 21 patients (54.8%) and laparotomy in the rest. The rate of conversion to open surgery was 11.7%. In 14 patients with MS type I (73.7%), and 4 (with MS type II 57.1%) LC was completed (Fig. 2). Of the patients who were initiated directly by laparotomy or converted from laparoscopy, 5 belonged to type I, 3 to type II, 5 to type III, and 4 to type IV. Intraoperative cholangiography was required to clarify the diagnosis in 8 cases. Hepatojejunostomy was completed in all cases of MS type 3 and 4 (Fig. 2). Mean hospital stay for all patients was 4.3 ± 2.8 days, being in the case of type III and IV of 7.6 ± 3.3 days. There was no postoperative mortality. Morbidity was 14.5%, highlighting a case of biliary fistula resolved with conservative treatment, and 2 cases that required percutaneous treatment for resolution of an intraabdominal postoperative collection. Table 1 shows the distribution of patients by type of MS, demographic, clinical, and laboratory data, morbidity, and postoperative hospital stay. The average postoperative follow-up was 13.4 ± 4 months and was completed in all patients. After the histologic study of the surgical piece, we found 2 cases of GC (5.7%) in stage T2A, but oncologic resection was completed in a second time in only 1 patient, excluding the other because of anesthetic criteria and advanced age.

DISCUSSION The frequency with which MS is presented in the series of cholelithiasis is highly variable:

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 ...
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