Mirizzi Syndrome

Opinion statement The complete and definitive treatment of patients with Mirizzi syndrome is surgical. The treatment goals are the removal of the gallbladder with the offending stone(s) and the repair of the bile duct defect. A high index of suspicion for early recognition of this condition is paramount to prevent bile duct injury. Biliary anatomy is delineated precisely by preoperative and intraoperative imaging tests. The dissection of the gallbladder is conducted in an antegrade, fundus-first fashion. Extensive dissection of Calot’s triangle is avoided. Instead, the gallbladder is opened, the impacted stone(s) is removed backward, and the confirmation of the presence a cholecystocholedochal fistula is established by direct inspection. A coexistent gallbladder carcinoma is excluded by taking frozen sections. In patients without biliary fistula (Mirizzi type I), simple cholecystectomy suffices to relieve the bile duct obstruction. In patients with biliary fistula (Mirizzi type II), the size of the fistula determines the type of repair. In general, small fistulas are repaired by choledochoplasty using a cuff of gallbladder remnant, whereas large bile duct defects require bilioenteric reconstruction (Roux-en-Y hepaticojejunostomy or choledochoduodenostomy). In patients unfit for surgery, biliary decompression is effectively accomplished by placement of stents using endoscopic or percutaneous techniques. Lithotripsy and removal of the offending stone can also be carried out in patients with Mirizzi type II. In general, nonsurgical treatment of Mirizzi syndrome is incomplete and places the patients on a path of intensive follow-up, multiple procedures, and the risk to continue suffering from complications of symptomatic gallstone disease. However, nonsurgical treatment allows for valuable time to prepare high-risk patients for a more elective and safer operation.     

Ultrasonographic and x-ray computed tomographic aspects of Mirizzi's syndrome

The Mirizzi syndrome is due to common hepatic duct obstruction secondary to the impaction of a large gallstone in the neck of the gallbladder or the cystic duct. The sonographic and computed tomography features in 3 cases of Mirizzi syndrome are described and compared with percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography findings. The Mirizzi syndrome was diagnosed preoperatively on sonography in 2 out of 3 cases and on plain computed tomography scans in all 3 cases. However pre or intraoperative visualization of the biliary tract is mandatory in suspected Mirizzi syndrome to detect the presence or absence of cholecystobiliary fistula, in order to adapt the operative strategy.     

Proposal of the term “gallstone cholangiopancreatitis” to specify gallstone pancreatitis that needs urgent endoscopic retrograde cholangiopancreatography

Opie's "pancreatic duct obstruction" and "common channel" theories are generally accepted as explanations of the mechanisms involved in gallstone acute pancreatitis(AP). Common channel elucidates the mechanism of necrotizing pancreatitis due to gallstones. For pancreatic duct obstruction, the clinical picture of most patients with ampullary stone impaction accompanied by biliopancreatic obstruction is dominated by life-threatening acute cholangitis rather than by AP, which clouds the understanding of the severity of gallstone AP. According to the revised Atlanta classification, it is difficult to consider these clinical features as indications of severe pancreatitis. Hence, the term "gallstone cholangiopancreatitis" is suggested to define severe disease complicated by acute cholangitis due to persistent ampullary stone impaction. It incorporates the terms "cholangitis" and "gallstone pancreatitis." "Cholangitis" refers to acute cholangitis due to cholangiovenous reflux through the foci of extensive hepatocyte necrosis reflexed by marked elevation in transaminase levels caused by persistent ampullary obstruction. "Gallstone pancreatitis" refers to elevated pancreatic enzyme levels consequent to pancreatic duct obstruction. This pancreatic lesion is characterized by minimal or mild inflammation. Gallstone cholangiopancreatitis may be valuable in clinical practice for specifying gallstone AP that needs urgent endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy.     

Mirizzi syndrome in an anomalous cystic duct： A case report

Mirizzi syndrome is a rare complication of gallstone disease, and results in partial obstruction of the common bile duct or a cholecystobiliary fistula. Moreover, congenital anatomical variants of the cystic duct are common, occurring in 18%-23% of cases, but Mirizzi syndrome underlying an anomalous cystic duct is an important clinical consideration. Here, we present an unusual case of type Ⅰ Mirizzi syndrome with an uncommon anomalous cystic duct, namely, a low lateral insertion of the cystic duct with a common sheath of cystic duct and common bile duct.     

Mirizzi's syndrome

A case is described emphasising rare complication of gallstone disease: the Mirizzi syndrome in which an impacted gallstone in the Hartmann's pouch or cystic duct causes common hepatic duct obstruction and by eroding a fistula. Diagnosis is made by endoscopic retrograde cholangiopancreatography and treatment includes cholecystectomy.     

Bouveret＇s syndrome complicated by a distal gallstone ileus

AIM: Gastric outlet obstruction caused by duodenal impaction of a large gallstone migrated through a cholecystoduodenal fistula has been referred as Bouveret‘s syndrome. Endoscopic lithotomy is the first-step treatment, however, surgery is indicated in case of failure or complication during this procedure .METHODS: We report herein an 84-year-old woman presenting with features of gastric outlet obstruction due to impacted gallstone. She underwent an endoscopic retrieval which was unsuccessful and was further complicated by distal gallstone ileus. Physical examination was irrelevant. RESULTS: Endoscopy revealed multiple erosions around the cardia, a large stone in the second part of the duodenum causing complete obstruction, and wide ulceration in the duodenal wall where the stone was impacted. Several attempts of endoscopic extraction by using foreign body forceps failed and surgical intervention was mandatory. Preoperative ultrasound evidenced pneumobilia whilst computerized tomography showed a large stone, 5cm×4cm×3cm, logging at the proximal jejunum and another one, 2.5cm×2cm×2cm, in the duodenal bulb causing a closed-loop syndrome. She underwent laparotomy and the jejunal stone was removed by enterotomy. Another stone reported as located in the duodenum preoperatively was found to be present in the gallbladder by intraoperative ultrasound. Therefore, cholecystoduodenal fistula was broken down, the stone was retrieved and cholecystectomy with duodenal repair was carried out. She was discharged after an uneventful postoperative course. CONCLUSION: As the simplest and the least morbid procedure, endoscopic stone retrieval should be attempted in the treatment of patients with Bouveret‘s syndrome. When it fails, surgical lithotomy consisting of simple enterotomy may solve me problem. Albhough cholecystectomy and cholecystoduodenal fistula breakdown is unnecessary in every case, conditions may urge the surgeon to perform such operations even though they carry high morbidity andmortality.     

Mirizzi Syndrome without Cholecystolithiasis

BACKGROUND: Mirizzi syndrome is a rare cause of biliary symptoms and jaundice. It describes an obstruction of the common hepatic bile duct by external compression caused by an impacted gallstone in the gallbladder neck or cystic duct. This setting is usually associated with cholecystolithiasis. CASE REPORT: A 64-year-old caucasian woman with intermittent abdominal pain and newly diagnosed jaundice was admitted to our clinic. An ERC was performed a few weeks earlier because of similar complaints without jaundice. At that time there was no evidence of choledocholithiasis. Now ERC surprisingly showed a gallstone impacted in the cystic duct, leading to an external compression of the common hepatic bile duct (Mirizzi syndrome). Since an endoscopic stone extraction failed, surgical intervention was performed. A laparoscopic cholecystectomy was performed without trans-cystic stone removal. After removal of the bile duct drainage it became evident that the impacted stone was still located in the remaining part of the cystic duct. After successful endoscopic extraction of the impacted stone the patient remained free of symptoms without recurrent jaundice. CONCLUSION: In rare cases Mirizzi syndrome without cholecystolithiasis can cause biliary symptoms. A close interdisciplinary cooperation is necessary in order to guarantee an excellent therapeutic management.     

Mirizzi syndrome

Opinion statement Mirizzi syndrome is an important complication of gallstone disease. If not recognized preoperatively, it can result in significant morbidity and mortality. Preoperative diagnosis may be difficult despite the availability of multiple imaging modalities. Ul-trasonography (US), CT, and magnetic resonance cholangiopancreatography (MRCP) are common initial tests for suspected Mirizzi syndrome. Typical findings on US suggestive of Mirizzi syndrome are a shrunken gallbladder, impacted stone(s) in the cystic duct, a dilated intrahepatic tree, and common hepatic duct with a normal-sized common bile duct. The main role of CT is to differentiate Mirizzi syndrome from a malignancy in the area of porta hepatis or in the liver. MRI and MRCP are increasingly playing an important role and have the additional advantage of showing the extent of inflammation around the gallbladder that can help in the differentiation of Mirizzi syndrome from other gallbladder pathologies such as gallbladder malignancy. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the diagnosis of Mirizzi syndrome. It delineates the cause, level, and extent of biliary obstruction, as well as ductal abnormalities, including fistula. ERCP also offers a variety of therapeutic options, such as stone extraction and biliary stent placement. Percutaneous cholangiogram can provide information similar to ERCP; however, ERCP has an additional advantage of identifying a low-lying cystic duct that may be missed on percutaneous cholangiogram. Wire-guided intraductal US can provide high-resolution images of the biliary tract and adjacent structures. Treatment is primarily surgical. Open surgery is the current standard for managing patients with Mirizzi syndrome. Good short-and long-term results with low mortality and morbidity have been reported with open surgical management. Laparoscopic management is contraindicated in many patients because of the increased risk of morbidity and mortality associated with this approach. Endoscopic treatment may serve as an alternative in patients who are poor surgical candidates, such as elderly patients or those with multiple comorbidities. Endoscopic treatment also can serve as a temporizing measure to provide biliary drainage in preparation for an elective surgery.     

Spontaneous gallbladder perforation, pericholecystic abscess and cholecystoduodenal fistula as the first manifestations of gallstone disease

BACKGROUND:Gallstone disease is common,and complications that are frequently encountered include acute cholecystitis and acute pancreatitis,but rarely gallbladder perforation. METHOD:Data were retrospectively collected from clinical case notes and a literature review is presented. RESULTS:A 72-year-old lady presented with spontaneous gallbladder perforation,pericholecystic abscess and cholecystoduodenal fistula as the first manifestations of gallstone disease.She was previously well and had no abdominal com...     

Mirizzi syndrome: evaluation by MR imaging

We report three cases of Mirizzi syndrome diagnosed by MR imaging. MR cholangiography revealed dilation of the intrahepatic bile ducts, narrowing of the common hepatic duct, the level of obstruction, and the location of gallstone in the cystic duct. MR showed thickening of the gallbladder wall and the pattern of wall enhancement. MR evaluation with MR cholangiography sequences proved to be useful in these patients with Mirizzi syndrome.     

Multidisciplinary management of Mirizzi syndrome with cholecystobiliary fistula: the value of minimally invasive endoscopic surgery

Mirizzi syndrome, a rare complication of gallstones, is defined by obstruction of the main bile duct. This obstruction may worsen and thus result in cholecystobiliary fistula. Surgical management of Mirizzi syndrome is complicated by the presence of inflamed tissue around the hepatic pedicle, making it impossible to distinguish between the main bile duct and the gallbladder. The surgeon's first task is to perform subtotal cholecystotomy(from the fundus of the gallbladder to the neck) without trying to locate the cystic duct. In a second step, the gallstones are extracted and the main bile duct is then repaired. In most cases, a T-tube is used to drain the main bile duct, and abdominal drainage is left in place(in case a bile fistula forms). This study concluded that preoperative drainage of the main bile duct in the treatment of Mirizzi syndrome types II and III is feasible and might help to decrease the postoperative complication rate.     

Gastric outlet obstruction by gallstone: Bouveret syndrome

Gallstone has rarely been described as a cause of gastrointestinal obstruction. However, the relative incidence of gallstone ileus increases significantly with age. The gastric outlet is very seldom the location of obstruction by a gallstone. The diagnosis of this condition is not difficult. Nevertheless, if treatment is delayed, high morbidity and mortality rates result. Comprehensive treatment aims to relieve the obstruction, to close the biliodigestive fistula and to prevent further gallbladder complications. The surgeon who deals with this type of illness should tailor the treatment plan according to the age, general condition, and intraoperative findings of the individual patient. This paper presents a case report of an 88-year-old woman with gastric outlet obstruction caused by a gallstone.     

Diagnosis of gallstone ileus by serial computed tomography

An unusual case of choledocholithiasis followed by gallstone ileus documented by serial computed tomography is reported. A 91-year-old woman underwent gastrostomy because she repeatedly developed aspiration pneumonia, and a common bile duct stone was detected. She and her family refused surgery once symptoms resolved. One year later, she presented with increasing, intermittent abdominal pain and nausea. Abdominal computed tomography revealed a common bile duct stone with inflammatory changes, but the patient still refused surgery. Three months later, she was admitted with abdominal pain and vomiting. On admission, plain abdominal radiographs demonstrated proximal small bowel obstruction. A long ileus tube was inserted through the gastric fistula. Two days after admission, gallstone ileus was diagnosed on abdominal computed tomography based on the presence of pneumobilia, disappearance of the common bile duct stone, fluid-filled bowel loops, and the discovery of an impacted stone in the small bowel. Ten and 15 days after admission, repeated computed tomography demonstrated the impacted stone in the terminal ileum. Seventeen days after admission, a laparotomy was performed, and a 5x3-cm gallstone was removed through an ileotomy.     

Gallstone ileus one quarter of a century post cholecystectomy

Gallstone ileus is a rare but potentially serious complication of cholelithiasis. It is usually preceded by history of biliary symptoms. It usually occurs as a result of a large gallstone creating and passing through a cholecysto-enteric fistula. Most of the time, the stone will pass the GI tract without any problems, but large enough stones can cause obstruction. The two most common locations of impaction are the terminal ileum and the ileocaecal valve because of the anatomical small diameter and less active peristalsis. We present an unusual case of small bowel obstruction secondary to gallstone ileus 24 years after an open cholecystectomy.     

Advances of recurrent risk factors and management of choledocholithiasis

Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%–22%, and common bile duct stones (CBDS) accounts for 8%–20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.     

Predicting cholecystocholedochal fistulas in patients with Mirizzi syndrome undergoing endoscopic retrograde cholangiopancreatography

BACKGROUND Mirizzi syndrome(MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography(ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct(CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.AIM To evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.METHODS From 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed.RESULTS Gallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas(P 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis(odds ratio 5.82, P = 0.002; 0.12, P = 0.008, respectively).CONCLUSION Gall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.     

An alternative surgical approach to a difficult case of Mirizzi syndrome： A case report and review of the literature

INTRODUCTION Mirizzi syndrome (MS) is a rare complication of long- standing cholelithiasis, which results from impaction of a large calculus or multiple small stones in the cystic duct or in the neck of the gallbladder causing extrinsic narrowing of the c…     

Successful endoscopic treatment of colonic gallstone ileus using electrohydraulic lithotripsy

The surgical management of gallstone ileus is complex and potentially highly morbid.Initial management requires enterolithotomy and is generally followed by fistula resection at a later date.There have been reports of gallstone extraction using various endoscopic modalities to relieve the obstruction,however,to date,there has never been a published case of endoscopic stone extraction from the colon using electrohydraulic lithotripsy.In this report,we present the technique employed to successfully perform an...     

Wire-guided intraductal US in the assessment of bile duct strictures with Mirizzi syndrome-like features at ERCP

BACKGROUND: Mirizzi syndrome refers to common hepatic duct obstruction caused by extrinsic compression that is usually from a stone impacted in the cystic duct. The utility of transpapillary intraductal US for assessment of biliary strictures with radiographic features of Mirizzi syndrome was studied retrospectively. METHODS: Intraductal US was performed in 16 patients with a common hepatic duct stricture caused by extrinsic compression and nonvisualization of the gallbladder by endoscopic retrograde cholangiography. An over-the-wire catheter US probe (20 MHz) was inserted into the bile duct. Intraductal US findings were compared with the final diagnoses at surgery. RESULTS: Intraductal US was successful in all patients. The extraluminal cause of the common hepatic duct stricture was detected in 14 patients (87.5%). In 9 patients, intraductal US detected an impacted stone outside the common hepatic duct. Intraductal US demonstrated extraluminal lesions without evidence of a stone in 5 patients, including a mass in 4 and asymmetrical, irregular thickening of the bile duct wall in 1 patient. In the remaining 2 patients, intraductal US demonstrated only a distended gallbladder. CONCLUSIONS: Transpapillary wire-guided intraductal US is useful for assessing biliary strictures with features that suggest Mirizzi syndrome and optimizes management of patients with these findings.