37例 Mirizzi综合征的诊断与治疗

目的　探讨Mirizzi综合征的诊断依据、病理分型和手术方法。方法　对我院从 1990年1月至 2 0 0 3年 6月收治的 37例Mirizzi综合征进行回顾性分析。结果　 37例均采取手术治疗 ,其中开腹手术 31例 ,腹腔镜手术 6例。手术方式为胆囊切除术、胆囊大部切除、肝总管瘘口修补、及肝总管空肠Roux en y吻合术。术中损伤胆管 1例。 32例获随访 ,随访时间 3个月至 5年 ,无明显并发症。结论　术前胆道影像学检查和术中探查是主要的诊断依据 ,治疗上应根据病理特点选择不同的手术方式     

Mirizzi syndrome: An extra hazard for laparoscopic surgery

Background : Mirizzi Syndrome (MS) is an important but uncommon complication of gallstones characterized by narrowing of the common hepatic duct (CHD) due to mechanical compression or inflammation. This study aimed to assess the impact of preoperative and intraoperative diagnosis of MS on the performance, safety and efficacy of laparoscopic cholecystectomy. Methods : From a consecutive series of 1281 patients having surgery for gall bladder disease between 1990 and 1998, nine patients with MS were identified from a prospective database and their clinical progress examined. Results : Five out of the nine patients with MS presented with pain (2/5 were also jaundiced), and four presented with acute cholecystitis. Liver function tests were abnormal in all patients. Preoperative diagnosis of MS based on ultrasound was made in only two patients, and in a third on findings of a nasobiliary cholangiogram. In six patients, the diagnosis was intraoperative. In seven patients cholecystectomy was completed by laparoscopy. Two patients needed conversion to open cholecystectomy. In two patients the common bile duct was mistaken for the cystic duct and the error was recognized on relaxation of traction on the gall bladder in one, but in the other a duct injury occurred that was not recognized until the postoperative period. Conclusions : Preoperative diagnosis of MS is difficult, and a high index of suspicion is necessary to avoid serious complications. Once the diagnosis is known, successful laparoscopic management is possible but care should be taken to avoid duct injury.     

Mirizzi syndrome: history, present and future development

BACKGROUND: Mirizzi syndrome was reported in 0.3-3% of patients undergoing cholecystectomy. The distortion of anatomy and the presence of cholecystocholedochal fistula increase the risk of bile duct injury during cholecystectomy. METHODS: A Medline search was undertaken to identify articles that were published from 1974 to 2004. Additional papers were identified by a manual search of the references from the key articles. RESULTS: A preoperative diagnosis was made in 8-62.5% of cases. Open surgical treatment gave good short-term and long-term results. There was a lack of good data in laparoscopic treatment. Conversion to open surgery rates was high, and bile duct injury rate varied from 0 to 22.2%. CONCLUSION: A high index of clinical suspicion is required to make a preoperative or intraoperative diagnosis, which leads to good surgical planning to treat the condition. Open surgery is the gold standard. Mirizzi syndrome should still be considered as a contraindication for laparoscopic surgery.     

Mirizzi综合征外科处理方法探讨

目的 探讨Mirizzi综合征临床合理有效的手术方法. 方法 回顾性分析1989年1月~2004年6月间采用带蒂胆囊瓣转移修补方法治疗Mirizzi综合征的临床资料. 结果 所有患者恢复良好,随访3~72月,无并发症发生. 结论 带蒂胆囊瓣转移修补方法治疗Mirizzi综合征所致的胆管缺损,是保持胆道生理功能完整的有效方法.     

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目的探讨对Mirizzi综合征实施临床合理有效的手术方法。方法自1996年9月至2004年2月采用带蒂胆囊瓣转移修复Mirizzi综合征Ⅱ、Ⅲ型胆管缺损16例,术后T管支撑3～6个月,胆道造影通畅。结果所有病人恢复良好,随访4～96个月,无并发症发生。结论带蒂胆囊瓣转移修复Mirizzi综合征Ⅱ、Ⅲ型胆管缺损,是保持胆道生理功能完整的有效方法。     

Mirizzi综合征31例临床分析

目的:探讨Mirizzi综合征的诊断及减少术中医源性胆管损伤的处理措施。方法:回顾分析我院31例Mirizzi综合征患者诊断、分型、手术方法等临床资料,并与同期3185例非Mirizzi综合征患者行胆囊切除术时医源性胆管损伤发生率进行比较。结果:31例Mirizzi综合征术前确诊9例,术中损伤胆管8例;3185例非Mirizzi综合征胆囊切除术中损伤胆管4例。结论:Mirizzi综合征已成为胆道外科手术中致胆管损伤的主要因素;ERCP、MRCP是诊断该病的主要检查方法;对术前确诊及高度怀疑此病的患者,主张开腹行胆囊切除、胆管修补或胆肠Roux-en-Y吻合术,这样会带来更多的安全性及获得正确的处理办法。     

内窥镜逆行性胰胆管造影联合腹腔镜及胆道镜治疗Mirizzi综合征

目的 探讨内窥镜逆行性胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)联合腹腔镜及胆道镜对不同类型Mirizzi综合征的相应治疗方法.方法 自2005年7月至2009年6月期间收治经手术证实为Mirizzi综合征的患者12例.应用ERCP联合腹腔镜及胆道镜对12例患者采取相应的治疗方法.结果 12例Mirizzi综合征患者合并胆总管结石7例.根据Csendes分型:Ⅰ型8例;Ⅱ型3例;Ⅲ型1例.12例患者均行ERCP+腹腔镜胆囊切除术(laporoscopic cholecystectomy,LC)+术中胆道镜探查及取石术.11例患者顺利完成三镜联合手术,于腹腔镜下行胆总管一期缝合4例,所有患者均经手术治愈,Ⅲ型患者拔除T管后,复查胆道造影,无胆道狭窄.结论 ERCP联合腹腔镜、胆道镜治疗Mirizzi综合征具有微创、安全、住院时间短、恢复快等优点.     

Mirizzi syndrome secondary to an adenoma of the cystic duct

Bile duct adenomas are uncommon lesions that can cause obstructive jaundice. We report the unusual case of a 54-year-old man who developed Mirizzi syndrome secondary to a bile duct papillary adenoma located in the cystic duct remnant. A case report is presented, together with a review of extrahepatic bile duct adenomas published in the English-language literature, with special attention directed toward the clinical manifestations, locations, and prognosis of these tumors. Bile duct adenomas are very rare tumors. Although cholangiography can detect many of these lesions, few cases were correctly diagnosed preoperatively. Most lesions were located in the distal common bile duct or at the ampulla of Vater. Pathologic examination often revealed foci of carcinoma in situ, dysplasia, or atypia. Local resection was performed in most cases. There were no previous case reports of extrinsic common bile duct obstruction caused by tumors within the cystic duct. We describe here a very rare, acalculous variant of Mirizzi syndrome secondary to a solitary papillary adenoma of the cystic duct. In general, bile duct adenomas are uncommon lesions that are difficult to diagnoses preoperatively. These tumors usually present with jaundice secondary to intraluminal biliary obstruction. These lesions are premalignant and should be managed by complete surgical resection.     

Mirizzi综合征的外科诊治体会

目的：提高临床上对Mirizzi综合征的认识,避免胆管损伤。方法：西文回顾性分析和总结我院从1988-1998年共收治的16例病例。结果：I型4例,行单纯胆囊切除;Ⅱ型8例和Ⅲ型3例,行胆囊切除胆管壁修补T管引流;Ⅳ型1例,行胆囊切除肝总管空肠Roux-Y吻合。择期手术13例,急诊手术3例。随访时间平均6.5年,无胆管狭窄情况。结论：为避免胆管损伤,应该做到⑴提高对本病理论上的认识;⑵术前有黄疸史,应行直接胆道造影,提高术前的诊断率;⑶术中应根据不同情况,选择合适术式。     

Pablo Luis Mirizzi: the man behind the syndrome

Pablo Luis Mirizzi (1893-1964), who was born and died in the city of Cordoba in Argentina, dedicated his life to the service of surgery and the teaching of his students. Although known for the introduction of the intraoperative cholangiogram and for describing the Mirizzi syndrome - a partial obstruction of the common hepatic duct secondary to an impacted gallstone in the cystic duct, very little else is known about this man behind the brilliant surgical pioneer of the twentieth century. This biography looks beyond his important contributions to medicine, to the many facets of the man himself.     

腹腔镜修复Mirizzi综合征所致的肝总管缺损

目的 探讨腹腔镜下修复Ⅱ、Ⅲ型Mirizzi综合征所致肝总管缺损的方法. 方法回顾性分析腹腔镜下完成的8例Ⅱ、Ⅲ型Mirizzi综合征手术治疗的经验.8例均在腹腔镜下完成胆囊次全切除和肝总管缺损修补术,其中6例Ⅱ型患者缺损位于肝总管侧壁,通过残存胆囊管直接缝合修复缺损,2例Ⅲ型缺损分别位于肝总管前侧壁和后侧壁,采用残留部分胆囊壶腹部补片法完成肝总管缺损修复术.结果 8例均在腹腔镜下完成胆囊次全切除及肝总管缺损修补术.手术时间80～150 min,平均110 min.术后随访6～24个月,无症状复发.结论 必须熟悉Mirizzi综合征的解剖特点,熟练掌握腹腔镜下缝合技术,针对不同的缺损部位和范围,选择恰当的修补方法.     

Mirizzi Syndrome with a Double Biliary Fistula

Mirizzi syndrome is a partial obstruction of the biliary tree caused by a stone impacted in the cystic duct, with or without development of a cholecystobiliary fistula. Clinical signs are non-specific and suggest at first an obstructive jaundice. We describe a patient with a type I Mirizzi syndrome with a cholecystocolic and a cholecysto-internal biliary fistula. The diagnosis was suggested by ultrasonography and tomodensitometry, and confirmed by endoscopic retrograde cholangiopancreatography. A partial cholecystectomy with a Roux-en-Y hepaticojejunostomy reconstruction was performed. A review of the literature covering its clinical presentation, diagnosis and surgical treatment is presented.     

Mirizzi综合征32例诊治体会

目的：总结Mirizzi综合征的诊断和治疗经验,探讨其临床特点。方法：对经手术证实的32例Mirizzi综合征的临床资料进行回顾性分析。结果：术前经ERCP及B超检查明确诊断者仅6例。行胆囊大部切除术21例,行胆囊切除加T管引流术5例,瘘口直接缝合修补3例,胆囊瓣瘘口修补2例,肝总管空肠吻合1例。结论：Mirizzi综合征术前诊断仍较困难,治疗应根据不同类型选择适当的手术方式。     

Mirizzi综合征24例诊治经验

为探讨Ｍｉｒｉｚｚｉ综合征在临床上的一种新的,合理的规范的分类方法。方法 对２４例此征病人从诊断和治疗的角度加以分析,结合以往对Ｍｉｒｉｚｚｉ综合征的分类方法,重新总结出一种新的分类方法,得出三种不同的类型：Ｉ型,由于胆囊管或胆囊颈部嵌顿的结石压迫肝总管或者堵塞肝总管而致肝总管狭窄为特点;Ⅱ型,由于胆囊管或胆囊颈部结石压迫肝总管,开成胆囊,肝总管瘘;Ⅲ型,反复的胆囊炎,胆管炎,以及其它良性疾病引起     

微创治疗Mirizzi综合征

目的 :综合利用腹腔镜、十二指肠镜、胆道镜 ,探索微创治疗Ⅱ型、Ⅲ型Mirizzi综合征的方法。方法 :治疗Ⅱ型、Ⅲ型Mirizzi综合征 2 1例 ,先经十二指肠镜行ERCP及ENBD治疗 ,后行腹腔镜胆总管探查、取石及胆总管或肝总管缺损修补术 ,术中胆道镜检查 ,不放置T管。结果 :2 1例中微创手术成功 19例 ,中转开腹 2例。无严重并发症及死亡病例。术后住院时间明显缩短 ,但手术时间较开腹手术长。部分病例随访半年以上未见远期并发症。结论 :利用多种内镜、腹腔镜手段治疗Mirizzi综合征在技术上切实可行、安全可靠。但腹腔镜下的缝合胆管缺损较困难 ,此术式可在腹腔镜技术较高的单位开展     

腹腔镜手术治疗Mirizzi综合征

目的:总结腹腔镜治疗Mirizzi综合征的经验.方法:回顾分析2004年6月至2010年8月为45例Mirizzi综合征患者行腹腔镜治疗的临床资料,并与同期25例开腹手术进行对比研究.结果:所有手术均获成功,腹腔镜组无一例中转开腹.腹腔镜组与开腹组平均手术时间分别为(79±12) min与(82±15) min(t=0...     

Management of Mirizzi syndrome: A new surgical approach

Background : In a prospective study of a patient population of 1340 with biliary calculus disease, that ran from January 1993 to December 1997, 34 patients (2.53%) were identified as having Mirizzi syndrome. Eight patients were found to have type I (A and B) and 26 patients were found to have type II Mirizzi syndrome. A history of recurrent biliary colic and jaundice was present in the majority of patients. Methods : Ultrasonography was helpful in five patients and endoscopic retrograde cholangiopancreatography was helpful in 17 patients in the diagnosis of this condition. Because the amount of gall bladder tissue used in choledochoplasty is not yet standardized, a new policy regarding choledochoplasty was adopted. In type IA, retrograde cholecystectomy with simple closure of cystic duct was carried out. In type IB, retrograde cholecystectomy and choledochoplasty with 5 mm cuff of the gall bladder was carried out. In type II lesions the procedure depended on the size of fistula. Patients with fistula sizes of less than one‐third of the common bile duct diameter underwent choledochoplasty with 5 mm cuff of the gall bladder, and patients with fistula sizes between one‐third and two‐thirds of the diameter of the common bile duct underwent choledochoplasty with 10 mm cuff of the gall bladder. Patients with fistula sizes of more than two‐thirds of the common bile duct diameter underwent Roux‐en‐Y hepaticojejunostomy. Results : There was no operative mortality and the complication rate was 17.64%. Conclusion : Although, out of 26 choledochoplasties, we encountered only one (3.84%) stump stone in a maximum follow‐up period of 59 months, further long‐term follow‐up studies are required to prove the efficacy of the procedure.     

Incidence and management of Mirizzi syndrome during laparoscopic cholecystectomy

Background: Benign extrinsic obstruction of the hepatic duct, known as Mirizzi syndrome (MS), is an uncommon complication of longstanding cholelithiasis. Since laparoscopic cholecystectomy (LC) replaced the open approach, Mirizzi syndrome has regained the interest of biliary surgeons. Methods: The Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) prospectively collected the data on 13,023 patients undergoing LC between 1995 and 1999. This database was investigated with special regard to patients with Mirizzi syndrome. Results: There were 39 patients (14 men and 25 women; mean age, 61 years) with MS (incidence, 0.3%). Thirty-four patients had type 1 MS and five had type 2. A gallbladder carcinoma was found in four patients (incidence, 11%). In the type 1 group, 23 patients underwent cholecystectomy only, 10 patients had a bile duct exploration and T-tube insertion, and one patient had a Roux-en-Y reconstruction. In three patients with type 2, a hepaticojejunostomy was performed; two others underwent simple closure and drainage (via T-tube) of the biliary fistula. The conversion rate was 74% (24 of 34 patients) in the type 1 group and 100% (five of five patients) for type 2. The overall complication rate was 18%. There were no deaths. Conclusions: Although MS is rarely encountered during LC, it must be recognized intraoperatively. Conversion to an open approach is often needed, and prior to any surgical intervention, gallbladder cancer must be excluded. Presented at the combined meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the 8th World Congress of Endoscopic Surgery, New York, NY USA, 13–16 March 2002     

Laparoscopic subtotal cholecystectomy for Mirizzi syndrome: A report of a case

IntroductionMirizzi syndrome is a rare complication of gallstone disease. The purpose of this report is to describe the utility of laparoscopic subtotal cholecystectomy for Mirizzi syndrome.Presentation of caseA 53-year-old female presented with dark urine and right upper quadrant pain. Blood tests revealed elevated liver and biliary enzyme levels. Magnetic resonance cholangiopancreatography showed a narrowed common hepatic duct compressed by a large gallstone, consistent with Mirizzi syndrome. Semi-urgent laparoscopic cholecystectomy was planned. At operation, circumferential dissection of the gallbladder neck was difficult. The fundus of the gallbladder was opened and a 2 cm stone extracted. The gallbladder neck was sutured and a drain placed. The postoperative clinical course was uneventful.DiscussionAfter laparoscopic cholecystectomy in patients with Mirizzi syndrome, complication rates, including bile duct injuries, is high. In patients with Mirizzi syndrome, removal of the responsible stone is the main purpose of treatment.ConclusionLaparoscopic subtotal cholecystectomy is a useful technique for patients with Mirizzi syndrome to avoid bile duct injury.