Mirizzi's Syndrome: Experience from a Multi-Institutional Review

Abstract

P.L. Mirizzi described in 1948 a partial or spastic obstruction of the common hepatic duct secondary to an impacted gallstone in the cystic duct or infundibulum of the gallbladder. The modern definition of Mirizzi's syndrome is thought to include four components: anatomic arrangement of the cystic duct at the gallbladder neck such that it runs parallel to the common hepatic duct; impaction of a stone in the cystic duct or neck of the gallbladder; mechanical obstruction of the common hepatic duct by the stone itself or by secondary inflammation; and intermittent or constant jaundice causing possible recurrent cholangitis and, if longstanding, secondary biliary cirrhosis. Intermittent symptomatology may make Mirizzi's syndrome difficult to diagnose preoperatively or intraoperatively. Bilio-biliary fistulas may or may not be present. Diagnosis and choice of operative repair may be best accomplished by open operative technique. Over a 24-year period two faculty members from Louisiana State University (LSU) Medical Center—Shreveport at Monroe and LSU Baton Rouge treated 4180 cases of cholelithiasis at six Louisiana university and private hospitals. Eleven cases of Mirizzi's syndrome were diagnosed on the basis of operative and preoperative notes with detailed description of size and extent of biliobiliary fistulas when they were present. These 11 cases were reviewed and followed from one to 20 years. Presentation, workup, operative findings, choice of operative repair, choice of operative approach, and complications were evaluated by retrospective chart review. Review of the pertinent literature for informative and comparative purposes was also completed. These 11 cases ranged from Csendes Type I to III. There were no Type IV cases. They were ultimately diagnosed and managed by classical open technique. Four laparoscopic procedures were converted to open technique following initial inspection. All four were converted to open as a result of inability to delineate structures in and adjacent to the triangle of Calot due to marked scarring in the subhepatic space. No iatrogenic injuries or major complications occurred. Mirizzi's syndrome occurs in fewer than 0.5 per cent of patients with cholelithiasis. Removal of stones with partial cholecystectomy and use of gallbladder or cystic duct remnant to oversew or repair Mirizzi fistulas should be considered. Roux-en-y hepaticojejunostomy becomes the procedure of choice when the vascularity or viability of the hepatic duct or tissues available for duct repair is questionable. Review of the literature reveals the increase in complications with laparoscopic versus open technique in Mirizzi's syndrome. Although very little direct evidence exists we believe that when this syndrome is diagnosed or strongly suspected open biliary operation is the procedure of choice because the increased potential for major complications with the use of laparoscopic technique far outweighs the potential slight increase in morbidity of an open procedure.