RESUMO
Mirizzi syndrome is a complication of cholelithiasis occurring in 0.25-6% of cases [1]. Clinical pattern includes jaundice due to prolapse of a large calculus into the common bile duct following cholecystocholedochal fistula. Ultrasound, CT, MRI, MRCP data, as well as some pathognomonic signs provide preoperative diagnostics of Mirizzi syndrome. In most cases, treatment of this syndrome requires open surgery. We report successful endoscopic treatment of a patient with long-standing bile stone disease complicated by Mirizzi syndrome. Postoperative complications of surgery performed in acute period of disease and further staged treatment using retrograde access are illustrated. Endoscopic treatment demonstrated minimally invasive management of disease presenting diagnostic and technical difficulties.
Assuntos
Colelitíase , Endoscopia , Síndrome de Mirizzi , Humanos , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia , Colelitíase/complicações , Colelitíase/diagnóstico , Colelitíase/cirurgia , Ducto Colédoco , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/etiologia , Síndrome de Mirizzi/cirurgiaAssuntos
Síndrome de Mirizzi , Pancreatopatias , Má Junção Pancreaticobiliar , Humanos , Síndrome de Mirizzi/diagnóstico por imagem , Síndrome de Mirizzi/etiologia , Ductos Pancreáticos/diagnóstico por imagem , Ductos Pancreáticos/anormalidades , Pancreatopatias/diagnóstico , Pancreatopatias/diagnóstico por imagemAssuntos
Cálculos , Colelitíase , Síndrome de Mirizzi , Síndrome Pós-Colecistectomia , Humanos , Síndrome Pós-Colecistectomia/diagnóstico , Síndrome Pós-Colecistectomia/etiologia , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/etiologia , Síndrome de Mirizzi/cirurgia , Ducto Cístico , Colelitíase/complicações , Colelitíase/diagnóstico , Colelitíase/cirurgia , Cálculos/complicaçõesRESUMO
Mirizzi Syndrome (MS) is a rare gallbladder disease described by Argentine surgeon, Pablo Luis Mirizzi in 1948. It concerns a wide range of clinical manifestations, including gallstone obstruction of the intestine. The modified classification by Csendes distinguishes five types of MS. The case described by the authors of this paper could be classified as type Vb, which means MS with a complication of obstruction. A 74-year-old woman with nonspecific, permanent, diffuse abdominal pain and bile vomiting was admitted to the emergency department where conservative treatment was administered. Based on the preoperative diagnosis of ileus, the patient was qualified for a laparotomy. The patient had a cholecystoduodenal fistula which was responsible for the displacement of the stone into the intestinal lumen and consequently for the mechanical obstruction of the intestine. It must be taken into account that the clinical manifestation of MS may be biliary obstruction, as occurred in the case presented below. Biliary symptoms may occur, but this is not a common situation, whereas half of patients with an obstruction have a history of biliary disease. The case presented here can be a valuable lesson in being mindful of the possibility of elderly and female patients developing biliary obstruction, even without having a history of chronic gallstone disease. Therefore, a meticulous intraoperative inspection should be performed in such cases in order to search for possible fistulas. KEY WORDS: Cholecystoduedenal fistula, Gallstone disease, Mirizzi syndrome.
Assuntos
Cálculos Biliares , Íleus , Fístula Intestinal/cirurgia , Obstrução Intestinal , Síndrome de Mirizzi , Idoso , Feminino , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Humanos , Íleus/etiologia , Íleus/cirurgia , Fístula Intestinal/complicações , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Síndrome de Mirizzi/etiologia , Síndrome de Mirizzi/cirurgia , ReoperaçãoAssuntos
Neoplasias dos Ductos Biliares , Colangiocarcinoma , Síndrome de Mirizzi , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Ductos Biliares Intra-Hepáticos , Colangiocarcinoma/diagnóstico por imagem , Colangiopancreatografia Retrógrada Endoscópica , Humanos , Síndrome de Mirizzi/diagnóstico por imagem , Síndrome de Mirizzi/etiologiaRESUMO
BACKGROUND Mirizzi syndrome is biliary obstruction caused by extrinsic compression of the distal common hepatic duct by a gallstone in the adjacent cystic duct or infundibulum of the gallbladder. Post-cholecystectomy Mirizzi syndrome (PCMS) is Mirizzi syndrome in the post-surgical absence of a gallbladder. This case report of PCMS and review of the literature illustrates the diagnostic and therapeutic challenges in evaluating and managing Mirizzi syndrome. CASE REPORT A 44-year-old female with a remote history of laparoscopic cholecystectomy presented to a community teaching hospital with acute and severe upper abdominal pain and tenderness. Laboratory data revealed markedly elevated transaminases of a magnitude most often observed with hepatitis from acute viral infection, ischemia, or exposure to a hepatotoxin. PCMS was ultimately diagnosed at endoscopic retrograde cholangiopancreatography after being misdiagnosed as choledocholithiasis on magnetic resonance cholangiopancreatography. After transfer to an academic quaternary care referral hospital, the patient's extrahepatic biliary tree was reportedly cleared of gallstones following endoscopically-directed shock-wave lithotripsy performed at repeat -endoscopic retrograde cholangiography. CONCLUSIONS Recognizing post-cholecystectomy syndrome, in general, and PCMS, in particular, is critical when caring for patients presenting with persistent or recurrent symptoms or signs of biliary obstruction following cholecystectomy. Expediently identifying and definitively relieving the biliary obstruction, while limiting the risk of iatrogenic complication, is the priority when caring for patients with PCMS.
Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Síndrome de Mirizzi/diagnóstico , Adulto , Colangiopancreatografia Retrógrada Endoscópica , Feminino , Cálculos Biliares/terapia , Humanos , Litotripsia , Síndrome de Mirizzi/etiologiaRESUMO
Gallstone disease is a leading cause of morbidity in the United States and usually requires surgical or endoscopic interventions for diagnosis and/or treatment. Although gallstone disease is classically associated with the inflammatory sequela of cholecystitis, gallstones can also contribute to other clinical presentations such as gallstone ileus, Mirizzi syndrome, and Bouveret syndrome. This article explores the common-and uncommon-causes of surgical pathology owing to gallstones with an emphasis on clinical identification, diagnostics, and management options.
Assuntos
Colecistite/diagnóstico , Cálculos Biliares/diagnóstico , Cálculos Biliares/terapia , Íleus/diagnóstico , Síndrome de Mirizzi/diagnóstico , Colecistite/etiologia , Colecistite/terapia , Cálculos Biliares/etiologia , Humanos , Íleus/etiologia , Íleus/terapia , Síndrome de Mirizzi/etiologia , Síndrome de Mirizzi/terapiaAssuntos
Procedimentos Cirúrgicos do Sistema Biliar , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistolitíase , Coledocolitíase , Síndrome de Mirizzi , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos do Sistema Biliar/instrumentação , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Colecistolitíase/complicações , Colecistolitíase/diagnóstico , Colecistolitíase/cirurgia , Coledocolitíase/complicações , Coledocolitíase/diagnóstico , Coledocolitíase/cirurgia , Descompressão Cirúrgica/métodos , Drenagem/métodos , Feminino , Humanos , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/etiologia , Síndrome de Mirizzi/fisiopatologia , Síndrome de Mirizzi/cirurgia , Stents , Resultado do TratamentoAssuntos
Carcinossarcoma/diagnóstico , Neoplasias da Vesícula Biliar/diagnóstico , Síndrome de Mirizzi/etiologia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinossarcoma/complicações , Carcinossarcoma/patologia , Carcinossarcoma/terapia , Quimioterapia Adjuvante , Colecistectomia Laparoscópica , Cisplatino/uso terapêutico , Desoxicitidina/análogos & derivados , Desoxicitidina/uso terapêutico , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/patologia , Vesícula Biliar/cirurgia , Neoplasias da Vesícula Biliar/complicações , Neoplasias da Vesícula Biliar/patologia , Neoplasias da Vesícula Biliar/terapia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/terapia , Resultado do Tratamento , GencitabinaRESUMO
BACKGROUND/AIM: Mirizzi's syndrome (MS) is an unusual complication of gallstone disease and occurs in approximately 1% of patients with cholelithiasis. Majority of cases are not identified preoperatively, despite the availability of modern imaging techniques. A preoperative diagnosis can forewarn the operating surgeon and avoid bile duct injuries in cases of complicated cholecystitis. A preoperative scoring system helpful and hence, we aim to devise a scoring system based on clinical, biochemical, and imaging features to predict the diagnosis of MS in cases of complicated cholecystitis. PATIENTS AND METHODS: From January 2000 to July 2013, 1,539 patients with cholelithiasis underwent cholecystectomy. Of these, 96 patients had complicated cholecystitis. Records of these patients were analyzed retrospectively. In these, 32 patients were found to be having MS that formed the study group. A scoring system was devised based on clinical, biochemical, and imaging parameters to predict the diagnosis of MS. Every positive parameter was given 1 point and patients rated on a scale of 0-10. RESULTS: Score of 3 or more was found to have a 90% sensitivity of predicting MS among complicated cholecystitis. Similarly, a score of 6 or more had an 80% sensitivity of predicting Mirizzi's types II, III, and IV indicating fistulization. Jaundice, leucocytosis, associated choledocholithiasis/hepatolithiasis, intrahepatic biliary radical dilatation, meniscus sign and mass at confluence were found to be significant parameters. CONCLUSION: We propose a simple scoring system based on clinical, biochemical, and imaging parameters that can be useful for predicting MS in patients with complicated cholecystitis.
Assuntos
Doenças dos Ductos Biliares/complicações , Colelitíase/complicações , Síndrome de Mirizzi/diagnóstico por imagem , Projetos de Pesquisa/normas , Doenças dos Ductos Biliares/prevenção & controle , Colangiografia/métodos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colangiopancreatografia por Ressonância Magnética/métodos , Colecistectomia/métodos , Colelitíase/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome de Mirizzi/classificação , Síndrome de Mirizzi/etiologia , Período Pré-Operatório , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia/métodosRESUMO
We present the case of a young female with symptoms of biliary colic and a biochemical profile consistent with biliary obstruction. Imaging was suspicious for Mirizzi's syndrome. Intraoperatively, the patient was found to have a complete intrahepatic gallbladder causing common hepatic duct compression with final pathology confirming acute cholecystitis. We review the embryological development of the gallbladder as well as clinical presentation of Mirizzi's syndrome. Special consideration for clinical workup and surgical management is discussed.
Assuntos
Colecistite Acalculosa/complicações , Coristoma/complicações , Vesícula Biliar , Hepatopatias/etiologia , Síndrome de Mirizzi/etiologia , Colecistite Acalculosa/diagnóstico , Colecistite Acalculosa/cirurgia , Doença Aguda , Adulto , Colangiopancreatografia Retrógrada Endoscópica , Coristoma/diagnóstico por imagem , Feminino , Humanos , Hepatopatias/diagnóstico por imagem , Imageamento por Ressonância Magnética , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/cirurgia , StentsAssuntos
Cálculos Biliares/etiologia , Atresia Intestinal/cirurgia , Síndrome de Mirizzi/etiologia , Nutrição Parenteral Total/efeitos adversos , Complicações Pós-Operatórias/terapia , Síndrome do Intestino Curto/terapia , Colecistectomia Laparoscópica/métodos , Procedimentos Cirúrgicos do Sistema Digestório , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/cirurgia , Humanos , Masculino , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/cirurgia , Complicações Pós-Operatórias/etiologia , Síndrome do Intestino Curto/etiologia , Adulto JovemRESUMO
INTRODUCTION: Mirizzi syndrome (MS) is a rare complication of cholelithiasis. Despite the success of laparoscopic cholecystectomy as a minimally invasive approach to gallstone disease, MS remains a challenge, also for open and robotic approaches, due to the subverted anatomy of the hepatocystic triangle. Moreover, when emergency surgery is needed, the optimal preoperative diagnostic assessment could not be always achievable. We aim to analyze our experience of MS treated in emergency and to assess the feasibility of a diagnostic and therapeutic decisional algorithm. METHODS: From March 2006 to February 2016, all patients with a preoperative diagnosis, or an intraoperative evidence of MS, were retrospectively analyzed at our Academic Hospital, including patients operated on in emergency or in deferred urgency. Eighteen patients were included in the study using exclusion criteria and were treated in elective surgery. RESULTS: The patients were distributed according to modified Csendes' classification: type I in 15 cases, type II in 2, type III in 0, type IV in 1, and type V in 0. In the type I group, diagnosis was intraoperatively performed. Laparoscopic approach was performed with cholecystectomy or subtotal cholecystectomy, when the hepatocystic triangle dissection was hazardous. Patients with preoperative diagnosis of acute abdomen and MS type IV were directly managed by open approach. CONCLUSIONS: Diagnosis of MS and the therapeutic management of MS are still a challenge, mostly in an emergency setting. Waiting for standardized guidelines, we propose a decisional algorithm in emergency, especially in nonspecialized centeres of hepatobiliary surgery.
Assuntos
Algoritmos , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/cirurgia , Abdome Agudo/etiologia , Idoso , Colecistectomia Laparoscópica , Colelitíase/complicações , Tomada de Decisão Clínica , Emergências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome de Mirizzi/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Laparoscopic cholecystectomy is the gold standard treatment of gallbladder disease. Post-cholecystectomy syndrome is a severe postoperative complication which can be caused by multiple mechanisms and can present with multiple disorders. The wide use of laparoscopy induces the need to understand more clearly the presentation and pathophysiology of this syndrome. Post-cholecystectomy Mirizzi syndrome is one form of this syndrome and, according to literature, this is the first report that clearly describes it. CASE PRESENTATION: We describe the case of a 62-year-old Greek woman who underwent laparoscopic cholecystectomy because of gallstone disease. A few days after surgery, post-cholecystectomy syndrome gradually developed with mild bilirubin increase in association with epigastric pain, nausea, and vomiting. After performing ultrasound, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography, we conducted a second laparoscopic surgery to manage the obstruction, which was converted to open surgery because of the remaining inflammation from the post-endoscopic retrograde cholangiopancreatography acute pancreatitis. Four polymeric laparoscopic clips were removed because they were identified as the cause of her post-cholecystectomy syndrome. She had a quick recovery without further complications. CONCLUSIONS: Postoperative Mirizzi syndrome induced by the migration of polymer laparoscopic clips is a rare (only one case referring to polymeric clips has been published in the literature) but a well-identified complication of laparoscopic cholecystectomy which can confuse the diagnostic and therapeutic field requiring simultaneous immediate management.
Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Corpos Estranhos/diagnóstico , Síndrome de Mirizzi/etiologia , Síndrome Pós-Colecistectomia/complicações , Instrumentos Cirúrgicos , Colangiopancreatografia Retrógrada Endoscópica , Colangiopancreatografia por Ressonância Magnética , Feminino , Corpos Estranhos/cirurgia , Humanos , Pessoa de Meia-Idade , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/cirurgia , Síndrome Pós-Colecistectomia/diagnóstico por imagem , Instrumentos Cirúrgicos/efeitos adversos , UltrassonografiaRESUMO
We report the first case of Mirizzi syndrome in a patient who presented with biliary obstruction caused by pure calcium carbonate stones. A 61 years old male with history of portal vein thrombosis presented with rash, nausea and jaundice. An ultrasound of biliary tree showed gallstones with dilatation of hepatic duct and intrahepatic biliary tree. There was suspicion of a stone in proximal CBD. CT scan showed an opaque gallbladder with dense radio-opaque material in its lumen. An ERCP was then performed revealing external common hepatic duct obstruction at the neck of the gallbladder. A plastic biliary stent was placed across the obstruction, followed by a cholecystectomy. Resected gallbladder specimen revealed thick whitish paste like material, and formed stones filling the gallbladder lumen. Laboratory testing showed this material to be composed of 100% calcium carbonate crystals.
Assuntos
Colecistectomia , Cálculos Biliares/complicações , Síndrome de Mirizzi/etiologia , Bile , Carbonato de Cálcio , Colangiopancreatografia Retrógrada Endoscópica , Cálculos Biliares/cirurgia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
AIM: To define the role of endoscopic interventions in diagnosis and treatment of Mirizzi syndrome. MATERIAL AND METHODS: Results of treatment of 41 patients with Mirizzi syndrome are presented. Endoscopic transpapillary interventions including cholangiography, papillosphincterotomy lithoextraction, nazobiliary drainage were used as a first step in all cases. RESULTS AND DISCUSSION: In 4 cases laparoscopic cholecystectomy was performed after biliary tree sanitation. In 6 advanced age patients with severe comorbidities common bile duct stenting alone was preferred. Open interventions were performed in 15 patients (36.6%) including cholecystectomy, choledocholithotomy with common bile duct drainage. CONCLUSION: It is shown that endoscopic transpapillary methods of diagnosis and treatment of Mirizzi syndrome provides adequate decompression and sanitation of the bile ducts in most cases and significantly reduces number of open surgical procedures.
Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/métodos , Colecistolitíase/complicações , Síndrome de Mirizzi , Idoso , Colangiopancreatografia Retrógrada Endoscópica/métodos , Descompressão Cirúrgica/métodos , Drenagem/métodos , Feminino , Humanos , Icterícia Obstrutiva/fisiopatologia , Icterícia Obstrutiva/cirurgia , Masculino , Pessoa de Meia-Idade , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/etiologia , Síndrome de Mirizzi/fisiopatologia , Síndrome de Mirizzi/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: ERCP is an established technique for the management of bile duct stones. Large bile duct stones (>1.2 cm) require additional techniques such as mechanical lithotripsy and balloon sphincteroplasty for ductal clearance. The literature on endoscopic management of cystic duct stones (CDSs) and Mirizzi syndrome (MS) is limited. We report our experience with cholangioscopy-assisted extraction of CDSs and MS in patients in whom conventional endoscopic and surgical techniques failed. METHODS: Between August 2011 and August 2014, 50 patients (15 males) diagnosed with MS (n = 40) and CDSs (n = 10) were recruited for the study. MRCP was the preferred diagnostic modality to outline the biliary anatomy. ERCP was performed by using an Olympus TJF 160/180 duodenoscope (Olympus, Tokyo, Japan). Cholangioscopy was performed by using the Spyglass system (Boston Scientific, Marlborough, Mass). Holmium laser lithotripsy (LL) was performed when conventional stone extraction techniques failed. RESULTS: Cholangioscopy-guided LL was required in 34 of 50 patients (68%) with MS and CDSs. Stone extractions using conventional endoscopy techniques were successful in 8 patients and with surgery in another 8 patients, and these patients were excluded from the final statistical analysis. The mean stone size for MS was 21 mm (range 15-41 mm), and the CDS size was 8 mm (range 6-12 mm). Single-session ductal clearance could be achieved in 32 patients (94%). Adverse events were mild and included fever (2 patients), transient abdominal pain (2 patients), and self-limited pancreatitis (2 patients). CONCLUSIONS: Cholangioscopy-guided LL is a useful technique for extraction of CDSs and in MS with high single-session success rates. It is also a rescue technique in patients in whom surgical stone extraction failed.
Assuntos
Colangiopancreatografia Retrógrada Endoscópica/métodos , Colelitíase/terapia , Ducto Cístico/cirurgia , Litotripsia a Laser/métodos , Síndrome de Mirizzi/terapia , Adulto , Idoso , Colangiopancreatografia por Ressonância Magnética , Colelitíase/complicações , Endoscopia do Sistema Digestório/métodos , Feminino , Humanos , Lasers de Estado Sólido/uso terapêutico , Masculino , Pessoa de Meia-Idade , Síndrome de Mirizzi/etiologia , Estudos Retrospectivos , Centros de Atenção Terciária , Resultado do Tratamento , Adulto JovemAssuntos
Fístula Biliar/etiologia , Colelitíase/complicações , Doenças do Ducto Colédoco/etiologia , Fístula Cutânea/etiologia , Doenças da Vesícula Biliar/etiologia , Síndrome de Mirizzi/etiologia , Idoso , Fístula Biliar/diagnóstico por imagem , Fístula Biliar/cirurgia , Colecistectomia , Colelitíase/cirurgia , Doenças do Ducto Colédoco/diagnóstico por imagem , Doenças do Ducto Colédoco/cirurgia , Comorbidade , Fístula Cutânea/diagnóstico por imagem , Fístula Cutânea/cirurgia , Drenagem , Emergências , Feminino , Doenças da Vesícula Biliar/diagnóstico por imagem , Doenças da Vesícula Biliar/cirurgia , Hérnia Umbilical/complicações , Hérnia Umbilical/cirurgia , Humanos , Íleo/irrigação sanguínea , Achados Incidentais , Isquemia/etiologia , Isquemia/cirurgia , Jejunostomia , Fígado/cirurgiaRESUMO
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.