Clinical Outcomes and Treatment Strategy of Mirizzi's Syndrome Treated With Surgery.

BACKGROUND: There is currently no standardized treatment for Mirizzi's syndrome (MS). We aim to explore the surgical treatment strategy for MS by analyzing its clinical characteristics and treatment outcomes. METHODS: This retrospective study analyzed the clinical data of 130 patients with MS who underwent surgery at our hospital from April 2013 to April 2020. RESULTS: The study population comprised 130 patients with MS, with an approximately balanced sex ratio and a median age of 58.5 years. The preoperative diagnostic rate was 82.3%. The diagnostic accuracy of ERCP was 92.5%, higher than that of MRCP and ultrasound. All patients underwent surgical treatment, with 74 cases of laparoscopic surgery, 43 cases of laparotomy, and 13 cases of laparoscopic surgery converted to laparotomy. A total of 23 patients experienced short-term and long-term complications after surgery, with a complication rate of 17.7%. There was no statistical difference between laparoscopic surgery and open surgery in terms of intraoperative hemorrhage, operative time, and postoperative complication rate. However, the length of hospital stay was shorter in the laparoscopic surgery compared to the open surgery, which was statistically different from each other. CONCLUSION: ERCP is the gold standard for the diagnosis of MS, especially for identifying the type of MS. ERCP plays an important role in both the preoperative and postoperative phases of MS. Our study demonstrated that laparoscopic surgery was a safe and feasible option for MS treatment, even requires less hospitalization than open surgery.

The Multifaceted Impact of Gallstones: Understanding Complications and Management Strategies.

Gallstones, or cholelithiasis, represent a prevalent gastrointestinal disorder characterized by the formation of calculi within the gallbladder. This review aims to provide a comprehensive analysis of the complications associated with gallstones, with a focus on their pathophysiology, clinical manifestations, diagnostic methodologies, and management strategies. Gallstone-related complications encompass a broad spectrum, including biliary colic, acute cholecystitis, choledocholithiasis, acute pancreatitis, and cholangitis. The pathogenesis of these complications primarily involves biliary obstruction and subsequent infection, leading to significant morbidity and potential mortality. Diagnostic evaluation of gallstone complications employs various imaging techniques, such as ultrasonography, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP), each with distinct advantages and limitations. Therapeutic approaches are discussed, ranging from conservative management with pharmacotherapy and bile acid dissolution agents to interventional procedures like extracorporeal shock wave lithotripsy (ESWL) and percutaneous cholecystostomy. Surgical management, particularly laparoscopic cholecystectomy, remains the gold standard for definitive treatment. Additionally, advancements in endoscopic techniques, including endoscopic sphincterotomy (EST) and cholangioscopy, are highlighted. This review synthesizes current research findings and clinical guidelines, aiming to enhance the understanding and management of gallstone-related complications among healthcare professionals, thereby improving patient outcomes and reducing the burden of this common ailment.

Endoscopic Retrograde Cholangiopancreatography (ERCP) for Suspected Mirizzi Syndrome Type IV as Both a Diagnostic and Bridge-to-Surgery Procedure.

Mirizzi syndrome (MS) is a challenging diagnosis due to its similar presentation with other biliary diseases; thus, the role of endoscopy is sometimes unclear, especially in altered anatomy. Radiological examinations may usually suspect it, but deeper examinations could be necessary to confirm it. Endoscopic retrograde cholangiopancreatography (ERCP) certainly has a therapeutic role in cases of jaundice, cholangitis or concurrent choledocolithiasis, although surgery is without doubt the definitive treatment in most of the cases. Therefore, surgeons may have a clearer picture of the condition of the biliary tree with respect to fistulas thanks to ERCP, particularly in patients with a higher grade of MS (type higher than 2 in the Csendes classification). Therefore, a complete removal of biliary stones is sometimes not possible due to size and location, so biliary stenting becomes the only option, even if transitory. Our brief report is a further demonstration of the fundamental role of ERCP in managing MS, even when it has no long-term therapeutic aim but is performed as bridge-to-surgery, especially in cases with a more difficult biliary anatomy due to the type of fistula. Moreover, we truly suggest discussing patients affected with MS in a multidisciplinary board, preferably in tertiary hepatobiliary centers.

Biliary reconstruction with localized creation: One case report of repairing bile duct injury and defect with autografts.

INTRODUCTION: Bile duct injuries caused by any reason are a disaster for patients and pose a significant psychological and technical challenge for surgeons. The use of Ligamentum teres hepatis and gallbladder flap as autografts is showing promising results in the repair of bile duct injury. CASE PRESENTATION: This article presents a challenging case of a patient with Mirizzi syndrome who experienced a complex bile duct defect and injury during cholecystectomy. We describe the successful reconstruction of the bile duct using ligamentum teres hepatis and remnant gallbladder flap simultaneously. DISCUSSION: Ligamentum teres hepatis and remnant gallbladder flap are ideal repair materials for repairing and reconstructing bile duct injuries due to their easy availability, good tissue compatibility, and low incidence of postoperative complications. It is essential to seek the assistance of an experienced biliary surgeon when bile duct injury occurs during operation. CONCLUSION: Ligamentum teres hepatis and gallbladder flap, as suitable autologous tissues, are viable options for repairing bile duct injuries and defects.

Mirizzi syndrome: The Trojan horse of gallbladder disease.

Background: The incidence of Mirizzi Syndrome ranges from 0.05 to 5.7 % of patients who undergo cholecystectomy. The purpose of this study is to examine the preoperative workup and postoperative outcomes for patients diagnosed with Mirizzi Syndrome. Methods: Retrospective chart review was conducted between January 2018 and January 2022 at a single institution. All adult patients who underwent cholecystectomy were included. Results: 1628 patients underwent cholecystectomy of which 47 were diagnosed with Mirizzi Syndrome. The majority of patients had type 1 Mirizzi Syndrome. Preoperative studies were often nondiagnostic and 81 % of cases were diagnosed intraoperatively. 66 % of cases were performed laparoscopically, an open approach was required for type V Mirizzi Syndrome. The complication rate was 25 %; most commonly a bile leak requiring ERCP. Conclusion: Mirizzi syndrome is more common than previously expected and related to patient's ability to seek timely medical care. Most cases can be completed laparoscopically however there is a high rate of complications. Key message: This study presents an additional cohort of patients found to have Mirizzi syndrome and supports the hypothesis that it is difficult to diagnose preoperatively. Cases should be attempted laparoscopically but there remains a high complication rate.

Mirizzi syndrome: Problems and strategies.

Mirizzi syndrome is a serious complication of gallstone disease. It is caused by the impacted stones in the gallbladder neck or cystic duct. One of the features of Mirizzi syndrome is severe inflammation or dense fibrosis at the Calot's triangle. In our clinical practice, bile duct, branches of right hepatic artery and right portal vein clinging to gallbladder infundibulum are often observed due to gallbladder infundibulum adhered to right hepatic hilum. The intraoperative damage of branches of right hepatic artery occurs more easily than that of bile duct, all of which are hidden pitfalls for surgeons. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferable tools for the diagnosis of Mirizzi syndrome. Anterograde cholecystectomy in Mirizzi syndrome is easy to damage branches of right hepatic artery and bile duct due to gallbladder infundibulum adhered to right hepatic hilum. Subtotal cholecystectomy is an easy, safe and definitive approach to Mirizzi syndrome. When combined with the application of ERCP, a laparoscopic management of Mirizzi syndrome by well-trained surgeons is feasible and safe. The objective of this review was to highlight its existing problems: (1) low preoperative diagnostic rate, (2) easy to damage bile duct and branches of right hepatic artery, and (3) high concomitant gallbladder carcinoma. Meanwhile, the review aimed to discuss the possible therapeutic strategies: (1) to enhance its preoperative recognition by imaging findings, and (2) to avoid potential pitfalls during surgery.

Mirizzi syndrome: A case report emphasizing safe management strategies and literature review.

INTRODUCTION AND IMPORTANCE: Mirizzi syndrome, a rare complication of cholelithiasis, involves gallstones causing common hepatic duct compression. It poses diagnostic challenges with nonspecific symptoms. Early recognition and surgical intervention are crucial, emphasizing a multidisciplinary approach for this complex condition with potential complications. CASE REPORT: A 69-year-old woman presented with pruritus, jaundice, and a history of hepatic colics. Laboratory results showed no signs of inflammation but indicated cholestasis. Imaging suggested Mirizzi syndrome type 1, confirmed by MRI. The patient underwent surgery, revealing Mirizzi syndrome type II with the presence of a cholecystocholedochal fistula involving less than one-third of the circumference of the main bile duct. Subtotal cholecystectomy and suturing of the main bile duct onto a T-tube were performed, resulting in a favorable recovery and normalization of blood tests after 10 days. CLINICAL DISCUSSION: Mirizzi syndrome, named after surgeon Pablo Luis Mirizzi, was first detailed in 1948. Clinical symptoms include jaundice, colic pain, and complications such as cholecystocholedochal fistula and gallstone ileus. Blood tests and imaging aid diagnosis. Surgical management targets obstruction relief and defect repair. Dissecting Calot's triangle carries risks. In complex cases, cholecysto-choledocus-duodenostomy may be considered. CONCLUSION: Mirizzi syndrome, a rare but significant condition, demands careful clinical attention to prevent underdiagnosis. Timely and appropriate management, utilizing imaging tests alongside ERCP, is essential for optimal outcomes and complication prevention.

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond.

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

The application of indocyanine green fluorescence imaging in laparoscopic cholecystectomy for Mirizzi syndrome types Ⅱ and Ⅲ / 中华肝胆外科杂志

Objective:To analyze the clinical value of indocyanine green (ICC) fluorescence imaging in Mirizzi syndrome type Ⅱ-Ⅲ laparoscopic cholecystectomy (LC).Methods:A retrospective analysis was performed on 80 patients diagnosed with Mirizzi syndrome types Ⅱ-Ⅲ who underdoing LC in Affiliated Hospital of Liaoning University of Traditional Chinese Medicine from October 2018 to February 2022, including 32 males and 48 females, aged (63.5±6.9) years. Patients were divided into two groups based on whether ICG fluorescence imaging technology was used, the control group ( n=38) that patients were treated with conventional LC and the experimental group ( n=42) patients were treated with LC guided by ICG fluorescence imaging. In the experimental group, the extrahepatic bile duct was identified by ICG fluorescence imaging during LC, and ICG was injected intraoperally to determine the reserved blood flow of gallbladder flap for fluorescence imaging and determine the resection line. Operation time, intraoperative blood loss, conversion rate of laparotomy and postoperative complications (bile leakage, incision infection, etc.) were compared between the two groups. Intraoperative fluorescence imaging and determination of the modified resection line of reserved gallbladder were analyzed in the observation group. Results:There was no significant difference in age, male proportion, type of Mirizzi syndrome and conversion rate of laparotomy between the two groups (all P>0.05). In the observation group, the operative time was (208.7±32.0) min, the intraoperative blood loss was (50.5±23.8) ml, and the biliary leakage was 7.1% (3/42), which was lower than that in the control group (228.2±33.9) min, (73.8±31.0) ml, 26.3% (10/38). The differences were statistically significant (all P<0.05). Of 37 cases (88%) showed common hepatic duct and common bile duct successfully in the observation group. In the observation group, ICG fluorescence imaging was used to determine the gallbladder resection line in 8 cases (19.0%). The gallbladder flap without fluorescence imaging was removed. Conclusion:ICG fluorescence imaging in LC for Mirizzi syndrome patients can identify the common bile duct and hepatic duct to guide surgical resection, determine the gallbladder flap resection line, reduce postoperative bile leakage and bleeding, and accelerate the surgical progress.

Síndrome de Mirizzi, complicación inusual de la colelitiasis / Mirizzi Syndrome, a Rare Complication of Cholelithiasis

Introducción: El síndrome de Mirizzi es una entidad clínica rara y difícil de tratar; sin embargo, los avances tecnológicos recientes han brindado a los cirujanos nuevas opciones para un diagnóstico y tratamiento más efectivos de esta afección. Objetivo: Presentar el caso de síndrome de Mirizzi, complicación inusual de la colelitiasis. Presentación del caso: Se presenta una paciente femenina, de 56 años de edad, que acude a nuestra institución por presentar ictericia intermitente, dolor en el hipocondrio derecho, coluria y acolia. Conclusiones: El síndrome de Mirizzi, complicación de la colelitiasis, es una entidad poco frecuente, de difícil diagnóstico preoperatorio, por lo que en un gran porcentaje de los casos se diagnostica intraoperatoriamente. Su tratamiento es quirúrgico(AU)

Introduction: Mirizzi syndrome is a rare condition, difficult to treat; however, recent technological advances have provided surgeons with new options for diagnosing and treating this condition more effectively. Objective: To present a case of Mirizzi syndrome, an unusual complication of cholelithiasis. Case presentation: The case is presented of a 56-year-old female patient, who comes to our institution with intermittent jaundice, right hypochondrium pain, choluria and acholia. Conclusions: Mirizzi syndrome, a complication of cholelithiasis, is a rare entity, difficult to diagnose preoperatively; therefore, a large percentage of it's cases are diagnosed intraoperatively. Its treatment is surgical(AU)

Gallstone as a cause of intestinal obstruction (Bouveret syndrome).

Gallstone ileus is a rare cause of bowel obstruction. Here we report about two cases with clinical findings and therapy options. Both patients were presented with typical ileus-like symptoms, although the surgical treatment differs due to the CT scan and intraoperative findings. There are many methods for treating patients with Bouveret syndrome. Endoscopy should be the first treatment option for young patients with no significant diseases in the medical history, depending on the size of the stone. Surgical approach is the next possible option. Combination of these two methods is associated with higher mortality. In case there is no extraluminal gas or intraperitoneal fluid in CT-scan, there is no need for an acute surgery. Conservative therapy prior to the intervention enables a precise planning of whether the endoscopic approach or open surgery would be beneficial for the patient.

Gallbladder Mysteries: A Diagnostic Dilemma in Mirizzi Syndrome With Acalculous Presentation.

Mirizzi syndrome (MS) is an uncommon condition caused by chronic gallbladder stones, leading to external compression and obstruction of the common hepatic duct. This report details an unusual MS case in a 65-year-old man who experienced right upper abdominal pain, jaundice, fever, and nausea. Diagnostic tests, such as ultrasound and CT scan, indicated acute acalculous cholecystitis resembling MS. However, a magnetic resonance cholangiopancreatography (MRCP) confirmed no gallstones in the biliary system. The patient's laparoscopic cholecystectomy was successful, with tissue analysis revealing intense gallbladder inflammation and epithelial necrosis but no gallstones. This case emphasizes the diagnostic complexities of atypical MS presentations and the need for comprehensive diagnostic methods, including MRCP. Additionally, the report advocates for standardized terminology in medical literature to ensure clear communication among medical professionals.

The Role of Cholangioscopy in Biliary Diseases.

Endoscopy plays a central role in diagnostic and therapeutic approaches to biliary disease in both benign and malignant conditions. A cholangioscope is an endoscopic instrument that allows for the direct exploration of the biliary tree. Over the years, technology has improved endoscopic image quality and allowed for the development of an operative procedure that can be performed during cholangioscopy. Different types of instruments are available in this context, and they can be used in different anatomical access points according to the most appropriate clinical indication. The direct visualization of biliary mucosa is essential in the presence of biliary strictures of unknown significance, allowing for the appropriate allocation of patients to surgery or conservative treatments. Cholangioscopy has demonstrated excellent performance in discriminating malignant conditions (such as colangiocarcinoma) from benign inflammatory strictures, and more recent advances (e.g., artificial intelligence and confocal laser endomicroscopy) could further increase its diagnostic accuracy. Cholangioscopy also plays a primary role in the treatment of benign conditions such as difficult bile stones (DBSs). In this case, it may not be possible to achieve complete biliary drainage using standard ERCP. Therapeutic cholangioscopy-guided lithotripsy allows for stone fragmentation and complete biliary drainage. Indeed, other complex clinical situations, such as patients with intra-hepatic lithiasis and patients with an altered anatomy, could benefit from the therapeutic role of cholangioscopy. The aim of the present review is to explore the most recent diagnostic and therapeutic advances in the roles of cholangioscopy in the management of biliary diseases.

Reverse Mirizzi Syndrome.

A man in his 40s presented to our Hospital with abdominal pain, jaundice, and pruritus. He had a history of Alagille Syndrome treated with cholecystojejunostomy in the neonatal period because of initial misdiagnosis of biliary atresia. Laboratory investigations showed hyperbilirubinemia (total bilirubin 1.76 mg/dL [<1.2 mg/dL]; conjugated 1.06 mg/dL [<0.3 mg/dL]) and cholestasis (GGT 78 U/L [<50 U/L]; ALP 200 U/L [<50 U/L]). Transabdominal ultrasound was limited by aerobilia due to the cholecystojejuno-anastomosis. Subsequent basal CT scan revealed an impacted stone within the patient's native common bile duct (CBD). Aerobilia in intrahepatic bile ducts and gallbladder was reported. Magnetic Resonance cholangiopancreatography confirmed the gallstone in the CBD compressing cystic duct and common hepatic duct, with dilation of the upstream bile ducts. Furthermore, the native CBD was obstructed by other gallstones. In Mirizzi syndrome, gallstones impacted in gallbladder's Hartmann's pouch or cystic duct extrinsically compress CBD. We suggest naming the present condition "Reverse Mirizzi Syndrome" (Renzulli Matteo Syndrome, RMS) because it is the exact opposite of Mirizzi syndrome.

Type I Mirizzi syndrome treated by electrohydraulic lithotripsy under the direct view of SpyGlass: A case report.

BACKGROUND: Mirizzi syndrome is an uncommon clinical complication for which the available treatment options mainly include open surgery, laparoscopic surgery, endoscopic retrograde cholangiopancreatography (ERCP), electrohydraulic lithotripsy, and laser lithotripsy. Here, a patient diagnosed with type I Mirizzi syndrome was treated with electrohydraulic lithotripsy under SpyGlass direct visualization, which may provide a reference to explore new treatments for Mirizzi syndrome. CASE SUMMARY: This paper describes a middle-aged female patient with suspected choledocholithiasis who complained for over 1 mo of intermittent abdominal pain, dark yellow urine, jaundice, and was proposed to undergo ERCP lithotomy. Mirizzi syndrome was found during the operation and confirmed by SpyGlass. Electrohydraulic lithotripsy was performed under the direct vision of SpyGlass. After the lithotripsy, the stones were extracted using the stone extraction basket and balloon. After the operation, the patient developed transient hyperamylasemia. Through a series of symptomatic treatments (such as fasting, fluids and anti-inflammation medications), the symptoms of the patient improved. Finally, laparoscopic cholecystectomy or open cholecystectomy was performed after a half-year post-operatively. CONCLUSION: Direct visualization-guided laser or electrohydraulic lithotripsy with SpyGlass is feasible and minimally invasive for type I Mirizzi syndrome without apparent unsafe outcomes.

Laparoscopic treatment of Mirizzi syndrome with subtotal cholecystectomy and electrohydraulic lithotripsy: A case report.

Mirizzi syndrome is a rare chronic cholecystitis complication. However, the current consensus on managing this condition remains controversial, especially through laparoscopic surgery. This report describes the feasibility of treating type I Mirizzi syndrome with laparoscopic subtotal cholecystectomy and electrohydraulic lithotripsic gallstone removal. A 53-year-old woman presented with dark urine and right upper quadrant pain for 1 month. On examination, she was jaundiced. Blood tests showed highly elevated liver and biliary enzyme levels. Abdominal ultrasound showed a slightly dilated common bile duct with suspicion of choledocholithiasis. However, endoscopic retrograde cholangiopancreatography showed a narrowed common bile duct extrinsically compressed by a gallstone in the cystic duct, establishing a Mirizzi syndrome diagnosis. Elective laparoscopic cholecystectomy was planned. At operation, the trans-infundibulum approach was used since dissection around the cystic duct was difficult due to severe local inflammation of Calot's triangle. The gallbladder's neck was opened, and the stone was removed by lithotripsy via a flexible choledochoscope. Common bile duct exploration through the cystic duct was normal. The fundus and body of the gallbladder were resected, followed by T-tube drainage and suturing of the gallbladder's neck. The patient's postoperative clinical course was uneventful. Treating Mirizzi syndrome remains a major challenge for hepatobiliary specialists even with open surgery due to high complication rates, including bile duct injuries. Treatment is primarily to clear out the responsible stone and necrotic tissue. Due to advances in endoscopic surgery and equipment, subtotal cholecystectomy with laparoscopic gallstone extraction provides a safe and effective option for patients with Mirizzi syndrome. Laparoscopic subtotal cholecystectomy with electrohydraulic lithotripsy is a feasible and useful approach for treating Mirizzi syndrome that avoids iatrogenic bile duct injury.

Mirizzi syndrome type V complicated with triple fistula: a case report.

BACKGROUND: Mirizzi syndrome (MS) is a complicated form of longstanding, symptomatic cholelithiasis. According to Beltran Classification MS Type V has been introduced to describe the cholecystoenteric fistula, with or without gallstone ileus. Mirizzi syndrome Type V with double fistula has been reported in the past; however, the triple fistula is an even rarer case, first described in the international literature so far. CASE PRESENTATION: A 77-year-old male was admitted to our surgical department with recurrent episodes of abdominal pain, which initially presented in the last 6 months and was accompanied with jaundice. Computed tomography showed findings of cholelithiasis, pneumobilia and choledocholithiasis. We performed an ERCP, which showed two fistulas of the gallbladder with the pyloric antrum and the duodenum, respectively. Surgical treatment was immediately undergone and during laparotomy, we confirmed these findings. We ligated and dissected these communications. In addition, a third fistula between the gallbladder and the common bile duct was identified. An insertion of a Kehr T-tube into the common bile duct was performed via the gallbladder. After 3 months, the Kehr T-tube was removed and in the subsequent 2 years of follow-up the patient was presented without complications. CONCLUSIONS: Mirizzi syndrome complicated with triple fistula, first described in the international literature, to the best of our knowledge, confirms the long natural history of inflammation.