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)

Síndrome de Mirizzi grado IV. Presentación de un caso

El Síndrome de Mirizzi es una afección derivada del impacto de un lito en el conducto cístico o infundíbulo de la vesícula biliar. La enfermedad litiásica, crónica y complicada de la vesícula biliar es un factor determinante. Se presenta el caso de un paciente con historia de íctero obstructivo, al cual se le diagnosticó inicialmente tumor periampular. Fue reevaluado y se le realizaron varias pruebas diagnósticas, hasta llegar al diagnóstico de Síndrome de Mirizzi, corroborado en el acto quirúrgico. El SM es una enfermedad rara de la vía biliar cuyo tratamiento es quirúrgico. La vía laparoscópica para la realización de la colecistectomía es la de elección para casos grado I y en casos seleccionados grado II. La colecistectomía y derivación bilioentérica (hepaticoyeyunostomía) conforman el tratamiento para el resto de los casos.

Mirizzi Syndrome is a condition derived from the impact of a stone in the cystic duct or infundibulum of the gallbladder. Chronic and complicated stone disease of the gallbladder is a determining factor. A patient with a history of obstructive jaundice, who was initially diagnosed with a periampullary tumor is presented. He was reassessed and several diagnostic tests were performed, until reaching the diagnosis of Mirizzi Syndrome, corroborated in the surgical act. MS is a rare disease of the bile duct whose treatment is surgical. The laparoscopic approach to perform cholecystectomy is the one of choice for grade I cases and in selected cases grade II. Cholecystectomy and bilioenteric bypass (hepaticojejunostomy) are the treatment for the rest of the cases.

Manejo mínimamente invasivo del síndrome de Mirizzi Va: Reporte de casos y revisión narrativa de la literatura / Minimally invasive management of Mirizzi syndrome Va: Case series and narrative review of the literature

Introducción El síndrome de Mirizzi (SM) es una patología infrecuente que es un reto para el cirujano. En el manejo quirúrgico, el abordaje abierto o el laparoscópico es un punto de discusión debido a la distorsión anatómica que se presenta. El objetivo de este estudio es analizar nuestra experiencia en el manejo laparoscópico de esta condición en el tipo Va. Materiales Realizamos un estudio descriptivo retrospectivo de pacientes con diagnóstico de SM tipo Va y tratados por abordaje laparoscópico, entre el 2014 y 2019, en dos centros de alto volumen de Bogotá, Colombia. Resultados Se evaluaron 1.073 pacientes que presentaron complicaciones por cálculos biliares, de los cuales 16 fueron diagnosticados con SM tipo Va. El 75% eran femeninos y el 25% masculinos; el 80% presentó ictericia y el 90% dolor abdominal. Doce pacientes presentaron fístula colecistoduodenal y cuatro fístula colecistocólica. Todos se manejaron de manera laparoscópica, en el 100% se logró realizar colecistectomía total y resección de fístula con cierre primario. La tasa de conversión fue del 0%, no hubo reingresos ni reintervención. El periodo de seguimiento fue de 18 meses. Conclusión El manejo laparoscópico en el SM es posible y seguro, teniendo en cuenta la experiencia del grupo quirúrgico y realizando una adecuada selección de los pacientes (AU)

Introduction Mirizzi's Syndrome (MS) is a rare pathology, known to be a challenge for the surgeon. In the surgical management, open approach vs laparoscopic is a topic of discussion due to anatomic variations. The aim of this study is to analyze our experience in the laparoscopic management of this condition in Type Va. Methods We made a descriptive retrospective study of patients diagnosed with MS type Va and treated by laparoscopic approach from 2014 to 2019, in two high volume centers of Bogotá, Colombia. Results 1073 patients who presented complications from gallstones were evaluated, of which 16 were diagnosed with MS type Va. 75% were females and 25% males; 80% presented jaundice and 90% abdominal pain; 12 patients showed cholecystoduodenal fistula and 4 cholecystocolic fistula. All patients underwent laparoscopic management, total cholecystectomy and fistula resection with primary closure was possible on a 100% of the patients. Conversion rate was 0%. The follow up was 18 months. Conclusion Laparoscopic management of MS is feasible and safe; the experience of the surgery group and selection of the patients is the key to a successful outcome (AU)

Minimally invasive management of Mirizzi syndrome Va: Case series and narrative review of the literature.

INTRODUCTION: Mirizzi's Syndrome (MS) is a rare pathology, known to be a challenge for the surgeon. In the surgical management, open approach vs laparoscopic is a topic of discussion due to anatomic variations. The aim of this study is to analyze our experience in the laparoscopic management of this condition in Type Va. METHODS: We made a descriptive retrospective study of patients diagnosed with MS type Va and treated by laparoscopic approach from 2014 to 2019, in two high volume centers of Bogotá, Colombia. RESULTS: 1073 patients who presented complications from gallstones were evaluated, of which 16 were diagnosed with MS type Va. 75% were females and 25% males; 80% presented jaundice and 90% abdominal pain; 12 patients showed cholecystoduodenal fistula and 4 cholecystocolic fistula. All patients underwent laparoscopic management, total cholecystectomy and fistula resection with primary closure was possible on a 100% of the patients. Conversion rate was 0%. The follow up was 18 months. CONCLUSION: Laparoscopic management of MS is feasible and safe; the experience of the surgery group and selection of the patients is the key to a successful outcome.

Minimally invasive management of Mirizzi syndrome Va: Case series and narrative review of the literature. / Manejo mínimamente invasivo del síndrome de Mirizzi Va: Reporte de casos y revisión narrativa de la literatura.

INTRODUCTION: Mirizzi's Syndrome (MS) is a rare pathology, known to be a challenge for the surgeon. In the surgical management, open approach vs laparoscopic is a topic of discussion due to anatomic variations. The aim of this study is to analyze our experience in the laparoscopic management of this condition in Type Va. METHODS: We made a descriptive retrospective study of patients diagnosed with MS type Va and treated by laparoscopic approach from 2014 to 2019, in two high volume centers of Bogotá, Colombia. RESULTS: 1073 patients who presented complications from gallstones were evaluated, of which 16 were diagnosed with MS type Va. 75% were females and 25% males; 80% presented jaundice and 90% abdominal pain; 12 patients showed cholecystoduodenal fistula and 4 cholecystocolic fistula. All patients underwent laparoscopic management, total cholecystectomy and fistula resection with primary closure was possible on a 100% of the patients. Conversion rate was 0%. The follow up was 18 months. CONCLUSION: Laparoscopic management of MS is feasible and safe; the experience of the surgery group and selection of the patients is the key to a successful outcome.

Síndrome de Mirizzi tipo V: Manejo laparoscópico / Mirizzi syndrome type V: laparoscopic management

Resumen Introducción: El Síndrome de Mirizzi es una complicación infrecuente de la enfermedad litiásica biliar, con una incidencia menor al 1% en países desarrollados, puede desarrollarse en cinco variantes, siendo menos frecuente la variante tipo V. La literatura actual discrepa sobre el manejo de esta condición, afirmando que la cirugía laparoscópica no es segura como procedimiento estándar. Caso Clínico: Se presenta el caso de Síndrome de Mirizzi en un hombre de 80 años, que es remitido al departamento de urgencias por sospecha de sepsis de origen abdominal, con estudio ecográfico de colelitiasis, neumobilia y dilatación de las vías biliares. Se realizó Colangiopancreatografía retrógrada endoscópica con imposibilidad técnica para la movilización y extracción de los cálculos por gran tamaño, recurriéndose a exploración a través de técnica laparoscópica, obteniéndose resultados satisfactorios. Conclusión: Para tratar el Síndrome de Mirizzi, es necesario considerar las características del paciente y la experiencia del cirujano ya que ambos factores influyen directamente en la modalidad del tratamiento, sus complicaciones y tasas de éxito. En el presente caso, la experiencia del autor principal en el manejo de procedimientos mínimamente invasivos y la consideración de reducir el riesgo de complicaciones como infecciones en un paciente frágil, fueron los factores que influyeron para la decisión de intervención laparoscópica.

Abstract Introduction: Mirizzi's syndrome is an infrequent complication of biliary lithiasic disease, with an incidence of less than 1% in developed countries, being even less frequent the type V variant. Current literature disagrees on the management of this condition, stating that laparoscopic surgery is not safe as a standard procedure. Clinical Case: We present the case of Mirizzi's Syndrome in an 80-year-old man, which is referred to the emergency department for suspicion of sepsis of abdominal origin, with ultrasound study of cholelithiasis, pneumoobilia and dilation of the bile ducts. Retrograde endoscopic cholangiopancreatography was performed with technical impossibility for the mobilization and extraction of large-size stones, resorting to exploration through laparoscopic technique, obtaining satisfactory results. Conclusion: It is necessary to emphasize that the type of Mirizzi syndrome, the patient's characteristics and the surgeon's experience directly influence the treatment modality, its complications and/or success rates. In the present case, the experience of the main author in the management of minimally invasive procedures and the consideration of reducing the risk of complications such as infections in a fragile patient, were the factors that influenced the decision for laparoscopic intervention.

Síndrome de Mirizzi que simulaba una neoplasia biliar maligna / Mirizzi syndrome simulating a biliary malignant neoplasm

El síndrome de Mirizzi puede cursar con manifestaciones clínicas y hallazgos imagenológicos y de laboratorio, similares a los encontrados en las neoplasias biliares malignas. Se describe el caso de un paciente cuyo enfoque clínico inicial y estudios de imágenes aportaron datos sugerentes de neoplasia de las vías biliares. Los marcadores tumorales (CA 19-9, CEA) resultaron elevados. Una nueva evaluación clínica, la laparoscopia exploradora y la exploración endoscópica de las vías biliares, permitieron establecer el diagnóstico de síndrome de Mirizzi. Después de la extracción del cálculo biliar y de la anastomosis entre el conducto hepático y el yeyuno, el paciente permaneció asintomático. En este caso, la reevaluación clínica y el uso del protocolo adecuado de estudio, contribuyeron a orientar y confirmar el diagnóstico de síndrome de Mirizzi, lo cual determinó la conducta terapéutica más acertada

Mirizzi syndrome can occur with clinical manifestations and imaging and laboratory findings, similar to those found in malignant biliary neoplasms. We describe the case of a patient whose initial clinical approach and imaging studies provided data suggestive of bile duct neoplasia. Tumor markers (CA 19-9, CEA) were high. A new clinical evaluation, an explorative laparoscopy and endoscopic bile duct exploration allowed establish the diagnosis of Mirizzi syndrome. After removal the bile duct stone and to perform an hepatico jejunostomy the patient remained asymptomatic. In this case the clinical reevaluation and the use of the appropriate study proto-col contributed to guide and confirm the diagnosis of Mirizzi syndrome, which determined the most successful therapeutic approach

Síndrome de Mirizzi tipo V, entidad infrecuente y compleja / Mirizzi's syndrome type V, a rare and complex entity

El síndrome de Mirizzi es una inflamación poco frecuente y crónica ocasionada por un cálculo impactado en la bolsa de Hartmann con obstrucción parcial o completa del conducto biliar principal, que infiere un difícil diagnóstico preoperatorio y controversial manejo terapéutico. El objetivo del trabajo fue exponer el tratamiento de cinco pacientes con diagnóstico de síndrome de Mirizzi tipo V. Se realizó una revisión de las bases de datos Pubmed, Dynamed y Conchrane en busca de artículos relacionados. Se presentó el tratamiento de esta entidad en cinco pacientes teniendo en cuenta la experiencia del autor y los hallazgos de la revisión realizada. La cirugía convencional es la vía ideal de acceso para el tratamiento de esta entidad utilizando las derivaciones bilioentéricas en sus variantes. Un alto índice de sospecha se requiere para un diagnóstico preoperatorio e intraoperatorio certero, con una óptima planificación quirúrgica(AU)

Mirizzi's syndrome is a rare and chronic inflammation caused by a gallstone impacted in the Hartmann's pouch with partial or complete obstruction of the main bile duct, which results in difficult preoperative diagnosis and controversial therapeutic management. To present the treatment of five patients diagnosed with Mirizzi's syndrome type V. A search for articles was carried out in the databases Pubmed, Dynamed and Conchrane. The treatment of this entity was presented in five patients, taking into account the author´s experience of the review´s findings. Conventional surgery is the ideal access route for this entity´s treatment using bilioenteric bypass in its variants. A high index of suspicion is required for accurate preoperative and intraoperative diagnosis, with optimal surgical planning(AU)

Síndrome de Mirizzi tipo V, entidad infrecuente y compleja / Mirizzi's syndrome type V, a rare and complex entity

El síndrome de Mirizzi es una inflamación poco frecuente y crónica ocasionada por un cálculo impactado en la bolsa de Hartmann con obstrucción parcial o completa del conducto biliar principal, que infiere un difícil diagnóstico preoperatorio y controversial manejo terapéutico. El objetivo del trabajo fue exponer el tratamiento de cinco pacientes con diagnóstico de síndrome de Mirizzi tipo V. Se realizó una revisión de las bases de datos Pubmed, Dynamed y Conchrane en busca de artículos relacionados. Se presentó el tratamiento de esta entidad en cinco pacientes teniendo en cuenta la experiencia del autor y los hallazgos de la revisión realizada. La cirugía convencional es la vía ideal de acceso para el tratamiento de esta entidad utilizando las derivaciones bilioentéricas en sus variantes. Un alto índice de sospecha se requiere para un diagnóstico preoperatorio e intraoperatorio certero, con una óptima planificación quirúrgica(AU)

Mirizzi's syndrome is a rare and chronic inflammation caused by a gallstone impacted in the Hartmann's pouch with partial or complete obstruction of the main bile duct, which results in difficult preoperative diagnosis and controversial therapeutic management. To present the treatment of five patients diagnosed with Mirizzi's syndrome type V. A search for articles was carried out in the databases Pubmed, Dynamed and Conchrane. The treatment of this entity was presented in five patients, taking into account the author´s experience of the review´s findings. Conventional surgery is the ideal access route for this entity´s treatment using bilioenteric bypass in its variants. A high index of suspicion is required for accurate preoperative and intraoperative diagnosis, with optimal surgical planning(AU)

Clinical-epidemiological profile of acute appendicitis: retrospective analysis of 638 cases / Perfil clínico-epidemiológico da apendicite aguda: análise retrospectiva de 638 casos

ABSTRACT Objective: to describe the clinical and epidemiological profile of acute appendicitis (AA) of the patients treated at a referral center in the Juiz de Fora macro-region, Minas Gerais State, Brazil. Methods: we conducted a retrospective, observational study in the Dr. Mozart Geraldo TeixeiraEmergency Hospital. We selected 638 patients diagnosed with AA, and analyzed the variables gender, age, evolutionary phase, length of hospital stay, pathological diagnosis, use of antibiotics, use of drains, complications and mortality. Results: AA was more prevalent in young adults (19-44 years) and males (65.20%). The mean hospital stay was seven days and phase II was the most prevalent. We found the histopathological diagnosis of primary tumor of the appendix in six patients (0.94%), adenocarcinoma being the most common histologic type (66.7%). Regarding the use of antibiotics, 196 patients underwent antibiotic prophylaxis and 306 received antibiotic therapy. Eighty-one patients used some kind of drain, for an average of 4.8 days. Seventeen patients died (2.67%), predominantly males (70.59%), with mean age of 38.47 years. Conclusion: AA has a higher prevalence in males and young adults. The length of stay is directly associated with the evolutionary phase. The most common complication is infection of the surgical site. Mortality in our service is still high when compared with developed centers.

RESUMO Objetivo: avaliar a epidemiologia e os resultados do tratamento cirúrgico de doentes portadores de graus III e IV, mais avançados, da Síndrome de Mirizzi (SM) de acordo com a classificação de Csendes. Métodos: estudo retrospectivo, de corte transversal através da revisão de prontuários de 13 pacientes portadores de graus III e IV da SM operados de dezembro de 2001 a setembro de 2013, entre 3691 colecistectomias realizadas neste período. Resultados: a incidência da SM foi 0,6% (23 casos) e os graus III e IV perfizeram 0,35% deste número. Houve um predomínio de tipo IV (12 casos). O diagnóstico pré-operatório foi possível em 53,8% dos casos. A conduta preferencial foi derivação biliodigestiva (10 casos) e foi optado por drenagem com tubo "T" e sutura da via biliar em três ocasiões especiais. Três pacientes apresentaram fístula biliar resolvida com conduta expectante e um caso de coleperitônio necessitou reoperação. No seguimento ambulatorial dos pacientes que realizaram a anastomose biliodigestiva (oito), 50% estão assintomáticos, 25% apresentaram estenose da anastomose e 25% perderam seguimento. O tempo médio de acompanhamento foi 41,8 meses. Conclusão: de incidência baixa e de diagnóstico pré-operatório em apenas metade dos casos, a SM em graus avançados tem na anastomose biliodigestiva sua melhor conduta, porém não isenta de morbimortalidade.

Mirizzi syndrome grades III and IV: surgical treatment / Síndrome de Mirizzi graus III e IV: tratamento cirúrgico

ABSTRACT Objective : to evaluate the epidemiology and outcomes of surgical treatment of patients with Mirizzi Syndrome (MS) grades III and IV, the most advanced according to Csendes classification. Methods : we conducted a retrospective, cross-sectional study by reviewing records of thirteen patients with grades III and IV MS operated from December 2001 to September 2013, among the 3,691 cholecystectomies performed in the period. Results : the incidence of MS was 0.6% (23 cases) and grades III and IV amounted to 0.35% of this number. There was a predominance of type IV (12 cases). The preoperative diagnosis was possible in 53.8% of cases. The preferred approach was biliary-digestive derivation (10 cases), and "T" tube drainage with suture of the bile duct was the choice in three special occasions. Three patients had biliary fistula resolved with clinical management, and one coliperitoneum case required reoperation. In the outpatient follow-up of patients who underwent biliodigestive anastomosis (eight), 50% are asymptomatic, 25% had anastomotic stricture and 25% lost follow-up. The mean follow-up was 41.8 months. Conclusion : MS in advanced degrees has low incidence, preoperative diagnosis in only half of cases, and has the biliodigestive anastomosis as the best conduct, but not without morbidity.

RESUMO Objetivo: avaliar a epidemiologia e os resultados do tratamento cirúrgico de doentes portadores de graus III e IV, mais avançados, da Síndrome de Mirizzi (SM) de acordo com a classificação de Csendes. Métodos: estudo retrospectivo, de corte transversal através da revisão de prontuários de 13 pacientes portadores de graus III e IV da SM operados de dezembro de 2001 a setembro de 2013, entre 3691 colecistectomias realizadas neste período. Resultados: a incidência da SM foi 0,6% (23 casos) e os graus III e IV perfizeram 0,35% deste número. Houve um predomínio de tipo IV (12 casos). O diagnóstico pré-operatório foi possível em 53,8% dos casos. A conduta preferencial foi derivação biliodigestiva (10 casos) e foi optado por drenagem com tubo "T" e sutura da via biliar em três ocasiões especiais. Três pacientes apresentaram fístula biliar resolvida com conduta expectante e um caso de coleperitônio necessitou reoperação. No seguimento ambulatorial dos pacientes que realizaram a anastomose biliodigestiva (oito), 50% estão assintomáticos, 25% apresentaram estenose da anastomose e 25% perderam seguimento. O tempo médio de acompanhamento foi 41,8 meses. Conclusão: de incidência baixa e de diagnóstico pré-operatório em apenas metade dos casos, a SM em graus avançados tem na anastomose biliodigestiva sua melhor conduta, porém não isenta de morbimortalidade.

El síndrome de Mirizzi, un desafío para el cirujano / Mirizzi syndrome, a challenge for the surgeon

El síndrome de Mirizzi es una inflamación poco frecuente y crónica ocasionada por un cálculo impactado en la bolsa de Hartmann con obstrucción parcial o completa del conducto biliar principal. Es una complicación prolongada de la enfermedad litiásica biliar e infiere un diagnóstico preoperatorio difícil, así como una compleja conducción terapéutica. El objetivo de este trabajo es realizar una actualización del tema sobre el diagnóstico y tratamiento de esta entidad. Se realizó una revisión de las bases de datos Pubmed, Dynamed y Conchrane (idioma inglés y español) en busca de los artículos relacionados con el síndrome de Mirizzi. Trabajos adicionales fueron identificados mediante búsqueda manual de las referencias de artículos relevantes. Se presentó una actualización detallada acerca del diagnóstico y tratamiento de esta entidad teniendo en cuenta la experiencia del autor y los hallazgos de la revisión realizada. Para lograr un diagnóstico preoperatorio e intraoperatorio certero se requiere un alto índice de sospecha, llevando a una óptima proyección quirúrgica para tratar esta entidad(AU)

Mirizzi syndrome is a rare and chronic inflammation, caused by a calculus stuck to the Hartmann bag, with partial or complete obstruction of the main bile duct. It is a lengthened complication of lithiasic biliary disease and effects a difficult preoperative diagnosis and a therapeutic complex treatment. To perform an updating about the of subject and to present the "state of art" diagnosis and treatment for this entity. A review of PubMed, Dynamed and Conchrane data was made (in both English and Spanish), looking for articles about Mirizzi syndrome. Additional papers were identified by manual search for references of relevant articles. A detailed updating on the diagnosis and treatment of this entity was presented, taking into account the experience of the author and the findings from the review. High suspicion index is required for an accurate preoperative and intraoperative surgical diagnoses leading to an optimal approach to treat this condition(AU)

El síndrome de Mirizzi, un desafío para el cirujano / Mirizzi syndrome, a challenge for the surgeon

El síndrome de Mirizzi es una inflamación poco frecuente y crónica ocasionada por un cálculo impactado en la bolsa de Hartmann con obstrucción parcial o completa del conducto biliar principal. Es una complicación prolongada de la enfermedad litiásica biliar e infiere un diagnóstico preoperatorio difícil, así como una compleja conducción terapéutica. El objetivo de este trabajo es realizar una actualización del tema sobre el diagnóstico y tratamiento de esta entidad. Se realizó una revisión de las bases de datos Pubmed, Dynamed y Conchrane (idioma inglés y español) en busca de los artículos relacionados con el síndrome de Mirizzi. Trabajos adicionales fueron identificados mediante búsqueda manual de las referencias de artículos relevantes. Se presentó una actualización detallada acerca del diagnóstico y tratamiento de esta entidad teniendo en cuenta la experiencia del autor y los hallazgos de la revision realizada. Para lograr un diagnóstico preoperatorio e intraoperatorio certero se requiere un alto índice de sospecha, llevando a una óptima proyección quirúrgica para tratar esta entidad(AU)

Mirizzi syndrome is a rare and chronic inflammation, caused by a calculus stuck to the Hartmann bag, with partial or complete obstruction of the main bile duct. It is a lengthened complication of lithiasic biliary disease and effects a difficult preoperative diagnosis and a therapeutic complex treatment. To perform an updating about the of subject and to present the state of art diagnosis and treatment for this entity. A review of PubMed, Dynamed and Conchrane data was made (in both English and Spanish), looking for articles about Mirizzi syndrome. Additional papers were identified by manual search for references of relevant articles. A detailed updating on the diagnosis and treatment of this entity was presented, taking into account the experience of the author and the findings from the review. High suspicion index is required for an accurate preoperative and intraoperative surgical diagnoses leading to an optimal approach to treat this condition(AU)

[Mirizzi syndrome: experience at Spanish Hospital of Veracruz]. / Síndrome de Mirizzi. Experiencia del Hospital Español de Veracruz.

BACKGROUND: Mirizzi syndrome is a complication of gallbladder stones impacted in Hartmann's pouch or cystic duct with compression of the bile duct. The diagnosis is made by imaging studies, although most of them are found through intraoperative surgical findings. Treatment is cholecystectomy and bile duct restoration when needed. OBJECTIVE: to analyze a series of cases of Mirizzi syndrome and compare the results with those published in the literature. CLINICAL CASE: We report 4 cases with Mirizzi syndrome in a cohort of 1,034 cases studied in the Hospital Español of Veracruz over 21 years. RESULTS: In our series the frequency of Mirizzi syndrome was 0.38%, the average age was 32.1 ± 58.4 years, 50% were male gender and 25% had jaundice with a demonstrable liver profile. In 1 case, ultrasound suggested Mirizzi syndrome and percutaneous cholangiography and computed tomography confirmed the diagnosis. All patients underwent laparoscopic cholecystectomy, and 2 transcystic cholangiographies were performed. One case was classified as Type I-A and three as type I-B. (Beltran and Csendes). The postoperative evolution was satisfactory in all and no mortality was presented. CONCLUSIONS: Mirizzi syndrome should be suspected in patients with gallstones who develop obstructive jaundice and it must be confirmed with imaging studies. The surgeon must take extreme precautions to avoid accidental injury to the bile ducts.

Antecedentes: el síndrome de Mirizzi es una complicación de la litiasis vesicular por cálculos impactados en la bolsa de Hartmann o conducto cístico que comprimen la vía biliar principal; el diagnóstico se establece mediante estudios de imagen, aunque la mayor parte son hallazgos transoperatorios; su tratamiento es la colecistectomía con restauración de la vía biliar. Objetivo: analizar una serie de casos de síndrome de Mirizzi y comparar los resultados con lo publicado en la bibliografía mundial. Casos clínicos: se comunican cuatro casos con síndrome de Mirizzi de una cohorte de 1,034 casos con enfermedad litiásica vesicular del Hospital Español de Veracruz, en 21 años. La frecuencia en esta muestra es de 0.38%, con edad promedio de 32.1 ± 58.4 años; 50% son hombres y 25% tuvo ictericia y coluria con perfil hepático demostrativo. En un caso el ultrasonido sugirió síndrome de Mirizzi; el diagnóstico se corroboró por colangiografía percutánea y tomografía computada. A todos los pacientes se les realizó colecistectomía laparoscópica, y en dos se efectuó colangiografía transcística. Un caso correspondió al tipo I-A y 3 al tipo I-B según la Clasificación de Beltrán y Csendes. La evolución postoperatoria fue satisfactoria y no hubo mortalidad. Conclusiones: el síndrome de Mirizzi debe sospecharse en pacientes con litiasis vesicular con ictericia obstructiva. El cirujano debe extremar las precauciones para evitar lesionar la vía biliar.

El manejo del síndrome de Mirizzien un servicio de cirugía general / Mirizzi syndrome management in a department of general surgery

Antecedentes: El síndrome de Mirizzi (SM) es una alteraciónanatómica de los conductos biliares a nivel de la desembocaduradel cístico, consecuencia tardía de la litiasis vesicular.Objetivo: Determinar el cuadro clínico del SM, clasificarlas lesiones y los resultados inmediatos del tratamiento.Pacientes y método: Estudio descriptivo y retrospectivode corte transversal basado en 16 pacientes (14 mujeres y 2hombres, con edad media de 58 años) intervenidos en el período2005-2010, en quienes se comprobó el SM en el acto operatorio.Resultados: Los síntomas principales fueron dolor e ictericia,La ecografía abdominal reveló colecistolitiasis en 15 (2 consignos inflamatorios agudos) y coledocolitiasis en 1 paciente; eldiámetro del colédoco era mayor a 7 mm en 10 pacientes; en 2pacientes se presumió la existencia del SM.Las lesiones eran de tipo II en el 50% y de tipo III en12.5%. Diez colecistectomías fueron completas y 6 parciales:una de ellas con plastia de la vía biliar principal (VBP) y otracon cierre de fístula duodenal; 8 pacientes fueron sometidos –además de la colecistectomía – a una coledocotomía y extracciónde cálculos.Conclusiones: Las lesiones eran fundamentalmente de tipoII y III; el tratamiento fue la colecistectomía asociada a la coledocotomía,el cierre de fístula colecisto-duodenal y la plastiade la vía biliar.

Síndrome de Mirizzi tipo IV: diagnóstico y manejo mediante colangiopancreatografía retrógrada endoscópica: reporte de caso / Mirizzi Syndrome Type IV: diagnosis and management through retrograde endoscopic cholangiopancreatography: case report

El síndrome de Mirizzi es una rara complicación de la colelitiasis, caracterizado por obstrucción mecánica del conducto hepatocolédoco por un cálculo impactado en el cístico o en el cuello vesicular. Después de un período de tiempo puede desarrollarse una fístula colecistobiliar por destrucción de la pared del colédoco. Según la clasificación de Csendes, el tipo IV es el menos frecuente. Se presentó un caso con antecedente de colelitiasis que ingresa con cuadro clínico compatible con colangitis aguda. Se realiza CPRE electiva, diagnosticándose síndrome de Mirizzi tipo IV y se coloca prótesis como puente para el tratamiento quirúrgico. Ante un paciente con esas características, la CPRE resulta un método diagnóstico y terapéutico indispensable(AU)

The Mirizzi syndrome is a cholelithiasis rare complication, characterized by the mechanical obstruction of the hepato choledocus duct by a calculus impacted in the cystic or in the vesicular neck. We presented a case with cholelithiasis antecedents entering the hospital with a clinical picture compatible with acute cholangitis. We made an elective cholangiopancreatography finding a big protraction of the intrahepatic biliary tracts, stretch of the supraduodenal choledoc with a common cystic-vesicular neck and choledocian environment, forming a great duct of near 20 mm diameter, having inside an ovoid filling mistake which bigger diameter is 15 mm, directed to the choledocus and to the vesicle. We diagnosed a Mirizzi syndrome Type IV. In a patient with those characteristics, the cholangiopancreatography is an unavoidable diagnostic and therapeutic method(AU)

Síndrome de Mirizzi tipo IV: diagnóstico y manejo mediante colangiopancreatografía retrógrada endoscópica: reporte de caso / Mirizzi Syndrome Type IV: diagnosis and management through retrograde endoscopic cholangiopancreatography: case report

El síndrome de Mirizzi es una rara complicación de la colelitiasis, caracterizado por obstrucción mecánica del conducto hepatocolédoco por un cálculo impactado en el cístico o en el cuello vesicular. Después de un período de tiempo puede desarrollarse una fístula colecistobiliar por destrucción de la pared del colédoco. Según la clasificación de Csendes, el tipo IV es el menos frecuente. Se presentó un caso con antecedente de colelitiasis que ingresa con cuadro clínico compatible con colangitis aguda. Se realiza CPRE electiva, diagnosticándose síndrome de Mirizzi tipo IV y se coloca prótesis como puente para el tratamiento quirúrgico. Ante un paciente con esas características, la CPRE resulta un método diagnóstico y terapéutico indispensable.

The Mirizzi syndrome is a cholelithiasis rare complication, characterized by the mechanical obstruction of the hepato choledocus duct by a calculus impacted in the cystic or in the vesicular neck. We presented a case with cholelithiasis antecedents entering the hospital with a clinical picture compatible with acute cholangitis. We made an elective cholangiopancreatography finding a big protraction of the intrahepatic biliary tracts, stretch of the supraduodenal choledoc with a common cystic-vesicular neck and choledocian environment, forming a great duct of near 20 mm diameter, having inside an ovoid filling mistake which bigger diameter is 15 mm, directed to the choledocus and to the vesicle. We diagnosed a Mirizzi syndrome Type IV. In a patient with those characteristics, the cholangiopancreatography is an unavoidable diagnostic and therapeutic method.

Mirizzi: o homem e a síndrome / Mirizzi: the man and the syndrome

A síndrome de Mirizzi é uma importante complicação da doença calculosa biliar. Pablo Luís Mirizzi, de Córdoba, Argentina, descreveu uma condição hoje conhecida como síndorme de Mirizzi, em 1948. Ele dedicou sua vida à Cirurgia e aos estudantes.

Mirizzi syndrome is an important complication of gallstone disease. Pablo Luís Mirizzi, from Córdoba, Argentina, described a condition now know as the Mirizzi syndrome, in 1948. He dedicated his life to surgery and his students.

Carcinoma de vesícula biliar mascarado por Síndrome de Mirizzi: relato de caso e revisão da literatura / Carcinoma of the gallbladder masked by Mirizzi Syndrome: case report andliterature review

Objetivos: este relato de caso visa descrever uma forma pouco comum de apresentação de câncer de vesícula biliar, mascarado pela Síndrome de Mirizzi.Descrição do caso: uma mulher consultou por náuseas, acolia e colúria, que haviam iniciado dois meses antes, e icterícia, de início recente. A ecografia abdominal evidenciou dilatação da via biliar com coledocolitíase e colelitíase. Uma colangiopancreatografia endoscópica retrógrada mostrou obstrução no terço médio do ducto hepático comum, não sendo visualizado cálculo. A suspeita diagnóstica inicial foi de Síndrome de Mirizzi. Foi inserida uma endoprótese na via biliar principal, com plano de cirurgia. Durante o procedimento cirúrgico foram encontradas lesões macroscópicas em peritônio e vesícula biliar, que indicaram interrupção da cirurgia e coleta de material para biópsia. O exame anatomopatológico evidenciou adenocarcinoma. A paciente teve alta hospitalar com acompanhamento oncológico e plano de quimioterapia.Conclusões: a concomitância da Síndrome de Mirizzi com carcinoma de vesícula é extremante rara, pois são doenças pouco frequentes. Para o diagnóstico definitivo do tumor de vesícula biliar é sempre imperativo o estudo anatomopatológico de todas as peças cirúrgicas.

Aims: This case report aims to describe an unusual presentation of gallbladder cancer, masked by Mirizzi Syndrome.Case description: a woman complained of nausea, dark urine and acholic stools started two months earlier, and jaundice started later. An abdominal ultrasound showed dilatation of the bile duct with choledocholithiasis and cholelithiasis. A cholangiopancreatography showed obstruction in the middle third of the common bile duct, without visualization of gallstones. The initial diagnosis was Mirizzi Syndrome. A stent was inserted in the main bile duct, to plan surgery. During surgery macroscopic lesions were found in gallbladder and peritoneum, which indicated interruption of the surgery and sample collection for biopsy. Pathological examination revealed adenocarcinoma. The patient was discharged with oncological follow-up plan and chemotherapy.Conclusions: The coexistence of Mirizzi Syndrome with carcinoma of the gallbladder is extremely rare, because both diseases are uncommon. Anatomopathological examination of all surgical specimens is always imperative for the definitive diagnosis of gallbladder tumor.

Resolución laparoscópica de litiasis vesicular complicada con fístula colecistobiliar y colecistoduodenal: síndrome de Mirizzi tipo V: a propósito de un caso complejo / Resolution laparoscopic gallstones complicated with fistula colecistobiliar and cholecystoduodenal: Mirizzi syndrome type V: report of a complex case

Presentamos un caso de fístula colecistobiliar y colecistoduodenal (síndrome de Mirizzi tipo Va) resuelto por abordaje laparoscópico. El síndrome de Mirizzi representa una complicación de la litiasis vesicular que supone un reto quirúrgico, especialmente desafiante si se realiza por laparoscopia, ya que su resolución puede requerir destrezas especiales y equipos e instrumentos a los que el cirujano general no está habituado. Describimos el caso de una paciente femenina de 58 años de edad que consultó por presentar cuadro de ictericia obstructiva de dos semanas de evolución, con alteración del perfil hepático y ultrasonido abdominal que evidencia litiasis vesicular y dilatación del colédoco, se realiza colangiopancreatografía retrógrada endoscópica (CPRE), donde se evidencia imagen de defecto a nivel de la unión císticocoledociana, sin lograr la extracción del mismo. Se realizó el abordaje por vía laparoscópica, evidenciando síndrome adherencial severo, con presencia de fístula colecistoduodenal y colecistobiliar. Se procedió a la disección y sección del trayecto fistuloso entre la vesícula y la primera porción del duodeno, con cierre primario de este último. Posteriormente se realizó coledocotomía longitudinal y exploración de la vía biliar con el uso del coledocoscopio extrayéndose un cálculo de 1,5 cm, se realizó el cierre primario de la coledocotomía, y finalmente colecistectomía subtotal a nivel de la bolsa de Hartman con autosuturadora lineal-cortante de 45 mm. El abordaje laparoscópico del paciente con litiasis vesicular y síndrome de Mirizzi enfrenta al equipo quirúrgico a una situación difícil, sin embargo, es una alternativa factible siempre y cuando sea realizado por cirujanos con experiencia en cirugía laparoscópica avanzada de la vía biliar y se cuente con los recursos necesarios

Case report of the laparoscopic resolution of a type V Mirizzi´s Syndrome. This syndrome is a rare complication of the choletihiasis that becomes a surgical challenge, especially if made under laparoscopy, because it demands special skills and equipments uncommon to the general surgeons. A 58 years old female patient who presents a two weeks history of obstructive biliary syndrome. Hepatic enzymes were high and abdominal ultrasonography revealed gallstones and a dilated common bile duct. Endoscopic retrograde pancreatography (ERCP) revealed biliary stones in the junction between cystic duct and the common bile duct and the instrumentation was not effective. The laparoscopic approach showed severe adherences around the gallbladder with a cholecystoduodenal fistula and a cholecystobiliary fistula. We continue with the dissection and resection of the cholecystoduodenal fistula using primary closure of the duodenum. Afterwards we performed the transcholedochal common bile duct exploration and the capture of a 1,5 cm stone. Then we proceed with the primary closure of the common bile duct and subtotal cholecystectomy at the Hartman’s pouch using a 45 mm lineal autosuture. The laparoscopic management of patient with gallstones and Mirizzi´s syndrome is a difficult situation for the surgical team. However it is possible and save whenever a surgical team and the require resources are available