Mirizzi syndrome: evaluation by MRI imaging

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.

Mirizzi Syndrome-The Past, Present, and Future

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

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.

Surgical strategies for Mirizzi syndrome: A ten-year single center experience

BACKGROUND

Mirizzi syndrome (MS) remains a challenging biliary disease, and its low rate of preoperative diagnosis should be resolved. Moreover, technological advances have not resulted in decisive improvements in the surgical treatment of MS. Complex bile duct lesions due to MS make surgery difficult, especially when the laparoscopic approach is adopted. The safety and long-term effect of MS treatment need to be guaranteed in terms of preoperative diagnosis and surgical strategy.

AIM

To analyze preoperative diagnostic methods and the safety, effectiveness, prognosis and related factors of surgical strategies for different types of MS.

METHODS

The clinical data of MS patients who received surgical treatment from January 1, 2010 to December 31, 2020 were retrospectively reviewed. Patients with malignancies, choledochojejunal fistula, lack of data and lost to follow-up were excluded. According to preoperative imaging examination records and documented intraoperative findings, the clinical types of MS were determined using the Csendes classification. The safety, effectiveness and long-term prognosis of surgical treatment in different types of MS, and their interactions with the clinical characteristics of patients were summarized.

RESULTS

Sixty-six patients with MS were included (34 males and 32 females). Magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) showed specific imaging features of MS in 58 cases (87.9%), which was superior to ultrasound scan (USS) in the diagnosis of MS and more sensitive to subtle biliary lesions than USS. The overall laparoscopic surgery completion rate was 53.03% (35/66), where the completion rates of MS type I, II and III were 69.05% (29/42), 42.86% (6/14) and zero (0/10), respectively. Thirty-one patients (46.97%) underwent laparotomy or conversion to laparotomy including 11 cases of iatrogenic bile duct injury which occurred in type I patients, and 25 of these patients underwent bile duct exploration, repair and T-tube drainage. In addition, 25 patients underwent intraoperative choledochoscopy and T-tube cholangiography. Overall, 21 cases (31.8%) were repaired by simple suturing, and 14 cases (21.2%) were repaired using the remaining gallbladder wall patch in the subtotal cholecystectomy. The ascendant of the Csendes classification types led to an increase in surgical complexity reflected by increased operation time, bleeding volume and cost. Gender, acute abdominal pain and measurable stone size had no effect on Csendes type of MS or final surgical approach. Age had no effect on the classification of MS, but it influenced the final surgical approach, hospital stay and cost. A total of 66 patients obtained a relatively high preoperative diagnostic rate and underwent surgery safely without serious complications, and no mortality was observed during the follow-up period of 36.5 ± 26.5 mo (range 13-76, median 22 mo).

CONCLUSION

MRI/MRCP can improve the preoperative diagnosis of MS. The Csendes classification can reflect the difficulty of treatment. The surgical strategies including laparoscopic surgery for MS should be formulated based on full evaluation and selection.

An Unusual Case of Mirizzi Syndrome With Double Spontaneous Gallbladder Fistulas With the Colon and the Duodenum Presenting As Acute Cholecystitis

The Mirizzi syndrome is amongst the rarest complications of long-standing gallstone disease. It is an even rarer occurrence when concurrent with a cholecystoenteric or cholecystoduodenal fistula and might not include an accompanying gallstone ileus. Chronic cholecystitis is the primary etiology, but pre-operative diagnosis is challenging due to its non-specific symptoms compared with acute cholecystitis. In this unusual case, the patient has a Csendes type Va Mirizzi syndrome associated with a double cholecystoduodenal and cholecystocolonic fistula, a rare presentation.

Mirizzi syndrome complicated by common hepatic duct fistula and left hepatic atrophy: a case report

Background

Mirizzi syndrome is a rare complication of chronic cholecystitis, usually caused by gallstones impacted in the cystic duct or the neck of the gallbladder. Mirizzi syndrome results in compression of the hepatic duct or fistula formation between the gallbladder and common bile duct (or hepatic duct, right hepatic duct, or even mutative right posterior hepatic duct). Clinical features include abdominal pain, fever, and obstructive jaundice. Severe inflammation and adhesion at Calot’s triangle are potentially very dangerous for patients with Mirizzi syndrome undergoing cholecystectomy.

Case presentation: We report the case of a 68-year-old Asian woman who presented with abdominal pain and jaundice. She had a medical history of gallstones, but no fever. Magnetic resonance cholangiopancreatography revealed cholecystitis, cholelithiasis, common hepatic duct stones, and ascites. Findings at surgery included a porcelainized, atrophic gallbladder that was full of gallstones, fistula formation between the gallbladder and common hepatic duct, and left hepatic atrophy. The prominent feature was the left hepatic atrophy, but stones were not visible pre-operatively in the left liver by radiologic examination.

Conclusions

This patient exhibited what can be considered a special type II of Mirizzi syndrome with a fistula of the common hepatic duct as well as left hepatic atrophy.

Current trends in the management of Mirizzi Syndrome: A review of literature

Mirizzi Syndrome is a rare and challenging clinical entity to manage. However, recent advances in technology have provided surgeons with new options for more effective diagnosis and treatment of this condition. This paper reviews these new diagnostic modalities and treatment approaches for the management of Mirizzi Syndrome.An online search language was performed using PubMed and Web of Science for literature published in English between 2012 and 2017 using the search terms "Mirizzi Syndrome" and "Mirizzi." In total, 16 case series and 11 case reports were identified and analyzed.The most frequently used diagnostic modalities were ultrasound, computed tomography (CT); magnetic resonance cholangiopancreaticography (MRCP); endoscopic retrograde cholangiopancreaticography (ERCP). A combination of ≥2 diagnostic modalities was frequently used to detect Mirizzi Syndrome. Literature shows that the specific type of Mirizzi Syndrome determined the type of treatment chosen. Open surgery was the preferred option, although there are documented cases of the use of minimally-invasive techniques, even in advanced cases. Laparoscopic, endoscopic or robot-assisted surgery, used individually or in combination with lithotripsy, were all associated with a favorable outcome.As yet, there are no internationally-accepted guidelines for the management of Mirizzi Syndrome. Laparotomy is the preferred surgical technique of choice, although an increasing number of surgeons are beginning to opt for minimally-invasive techniques. The number of papers in the existing literature describing diagnostic and treatment procedures is relatively small at present, thus making it difficult to reasonably propose an evidence-based standard of care for Mirizzi Syndrome.

Adult bile duct strictures: role of MR imaging and MR cholangiopancreatography in characterization

Bile duct strictures in adults are secondary to a wide spectrum of benign and malignant pathologic conditions. Benign causes of bile duct strictures include iatrogenic causes, acute or chronic pancreatitis, choledocholithiasis, primary sclerosing cholangitis, IgG4-related sclerosing cholangitis, liver transplantation, recurrent pyogenic cholangitis, Mirizzi syndrome, acquired immunodeficiency syndrome cholangiopathy, and sphincter of Oddi dysfunction. Malignant causes include cholangiocarcinoma, pancreatic adenocarcinoma, and periampullary carcinomas. Rare causes include biliary inflammatory pseudotumor, gallbladder carcinoma, hepatocellular carcinoma, metastases to bile ducts, and extrinsic bile duct compression secondary to periportal or peripancreatic lymphadenopathy. Contrast material-enhanced magnetic resonance (MR) imaging with MR cholangiopancreatography is extremely helpful in the noninvasive evaluation of patients with obstructive jaundice, an obstructive pattern of liver function, or incidentally detected biliary duct dilatation. Some of these conditions may show characteristic findings at MR imaging-MR cholangiopancreatography that help in making a definitive diagnosis. Although endoscopic retrograde cholangiopancreatography with tissue biopsy or surgery is needed for the definitive diagnosis of many of these strictures, certain MR imaging characteristics of the narrowed segment (eg, thickened wall, long-segment involvement, asymmetry, indistinct outer margin, luminal irregularity, hyperenhancement relative to the liver parenchyma) may favor a malignant cause. Awareness of the various causes of bile duct strictures in adults and familiarity with their appearances at MR imaging-MR cholangiopancreatography are important for accurate diagnosis and optimal patient management.

Acute acalculous cholecystitis determining Mirizzi syndrome: case report and literature review

Background

Although Mirizzi syndrome is widely reported in literature, little is known about acute acalcholous cholecystitis determinig the findings of a Mirizzi syndrome.

Case presentation

We report a case of MRCP-confirmed Mirizzi syndrome in acute acalculous cholecystitis resolved by surgery.

Conclusion

Acute acalcholosus cholecystitis determinig a Mirizzi Syndrome should be included in the Mirizzi classification as a type 1. Thus it could be useful to divide the type 1 in two entity (compression by stone and compression by enlarged gallbladder). Magnetic Resonance should be considered the preferred diagnostic tool in any case of Mirizzi syndrome suspicious.

Magnetic resonance imaging of the pediatric pancreaticobiliary system

Magnetic resonance cholangiopancreatography (MRCP) is an extremely useful tool for evaluating a wide variety of disorders affecting the pancreaticobiliary system in neonates/infants, children, and adolescents. This imaging technique has numerous distinct advantages over alternative diagnostic modalities, such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography, including its noninvasive nature and lack of ionizing radiation. Such advantages make MRCP the preferred first-line method for advanced imaging the pediatric pancreaticobiliary tree, after ultrasonography. This article presents a contemporary review of the use of MRCP in the pediatric population, including techniques, indications, and the imaging appearances of common and uncommon pediatric disorders.

Appraisal of diagnosis and surgical approach for Mirizzi syndrome

BACKGROUND

Mirizzi syndrome is an important and rare complication of gallstone disease. This study aims to evaluate the treatment approach by analysing the diagnostic method and the outcome of surgical treatment in our hospital.

METHODS

We retrospectively analysed the data of 198 patients with Mirizzi syndrome between January 2004 and January 2010. The records were reviewed for demography, clinical presentation, diagnostic method, operative procedure, postoperative complication and follow-up.

RESULTS

The incidence of Mirizzi syndrome was 0.66% of 29 875 patients who underwent cholecystectomy for cholelithiasis. The incidence of types I, II, III and IV was 59.1%, 24.7%, 13.1% and 3.1%, respectively. In this study, ultrasonography and magnetic resonance cholangiopancreatography (MRCP) could have the suspicion of Mirizzi syndrome in 77.8% and 82.3% of cases. Cholecystectomy also has been shown to be effective for type I Mirizzi syndrome. Our common surgical approach in Mirizzi syndrome types II and III was partial cholecystectomy without removal of the portion of gallbladder around the fistula margin. For some cases, choledochoplasty was needed. For Mirizzi syndrome type IV, we performed hepaticojejunostomy for all patients.

CONCLUSION

Ultrasound, MRCP and endoscopic retrograde cholangiopancreatography in combination with choledochoscope procedure in operation could improve the diagnostic sensitivity of Mirizzi syndrome. Intraoperative choledochoscope is effective to confirm Mirizzi syndrome during operation. Open surgery is the current standard for managing patients with Mirizzi syndrome. Laparoscopic surgery should be confined to Mirizzi syndrome type I and patients should be selected very strictly.

Mirizzi syndrome

Mirizzi syndrome is an important complication of gallstone disease. If not recognized preoperatively, it can result in significant morbidity and mortality. Preoperative diagnosis may be difficult despite the availability of multiple imaging modalities. Ultrasonography (US), CT, and magnetic resonance cholangiopancreatography (MRCP) are common initial tests for suspected Mirizzi syndrome. Typical findings on US suggestive of Mirizzi syndrome are a shrunken gallbladder, impacted stone(s) in the cystic duct, a dilated intrahepatic tree, and common hepatic duct with a normal-sized common bile duct. The main role of CT is to differentiate Mirizzi syndrome from a malignancy in the area of porta hepatis or in the liver. MRI and MRCP are increasingly playing an important role and have the additional advantage of showing the extent of inflammation around the gallbladder that can help in the differentiation of Mirizzi syndrome from other gallbladder pathologies such as gallbladder malignancy. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the diagnosis of Mirizzi syndrome. It delineates the cause, level, and extent of biliary obstruction, as well as ductal abnormalities, including fistula. ERCP also offers a variety of therapeutic options, such as stone extraction and biliary stent placement. Percutaneous cholangiogram can provide information similar to ERCP; however, ERCP has an additional advantage of identifying a low-lying cystic duct that may be missed on percutaneous cholangiogram. Wire-guided intraductal US can provide high-resolution images of the biliary tract and adjacent structures. Treatment is primarily surgical. Open surgery is the current standard for managing patients with Mirizzi syndrome. Good short- and long-term results with low mortality and morbidity have been reported with open surgical management. Laparoscopic management is contraindicated in many patients because of the increased risk of morbidity and mortality associated with this approach. Endoscopic treatment may serve as an alternative in patients who are poor surgical candidates, such as elderly patients or those with multiple comorbidities. Endoscopic treatment also can serve as a temporizing measure to provide biliary drainage in preparation for an elective surgery.

Combination of magnetic resonance cholangiopancreatography and computed tomography for preoperative diagnosis of the Mirizzi syndrome

OBJECTIVE

To determine the diagnostic accuracy of combined magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) for preoperative diagnosis of Mirizzi syndrome.

MATERIALS AND METHODS

Fifty-two patients with surgically proven Mirizzi syndrome (n = 13) and cholecystitis without evidence for Mirizzi syndrome (n = 39) underwent both MRCP using single-shot turbo spin echo and 3-dimensional turbo spin echo sequences and CT. Two blinded observers independently and retrospectively reviewed the combination of MRCP and CT images and CT images alone. Diagnostic accuracy for a combined protocol and CT was evaluated.

RESULTS

The overall sensitivity, specificity, positive and negative predictive values, and accuracy of the combination of MRCP and CT were 96.0%, 93.5%, 83.5%, 98.5%, and 94.0%, respectively. Corresponding values of CT were 42.0%, 98.5%, 93.0%, 83.5%, and 85.0%, respectively. The sensitivity, negative predictive value, and accuracy of combined protocol were significantly higher than those of CT alone (P = 0.000, 0.001, and 0.042, respectively). Interobserver agreement was better for combined images (kappa = 0.906) than for CT images alone (kappa = 0.812).

CONCLUSIONS

A combination of MRCP and CT is useful for preoperative diagnosis of Mirizzi syndrome.

The Mirizzi syndrome: multidisciplinary management promotes optimal outcomes

The Mirizzi syndrome (MS) is a rare cause of obstructive jaundice produced by the impaction of a gallstone either in the cystic duct or in the gallbladder, resulting in stenosis of the extrahepatic bile duct and, in severe cases, direct cholecystocholedochal fistula formation. Sixteen patients were treated for MS in our center over the 12-year period 1993--2005 for a prevalence of 0.35% of all cholecystectomies performed. One patient was diagnosed only at the time of cholecystectomy. The other 15 patients presented with laboratory and imaging findings consistent with choledocholithiasis and underwent preoperative endoscopic retrograde cholangiopancreatography, which established the diagnosis in all but one patient. All patients underwent cholecystectomy. An initial laparoscopic approach was attempted in 14 patients, of whom 11 were converted to open procedures. MS was recognized operatively in 15 patients with definitive stone extraction and relief of obstruction in 13 patients. T-tubes were placed in 10 patients and 1 patient required a choledochoduodenostomy. Two patients required postoperative laser lithotripsy via a T-tube tract to clear their stones; and in another patient, MS was detected and treated via postoperative endoscopic retrograde cholangiopancreatography (ERCP). MS remains a serious diagnostic and therapeutic challenge for endoscopists and biliary surgeons.

[Mirizzi syndrome type II with a gastric antrum erosion: an atypical presentation]

The Mirizzi's syndrome is an unusual complication of long-standing gallstone disease that occurs in 0.7% to 1.4% of all cholecystectomies performed. It was originally described as an obstruction of the proximal bile duct secondary to external compression by a large stone located in the Hartmann pouch or secondary to local inflammatory changes. In recent years, extension of Mirizzi's eponym has been used to define obstructive jaundice induced by different grades of compression and erosion of the bile duct wall by a stone, which can evolve to a complete cholecystocholedocal fistula, with compression and dilatation of the proximal bile duct by the stone. Herein we present a case of Mirizzi's syndrome type II with a gastric antrum erosion associated, in highlighting the essential of the pre-operative diagnosis by endoscopic retrograde cholangiography (ERC) or MR cholangiography, to avoid iatrogenic injuries of the bile ducts, because the syndrome has been cited as a trap in the surgery gallstones. This case is an example that the natural history of Mirizzi's syndrome cannot stop with the compression or the cholecysto-biliary fistula, but it may result in a complex fistula with the neighbouring digestive organs.

MR imaging of the gallbladder: a pictorial essay

The gallbladder serves as the repository for bile produced in the liver. However, bile within the gallbladder may become supersaturated with cholesterol, leading to crystal precipitation and subsequent gallstone formation. The most common disorders of the gallbladder are related to gallstones and include symptomatic cholelithiasis, acute and chronic cholecystitis, and carcinoma of the gallbladder. Other conditions that can affect the gallbladder include biliary dyskinesia (functional), adenomyomatosis (hyperplastic), and postoperative changes or complications (iatrogenic). Ultrasonography (US) has been the traditional modality for evaluating gallbladder disease, primarily owing to its high sensitivity and specificity for both stone disease and gallbladder inflammation. US performed before and after ingestion of a fatty meal may also be useful for functional evaluation of the gallbladder. However, US is limited by patient body habitus, with degradation of image quality and anatomic detail in obese individuals. With the advent of faster and more efficient imaging techniques, magnetic resonance (MR) imaging has assumed an increasing role as an adjunct modality for gallbladder imaging, primarily in patients who are incompletely assessed with US. MR imaging allows simultaneous anatomic and physiologic assessment of the gallbladder and biliary tract in both initial evaluation of disease and examination of the postoperative patient. This assessment is accomplished chiefly through the use of MR imaging contrast agents excreted preferentially via the biliary system.

Evaluation of the biliary tract: The value of performing magnetic resonance cholangiopancreatography in conjunction with a 3-D spoiled gradient-echo gadolinium enhanced dynamic sequence

The 3-D gradient-echo (GRE) sequence allows thinner sections and better resolution of biliary obstruction. When the presence of biliary obstruction is identified using magnetic resonance cholangiopancreatography, the addition of the 3-D GRE sequence may be helpful for diagnosing biliary obstruction. By showing the changes in the bile duct wall, within the duct lumen and around the bile duct, this technique can be helpful for distinguishing benign from malignant stricture as well as a stone from an enhancing intraluminal mass.

MR imaging of acute biliary disorders

In patients with acute right-sided epigastric pain, jaundice, and a high fever, it is essential to accurately diagnose the cause of the symptoms, differentiate acute biliary disorders from nonbiliary disorders, and evaluate the severity of the disease. Gray-scale ultrasonography (US) and computed tomography (CT) are useful primary imaging modalities, but their results are not always conclusive. Magnetic resonance (MR) imaging, including MR cholangiopancreatography, can be a valuable complement to US and CT when additional information is needed. MR images have excellent tissue contrast and can provide more specific information, allowing diagnosis of complications that arise from acute cholecystitis, such as empyema, gangrenous cholecystitis, gallbladder perforation, enterocholecystic fistula, emphysematous cholecystitis, and hemorrhagic cholecystitis. In addition, causes of obstructive jaundice, acute suppurative cholangitis, and hemobilia can be clearly demonstrated with multisequence MR imaging. Single-section MR cholangiopancreatography and heavily T2-weighted imaging, in combination with fat-suppressed T1- and T2-weighted imaging, provide comprehensive and detailed information about the biliary system around the obstruction site, biliary calculi, inflammatory processes, purulent material, abscesses, gas, and hemorrhage. Contrast-enhanced MR imaging is useful for evaluation of the gallbladder wall; lack of enhancement and disruption of the wall may be findings specific for gangrenous cholecystitis and gallbladder perforation, respectively.

[Mirizzi syndrome and gallbladder cancer]

Mirizzi syndrome (MS) has a low incidence in patients with gallbladder disease. The coexistence of gallbladder cancer seems to be more frequent in patients with MS than in those with gallstones only. We present two patients with MS type II and gallbladder cancer (stages T4N1M0 and T3NxMx). The etiopathogenic mechanisms, diagnostic methods and therapeutic options are discussed.

Mirizzi syndrome: history, present and future development

BACKGROUND

Mirizzi syndrome was reported in 0.3-3% of patients undergoing cholecystectomy. The distortion of anatomy and the presence of cholecystocholedochal fistula increase the risk of bile duct injury during cholecystectomy.

METHODS

A Medline search was undertaken to identify articles that were published from 1974 to 2004. Additional papers were identified by a manual search of the references from the key articles.

RESULTS

A preoperative diagnosis was made in 8-62.5% of cases. Open surgical treatment gave good short-term and long-term results. There was a lack of good data in laparoscopic treatment. Conversion to open surgery rates was high, and bile duct injury rate varied from 0 to 22.2%.

CONCLUSION

A high index of clinical suspicion is required to make a preoperative or intraoperative diagnosis, which leads to good surgical planning to treat the condition. Open surgery is the gold standard. Mirizzi syndrome should still be considered as a contraindication for laparoscopic surgery.

Mirizzi syndrome: laparoscopic management by subtotal cholecystectomy

BACKGROUND

The authors present their experience with laparoscopic subtotal cholecystectomy for the management of Mirizzi's syndrome and their review of the literature.

METHODS

Over a period of 24 months, five cases of Mirizzi's syndrome were encountered, representing 1.5% of all the laparoscopic cholecystectomies performed in the authors' unit. The sex ratio was 4 females to 1 male, and the mean age of the patients was 66 years. All underwent a subtotal cholecystectomy.

RESULTS

All procedures were completed laparoscopically. Morbidities involved one case of biliary peritonitis and a one case of biliary leak requiring endoscopic stenting.

CONCLUSION

Mirizzi's syndrome cannot always be anticipated on the basis of preoperative staging, and often is encountered during the procedure. The "anatomic scenario" of this condition should be suspected for patients presenting with conditions such as empyema or mucocoele when there is a likelihood of stone impaction in the infundibulum of the gallbladder. Subtotal cholecystectomy with secure intraperitoneal biliary drainage appears to be a safe option for these patients.

Elevated CA 19-9 Levels in a Patient with Mirizzi Syndrome: Case Report

CA 19-9 is a marker of malignancy of the pancreas and biliary tract. We report the case of a patient who had significantly elevated serum CA 19-9 levels and imaging studies suggestive of malignancy. On laparotomy, the patient was found to have Mirizzi syndrome, an uncommon cause of biliary obstruction from an impacted gallstone. This case illustrates that elevated serum CA 19-9 levels must be interpreted cautiously in cases of biliary obstruction.

Carcinoma in situ of the cystic duct

Cholelithiasis and cholesterolosis associated with carcinoma in situ of the cystic duct epithelium was observed in a male patient. Ultrastructurally, small acini-like lined a thickened, reduplicated basal lamina encompassing a pleiomorphic population of cells, including typical cholecystocytes, a poorly differentiated type, and cells containing modified mucous vesicles with heterogeneous fatty deposits. Even though the etiology of this apparent neoplastic epithelium and of its thickened basal lamina is unclear, it is hypothesized to be the result of an altered control of cell adhesion mechanisms, resulting from a repeated renewal of the typical epithelium abraded by the passage of the stones and the biliary sludge, associated with inflammatory stimuli that accompany cholecystolithiasis. Based on recent studies, it is suggested that investigations of molecular markers in extrahepatobiliary tract lesions and retrospective studies of these archival tissues could clarify the association of these neoplastic changes with other hepato-biliary lesions.

MR Imaging of the Gallbladder and Biliary System

MR imaging is an established technique for the diagnosis of a spectrum of biliary and gallbladder pathologies and continues to improve with the advent of technologic advances, including new contrast agents and new sequences that are capable of improving upon the contrast resolution and signal-to-noise that are afforded by conventional MR imaging. These improvements already have shown promise for the increasing role of MRC as the initial modality in assessing living liver donors and evaluating post-operative hepato-biliary complications. Improved spatial resolution and the added functional or physiologic information afforded by MR imaging promise ever expanding clinical applicability and usefulness.

MR imaging in abdominal emergencies

The use of MR imaging in the emergency setting is evolving. Clear indications include situations in need of contrast media when iodinated contrast cannot be administered or to facilitate assessments in pregnant patients and children when exposure to ionizing radiation is considered unacceptable. The availability of rapid, motion-immune sequences now makes MR imaging a feasible study in less cooperative patients extending the range of patients for whom a diagnostic study can be achieved. Capitalizing on the unique benefits of MR imaging there is optimism that MR imaging can eliminate test redundancy and impact patient care in a cost-effective manner. Further investigations are needed to identify the diagnostic algorithms for which this favorable use holds true.

Ultrasound and CT evaluation of emergent gallbladder pathology

Ultrasound is the initial imaging modality of choice for the evaluation of suspected acute gallbladder disorders, and is often sufficient for correct diagnosis. CT also plays a vital role, however, in the evaluation of acute gallbladder pathology. CT is particularly useful in situations where ultrasound findings are equivocal. CT is also extremely valuable in the assessment of suspected complications of acute cholecystitis, particularly emphysematous cholecystitis, hemorrhagic cholecystitis, and gallbladder perforation, which are often very difficult diagnoses to establish at sonography. If CT is the initial imaging test performed in a patient with abdominal pain of uncertain etiology, recognition of the various disorders described in this article may eliminate the need for further imaging and facilitate appropriate management.

Mirizzi Syndrome

The complete and definitive treatment of patients with Mirizzi syndrome is surgical. The treatment goals are the removal of the gallbladder with the offending stone(s) and the repair of the bile duct defect. A high index of suspicion for early recognition of this condition is paramount to prevent bile duct injury. Biliary anatomy is delineated precisely by preoperative and intraoperative imaging tests. The dissection of the gallbladder is conducted in an antegrade, fundus-first fashion. Extensive dissection of Calot's triangle is avoided. Instead, the gallbladder is opened, the impacted stone(s) is removed backward, and the confirmation of the presence a cholecystocholedochal fistula is established by direct inspection. A coexistent gallbladder carcinoma is excluded by taking frozen sections. In patients without biliary fistula (Mirizzi type I), simple cholecystectomy suffices to relieve the bile duct obstruction. In patients with biliary fistula (Mirizzi type II), the size of the fistula determines the type of repair. In general, small fistulas are repaired by choledochoplasty using a cuff of gallbladder remnant, whereas large bile duct defects require bilioenteric reconstruction (Roux-en-Y hepaticojejunostomy or choledochoduodenostomy). In patients unfit for surgery, biliary decompression is effectively accomplished by placement of stents using endoscopic or percutaneous techniques. Lithotripsy and removal of the offending stone can also be carried out in patients with Mirizzi type II. In general, nonsurgical treatment of Mirizzi syndrome is incomplete and places the patients on a path of intensive follow-up, multiple procedures, and the risk to continue suffering from complications of symptomatic gallstone disease. However, nonsurgical treatment allows for valuable time to prepare high-risk patients for a more elective and safer operation.

MR imaging of the gallbladder

T2-weighted imaging and MRCP, which have high sensitivity to edema and fluid, are paramount in the evaluation of certain gallbladder diseases, such as cholelithiasis, cholecystitis, adenomyomatosis, and cystic duct abnormalities. Dynamic gadolinium-enhanced MR imaging has the potential to differentiate among the many nonspecific-appearing lesions involving the gallbladder. MR imaging may not yet replace ultrasound as the workhorse of acute gallbladder imaging. Currently, MRCP is an ideal complementary study to inconclusive sonographic studies and can help plan surgical intervention in the setting of acute cholecystitis. Further investigation of hepatobiliary contrast agents, however, may reveal that MR imaging may be considered as first-line imaging in the acute setting.