Another paper on Mirizzi Syndrome?

Mirizzi Syndrome: an unexpected problem of cholelithiasis. Our experience with 27 cases

PURPOSE

Mirizzi syndrome is a rare complication of long standing cholelithiasis. The purpose of this study is to retrospectively estimate the diagnostic and treatment methods applied in patients with Mirizzi syndrome.

MATERIALS AND METHODS

Our experience with 27 cases with Mirizzi syndrome is presented. They were diagnosed either by imaging techniques, or during surgical operation. All of the patients were managed surgically.

RESULTS

8 patients were diagnosed preoperatively and the rest intraoperatively. Morbidity rate after surgery was 18,5%, and mortality rate was zero. The patients presented free of symptoms three months after surgery during the follow-up.

CONCLUSION

Mirizzi syndrome is rarely diagnosed preoperatively and US proved inadequate for this purpose. Surgery is the only therapy and usually provides additionally definitive diagnosis.

Is preoperative histological diagnosis necessary before referral to major surgery for cholangiocarcinoma?

Major surgical resection is often the only curative treatment for cholangiocarcinoma. When imaging techniques fail to establish the accurate diagnosis, biopsy of the lesion is unavoidable. However, biopsy is not necessarily required for topography of the cholangiocarcinoma (intrahepatic or extrahepatic). 1) In extrahepatic cholangiocarcinoma (ECC), clinical features and radiological imaging relate to biliary obstruction. Provided that between 8% and 43% of bile duct strictures are not ECC, the lesions mimicking ECC that should be ruled out are gallbladder cancer, Mirizzi syndrome, primary sclerosing cholangitis (PSC), autoimmune pancreatitis and portal biliopathy. Systematic biopsy is usually difficult and has poor sensitivity, but a good knowledge of these mimicking ECC diseases, along with precise analysis of clinical and imaging semiology, may lead to a correct diagnosis without the need for biopsy. 2) Intrahepatic cholangiocarcinoma (ICC) developing in normal liver appears as a hypovascular tumour with fibrotic component and capsular retraction that can be confused with fibrous metastases such as breast and colorectal cancers. The lack of the primary site, a relatively large tumour size and ancillary findings such as bile duct dilatation may provide a clue to the diagnosis. If not, we advocate local resection with lymph node dissection, since ICC is the most likely diagnosis and surgery is the only curative treatment. In the event of adenocarcinoma from unknown primary, surgery is an effective treatment even if prognosis is poor.

Mirizzi syndrome: ten years experience from a teaching hospital in Riyadh

OBJECTIVE

Mirizzi syndrome (MS) is an uncommon presentation of cholelithiasis. This study aims to find the incidence and analyze the outcome of management of this condition at Riyadh Medical Complex (RMC) with particular reference to diagnostic methods and outcome of surgical treatment.

METHODS

Retrospective study on 17 consecutive patients of MS diagnosed and managed at RMC over ten year period. The records were reviewed for demography, clinical presentation, diagnostic methods, operative procedures, postoperative complication and follow up.

RESULTS

The incidence of MS syndrome was 0.7% of 2415 cholecystectomies. There was preponderance of Type I variety (58.8%). Ultrasonography was able to diagnose 82% cases. ERCP suggested the diagnosis in all cases and helped further in classifying and management of these patients. All Type I cases were managed with partial cholecystectomy, two underwent laparoscopic surgery. Three Type II patients were managed by partial cholecystectomy alone. Three patients with Type III variety had choledochoplasty whereas one remaining patient with Type IV variety underwent hepatico-jejunostomy. All patients had complete recovery with 17.6% procedure-related morbidity and no hospital mortality. All patients are doing well over a mean follow up 6.5 years.

CONCLUSION

Preoperative diagnosis of Mirizzi syndrome by ultrasound and ERCP is essential to prevent serious complications during surgery. Partial cholecystectomy is an adequate procedure for Types I & II MS. Choledochoplasty provides an effective surgical repair in Type III cases. Although laparoscopic cholecystectomy in MS may be hazardous, it may still be tried in preoperatively diagnosed type I cases, provided the surgeon is experienced and keeps a low threshold for conversion open surgery.