Mirizzi's syndrome: Experience from a multi-institutional review

P,L. Mirizzi described in 1948 a partial or spastic obstruction of the comm on hepatic duct secondary to an impacted gallstone in the cystic duet or in fundibulum of the gallbladder. The modern definition of Mirizzi's syndrome is thought to include four components: anatomic arrangement of the cystic d uct at the gallbladder neck such that it runs parallel to the common hepati c duct; impaction of a stone in the cystic duct or neck of the gallbladder; mechanical obstruction of the common hepatic duct by the stone itself or b y secondary inflammation; and intermittent or constant jaundice causing pos sible recurrent cholangitis and, if longstanding, secondary biliary cirrhos is. Intermittent symptomatology may make Mirizzi's syndrome difficult to di agnose preoperatively or intraoperatively. Bilio-biliary fistulas may or ma y not be present. Diagnosis and choice of operative repair may be best acco mplished by open operative technique. Over a 24-year period two faculty mem bers from Louisiana State University (LSU) Medical Center-Shreveport at Mon roe and LSU Baton Rouge treated 4180 cases of cholelithiasis at six Louisia na university and private hospitals. Eleven cases of Mirizzi's syndrome wer e diagnosed on the basis of operative and preoperative notes with detailed description of size and extent of bilio-biliary fistulas when they were pre sent. These 11 cases were reviewed and followed from one to 20 years. Prese ntation, workup, operative findings, choice of operative repair, choice of operative approach, and complications were evaluated by retrospective chart review, Review of the pertinent literature for informative and comparative purposes was also completed. These 11 cases ranged from Csendes Type I to III. There were no Type IV cases. They were ultimately diagnosed and manage d by classical open technique. Four laparoscopic procedures were converted to open technique following initial inspection. All four were converted to open as a result of inability to delineate structures in and adjacent to th e triangle of Calot due to marked scarring in the subhepatic space. No iatr ogenic injuries or major complications occurred. Mirizzi's syndrome occurs in fewer than 0.5 per cent of patients with cholelithiasis. Removal of ston es with partial cholecystectomy and use of gallbladder or cystic duct remna nt to oversew or repair Mirizzi fistulas should be considered. Roux-en-y he paticojejunostomy becomes the procedure of choice when the vascularity or v iability of the hepatic duct or tissues available for duct repair is questi onable, Review of the literature reveals the increase in complications with laparoscopic versus open technique in Mirizzi's syndrome. Although very li ttle direct evidence exists we believe that when this syndrome is diagnosed or strongly suspected open biliary operation is the procedure of choice be cause the increased potential for major complications with the use of lapar oscopic technique far outweighs the potential slight increase in morbidity of an open procedure.