A Standardized Surgical Approach for the Treatment of Mirizzi Syndrome

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Abstract
Mirizzi syndrome is a rare complication of long-standing gallstone disease and is defined as a partial or complete common bile duct obstruction caused by an impacted gallstone in the gallbladder neck or cystic duct. A subclassification of Mirizzi syndrome into type-I and II lesions has been proposed. Based on this classification a standardized surgical approach is now proposed. In a retrospective series of 18 cases with Mirizzi syndrome, found among 1,759 cholecystectomies performed since June 1986, we treated 7 type-I and 11 type-II lesions. There were 11 females and 7 males with an average age of 74.8 (range 32-87) years, and there was an increased incidence (27%) of concomitant gallbladder cancer found. All type-I lesions were treated by partial cholecystectomy, and 5 patients had concomitant exploration of the common bile duct with T-tube drainage. All type-II lesions received cholecystocholedochalenteric bypass surgery, namely 8 with a Roux-en-Y enterostomy and 3 with duodenostomy. Two patients (1 type-I+ and 1 type-II lesion) had a laparoscopic approach but needed conversion to open surgery because of severe inflammatory adhesions. There was no postoperative mortality and postoperative morbidity was low at 27% (5 of 18 patients). We had 1 case with postoperative bile leakage and 1 with hemorrhage. Three patients who had had biliary-enteric bypass procedures developed benign hepatic duct strictures which were all treated conservatively using endoscopic stenting. This management strategy has yielded very satisfactory results and laparoscopic surgery has been limited to a very small number of patients with type-I lesions.

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