Mirizzi syndrome

the external biliary compression

1. Mirizzi’s syndrome Dr.Asif Mian Ansari DNB Resident Dept. of General surgery Max super speciality Hospital, Mohali , Punjab

2. Introduction Extrinsic bile duct compression syndrome Pablo Luis Mirizzi (1948)  Hepatic duct syndrome Kehr (1905) & Ruge (1908)  partial CHD obstruction secondary to impacted calculi & associated inflammation Compression of common hepatic duct  obstruction  liver dysfunction

3. Introduction Incidence : <1% in developed countries 4.7 to 5.7% in developing countries Fourth to seventh decade of life Gall bladder cancer (>25%) Updates in Mirizzi syndrome, Alan Isaac et al. HepatoBiliary Surg Nutr 2017;6(3):170-178

4. Classification McSherry et al.(1982)  2 types Type I: partial or complete external obstruction of CHD Type II: cholecysto-choledochal fistula Csendes et al.(1989)  4 types Subclassified cholecysto-choledochal fistula In 2007, Csendes extended the classification which was validated by Beltran

5. Classification Type I Type III Type II Type IV Type V

6. Classification Type Incidence Mortality I 10.5-52 % 0.6 % II 23.2-41 % 4.0 % III 44 8.0 % IV 1-6 % 20 % V 29 % 15-22 % Updates in Mirizzi syndrome, Alan Isaac et al. HepatoBiliary Surg Nutr 2017;6(3):170-178

7. Clinical presentation Fever Pain right upper abdomen Jaundice Nausea & vomiting Dark colored urine Patient may present as a case of acute cholecystitis , acute cholangitis or acute pancreatitis

8. Anatomy of Mirizzi’s syndrome Gallbladder Atrophy—anomalous communication with: bile duct, stomach, duodenum, colon, another abdominal viscera Infundibulum (Hartmann’s pouch) Impacted gallstone Bile duct External compression, gallstone eroded, distal, normal caliber, normal thickness walls Proximal, normal caliber, thick and inflamed walls Cystic duct Abnormal high merger with common hepatic duct Entrance to right hepatic duct Congenital anatomical variations Fistula cholecysto-choledochal fistula , cholecysto -enteric fistula

9. Evaluation : LAB investigations High bilirubin , ALP and Transaminases Elevated CA 19-9 (>20000 in Type II or more)

10. Radiology Ultrasonography : Contracted GB Impacted stone IHBR Dilatation above obstruction Sensitivity 8.3 to 57 % Specificity 90.9 to 100 %

11. Radiology Computed tomography scan: Malignancy can be ruled out Peri-ductal inflammation can be misinterpreted as Ca 40-45 % sensitive * Mirizzi Syndrome: Our Experience with 27 Cases in PUMC Hospital; Xie - qun Xu , Chin Med Sci J Vol. 28, No. 3 September 2013

12. Radiology ERCP Detailed anatomy of syndrome Allows intervention (biopsy/removal of calclui / stenting ) Complications * Mirizzi Syndrome: Our Experience with 27 Cases in PUMC Hospital; Xie - qun Xu , Chin Med Sci J Vol. 28, No. 3 September 2013 METHOD OF CHOICE

13. Radiology MRCP Degree of obstruction Other causes of obstruction Non invasive Sometimes unable to diagnose fistula Sen – 77.8 to 100 % Sp – 93.5 %

14. Intraoperative diagnosis Most common Contracted gall bladder with distorted anatomy Impacted stones in neck Obliterated calot’s

15. Treatment TYPE I Cholecystectomy with cholangiography TYPE II Subtotal cholecystectomy; (II) stone extraction, suture of bile duct and catheterization in T; (III) Roux-en-Y hepaticojejunostomy ; (IV) cholecysto-choledocho-duodenostomy ; (V) cholecysto-choledocho-jejunostomy TYPE III (I) Subtotal cholecystectomy; (II) stone extraction, suture of bile duct and catheterization in T; (III) Roux-en-Y hepaticojejunostomy ; (IV) choledochoplasty TYPE IV (I) Subtotal cholecystectomy; (II) bilioenteric to the duodenum anastomosis ; (III) Roux-en-Y hepaticojejunostomy TYPE Va (I) Division and simple suture of biliary-enteric fistulas on the viscera involved; (II) total or subtotal cholecystectomy according to the presence of a cholecystobiliary fistula TYPE V b (I) Treating gallstone ileus ; (II) in second intention total or subtotal cholecystectomy

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