ERCP findings of Mirizzi's type II Syndrome

May 25, 2007
Surgical Rounds, April 2006, Volume 0, Issue 0

Henry Talus, Chief Resident, Department of Surgery, Harlem Hospital Center, New York, NY; Sitaram Pillarisetty, Assistant Clinical Professor, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, Chief of Laparoscopic and Endoscopic Surgery, Department of Surgery, Harlem Hospital Center, New York, NY

Henry Talus, MD Chief Resident

Department of Surgery

Harlem Hospital Center

New York, NY

Sitaram Pillarisetty, MD

Assistant Clinical Professor

Department of Surgery College of Physicians and Surgeons Columbia University

New York, NY

Chief of Laparoscopic and Endoscopic Surgery

Department of Surgery

Harlem Hospital Center

New York, NY

Mirizzi's syndrome is an un?common complication of longstanding gallstone disease, re?sulting in obstructive jaundice. The syn?drome occurs in 0.7% to 1.1% of all patients undergoing cholecystectomy.1-3 McSherry and colleagues classified Mi?rizzi's syndrome into two types based on endoscopic retrograde cholangiopancreatography (ERCP) findings.4 Type I involves external compression of the com?mon hepatic duct by a large stone impacted at the cystic duct or Hartmann's pouch. Type II involves the presence of a cholecystocholedochal fistula, which is caused by the stone partially or completely eroding into the common bile duct. We report the case of a 36-year-old woman who presented with obstructive jaundice and was found to have type II Mirizzi's syndrome based on the ERCP findings. Open partial cholecystectomy, common bile duct exploration, removal of the stone, and cholecystoduodenostomy were performed to treat this patient.

Case report

?

A 36-year-old woman was admitted to a community hospital because of a 6-day history of right upper quadrant abdominal pain, jaundice, and nausea. The pa?tient had experienced a few similar episodes over the previous year, which resolved spontaneously. Abdominal examination elicited mild tenderness in the right upper quadrant with no signs of peritonitis on palpation. The patient had no other comorbidities. Per?tinent laboratory results revealed a white blood cell count of 9.0 x 103/L, total bilirubin of 8.9 mg/dL, direct bilirubin of 6.2 mg/dL, and alkaline phospha?tase of 235 U/L. All other laboratory values were within normal limits. The pa?tient underwent abdominal ultrasonography, which showed a 1-cm gallstone in the neck of the gallbladder, a gallbladder wall thickness of 2.7 mm, and a common bile duct that was dilated to 1.6 cm. Be?cause ERCP was unsuccessful at the community hospital, she was referred to our institution.

Before undergoing ERCP at our hospital, the patient received prophylactic antibiotics. ERCP revealed a dilated com?mon bile duct with a stone at the distal end and compression of the common hepatic duct by a large stone impacted in the Hartmann's pouch (Figures 1 and 2). Type II Mirizzi's syndrome was diagnosed by passage of a guidewire into the gallbladder via the fistula (Figure 3). Re?moval of the stones after sphincterotomy was not successful using Dormia baskets and balloon catheters. A biliary stent was placed to drain the common hepatic duct (Figure 4), and the decision was made to do an open cholecystectomy followed by exploration of the common bile duct. Two days later, a laparotomy was performed through a right subcostal incision. The gallbladder was found to be contracted and thickened. Dense fibrosis, inflammation, and adhesions were noted near Calot's triangle and the hepatoduodenal ligament. Cholecystectomy was performed using the fundus-first technique, which spared part of the Hartmann's pouch. Upon reaching the neck of the gallbladder, a type II Mirizzi's fistula was identified between the Hartmann's pouch and common bile duct. A 1.5-cm, im?pacted gallstone that eroded into the common bile duct was gently removed via the open Hartmann's pouch. The distal common bile duct was explored, but removal of the distal impacted stone was not successful. A cholecystoduodenostomy was performed using 3.0 poliglecaprone continuous sutures. Two closed-suction drains were placed in the Morrison's pouch and the abdomen was closed.

The patient had an uneventful postoperative recovery and her direct bilirubin dropped to 0.9 mg/dL a few days after the operation. She was discharged from the hospital on postoperative day 5 with one drain in situ, which was removed on postoperative day 8.

Discussion

Mirizzi's syndrome is caused by longstanding impacted stones at the cystic duct or Hartmann's pouch, which result in partial or complete obstruction of the common bile duct, leading to obstructive jaundice.5 Mirizzi's syndrome is diagnosed in 0.7% to 1.1% of all patients undergoing cholecystectomy.1-3 In 1982, McSherry and colleagues divided Mirizzi's syndrome into two types based on the ERCP findings.4 Type I involves external compression of the common hepatic duct by a large stone impacted at the cystic duct or Hartmann's pouch. Type II involves a cholecystocholedochal fistula, which is caused by the stone partially or completely eroding into the common bile duct.

Preoperative diagnosis of Mirizzi's syndrome is invaluable in devising a man?agement strategy. Ultrasonography of the biliary system and ERCP (with or without computed tomography scanning) are sensitive and specific enough to establish a preoperative diagnosis.6 Dur?ing ERCP, clinicians should have a high index of suspicion for Mirizzi's syndrome in any patient with obstructive jaundice whose ultrasound shows stones in the cystic duct and evidence of cholecystitis. Because ERCP allows drainage to relieve cholangitis, some studies indicate it may improve the surgical results.7-9

Patients with Mirizzi's syndrome usually have a shrunken gallbladder with dense adhesions and severe inflammatory changes in Calot's triangle and along the hepatoduodenal ligament.10 Re?moval of the entire gallbladder increases the risk of bile duct injury and the morbidity associated with bile duct repair.2 During the operation, the general principle is to avoid dissection of Calot's triangle and to do a partial cholecystectomy using a fundus-first technique.1,10-14 This strategy should be sufficient for treating type I Mirizzi's syndrome because it removes the gallstone, allowing the obstructive jaundice to re?solve, and prevents late stricture formation.1,10,11,13-15 Common bile duct exploration is not necessary if the operative cholangiogram shows no stones in this duct.10

Management of type II Mirizzi's syndrome is more challenging. The choice of operation depends on the size of the fistula and the quality of the surrounding tissue. If primary suture closure (with or without a flap from the remnant gallbladder wall) is possible to repair the fistula, a T-tube is inserted into the common bile duct to protect the repair.1,15-17 If primary suture closure cannot be performed safely, a bilioenteric anastomosis should be undertaken.1,10 A cholecystocholedochoduodenostomy was required to treat our patient because the defect was large and there was an impacted stone in the distal common bile duct.

Conclusion

ERCP is extremely useful in diagnosing Mirizzi's syndrome and assessing the anatomy. Partial cholecystectomy and removal of gallstones is the treatment of choice for type I Mirizzi's syndrome. Primary suture repair with a T-tube or a bilioenteric anastomosis are the treatment options for patients with type II Mirizzi's syndrome. If there is obstruction of the distal common bile duct, the latter option is used.

References

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13. Redaelli CA, Buchler MW, Schilling MK, et al. High coincidence of Mirizzi syndrome and gallbladder carcinoma. Surgery. 1997;121(1): 58-63.

14. Sutton JP, Sachatello CR. The confluence stone. A hazardous complication of biliary tract disease. Am J Surg. 1967;113(5): 719-722.

15. Csendes A, Diaz JC, Burdiles P, et al. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg. 1989;76(11):1139-1143.

16. Dewar G, Chung SC, Li AK. Operative strategy in Mirizzi syndrome. Surg Gynecol Obstet. 1990;171(2):157-159.

17. Yip AW, Chow WC, Chan J, et al. Mirizzi syndrome with cholecystocholedochal fistula: preoperative diagnosis and management. Surgery. 1992;111(3): 335-338.

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