Dr Issam Awadallah Department Of General Surgery, SMC Mirizzi Syndrome Dr Issam Awadallah Department Of General Surgery, SMC

DEFENITION common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann’s pouch of the gallbladder.

Professor Pablo Luis Mirizzi (1893-1964). Mirizzi reported his syndrome for the first time in 1940

Incidence Mirizzi syndrome is estimated to occur in 0.05 to 4 percent of patients undergoing surgery for cholelithiasis

Predisposing Factors A long cystic duct parallel to the bile duct A low insertion of the cystic duct into the bile duct, have been regarded as predisposing factors for the development of Mirizzi syndrome

Pathophysiology The pathophysiological process leading to the subtypes of Mirizzi syndrome has been explained by means of a pressure ulcer caused by an impacted gallstone at the gallbladder infundibulum leading to an inflammatory response causing first external obstruction of the bile duct, and eventually eroding into the bile duct and evolving to a cholecystocholedochal or cholecystohepatic fistula.

McSherry Classification McSherry Classification Mirizzi syndrome classified into two types based on the ERCP features Type I: CHD compression without fistula Type II: presence of cholecystocholedochal fistula.

Csendes Classification Csendes Classification Mirizzi syndrome classified into four types: Type I: extrinsic compression of common duct due to an impacted stone at gallbladder neck or cystic duct Type II: cholecystobiliary (either cholecystohepatic or cholecystocholedochal) fistula with the defect less than 1/3 of the duct circumference Type III: fistula formation, wall defect up to 2/3 Type IV: fistula formation, complete destruction of the duct wall

DIAGNOSIS Clinical picture Labratory investigations Ultrasound MRCP ERCP Intraoperative diagnosis

Literature The surgical treatment of Mirizzi syndrome avoids a truly standardized approach and must be individualized depending on the stage of the disease and the expertise of the surgical team

The case 83 y/o man. 6months ago; recurrent attacks of jaundice, RUQ pain and occasional fever. Hx: DM and HTN (controlled). Lab: elevated ALP, LFTs & Bilirubin. US: CBD (1 cm), with stone inside, also big GBS. Patient optimized (Ab, fluids, labs etc..) ERCP: sphinecterotomy , extraction of one CBD stone was done.

Extraction of large CBD stone

Response 5 days post ERCP; abd. pain, increasing jaundice. MRCP

A second ERCP was done and revealed a picture of Mirrizi syndrome (Big stone inside GB compressed the common hepatic duct) so plastic stent inserted inside CBD.

AGAIN ! A 3 weeks later: jaundice / abd. Pain.

Surgery Lap. Chole. Difficult identification. Open chole. Stuck GB with difficult anatomy. Cholecystomy: huge stone extracted, 3 ways folly’s catheter inserted at GB.

RESULTS Uneventful post-operative course. Clinical / lab. Improvement. Day 6: drain removed/ Pt. discharged.

CONCLUSION So,,, cholecystostomy and GBS extraction appears to be a valid safe surgical option for Mirizzi syndrome when it is difficult to identify the key steps of safe surgey.