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

2. 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.

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

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

5. 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

6. 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.

7. 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.

8. 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

10. DIAGNOSIS Clinical picture Labratory investigations Ultrasound MRCP
ERCP
Intraoperative diagnosis

11. 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

12. 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.

13. Extraction of large CBD stone

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

18. 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.

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

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

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

23. 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.