A Retrospective Review of the Diagnostic and Management Challenges of Mirizzi Syndrome at the Singapore General Hospital.
Mirizzi syndrome (MS) occurs when gallstone impaction in Hartmann's pouch results in extrinsic obstruction of the common bile duct, and fistulation may occur. We retrospectively reviewed electronic records of patients surgically treated for MS from November 2001 to June 2012. Patient presentations, diagnostic methods, treatments and complications were recorded. Sixty-four patients were grouped according to a classification proposed by Beltran et al. [World J Surg 2008; 32: 2237-2243]. Forty-three (66.2%), 18 (27.7%) and 3 (4.6%) patients were classified as types I, II, and III respectively. Magnetic-resonance-cholangiopancreaticography was the most sensitive imaging modality, suggesting MS in 24 (88.9%), followed by CT scan (40%) and ultrasonography (11.4%). Forty-four underwent Endoscopic-retrograde-cholangiopancreaticography and 29 (65.9%) suggested the presence of MS. MS was accurately diagnosed pre-operatively in 48 (73.8%) patients. In type I, 40 (93.0%) patients underwent cholecystectomy, while 3 required hepaticojejunostomy. In type II, 12 (66.7%) underwent cholecystectomy and 5 (27.8%) required hepatico-enteric anastomosis. In type III, 1 underwent cholecystectomy and 2 (66.7%) required hepatico-enteric anastomosis. Laparoscopic cholecystectomy was attempted in 20 (30.8%) patients and 13 (65.0%) required conversion. Twenty-nine (44.6%) underwent intra-operative-cholangioscopy, 30 (46.2%) underwent intra-operative-cholangiogram and 41 (63.1%) underwent intra-operative T-tube placement. Six (9.2%) experienced intra-operative complications, 12 (18.5%) experienced post-operative complications and 10 (15.4%) experienced late complications. MS is a challenging condition and multimodal diagnostic approach has the greatest yield in achieving accurate pre-operative diagnosis. If suspicion is high, a trial of laparoscopic dissection with low threshold for open conversion is recommended.
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