Pitfalls in the management of Mirizzi's syndrome.
Pressure on the common hepatic duct due to a gallstone impacted in Hartmann's pouch or cystic duct results in jaundice and cholangitis. Repeated episodes of inflammation and pressure necrosis lead to the formation of a cholecysto-choledochal fistula (Mirizzi's syndrome Type I & II). Preoperative diagnosis is difficult and a formal cholecystectomy may lead to bile duct injury. Of the 792 patients operated upon for symptomatic gallstone disease from June 1992 to June 1997 at our centre, 18 patients (2%) had Mirizzi's syndrome. There were 11 females and 5 males, with a mean age of 48 (SD 20; range 20-74) years. Thirteen patients (81%) presented with cholangitis. Ultrasound scan suggested the diagnosis of carcinoma gallbladder in 9 (56%). Endoscopic Retrograde Cholangiopancreatography (ERCP) confirmed the diagnosis in 16. Cholecystectomy was done by the fundus first technique. A complete cholecystectomy was done only if there was no cholecysto-choledochal fistula (n = 5), otherwise a cuff of gallbladder was used to repair the bile duct (n = 10). Hepatico-jejunostomy was done to drain the fistula in one patient. A T-tube drain was placed in the common bile duct (CBD) and a cholangiogram done, before closing the abdomen in all. Histology revealed carcinoma in fundus of gallbladder in one patient (6%). One patient died of haemobilia 3 weeks after operation. Wound infection developed in 5 (30%) patients and 12 (75%) have been followed up for a median period of 28 months. One patient developed a biliary stricture with intrahepatic stones and later underwent a hepatico-jejunostomy. Two have undergone repair of incisional hernia. High index of clinical suspicion, ERCP to clinch the diagnosis, NBD to drain the infected bile, a fundus first partial cholecystectomy and primary repair of CBD, followed by a peroperative T-tube cholangiogram, usually leads to a satisfactory outcome.
Sharma
A K
AK
Gastroenterology Centre (Medical and Surgical), Army Hospital (Research & Referral), Delhi. lilki@giasdi101.vsnl.net.in
Rangan
H K
HK
Choubey
R P
RP
Thakur
S K
SK
Kumar
A
A
D001658:Biliary Fistula / Q000209:etiology / Q000628:therapy*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002761:Cholangitis / Q000209:etiology / Q000628:therapy*; D002763:Cholecystectomy; D002769:Cholelithiasis / Q000150:complications* / Q000628:therapy; D003137:Common Bile Duct Diseases / Q000209:etiology / Q000628:therapy*; D004322:Drainage; D005260:Female; D005705:Gallbladder Diseases / Q000209:etiology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013577:Syndrome