title: Complicated gallstone disease: diagnosis and management of Mirizzi syndrome.
abstract: Mirizzi syndrome (MS) is characterized by an obstruction of the proximal bile duct due to extrinsic compression by either an impacted stone in the gallbladder neck or local inflammatory changes. Although this is a rare syndrome in developed countries (0.7-1.4 %), preoperative diagnosis and careful surgical management are essential to avoid bilio-vascular injuries and misdiagnosed malignancy.
  
  
  
  The purpose of this study was to review our experience in the diagnosis and management of MS, assess the role of laparoscopy and the risk of concomitant gallbladder carcinoma. This study took place in a large county hospital which serves indigent and undocumented immigrants without easy access to healthcare. Data were collected through a retrospective chart review of 4939 patients that underwent cholecystectomy over 6 years. Patient demographics, preoperative, intraoperative, postoperative data and outcomes were analyzed.
  
  
  
  MS was identified in 60 of 4939 patients (1.21 %) who underwent cholecystectomy. The mean age at presentation was 47 years, and 35 patients were females. The most common symptom at presentation was abdominal pain (100 %) followed by nausea/vomiting (87 %) and jaundice (43 %). Type I MS was diagnosed in 16 patients and 44 had type II MS. Preoperative diagnosis was achieved in 43 patients (71 %). Magnetic resonance cholangiopancreatography was the best diagnostic modality. Laparoscopic cholecystectomy was successful in 4 out of 16 patients with type I MS. Three patients (5.26 %) had simultaneous gallbladder cancer. Overall morbidity was 27 % and mortality was 0. Clavien grade ≥3 complications were seen in six patients (10 %). The mean length of follow-up was 2.3 months (range 0-5) for type I MS patients and 5.4 months (range 0-46) for type II patients.
  
  
  
  MS is rare, but preoperative diagnosis or intraoperative suspicion is important. Laparoscopic cholecystectomy may be possible in selected type I cases. Open cholecystectomy is the standard of care for type II MS.
authors: Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033-4612, USA. sujit.kulkarni@med.usc.edu.
authors: Sujit S
authors: SS
authors: Kulkarni
authors: Keck School of Medicine, Los Angeles, CA, USA.
authors: Mayo
authors: M
authors: Hotta
authors: Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033-4612, USA.
authors: Linda
authors: L
authors: Sher
authors: Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033-4612, USA.
authors: Robert R
authors: RR
authors: Selby
authors: Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033-4612, USA.
authors: Dilipkumar
authors: D
authors: Parekh
authors: Department of Medicine, Keck Medical Center, University of Southern California, Los Angeles, Los Angeles, CA, USA.
authors: James
authors: J
authors: Buxbaum
authors: Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033-4612, USA.
authors: Maria
authors: M
authors: Stapfer
mesh_terms: D000328:Adult; D049448:Cholangiopancreatography, Magnetic Resonance; D002763:Cholecystectomy; D005260:Female; D005706:Gallbladder Neoplasms / Q000175:diagnosis; D006801:Humans; D008297:Male; D008875:Middle Aged; D057792:Mirizzi Syndrome / Q000145:classification / Q000175:diagnosis* / Q000601:surgery*; D012189:Retrospective Studies
keywords: Bile duct injury; Gallbladder cancer; Gallstone disease; Mirizzi syndrome