My take on Mirrizzi syndrome

Pablo Luis Mirrizzi was a much loved surgeon and medical educator from Cordoba in Argentina. He described obstruction of the common hepatic duct arising from compression by a gall stone in the cystic duct.  He introduced the operative cholangiogram as well as describing the syndrome which bears his name. If you are interested in surgical history you can read more about his life in this very nice article in the Australia and New Zealand Journal of Surgery from Guy Maddern.

As with many things in surgery this initial description was extended to include external compression of the common hepatic duct from gallstones in the gall bladder. Along with this broadening of definition came the inevitable requirement for a formal classification of Mirrizzi syndrome and its subtypes.

Type I – No fistula present

  • Type IA – Presence of the cystic duct
  • Type IB – Obliteration of the cystic duct

Types II-IV – Fistula present

  • Type II – Defect smaller than 33% of the CBD diameter
  • Type III – Defect 33-66% of the CBD diameter
  • Type IV – Defect larger than 66% of the CBD diameter

represented here in this figure taken from Chatzoulis et al BMC Surgery 2007, 7:6.

My classification is much more simple and is based on whether there is a fistula or not. I am not particularly interested in how big the hole in the bile duct is because I dont think it really matters.

If there is no fistula you can simply perform a cholecystectomy and leave the bile duct alone. Part of the obstruction of the bile duct is caused by inflammation and this will rapidly resolve following cholecystectomy. If the wall of the gall bladder or cystic duct is firmly adherent to the common hepatic or common bile duct I would leave it alone for fear of either creating a fistula or devascularizing the bile duct. In this setting post operative stricture formation is rare.

If there is a fistula there are a number of operations which have been described including using serosal patches gallbladder rotation flaps and all sorts of ingenious techniques to close the defect in the bile duct. My advice is to not do any of these but to simply transect the bile duct, tie or suture off the distal end and perform a hepaticojejunostomy Roux-en-Y.

Cartoon indicating surrounding zone of damage around fistula created by a gallstone

I have never had a problem with recurrent biliary stricture from Mirrizzi’ syndrome with a fistula after doing a hepaticojejunostomy but I have seen several problems in patients who have had flap or patch type repair procedures. My logic (perhaps flawed) for this approach is based on the problem that causes the fistula. Imagine trying to insert a bowling ball into a drain pipe from the side (this is probably not a good analogy). Even if you manage to make a small hole in the drainpipe at the apex of the ball, the area surrounding the hole will undoubtedly be damaged and this tends to heal by scarring, resulting in the risk of stricture formation.

My advice for Mirrizzi syndrome- keep it simple both in classification and treatment.

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