Mirizzi syndrome: History, current knowledge and proposal of a simplified classification

Table 1 Mirizzi syndrome “anatomy”

Gallbladder	Cystic duct	Bile duct	Fistulas
Thick or thin atrophic walls[25,26,37]	Obliterated cystic duct[2,25,37]	Partial obstruction by external compression or by a gallstone eroding into the bile duct	Cholecystocholedochal fistula[28]
Impacted gallstones at the infundibulum or at the Hartmann’s pouch[26,30,32,37]	Occasional absence of cystic duct[2,25,30]	Normal caliber distal bile duct with walls of normal thickness[2,25,32]	Cholecystoenteric fistula[4,8,28]
	A long cystic duct running parallel to the common bile duct with low insertion[1,25,26,30,31,34]	A dilated proximal bile duct with thick inflamed walls[2,25,32]
	A normal short cystic duct[2,26,30]

Table 2 Mirizzi syndrome milestones and historical classification

Author	External compression of common hepatic duct	Cholecystocholedochal fistula	Cholecystoenteric fistula
Puestow[19], 1942	-	Mirizzi II	-
Mirizzi[13], 1948	Mirizzi I	-	-
Corlette et al[23], 1975	-	Mirizzi II (Fistula type I and II)
McSherry et al[24], 1982	Mirizzi I	Mirizzi II	-
Csendes et al[7], 1989	Mirizzi I	Mirizzi II, III, IV	-
Csendes et al[4], 2008	Mirizzi I	Mirizzi II, III, IV	Mirizzi Va, Vb

Table 3 Incidence of the different types of Mirizzi syndrome according to Csendes 2007 classification

Type of Mirizzi	Incidence (%)[4,7,14,28,29]
I	10.5-78
II	15-41
III	3-44
IV	1-4
V	29

Table 4 New proposed classification and suggested surgical treatment for Mirizzi syndrome

Type of Mirizzi	Description	Treatment
I	External compression of the bile duct	Open cholecystectomy
		Open subtotal cholecystectomy
		Laparoscopic cholecystectomy
		Laparoscopic subtotal cholecystectomy
IIa	Cholecystobiliary fistula < 50% the diameter of the bile duct	Open cholecystectomy
		Open subtotal cholecystectomy
IIb	Cholecystobiliary fistula > 50% the diameter of the bile duct	Open subtotal cholecystectomy
		Biliary-enteric derivation:
		Side-to-side to the duodenum
		En-Y-de-Roux to the Jejunum
IIIa	Cholecystobiliary fistula and cholecystoenteric fistula without gallstone ileus	Simple closure of the fistula and treatment of the gallbladder according to the presence of Mirizzi I, IIa or IIb
IIIb	Cholecystobiliary fistula and cholecystoenteric fistula with gallstone ileus	Treatment of the gallstone ileus and deferred treatment of the gallbladder according to the presence of Mirizzi I, IIa or IIb