• Mirizzi syndrome
• cholelithiasis
• laparoscopic cholecystectomy
• laparoscopic procedures

• biliary-enteric anastomosis
• cholecystobiliary fistula
• choledocholithiasis
• cholelithiasis
• mirizzi syndrome
• obstructive jaundice
• subtotal cholecystectomy

• cystic duct fibrosis
• hydrops gallbladder
• laparoscopic cholecystectomy
• magnetic resonance cholangiopancreatography
• mirizzi syndrome
• obstructive jaundice

• Artery injury
• Bile duct injury
• Mirizzi syndrome
• Subtotal cholecystectomy
• Surgical treatment

• Humans
• Mirizzi Syndrome/diagnostic imaging
• Mirizzi Syndrome/surgery
• Cholangiopancreatography, Endoscopic Retrograde
• Cholelithiasis/surgery
• Cholecystectomy
• Bile Ducts

• Mirizzi syndrome
• bile duct injury
• cholecystectomy
• choledocholithiasis
• cholelithiasis
• laparoscopic
• subtotal cholecystectomy

• Humans
• Mirizzi Syndrome/diagnosis
• Mirizzi Syndrome/surgery
• Mirizzi Syndrome/complications
• Gallstones/complications
• Fistula/complications
• Fistula/surgery
• Cholecystectomy
• Cholecystectomy, Laparoscopic

• bile leak/injury rate
• conversion rate
• laparoscopic cholecystectomy
• major complication rate
• open cholecystectomy

Mirizzi syndrome (MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct (CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.

To evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.

From 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed.

Gallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas (P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis (odds ratio 5.82, P = 0.002; 0.12, P = 0.008, respectively).

Gall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.

• Cholecystectomy
• Cholecystocholedochal fistula
• Common bile duct
• Endoscopic retrograde cholangiopancreatography
• Mirizzi syndrome

• Cholangiopancreatography, Endoscopic Retrograde
• Cholecystectomy
• Cholecystectomy, Laparoscopic
• Common Bile Duct
• Fistula
• Humans
• Mirizzi Syndrome/diagnostic imaging
• Mirizzi Syndrome/surgery

• Cholecystitis
• Mirizzi's syndrome
• cholecystobiliary fistula
• choledocholithiasis
• hepatolithiasis

• Cholecystectomy
• Classification
• Gallstone
• Management
• Mirizzi syndrome

• Adult
• Aged
• Aged, 80 and over
• Anastomosis, Surgical/adverse effects
• Cholangiography
• Cholangiopancreatography, Endoscopic Retrograde
• Cholangiopancreatography, Magnetic Resonance
• Cholecystectomy, Laparoscopic/adverse effects
• Female
• Hepatic Duct, Common/surgery
• Hospitals, General
• Humans
• Intestine, Small/surgery
• Male
• Middle Aged
• Mirizzi Syndrome/diagnostic imaging
• Mirizzi Syndrome/surgery
• Multimodal Imaging
• Retrospective Studies
• Singapore
• Tomography, X-Ray Computed
• Ultrasonography
• Young Adult

Mirizzi syndrome, also known as extrinsic biliary compression syndrome, is a rare clinical entity in which the common bile duct is obstructed by compression by the impaction of one or more gallstones in the cystic duct or gallbladder infundibulum. This case illustrates an absolutely asymptomatic presentation of Mirizzi syndrome in a 62-year-old, otherwise healthy, woman. Mirizzi syndrome was treated with preemptive laparotomy cholecystectomy. The present case is exemplary for careful evaluation with the proper index of suspicion in establishment of preoperative diagnosis as well as prompt treatment prior to development of complications.

• cholecystectomy
• gallstone
• mirizzi syndrome

• Cholecystectomy
• Cholecystoenteric fistula
• Cholelithiasis
• Mirizzi syndrome

• Choledochotomy
• Cystocholedochal
• Infundibulotomy
• Laparoscopic bile duct exploration
• Mirizzi syndrome
• Single-incision laparoscopic surgery
• Transfistulous

• Adult
• Cholangiopancreatography, Endoscopic Retrograde
• Cholecystectomy, Laparoscopic
• Choledocholithiasis/diagnosis
• Choledocholithiasis/surgery
• Common Bile Duct/surgery
• Female
• Humans
• Length of Stay
• Male
• Middle Aged
• Mirizzi Syndrome/diagnosis
• Mirizzi Syndrome/surgery
• Operative Time
• Retrospective Studies

• Mirizzi syndrome
• cholecystitis
• cholelithiasis
• gallstone disease

Mirizzi's syndrome (MS) poses great diagnostic and management challenge to the treating physician. We presented our experience of MS cases with respect to clinical presentation, diagnostic difficulties, surgical procedures and outcome.

Prospectively maintained data of all surgically treated MS patients were analyzed.

A total of 169 MS patients were surgically managed between 1989 and 2011. Presenting symptoms were jaundice (84%), pain (75%) and cholangitis (56%). Median symptom duration s was 8 months (range, <1 to 240 months). Preoperative diagnosis was possible only in 32% (54/169) of patients based on imaging study. Csendes Type II was the most common diagnosis (57%). Fistulization to the surrounding organs (bilio-enteric fistulization) were found in 14% of patients (24/169) during surgery. Gall bladder histopathology revealed xanthogranulomatous cholecystitis in 33% of patients (55/169). No significant difference in perioperative morbidity was found between choledochoplasty (use of gallbladder patch) (15/89, 17%) and bilio-enteric anastomosis (4/28, 14%) (p=0.748). Bile leak was more common with choledochoplasty (5/89, 5.6%) than bilio-enteric anastomosis (1/28, 3.5%), without statistical significance (p=0.669).

Preoperative diagnosis of MS was possible in only one-third of patients in our series. Significant number of patients had associated fistulae to the surrounding organs, making the surgical procedure more complicated. Awareness of this entity is important for intraoperative diagnosis and consequently, for optimal surgical strategy and good outcome.

• Bile duct disease
• Cholestasis
• Mirizzi syndrome

Biliary fistulas are rare complications of gallstone. They can affect either the biliary or the gastrointestinal tract and are usually classified as primary or secondary. The primary fistulas are related to the biliary lithiasis, while the secondary ones are related to surgical complications. Laparoscopic surgery is a therapeutic option for the treatment of primary biliary fistulas. However, it could be the first responsible for the development of secondary biliary fistulas. An accurate preoperative diagnosis together with an experienced surgeon on the hepatobiliary surgery is necessary to deal with biliary fistulas. Cholecystectomy with a choledocoplasty is the most frequent treatment of primary fistulas, whereas the bile duct drainage or the endoscopic stenting is the best choice in case of minor iatrogenic bile duct injuries. Roux-en-Y hepaticojejunostomy is the extreme therapeutic option for both conditions. The sepsis, the level of the bile duct damage, and the involvement of the gastrointestinal tract increase the complexity of the operation and affect early and late results.

Gallstone obstruction of the cystic duct, resulting in chronic cholecystitis and pressure necrosis leads to the formation of biliobiliary fistula (BBF). We herein reported a case of Mirizzi syndrome (MS) with an unusual type of BBF (Corlette type I) that was successfully managed by a staged treatment strategy. The patient was diagnosed with a solitary gallstone, marked atrophy of the gallbladder, and BBF and underwent mucosal incineration of the atrophic gallbladder and simple closure, followed by extirpation of gallbladder. Although an optimal treatment strategy has not yet been established for MS with BBF because of its rarity and anatomical variations in fistulas, the current treatment strategy may be applicable. In conclusion, clinicians need to carefully diagnose and evaluate chronic cholecystitis in MS with BBF and adopt an optimal treatment strategy to avoid the complication associated with this disease.

• Biliobiliary fistula
• Chronic cholecystitis
• Mirizzi syndrome
• Surgery

• Adult
• Aged
• Anastomosis, Surgical
• Cholangiopancreatography, Endoscopic Retrograde
• Cholangiopancreatography, Magnetic Resonance
• Cholecystectomy/methods
• Cholelithiasis/complications
• Cholelithiasis/surgery
• Common Bile Duct/surgery
• Female
• Follow-Up Studies
• Humans
• Incidence
• Jejunum/surgery
• Laparoscopy
• Liver/surgery
• Male
• Middle Aged
• Mirizzi Syndrome/diagnosis
• Mirizzi Syndrome/epidemiology
• Mirizzi Syndrome/etiology
• Mirizzi Syndrome/surgery
• Postoperative Complications
• Retrospective Studies
• Treatment Outcome
• Ultrasonography

Chronic complications of symptomatic gallstone disease, such as Mirizzi syndrome, are rare in Western developed countries with an incidence of less than 1% a year. The importance and implications of this condition are related to their associated and potentially serious surgical complications such as bile duct injury, and to its modern management when encountered during laparoscopic cholecystectomy. The pathophysiological process leading to the subtypes of Mirizzi syndrome has been explained by means of a pressure ulcer caused by an impacted gallstone at the gallbladder infundibulum, leading to an inflammatory response causing first external obstruction of the bile duct, and eventually eroding into the bile duct and evolving to a cholecystocholedochal or cholecystohepatic fistula. This article reviews the life of Pablo Luis Mirizzi, describes the earlier and later descriptions of Mirizzi syndrome, discusses the pathophysiological process leading to the development of these uncommon fistulas, reviews the current diagnostic modalities and surgical approaches and finally proposes a simplified classification for Mirizzi syndrome intended to standardize the reports on this condition and to eventually develop a consensual surgical approach to this unexpected and seriously dangerous condition.

• Cholelithiasis
• Chronic gallbladder disease
• Gallstone disease
• Mirizzi syndrome

Mirizzi’s syndrome is a rarely observed disorder that presents with obstructive jaundice. The condition is caused by a stone impacted in the gall bladder neck or cystic duct that impinges on the common hepatic duct, with or without a cholecystocholedochal fistula. The condition is often confused with other serious conditions such as hilar cholangiocarcinoma, which present with similar clinical and imaging findings, and a pre-operative diagnosis may be a serious challenge.

We present the case of a 44-year-old Asian man with Mirizzi’s syndrome who was initially diagnosed as having cholangiocarcinoma based on his clinical presentation, raised cancer antigen 19–9 levels and radiological findings. Our patient was diagnosed as having Mirizzi’s syndrome intra-operatively and subsequently a cholecystectomy was performed with restoration of biliary drainage. Careful clinical assessment during surgery with the help of intra-operative frozen section helped in establishing the definitive diagnosis and altered the surgical procedure for our patient.

Pre-operative diagnosis of Mirizzi’s syndrome could be challenging as the clinical, biochemical and radiological presentation is similar to other conditions causing obstructive jaundice such as choledocholithiasis, bile duct stricture or cholangiocarcinoma. A high index of suspicion and careful surgical assessment may help in establishing a diagnosis and alter the clinical course for our patient.

• Cholecysto-enteric fistula
• Endoscopic retrograde cholangiopancreatography
• Gallstone
• Mirizzi syndrome
• Obstructive jaundice

Mirizzi syndrome is a rare cause of intermittent obstructive jaundice, where an impacted stone in the cystic duct or Hartmann’s pouch mechanically obstructs the common bile duct (CBD). We report a rare case of double cholecysto-biliary and cholecysto-enteric fistulae, in a 75-year-old female patient, presenting with a right upper quadrant abdominal pain and intermittent obstructive jaundice. Endoscopic retrograde cholangiopancreatography suggested Mirizzi syndrome. Operative findings included erosions of the lateral wall of the CBD and the second portion of the duodenum due to impacted gallstones. The defects were reconstructed primarily and a Kehr tube was inserted. The patient had an uneventful postoperative course and was discharged on the 14th postoperative day.

• Mirizzi syndrome
• Obstructive jaundice
• Gallstone
• Cholecysto-enteric fistula
• Endoscopic retrograde cholangiopancreatography

• Aged
• Carcinoma/diagnosis
• Cholangiopancreatography, Endoscopic Retrograde
• Choledocholithiasis/diagnostic imaging
• Choledocholithiasis/pathology
• Choledocholithiasis/surgery
• Cholestasis, Extrahepatic/diagnosis
• Cholestasis, Extrahepatic/etiology
• Cholestasis, Extrahepatic/surgery
• Common Bile Duct Neoplasms/diagnosis
• Diagnosis, Differential
• Humans
• Male
• Stents
• Syndrome

• Cholecystobiliary fistula
• Mirizzi syndrome
• Obstructive jaundice

• Adult
• Aged
• Aged, 80 and over
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholecystectomy/methods
• Choledocholithiasis/complications
• Choledocholithiasis/diagnosis
• Choledocholithiasis/surgery
• Cholestasis, Extrahepatic/diagnosis
• Cholestasis, Extrahepatic/etiology
• Cholestasis, Extrahepatic/surgery
• Diagnosis, Differential
• Female
• Follow-Up Studies
• Gallstones/complications
• Gallstones/diagnosis
• Gallstones/surgery
• Humans
• Male
• Middle Aged
• Prospective Studies
• Syndrome
• Treatment Outcome

• Aged
• Biliary Fistula/etiology
• Biliary Fistula/surgery
• Common Bile Duct Diseases/etiology
• Common Bile Duct Diseases/surgery
• Gallbladder Diseases/etiology
• Gallbladder Diseases/surgery
• Gallstones/complications
• Gallstones/surgery
• Humans
• Jaundice, Obstructive/etiology
• Jaundice, Obstructive/surgery
• Liver Diseases/etiology
• Male

Mirizzi syndrome is a rare complication of prolonged cholelithiasis with presence of large, impacted gallstone into the Hartman's pouch, causing chronic extrinsic compression of common bile duct (CBD). Fistula formation between the CBD and the gallbladder may represent an outcome of that condition. According to Mirizzi's classification and Csendes's subclassification, Mirizzi syndrome type IV represents the most uncommon type (4%).

Spontaneous biliary-enteric fistulas have also been rarely reported (1.2–5%) in a large series of cholecystectomies. Cholecystocolic fistula is the most infrequent biliary enteric fistula, causing significant morbidity and representing a diagnostic challenge.

We describe a very rare, to our knowledge, combination of Mirizzi syndrome type IV and cholecystocolic fistula. A 52 year old male, presented to our clinic complaining of episodic diarrhea (monthly episodes lasting 16 days), high temperature (38°C–39°C), right upper quadrant pain without jaundice. The definitive diagnosis was made intraoperatively. Magnetic Resonance Imaging (MRI) and Endoscopic Retrograde Cholangiopancreatography (ERCP) demonstrated the presence of Mirizzi syndrome with cholecystocolic fistula formation. The patient was operated upon, and cholecystectomy, cholecystocolic fistula excision and Roux-en-Y biliary-enteric anastomosis were undertaken with excellent post-operative course.

Appropriate biliary tree imaging with ERCP and MRI/MRCP is essential for the diagnosis of Mirizzi syndrome and its complications. Cholecystectomy, fistula excision and biliary-enteric anastomosis with Roux-en-Y loop appears to be the most appropriate surgical intervention in order to avoid damage to Calot's triangle anatomic elements. Particularly in our case, ERCP was a valuable diagnostic tool that Mirizzi syndrome type IV and cholecystocolic fistula.

• Biliary Fistula/complications
• Biliary Fistula/surgery
• Cholangiopancreatography, Endoscopic Retrograde
• Choledocholithiasis/complications
• Choledocholithiasis/surgery
• Colonic Diseases/complications
• Colonic Diseases/surgery
• Common Bile Duct/pathology
• Common Bile Duct Diseases/complications
• Common Bile Duct Diseases/surgery
• Constriction, Pathologic
• Humans
• Intestinal Fistula/complications
• Intestinal Fistula/surgery
• Magnetic Resonance Imaging
• Male
• Middle Aged
• Syndrome

• Aged
• Biliary Fistula/epidemiology
• Common Bile Duct Diseases/epidemiology
• Common Bile Duct Diseases/pathology
• Female
• Gallbladder Neoplasms/epidemiology
• Gallbladder Neoplasms/pathology
• Humans
• India/epidemiology
• Male
• Middle Aged
• Retrospective Studies
• Syndrome

• Cholecystectomy
• Common Bile Duct Diseases/classification
• Common Bile Duct Diseases/diagnosis
• Common Bile Duct Diseases/epidemiology
• Common Bile Duct Diseases/surgery
• Comorbidity
• Endoscopy, Gastrointestinal
• Gallbladder Neoplasms/diagnosis
• Gallbladder Neoplasms/epidemiology
• Humans
• Intestinal Fistula/epidemiology
• Intestinal Fistula/surgery
• Laparoscopy
• Syndrome

Mirizzi syndrome (MS) is an uncommon complication of gallstone disease and occurs in approximately 1% of all patients suffering from cholelithiasis. The syndrome is characterized by extrinsic compression of the common hepatic duct frequently resulting in clinical presentation of intermittent or constant jaundice. Most cases are not identified preoperatively. Surgery is the indicated treatment for patients with MS. We report here a 71-year-old male patient referred to the surgical outpatient department for diffuse upper abdominal pain and mild jaundice (bilirubin rate: 4.2 mg/dL). Ultrasound examination revealed a stone in the cystic duct compressing the common hepatic duct. The patient had a history of gastrectomy for gastric ulcer 30 years ago. MRCP revealed a stone impacted in the cystic duct causing obstruction of the common hepatic duct by extrinsic compression. With these findings the preoperative diagnosis was indicative of MS. At laparotomy a moderately shrunken gallbladder was found embedded in adhesions containing a large stone which was palpable in the common bile duct. The anterior wall of the body of the gallbladder was opened by an incision which extended longitudinally along the gallbladder towards the common bile duct. The stone measuring 3.0 cm in diameter, was then removed setting astride a large communication with the common bile duct. A Roux-en-Y cholecysto-choledocho-jejunostomy was performed. The subhepatic region was drained. The patient had an uneventful recovery. He was discharged eleven days after operation and remained well after a 30-mo follow-up.

• Benign jaundice
• Hepatic duct obstruction
• Impacted gallstone
• Cholecystobiliary fistula

• Abdominal Pain/diagnosis
• Abdominal Pain/etiology
• Aged
• Anastomosis, Surgical
• Cholelithiasis/complications
• Cholelithiasis/diagnosis
• Cholelithiasis/surgery
• Gallbladder/surgery
• Hepatic Duct, Common/physiopathology
• Humans
• Jaundice, Obstructive/diagnosis
• Jaundice, Obstructive/etiology
• Jejunostomy/methods
• Male
• Syndrome

• Biliary Tract Diseases/diagnosis
• Biliary Tract Diseases/therapy
• Cholangiopancreatography, Endoscopic Retrograde
• Diagnosis, Differential
• Duodenoscopes
• Endoscopy, Digestive System/methods
• Humans
• Lithotripsy
• Sensitivity and Specificity

• Adult
• Aged
• Biliary Tract Surgical Procedures
• Cholelithiasis/complications
• Cholelithiasis/diagnosis
• Cholelithiasis/surgery
• Cholestasis, Extrahepatic/complications
• Cholestasis, Extrahepatic/diagnosis
• Cholestasis, Extrahepatic/surgery
• Cystic Duct
• Female
• Hospitals, Teaching
• Humans
• Male
• Middle Aged
• Retrospective Studies
• Saudi Arabia
• Syndrome
• Treatment Outcome

• mirizzi's syndrome
• biliary fistula
• cholecystocholedochal fistula