Intraoperative Management of Mirizzi Syndrome with Cholecystohepaticodochal Fistula: A Case Report.

Christopher F McNicoll, MD, MPH, MS1, Raffi A Kotoyan, MD1, Lindsay M Wenger, MD1, Cory G Richardson, MD1, Charles R St. Hill, MD, MSc, FACS1, Matthew S Johnson, MD2, Nathan I Ozobia, MD, FACS3. 1Department of Surgery, University of Nevada School of Medicine, 2Desert Surgical Associates, Las Vegas, Nevada, 3University Medical Center of Southern Nevada

Pablo L. Mirizzi described in 1948 the eponymous syndrome of obstructive jaundice caused by a gallstone compressing the common hepatic duct.  Cholecystobiliary and bilioenteric fistulae are complications of Mirizzi syndrome, as further classified by McSherry and Csendes in 1982 and 1989, respectively.  Mirizzi syndrome affects 0.7% to 1.1% of patients undergoing cholecystectomy, though fistulae are less common.  Unusual biliary anatomic variants in 25% to 43% of patients complicate the diagnosis, though cholangiography or endoscopic retrograde cholangiopancreatography (ERCP) by the surgeon is beneficial.  We describe the management of a cholecystohepaticodochal fistula secondary to Mirizzi Syndrome, involving a biliary anatomical variant.

This 59 year old male presented to the emergency department with one month of intermittent right upper quadrant pain, nausea, vomiting, dark colored urine, acholic stool, 15 pound weight loss, scleral icterus, and jaundice.  His abdomen was soft, nondistended, without Murphy sign, but with mild tenderness in the right upper quadrant and hepatomegaly.  One month prior, he was treated non-operatively for cholecystitis at an outside hospital with ciprofloxacin and metronidazole.  Abdominal ultrasound revealed gallstones, 6 millimeter gallbladder wall, dilated intrahepatic ducts, 1.9 centimeter common hepatic duct with possible hepaticodocholithiasis, and no choledocholithiasis or pericholecystic fluid.  Laboratory evaluation revealed total bilirubin 8.5 mg/dL, alkaline phosphatase 722 U/L, AST 212 U/L, ALT 225 U/L, no leukocytosis, INR 1.0, and urine bilirubin 4+.  On hospital day 3, a gastroenterologist performed an ERCP with stent placement and sphincterotomy, reporting a large proximal common bile duct stone that could not be removed.  On hospital day 5, a laparoscopic converted to open cholecystectomy was performed after difficulty in obtaining the critical view of safety given extensive adhesions.  A fistula was identified between the infundibulum and the right posterior sectoral duct, eroding one-third of the duct wall and obliterating the cystic duct.  Multiple stones, but no stent, were observed in the operative field.  Cholangiography confirmed the stent from the common bile duct to the right anterior sectoral duct, signifying a variant found in 2% to 4% of patients. The hepaticodochotomy was closed primarily with a T-tube, removed 12 weeks later in the office, and he is asymptomatic.  An ERCP will remove the stent and any residual stones.

The delay in recognizing this complicated Mirizzi syndrome in a biliary tract variant could have been averted if adequate ERCP images were obtained pre-operatively. This would have better informed the subsequent surgical approach, with potential savings in operative time.

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