The name "Mirizi syndrome" is associated with the name of the surgeon from Argentina, Mirizi, who is the author of many works related to the physiology of bile secretion, as well as a clinical practitioner in the field of intraoperative cholegraphy.
In 1948, in his scientific work, the doctor described the radiological semiotics of hepatitis syndrome, the striking signs of which were stasis of bile and contracture of the bile duct. A picture of calculous syndrome, which is expressed in the appearance of a fistula between the gallbladder and hepaticoholedoch, was also presented.
Existing Contradictions
Not everyone is familiar with such an ailment as Mirizzy's syndrome. What is it, we will tell below. But first, it is worth noting that to date, in medicine, the concept itself is not fully defined. So, many doctors believe that the basis of the disease is the narrowing of the lumen in the duct of the liver. The most detailed formulation of the syndrome involves the identification of pathology with stenosis of the liver duct or region of the Hartmann calculus pocket, which is accompanied by an inflammatory process in the gallbladder and manifests itself in cholangitis or jaundice.
Mirizzy's syndrome, the classification of which is presented in this article, according to many scientists, is characterized not only by narrowing of the lumen. The pathological process covers the right lobar and common bile duct.
Scientists interpret the syndrome in a completely different way, who believe that the underlying disease is a vesicomedical fistula. There are opposing views on the location of the pathological process. Some scientific articles mention the location of the connections between the gallbladder and the common duct of the liver, and other research papers give examples of the presence of fistulas between the gallbladder and the common bile duct.
For example, in the classification of M.V. Corlette, H. Bismuth (1975) presents two types of biliary-biliary fistula depending on the location of the pathological anastomosis (above or below the main connection of the bile and cystic duct).
Some researchers attribute the manifestation of the disease to a narrowing of the lumen of hepatic choledochus and the formation of cholecystocholedochal fistula.
A diverse interpretation of the essence of the syndrome complicates the perception of its essence and complicates the search for effective methods of its treatment.
Recently, you can often find a new interpretation of such a pathology as Mirizzy's syndrome? Its types are represented by two variants of the course of the disease:
- acute form in which the lumen of hepaticoholedoch is narrowed;
- a chronic form that provokes the appearance of a fistula between hepatic choledochus and the lumen of the gallbladder.
Classic description
The classic description of such a pathological process as Mirizzy's syndrome, the photo of which is presented in this article, includes four main points:
- close parallel position of the gallbladder duct and the main duct of the liver;
- the presence of a stone in the duct of the gallbladder or in its neck;
- obstructive process of the liver duct, which is caused by a fixed calculus in the duct of the gallbladder and the inflammatory process around it;
- the presence of jaundice with or without cholangitis.
Classification principles
What types of illnesses such as Mirizzy's syndrome are divided into? The classification assumes the level of destruction of the wall of the main duct of the liver by the cystic-choledochal fistula (Csendes):
- Type I - compression of the common duct of the liver with a stone of the neck of the gallbladder or its duct.
- Type II - the presence of a cystic-choledochal fistula, occupying less than 1/3 of the circumference of the common duct of the liver;
- Type III - the presence of a cystic-choledochal fistula, which occupies 2/3 of the circumference of the liver duct;
- Type IV - the presence of a cystic-choledochal fistula, which occupies the entire circumference of the liver duct, while the duct wall is completely destroyed.
Causes of the syndrome
The main reasons for the development of such an ailment as Mirizzy's syndrome are:
- compression of the lumen of the bile duct from the outside, provoked by acute calculous cholecystitis;
- the presence of stricture of the bile duct located outside the liver;
- formation of perforation of hepatic choledoch in the presence of stricture;
- the development of the vesico-choledochal fistula with the parallel elimination of stricture.
Depending on the structure of the biliary ducts, the size and weight of calculi, as well as the methods of therapy, the process may stop at any of the above stages, but the transformation from slight compression of the bile duct into the cystic-choledochal fistula can be observed only with gallstone disease.
Compression of the bile duct degenerates into a stricture if surgery is delayed, and the disease becomes chronic, in which the period of remission is replaced by an exacerbation. After the lapse of time, the walls of the gallbladder and hepaticoholedoch begin to come into contact, which is provoked by a large stone in the Hartmann’s pocket. Under the pressure of its weight, the state of trophism worsens, a pressure sore of the gallbladder and duct wall occurs. Then a vesicoledochal fistula is formed.
Through a similar pathological message from the gallbladder, calculi get into the lumen of the hepaticoholedoch. The fistula increases in diameter due to the reduction of its tissue in the compression zone. As a result, the narrowing of the proximal hepatic choledochus is eliminated, the gall bladder decreases in size, its neck, Hartmann's pocket and most of the body disappear. As a result, the gallbladder becomes similar to a diverticulum-like formation, which has a message with the lumen of the extrahepatic bile duct using a wide anastomosis. As a rule, the duct of the bladder is absent.
Symptomatology
How is Mirizi syndrome manifested? Symptoms are characteristic of cholecystitis occurring in acute or chronic form with the development of a mechanical form of jaundice. In the vast majority of patients, an additional existing gallstone disease with frequent seizures alternating with periods of a mechanical form of jaundice is noted in the medical history. About scientific evidence, the most striking and often manifested symptoms are pain in the upper right abdomen. Pain and jaundice bother in 60-100% of cases.
More often jaundice appears in the presence of a vesico-choledochal fistula.
With cholangitis, a fever is noted. Sometimes pain in the hypochondrium, intoxication, development of pancreatitis (acts as a layering on the general disease) are disturbing. In the blood, the indicator of bilirubin, ALT, AST and alkaline phosphatase increases.
Who is more common?
Mirizzy's syndrome occurs in 0.1% of patients with gallstone disease. With surgical intervention is observed in 0.7-2.5% of patients. Both men and women of absolutely all races and nations fall ill. In old age, the disease is much more common.
Diagnostic Methods
What is the difficulty of treating a pathology such as Mirizzy's syndrome? Diagnosis and surgical tactics are not fully defined.
In modern medicine, there are no generally accepted rules for conducting diagnostic procedures. Despite the progress in medical imaging of various diseases, the diagnosis before surgery is difficult to establish. This succeeds in about 20% of cases. Only a few researchers note that an ultrasound examination of the disease before surgery reaches an accurate indicator in 67.1% of cases, MRI in 94.4%, intraductal echography in 97% and endoscopic retrograde pancreatocholangiography in 100%.
All this suggests that modern methods of instrumental diagnosis do not always make it possible to identify Mirrisi syndrome in the period preceding surgery.
Most often with ultrasound, the following symptoms are found:
- expansion of the duct inside the liver, as well as its proximal section, located in parallel with the unexpanded common duct of the gallbladder;
- finding the gallbladder in a shriveled state.
CT scores of Mirizzy's syndrome coincide with signs that are detected by ultrasound diagnosis. Although CT cannot provide important information to supplement the ultrasound method, its role in determining the presence of a malignant tumor in the proximal gallbladder duct is quite high, which is of great importance in differentiating Mirrisi syndrome with cancer.
Magnetic resonance imaging, retrograde endoscopy, and pancreatocholangiography (ERCP) are equivalent diagnostic methods for identifying stricture elements and cholecystocholedoheal fistula. The obtained images in the T1 and T2 modes allow to more accurately distinguish the inflammatory process from oncology, which is not always possible by CT and ultrasound. However, due to the high cost of an MRI scan, this diagnostic method is not used in all medical centers.
Magnetic resonance cholangiopancreatography is a relatively new, but little explored type of diagnosis. A number of scientists consider it as the most promising type for designating such a pathology as Mirrisi syndrome.
Some scientists in their writings note the benefits of laparoscopic ultrasound of the pancreatoduodenal region. With surgical intervention in cases of suspected SM, this diagnostic method makes it possible in real time to build an image of the bile ducts in several planes of the fetus with a different angle. However, at present, this method remains inaccessible and unstudied to the end.
It should be noted that, despite the presence of various diagnostic methods, it is still extremely difficult to establish the presence of SM, which can mislead the surgeon and provoke damage to the common bile duct, which is mistakenly perceived as a gall bladder or a wide duct. The lack of generally accepted diagnostic methods before surgery encourages the development of optimal methods.
Treatment principles
How is Mirizi syndrome eliminated? Treatment involves two main areas: X-ray endoscopic method and surgical intervention.
X-ray endoscopic treatment can be used as an initial stage before surgery as preparation for surgery. It acts as an independent method for the treatment of patients with SM in the case of a high level of anesthetic risk.
The disadvantages of REV, many researchers include:
- radiation exposure to patients and medical staff;
- high price for endoscopic and radiological examination;
- the impossibility of eliminating the narrowing of the lumen of the proximal choledochus.
According to the scientific literature, methods of surgical intervention vary greatly. There are various options for surgical operations for SM.
Some doctors believe that treating Mirrisi syndrome with laparoscopy is absolutely contraindicated.
A more common form of surgery in the first type of syndrome is cholecystectomy, which is supplemented by drainage of the common bile duct.
How does Mirizzy's syndrome stop in the presence of a bilobiliary fistula? The situational task requires separation and subsequent restoration of the integrity of the chlohedochus. As one of the methods for closing the common bile duct, which is used by most surgeons, is the elimination of a defect in its wall by means of the left part of the gallbladder. However, some doctors believe that left tissue may increase the risk of residual choledocholithiasis.
In the presence of a cholecystobiliary fistula, it is recommended to perform choledochoplasty on temporary stents. The need for this type of operation, many scientists explain the presence of long-term changes in the inflammatory nature in the area of the hepatoduodenal ligament, so that SM can be perceived as a model of damage to the walls of the bile ducts. With their significant deformation, the walls of the bile duct are included in the fistula.
During surgery, there is a high level of risk of complications.
Possible complications
Most often, after surgery, there is such a complication as stricture of the common bile duct. According to Russian researcher G.I. Dryazhenkov (2009), out of 46 patients who underwent surgery, stricture developed in 6.5%.
What are the results of the operation on the so-called lost drainage, which was done to four patients with the initial form of SM (stenotic appearance)? Researchers V.S. Saveliev, V.I. Revyakin (2003) note the positive dynamics of the course of the disease, however, they explain the removal of the drainage system from the duct area by the following reasons:
- the development of jaundice;
- obstruction of drainage, provoked by the formation of small stones;
- salt deposition on the drainage walls;
- the accumulation of detritus, similar in texture to putty, which provokes repeated attacks of cholangitis.
The highest degree of difficulty is the operation on patients with a high degree of destruction of the bile duct wall. If the disease is at the third or fourth stage, then a higher mortality rate after surgery. With a disease in the third or fourth degree, most surgeons advocate for choledochojejunoanastomosis.
Treatment after surgery
How is Mirizi's syndrome stopped? Treatment after surgery involves passing a general blood test the day after surgery, a week and a day before discharge from the hospital. Sutures are removed on day 10.
The average length of hospital stay for patients is 10-12 days. The total recovery period is two months.
Typically, patients are shown rest in a sanatorium in the rehabilitation department.
Conclusion
Today, Mirizzy's syndrome, a classification, diagnosis, the treatment of which is described in this article, is considered by medicine as one of the complications of gallstone disease. However, in the field of diagnosis and surgical intervention, a number of unresolved issues remain.
Despite the fact that there is a wide range of different types of surgical intervention, the results of treatment do not always meet the expected ones.
During the operation, the level of intra- and postoperative complications increases.
Difficulties in carrying out diagnostic measures, the risk of damage to the bile duct, a small number of observations, as well as a wide range of surgical procedures are a prerequisite for a more in-depth study of the problem.
The introduction of modern principles of diagnosis and the development of optimal tactics in the field of surgery, depending on the stage of development of the disease, makes it possible to optimize the treatment of patients with this complication of cholelithiasis.