Diagnosis and treatment of Mirizzi syndrome: 23-year mayo clinic experience

Background: Mirizzi syndrome (MS) is characterized by extrinsic compression of the common hepatic duct by stones impacted in the cystic duct or gallbladder neck. Open cholecystectomy (OC) has been the standard treatment; however, laparoscopy has challenged this approach. Study Design: The objective of this study was to review our clinical experience with MS since the introduction of laparoscopic cholecystectomy (LC) and determine the impact of alternative approaches. We conducted a retrospective review of patients with MS from January 1987 to December 2009. Results: There were 36 patients with MS among 21,450 cholecystectomies (frequency 0.18%). Seventeen were women. The most common presenting symptoms were abdominal pain (n = 23) and jaundice (n = 19). Preoperative diagnostic studies included ultrasonography (n = 27), CT (n = 24), and endoscopic retrograde cholangiopancreatography (n = 32). Cholecystectomy was performed in 35 patients; LC was initiated in 15 and OC in 21. Conversion rate from LC to OC was 67%. Five patients who had successful LC had type I MS. Of the patients who underwent LC with conversion or OC, 14 had type I and 16 had type II MS. The cystic duct for type I and the bile duct for type II MS were managed diversely according to surgeon's preference. There was no operative mortality. Morbidity was 31% with Clavien class I in 2, IIIa in 4, IIIb in 1, and IV in 3 patients. Mean hospitalization was 9 days (range 2 to 40 days). Mean follow-up was 37 months (range 1 to 187 months). Conclusions: Low incidence and nonspecific presentation of MS precludes referral and substantive individual experience. Although LC may be applicable in selected patients with type I MS, OC remains the standard of care.