Case Report

En-Bloc Cholecystectomy and Segmental Colectomy for Mirizzi Syndrome Type Va - Diagnosis and Management of a Rare Condition.

Seyed Mohammad Javad Taghavi and Yasser Farooque
World Journal of Medical and Surgical Case Reports 2020, 9:3

Abstract

Introduction

Mirizzi syndrome is defined as hepatic duct obstruction by an impacted gallstone in the cystic duct or infundibulum. Classification is based on the degree of obstruction or fistulation between the cystic duct, hepatic duct, duodenum and colon. Diagnosis is challenging and often made intraoperatively. The absence of preoperative diagnosis increases the risk of bile duct injury up to 17%.This highlights the importance of preopreative diagnosis and planning.

Case Presentation

A 57 year old female presented with right upper quadrant pain, nausea, fever, tachycardia on a background of gastric bypass for weight loss, with a 2 metre Roux limb. Imaging revealed biliary dilation with gallbladder wall thickening. MRCP revealed biliary obstruction with a large infundibular gallstone obstructing the hepatic duct. Colonoscopy and gastroscopy were performed to rule out gastrointestinal malignancy. Colonoscopy revealed bile stained mucosa confirming a cholecysto-enteric fistula, confirming Mirizzi syndrome type Va. The patient underwent open cholecystectomy, segmental transverse colectomy with primary repair, choledochotomy with removal of bile duct stones and bile duct repair over a T-tube with an uneventful postoperative course. Histology showed benign cholecystitis.

Conclusions

The diagnostic challenge in this patient was the presence of a 2 meter long Roux limb from her previous gastric bypass, precluding ERCP, a key investigation in the diagnosis of Mirizzi synrome. Colonoscopy was therefore invaluable in establishing the diagnosis and allowing for appropriate operative planning. This case demonstrates the diagnosis and management of a rare condition in a challenging diagnostic setting and highlights the importance of preoperative diagnosis and careful operative planning. The use of colonoscopy in the diagnosis of this condition presents a novel approach to the investigation of Mirizzi syndrome.

Key Words

Hepatobiliary; Surgery; Planning; Mirizzi; Gallstone; Fistula

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