Surgical strategies for Mirizzi syndrome: A ten-year single center experience

Table 1 Demographic data of Mirizzi syndrome patients, n (%), (mean ± SD), (range and median)

Category
Male/Female		34/32
Age (yr)		48.1 ± 15.0, 18-83, 47
Admission route (Emergency/Outpatient)		48/18
Previous admissions		2.24 ± 0.96, 1-3, 3
Months from discovery of gallstone to this admission		17.8 ± 4.51, 9-22, 21
Confirmed episodes of abdominal pain		2.15 ± 1.04, 1-6, 2
Total bilirubin (μmol/L)	≤ 28	31 (47.0%)
	28-56	27 (40.9%)
	> 56	8 (12.1%)
Postoperative pathologicalresults ofgallbladder	Acute inflammation	24 (36.4%)
	Acute inflammation and gangrene	8 (12.1%)
	Acute suppurative inflammation	9 (13.6%)
	Chronic inflammation	12 (18.2%)
	Chronic suppurative inflammation	5 (7.6%)
	Xanthogranuloma	8 (12.1%)
Preoperative PTCD		6 (9.1%)
Preoperative treatment time (d)		6.35 ± 3.28, 2-20, 6
Postoperative treatment time (d)		7.36 ± 3.66, 3-19, 6.5
Total hospitalization time (d)		13.76 ± 5.41, 6-31, 13
Hospitalization cost (CNY Yuan)		24549 ± 6536, 13596-40815, 23044

PTCD: Percutaneous transhepatic cholangio pancreatic drainage.

Table 2 Diagnosticclues of Mirizzi syndrome by ultrasound scan and magnetic resonance imaging/magnetic resonance cholangiopancreatography in different cases

Imaging examination		Type I	Type II	Type III	Statistics	Total bilirubin (μmol/L)			Statistics
						≤ 28	28-56	> 56
USS	+	10	8	6	χ2 = 12.00; P = 0.002	11	9	4	χ2 = 0.760; P = 0.684
	-	32	6	4		20	18	4
MRI/MRCP	+	34	14	10	χ2 = 5.202; P = 0.074	23	27	8	χ2 = 10.28; P = 0.006
	-	8	0	0		8	0	0

USS: Ultrasound scan; MS: Mirizzi syndrome; MRI: Magnetic resonance imaging; MRCP: Magnetic resonance cholangiopancreatography.

Table 3 Effects of Csendes classification on surgical methods, operative time, bleeding volume, hospitalization time and cost (n = 66), (mean ± SD), (range, median)

		Type I	Type II	Type III	Type IV	Statistics
n (%)		42 (63.64%)	14 (21.21%)	10 (15.15%)	0
Total bilirubin (μmol/L)	≤ 28	29	2	0	-	χ2 = 51.42; P = 0.000
	28-56	13	11	3	-
	> 56	0	1	7	-
Surgical methods	LC	29	62	0	-	χ2 = 29.91; P = 0.000
	LC convert to OC	2	32	0	-
	LC convert to OC + BDER + T-tube	71,2	43	83	-
	OC	0	12	0	-
	OC + BDER + T-tube	41,2	0	23	-
Hospitalization time (d)		12.8 ± 4.8; 6-25, 12.5	15.1 ± 6.2; 8-26, 13.5	15.9 ± 6.1; 8-31, 15	-	F = 1.981; P = 0.146
Treatment cost (CNY Yuan)		23037 ± 5522; 13596-40815, 21963	24916 ± 7146; 15108-36557, 23593	30387 ± 6865; 17161-40568, 28624	-	F = 5.909; P = 0.004
Operative time (minutes)		154.4 ± 91.1; 50-395, 122.5	230.4 ± 133.7; 80-480, 175	219.0 ± 122.2; 95-520, 177.5	-	F = 3.486; P = 0.037
Bleeding volume (mL)		96.6 ± 81.5; 20-340, 60	191.4 ± 123.3; 30-390, 180	163.5 ± 114.3; 25-400, 140	-	F = 5.919; P = 0.004

¹Bile duct exploration and repair due to intraoperative iatrogenic bile duct injury (BDI).

²Simple suture due to small fistula or slight BDI.

³Repaired with remaining gallbladder wall patch following subtotal cholecystectomy.

LC: Laparoscopic cholecystectomy; OC: Open cholecystectomy; BDER: Bile duct exploration and repair.

Table 4 Intraoperative data and technical details (n = 66)

Category		n = 66
Final surgical approach	3-port laparoscopic surgery	24, 36.4%
	4-port laparoscopic surgery	11, 16.7%
	Right subcostal incision	31, 46.9%
Maximum diameter of stone (cm)		2.15 ± 1.17, 0.5-6, 2
Fistula size (mm)	Longitudinal diameter	4.1 ± 1.0, 2-6, 4
	Transverse diameter	4.5 ± 1.4, 2-8, 4
Diameter of extra hepatic bile duct (mm)		Maximum 14 ± 2.8, 10-22, 14
		Minimum 8.4 ± 1.8, 6-12, 8
Iatrogenic BDI		11, 16.7% (11 in type I)
Retrograde resection of gallbladder		36, 54.5%
BDER (35, 53%)	Simple suture repair	21, 31.8% (11 in type I, 10 in type II)
	STC and repair using gallbladder wall	14, 21.2% (4 in Type II,10 in type III)
T-tube (25, 37.9%) (14-22 Fr, 18 Fr)		Transfistula 3 (in type III)
		Transbiliary incision 22
Cholangiography (25, 37.9%)	Trans-PTCD	61
	Trans-T-tube	25
Choledochoscopy (25, 37.9%)	Trans-fistula	3
	Trans-cystic duct	2
	Trans-biliary incision	20
Operative time (min)		180 ± 110, 50-520, 140
Bleeding volume (mL)		127 ± 104, 87.5, 20-400

¹At the beginning of operation, cholangiography was performed using the percutaneous transhepatic cholangio pancreatic drainage tube to confirm the anatomical structure of the biliary duct.

BDER: Bile duct exploration and repair; STC: Subtotal cholecystectomy; PTCD: Percutaneous transhepatic cholangio pancreatic drainage; BDI: Bile duct injury.

Table 5 Postoperative complications (n = 66)

Postoperative complications	n (%)
Incision infection	7 (10.6)
Bile leakage	9 (13.6)
Bloody drainage	4 (6.1)
Cholangitis	5 (7.6)
Abnormal liver function	14 (21.2)
Biliary stricture	1 (1.5)
Residual or recurrent stone	5 (7.6)
Pneumonia	3 (4.5)
Gastrointestinal dysfunction	7 (10.6)