Conservative Management of Mirizzi Syndrome in Community Hospital Setting

Mirizzi syndrome (MS) is a rare complication of chronic cholecystitis caused by the gallbladder wall compression of the common hepatic duct (MS1, based on McSherry classification) or as a cholecystocholedochal fistula (MS2). The incidence of MS in symptomatic cholelithiasis is very low. Patients often present with obstructive jaundice and right upper quadrant abdominal pain; symptoms not clinically unique from biliary colic or cholecystitis, and often misdiagnosed preoperatively. We present the case of a 76-year-old female, initially diagnosed with chronic cholecystitis, who was found to have MS2 intraoperatively. She denied a prior history of abdominal surgery or biliary instrumentation. The patient underwent a subtotal cholecystectomy with common bile duct exploration, t-tube placement, and wide local drainage. She progressed well and was discharged home from the hospital on day seven with outpatient hepatobiliary surgery follow-up. At one-month follow-up, the patient had t-tube output of 200-300cc per day with remaining drains removed after having diminished output and no signs of biloma on CT. At the two-month follow-up, the patient had a minimal t-tube output with t-tube cholangiography showing contrast dye into the duodenum. Her t-tube was clamped and was removed at the three-month follow-up. Surgical management of MS1 is generally laparoscopic or open cholecystectomy. Management of MS2 is complex and dependent on anatomic and pathologic factors. Surgical repair generally focuses on biliary-enteric reconstruction, with cholecystcholedochoduodenostomy or Roux-en-Y hepaticojejunostomy. Conservative surgical approach with subtotal cholecystectomy, common bile duct exploration, and biliary drainage is also reported as a safe alternative option. MS is a rare complication of chronic cholecystitis, and can be a cause of cholecystocholedochal fistula, which is often discovered intraoperatively during cholecystectomy; general surgeons should be familiar with conservative management of MS.