Mirizzi syndrome grades III and IV: surgical treatment

ABSTRACT Objective : to evaluate the epidemiology and outcomes of surgical treatment of patients with Mirizzi Syndrome (MS) grades III and IV, the most advanced according to Csendes classification. Methods : we conducted a retrospective, cross-sectional study by reviewing records of thirteen patients with grades III and IV MS operated from December 2001 to September 2013, among the 3,691 cholecystectomies performed in the period. Results : the incidence of MS was 0.6% (23 cases) and grades III and IV amounted to 0.35% of this number. There was a predominance of type IV (12 cases). The preoperative diagnosis was possible in 53.8% of cases. The preferred approach was biliary-digestive derivation (10 cases), and "T" tube drainage with suture of the bile duct was the choice in three special occasions. Three patients had biliary fistula resolved with clinical management, and one coliperitoneum case required reoperation. In the outpatient follow-up of patients who underwent biliodigestive anastomosis (eight), 50% are asymptomatic, 25% had anastomotic stricture and 25% lost follow-up. The mean follow-up was 41.8 months. Conclusion : MS in advanced degrees has low incidence, preoperative diagnosis in only half of cases, and has the biliodigestive anastomosis as the best conduct, but not without morbidity.摘要 目的：评估按照Csendes分类法属于最晚期的Ⅲ、Ⅳ型Mirizzi综合征（Mirizzi Syndrome, MS）患者的流行病学特征及手术治疗结局。 方法：本研究为回顾性横断面研究，回顾了2001年12月至2013年9月期间收治的13例Ⅲ、Ⅳ型MS患者的临床病历资料，该时段内共完成胆囊切除术3691例。 结果：本研究中MS总发生率为0.6%（共23例），其中Ⅲ、Ⅳ型MS占该总数的0.35%。以Ⅳ型病例居多，共12例。术前确诊率为53.8%。首选术式为胆肠吻合引流术（10例），3例特殊病例采用胆管缝合联合T管引流术。3例胆道瘘患者经临床保守治疗后痊愈，1例胆漏性腹膜炎患者需接受再次手术治疗。对接受胆肠吻合术的8例患者进行门诊随访，其中50%无临床症状，25%出现吻合口狭窄，25%失访。平均随访时长为41.8个月。 结论：晚期MS发生率较低，术前确诊率仅为半数，胆肠吻合术为其最优治疗方案，但该术式仍存在术后并发症风险。