Sindromul Mirizzi – diagnostic şi tratament

Abstract

Introducere: Sindromul Mirizzi (SM) este o complicaţie rară a litiazei veziculare cronice cu o incidenţă de 0,7-1,4% la pacienţii colecistectomizaţi. Iniţial SM a fost descris ca o obstructie totalaţsau partialţ a căii biliare principale cu un calcul inclavat în infundibulul vezicular sau ductul cistic printr-o compresie extrinsecă, complicată cu icterul obstructiv. Conform clasificaţiei Csendes se disting următoarele tipuri de SM: tip I, cand calea biliară principală este comprimată de un calcul inclavat în infundibulul vezicular sau ductul cistic fară formarea fistulei colecistobiliare; tip II-IV cu prezenţa fistulei colecistobiliare cu diferit grad de eroziune a canalului hepatic comun. Materiale şi metode: Pe perioada anilor 2006-2011 raportăm 5 cazuri de SM: 1 pacient cu SM tip I, 2 pacienţi – tip II şi 2 pacienţi – tip IV. Doar la doi pacienţi diagnosticul de SM a fost suspectat preoperator prin colecistopancreatografie retrogradă endoscopică, iar în 3 cazuri diagnosticul a fost instalat intraoperator. La toţi pacienţii icterul mecanic era insoţit de colangita purulentă. Rezultate: Operatia a avut ca scop colecistectomie cu lichidarea fistulei bilio-biliare şi rezolvarea icterului obstructiv. Operaţia s-a finisat cu aplicarea anastomozei hepaticojejunale pe ansa Roux cu stent biliar (1 bolnav), drenarea coledocului tip Kehr (3), drenarea coledocului tip Halsted (1). Toţi pacienţii în perioada postoperatorie precoce au fost examinaţi prin fistulocolangiografie pentru controlul permiabilitătii căilor biliare. Concluzii: SM este o complicaţie rară a litiazei veziculare, responsabil de icter si colangită, diferenţierea preoperatorie cu cancerul biliar fiind dificilă. Rezolvarea chirurgicală a SM depinde de forma morfopatologică conform clasificării Csendes.

Introduction: Mirizzi syndrome (MS) is a rare complication of longstanding gallbladder stone disease, with an incidence of 0.7-1.4% from all cholecystectomies. SM was originally described as a gallstones impacted in the neck of the gallbladder or cystic duct, which can obstruct the common bile duct (CBD) by extrinsic compression causing obstructive jaundice. According to Csendes classification the following types of MS are distinguished: type I, when the CBD is compressed by a gallstone impacted in cystic duct, without biliary fistula, type II-IV with the bilio-biliary fistula with different degree of destruction of the common hepatic duct wall. Materials and methods: We report 5 patients with MS, treated during the period of 2006-2011: 1 patient with type I MS, 2 patients with type II, and 2 patients with type IV. Only in two patients the MS was suspected prior surgery using endoscopic retrograde cholecystopancreatography, in another three cases the diagnosis was established intraoperatively. Mechanical jaundice in all patients was accompanied by purulent colangitis. Results: The aim of surgery included cholecystectomy, abolition of cholecysto-choledochal fistula, and elimination of obstructive jaundice. Procedure was completed by Roux-en-Y hepaticojejunostomy with biliary stent placement (1patient), suture closure over a T-tube (3), and Halsted tube (1). In the early postoperative period all patients underwent cholangiography in order to control the permeability of the biliary ducts. Conclusions: MS is a rare complication of the gallbladder calculous disease which is responsible for obstructive jaundice and cholangitis, the preoperative differentiation with biliary cancer is difficult. The surgical procedure for MS depends on its morphological form according to Csendes classification.