Stabilirea diagnosticului şi tratamentul chirurgical în sindromul Mirizzi

Abstract

Introducere. Aproximativ 0,1% dintre pacienţii cu litiază biliară dezvoltă sindromul Mirizzi (SM). Conduita diagnostică şi curativă impune necesitatea folosirii unui algoritm de diagnostic bine definit, sporind rata de stabilire a diagnosticului preoperator şi micşorarea ratei de complicaţii intra şi postoperatorii. Scop. Analiza metodelor de diagnostic preoperator cu stabilirea criteriilor imagistice şi clinice sugestive SM şi abordarea chirurgicală în dependenţă de tipul morfologic al fistulei colecisto-biliare. Material şi metode. Lotul de cercetare a inclus 79 pacienţi. Metodele imagistice folosite au fost: USG-79(100%), ERCP-71(89,8%), MRCP-22(27,8%), CT cu contrast-14(17,7%). În toate cazurile sau folosit cel puţin 2 metode imagistice. Tratamentul chirurgical a inclus colecistectomia cu sau fără drenarea căii biliare principale (CBP) şi rezolvarea fistulei. Rezultate. Tip I SM-20(25,3%) cazuri, s-a practicat colecistectomia, în 16(20,2%) cazuri laparascopic. Tip II-29(36,7%) diametrul fistulei sub 1/3 din diametrul CBP, s-a efectuat plastia defectului cu drenarea tip Kehr. Tip 111-18(22,7%) defectul CBP a constituit 2/3, din care în 12 cazuri (15,1%) s-a efectuat plastia CBP cu lambou vascularizat din vezicula biliară şi drenarea tip Robson, în alte 6 cazuri (7,5%) s-a efectuat hepatico-jejuno anastomoză (HJA) pe ansa Roux. Tip IV-10(12,6%), defectul parietal a fost de peste 67% din diametrul CBP, s-a efectuat HJA pe ansa Roux. Tip V-2(2,5%) s-a efectuat drenarea tip Kehr şi suturarea fistulei enterice. Concluzii. Algoritmul optimizat a permis stabilirea diagnosticului preoperator în 31(39,2%) cazuri. Metodele elective în diagnosticul fistulelor colecisto-biliare a fost ERCP şi MRCP. Ajustarea tehnicii chirurgicale conform tipului de sindrom Mirizzi, a favorizat evoluţia postoperatorie.

Introduction. Approximately 0.1% of patients with gallbladder lithiasis develop Mirizzi syndrome (MS). The diagnostic and curative management requires the use of a well-defined diagnostic algorithm, increasing the rate of preoperative diagnosis and decreasing the rate of intra-and postoperative complications. Objective. Analysis of preoperative diagnostic methods with establishment of imaging and clinical criteria suggestive of MS and surgical approach depending on the morphologic type of gallbladder-biliary fistula. Material and methods. The research group included 79 patients. The imaging methods used were: USG-79(100%), ERCP-71(89.8%), MRCP-22(27.8%), CT with contrast-14(17.7%). In all cases or used at least 2 imaging methods. Surgical treatment included cholecystectomy with or without drainage of the main bile duct (MBD) and resolution of the fistula. Results. Type I SM-20(25.3%) cases, cholecystectomy was performed, in 16(20.2%) cases laparascopically. Type II-29(36.7%), the diameter of the fistula was less than 1/3 of the diameter of the MBD, the defect was placed with Kehr drainage. Type 111-18(22.7%), the defect was 2/3, of which in 12 cases (15.1%) the defect was placed with vascularized flap from the gallbladder and Robson drainage, in other 6 cases (7.5%) hepatico-jejunostomy (HJS) was performed on Roux loop. Type IV-10 (12.6%), the parietal defect was more than 67% of the diameter of the MBD, HJS was performed. Type V-2 (2.5%) Kehr drainage and suturing of the enteric fistula was performed. Conclusion. The optimized algorithm allowed preoperative diagnosis in 31 (39.2%) cases. The elective methods in the diagnosis of cholecystobiliary fistulas were ERCP and MRCP. The adjustment of the surgical technique according to the type of Mirizzi syndrome favored the postoperative course.