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PubMedDate not supplied

Routine intraoperative cholangiography is feasible and efficient during laparoscopic cholecystectomy.

BACKGROUND/AIMS: This is the evaluation of the feasibility and results of routine laparoscopic intraoperative cholangiography. PATIENTS AND METHODS: A multicentric prospective study in 315 consecutive patients undergoing elective or urgent laparoscopic cholecystectomy. RESULTS: The success rate was 94%. Mean duration of intraoperative cholangiography was 12 min. Sixteen of 18 failures were related to a narrow cystic duct. One cystic duct avulsion (ligated under laparoscopy) and 2 false positive cholangiograms (1 transcystic exploration, 1 conversion) were noted. Intraoperative cholangiography revealed aberrant bile ducts possibly at risk to injury from dissection in four patients (1.3 per cent). Intraoperative cholangiography disclosed unsuspected stones in 10 patients (4%). Forty-five patients had a preoperative suspicion of choledocholithiasis: choledocholithiasis were found at intraoperative cholangiography in 3 of 13 patients who had preoperative endoscopic sphincterotomy for stone extraction, in 1 of 11 patients with normal preoperative endoscopic cholangiography, and in 11 of 21 patients undergoing surgery alone (57%). CONCLUSION: If complete clearance of choledocholithiasis is to remain the objective of surgical treatment of biliary lithiasis including laparoscopic cholecystectomy, then routine intraoperative cholangiography is feasible and efficient.

Adolescent↗
PubMed1997

Evolving management of common bile duct stones in the laparoscopic era.

The role of laparoscopic duct exploration in the management of common bile duct (CBD) stones is unclear. The aim of this study is to audit the current management of choledocholithiasis in our unit and to report on the introduction of laparoscopic management, comparing it with established techniques. Over a 5-year period, 173 patients presented with CBD stones. In 105 (61%) patients, primary management of choledocholithiasis was by endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) which was successful in 85 (81%) cases. Of the 20 patients with retained stones following ES, 18 underwent subsequent surgical exploration. Fifty (29%) patients underwent open CBD exploration as a primary treatment, resulting in complete clearance in 43 (86%) cases. Retained CBD calculi following open surgery occurred in seven cases and were ultimately treated by post-operative ES (n = 5), and observation (n = 2). Eighteen (10%) patients underwent primary laparoscopic CBD exploration. Four cases were converted to open surgery. Of the 14 completed laparoscopic duct explorations, 12 (86%) were successful. Two patients had retained stones, requiring secondary treatment with ERCP and ES. There was no mortality in the entire series. The complication rate was 12.4% with ERCP, 14% with open surgery, and zero with laparoscopic CBD exploration. There was no significant difference in hospital stay between groups. We conclude that the management of choledocholithiasis is in evolution, and early results suggest that laparoscopic CBD exploration compares favourably with established open surgical and endoscopic methods.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1997

[Lithiasis of the extrahepatic bile ducts].

This is a literature survey on issues relating to average incidence rate of choledocholithiasis for the last few years, basic mechanisms and factors underlying the formation of biliary calculi, as well as form and location of the concrements, with a special reference to the impact of the latter on the course run by the disease. Choledocholithiasis is divided in two forms--primary and secondary: in the former the underlying causes and criteria for the occurrence of calculi are described, and in the latter--the factors and conditions promoting migration of the concrements towards the bile ducts, with emphasis on the importance of the division suggested in choledocholithiasis treatment. The clinical picture with its characteristic symptoms, and the pathogenesis of the latter are also discussed. Evolution of the disease left without adequate intervention has unfavourable prognosis. A description is submitted of the various complications and their characteristic manifestations observed. Differential diagnosis is made both often and rarely met with diseases presenting similar symptomatology.

Bile Ducts, Extrahepatic↗
PubMed1998

[Diagnosis of common bile duct stones by MR imaging, mainly MR cholangiopancreatography].

We evaluated the accuracy of MR imaging (MRI), mainly MR cholangiopancreatography (MRCP), in the diagnosis of choledocholithiasis in comparison with ultrasound (US), computed tomography (CT), direct cholangiography, and intravenous cholangiography (DIC). Thirty-seven patients with biliary disease diagnosed by surgery and direct cholangiography underwent MRI with T1-weighted images (T1-WI), T2-weighted images (T2-WI), and MRCP (source images and projection images). The rate of stone detection was evaluated for each MRI image and modality. Fifteen of 37 patients were found to have common bile duct stones at surgery. The depiction rate of T1-WI, T2-WI, source images, and projection images were 7%, 67%, 93%, and 53%, respectively. The depiction rate of MR, US, CT, direct cholangiography, and DIC were 100% (15/15), 25% (3/12), 64% (9/14), 71% (5/7), and 57% (4/7), respectively. In addition, there were two false-positive cases, one of duodenal diverticulum (Lemmel's syndrome) and the other of hemobilia. MRI had a sensitivity of 100%, specificity of 91%, and accuracy of 94% in the diagnosis of common bile duct stones. In conclusion, MRI is useful for evaluating suspected choledocholithiasis. In spite of the high depiction rate of the source images, other images should also be taken into consideration in the diagnosis of choledocholithiasis.

Adult↗
PubMed2005

Primary closure of the common duct over endonasobiliary drainage tubes.

The T-tube remains the standard method of intraductal drainage after open choledochotomy for choledocholithiasis. We studied the use of an endonasobiliary drainage (ENBD) tube as an alternative to the T-tube for postoperative intraductal drainage. A series of 20 patients with documented choledocholithiasis in whom endoscopic methods of stone retrieval failed to clear the common bile duct (CBD) were selected for the study. All patients had ENBD tubes placed preoperatively at endoscopic retrograde cholangiopancreaticography and then were subjected to open choledocholithotomy with primary closure of the choledochotomy over the ENBD. The age of the patients in the study group ranged from 18 to 75 years. Three patients (15%) had acute cholangitis at the time of surgery. Stones were confirmed at surgery in 85% of the patients, and the size of the CBD was found to range from 1.0 to 2.3 cm. All 20 patients underwent closure of the common duct over an ENBD tube without any difficulty. None of the patients experienced biliary complications such as bile leaks, biliary peritonitis, biliary fistula, pancreatitis, or cholangitis. No patient had any residual stone as documented by postoperative cholangiograms. Abdominal drains remained in place for 2 to 4 days, and the ENBD tubes were removed between days 6 and 8. The length of the postoperative hospital stay varied from 7 to 15 days, with 65% of the patients going home before postoperative day 8.

Adolescent↗
PubMed2003

Acute biliary pancreatitis, endoscopy, and laparoscopy.

Current practices for diagnosis and treatment of common bile duct stones are not evidence-based. Acute biliary pancreatitis (ABP) is a specific situation in which endoscopic procedures are either overused or misused. Pancreatitis is a poor marker for choledocholithiasis. Prognostic systems are accurate to discern those patients with ABP who do not need aggressive procedures. Patients with a benign ABP do not need an endoscopic approach. Laparoscopic common bile duct exploration is an underrated treatment for patients with choledocholithiasis. Laparoscopic approach to infected necrotic collections and pseudocysts warrant further investigations.

Acute Disease↗
PubMed2006

Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis.

BACKGROUND: Laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOEST) was compared with laparoscopic exploration of the common bile duct (LCBDE) for cholecystocholedocholithiasis in an attempt tried to find the best mini-invasive treatment for the cholelithiasis and choledocholithiasis. METHODS: For this study, 234 patients with cholelithiasis and choledocholithiasis diagnosed by preoperative B-ultrasonography and intraoperative cholangiogram were divided at random into an LC-LCBDE group (141 cases) and an LC-IOEST group (93 cases). The surgical times, surgical success rates, number of stone extractions, postoperative complications, retained common bile duct stones, postoperative lengths of stay, and hospital charges were compared prospectively. RESULTS: There were no differences between the two groups in terms of surgical time, surgical success rate, number of stone extractions, postoperative complications, retained common bile duct stones, postoperative length of stay, and hospital charge. CONCLUSION: Both LC-IOEST and LC-LCBDE were shown to be safe, effective, minimally invasive treatments for cholecystocholedocholithiasis.

Adolescent↗
PubMed2005

Laparoscopic cholecystectomy in children with chronic hemolytic anemia. Is the outcome related to the timing of the procedure?

BACKGROUND: The aim of this study was to evaluate whether the outcome in children with chronic hemolytic anemia (CHA) and cholelithiasis undergoing laparoscopic cholecystectomy (LC) is related to the operation timing. METHODS: From June 1995 to December 2004, 46 children with CHA were referred to our division of surgery for cholelithiasis. All 46 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them before the onset of symptoms. The operation was accepted in the period of study by 24 children and refused by 22. The patients were divided into three groups (group A, asymptomatic; group B, symptomatic; and group C, emergency admitted) depending on clinical presentation and operation timing, and the respective outcomes were compared. RESULTS: Elective LC in asymptomatic children (group A) is safe with no major complications reported. In children who refused surgery (groups B and C), we observed four sickle cell crises, four acute cholecystitis, and two choledocholithiasis, and all these complications were related to waiting. Two sickle cell crises occurred in symptomatic children waiting for surgery during biliary colic. The risk of emergency admission in children with cholelithiasis and CHA awaiting surgery was found to be high: 28% of the children admitted in emergency after a mean of 32 months (range, 22-36). Morbidity rate and postoperative stay increased when children with hemoglobinopathies underwent emergency LC. CONCLUSIONS: Elective LC should be the gold standard in children with CHA and asymptomatic cholelithiasis in order to prevent the potential complications of cholecystitis and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

Adolescent↗
PubMed2006

An audit of the outcome of long-term biliary stenting in the treatment of common bile duct stones in a general hospital.

BACKGROUND: This study audited the clinical outcome of a cohort of patients with choledocholithiasis treated with long-term biliary stenting in order to determine the feasibility of this practice. METHODS: Over 2 years, 83 patients with symptomatic choledocholithiasis were treated with long-term stenting because they either refused further treatments or were medically unfit for further procedures after the initial endoscopic retrograde cholangiopancreatography (ERCP). Recurrence of clinical events, need for stent change, morbidity, and mortality were analyzed. As a secondary analysis, published data on long-term biliary stenting were reviewed. RESULTS: ERCP and biliary stenting were successful in all cases with no complications. The mean follow-up was 19 months (1-103 months). The median number of ERCPs performed was 1 (1-4). The mean duration of stent patency was 12.4 months (1-54.8 months). A total of 28 clinical events (cholangitis, 71%) occurred in 24 patients during follow-up, for a late complication rate of 33.7%. ERCP was repeated and the stents changed on 15 occasions in 11 asymptomatic patients with abnormal liver function tests detected on routine follow-up. No biliary-related mortality occurred. Review of published data revealed a mean late complication rate of 22.4% (0%-64%), a biliary-related mortality rate of 3.5% (0%-21.1%), and a nonbiliary-related mortality rate of 20.8% (0%-60.3%). CONCLUSIONS: Long-term biliary stenting is a feasible option for patients who decline or are medically unfit for further elective endoscopic or surgical procedures. Close follow-up is mandatory to detect and treat late complications.

Aged↗
PubMed2005

Can MRCP replace the diagnostic role of ERCP for patients with choledochal cysts?

BACKGROUND: MRCP is rapidly replacing diagnostic ERCP in various pancreaticobiliary diseases. This study was designed to evaluate the accuracy of MRCP in detecting and determining the extent of choledochal cysts, as well as associated ductal anomalies or lesions. METHODS: The study design was an 8-year retrospective survey conducted at a tertiary referral center, Asan Medical Center (University of Ulsan College of Medicine, Seoul, Korea). There were 72 patients with choledochal cysts. All patients underwent both MRCP and ERCP. MRCP findings were compared with those of ERCP as the criterion standard. RESULTS: The overall detection rate of MRCP for choledochal cysts was 96% (69/72). The sensitivity, the specificity, the positive predictive value, and the negative predictive value of MRCP for classifying choledochal cysts according to Todani's classification were 81%, 90%, 86%, and 86% in type I, respectively; 73%, 100%, 100, and 95% in type III, respectively; 83%, 90%, 80%, and 91% in type IVa, respectively; 100%, 100%, 100%, and 100% in type IVb, respectively; and 100%, 100%, 100%, and 100% in type V, respectively. The sensitivity, the specificity, and the accuracy of MRCP for detecting ductal anomalies were 83%, 90%, and 86%, respectively. The detection rate of MRCP for concurrent cholangiocarcinoma and choledocholithiasis was 87% (13/15) and 100% (8/8), respectively. CONCLUSIONS: MRCP showed overall good accuracy in the detection and the classification of choledochal cysts and revealed associated cholangiocarcinoma and choledocholithiasis with excellent accuracy. MRCP, therefore, may supersede the diagnostic role of ERCP for the patients with choledochal cysts. However, MRCP showed limited capacity to detect minor ductal anomalies or small choledochocele.

Adolescent↗
PubMed2004

Catheter probe extraductal EUS reliably detects distal common bile duct abnormalities.

BACKGROUND: This prospective study evaluated whether extraductal catheter probe EUS as an adjunct to endoscopic retrograde cholangiography can detect or rule out choledocholithiasis and other pathologic conditions of the distal common bile duct. METHODS: A total of 119 patients referred because of suspected choledocholithiasis or other bile flow obstruction for endoscopic retrograde cholangiography and papillotomy were included in this prospective study. Extraductal EUS of the distal common bile duct with a radial-scanning catheter probe was followed immediately by endoscopic retrograde cholangiography and papillotomy by a second examiner who was blinded to the EUS findings. Extraductal EUS and endoscopic retrograde cholangiography findings were compared. RESULTS: Extraductal EUS detected 33/34 bile duct stones and all papillary adenomas (16 patients). In 8/34 patients, stones were missed on cholangiography but were seen after papillotomy and stone extraction. Extraductal EUS missed 10 peripheral lesions, one pancreatic tumor, and two distal bile duct stenoses. Overall, the sensitivity of EDUS was 78% and specificity was 98%. CONCLUSIONS: Extraductal EUS accurately detects abnormalities involving the distal common bile duct, especially small stones. The use of catheter probe EUS imaging during interventional endoscopy can help to avoid unnecessary papillotomy and can influence therapeutic strategy.

Adolescent↗
PubMed2004

Does intravenous glucagon improve common bile duct visualisation during magnetic resonance cholangiopancreatography? Results in 42 patients.

INTRODUCTION: Magnetic resonance cholangiopancreatography (MRCP) has been demonstrated as a reliable, non-invasive means of biliary tract imaging among patients with suspected choledocholithiasis. The aim of this study was to establish the impact of intravenous glucagon administration (IVGA) upon visualisation of the common bile duct (CBD) and ampulla of Vater during MRCP. MATERIALS AND METHODS: Forty-two consecutive, non-diabetic subjects with a working diagnosis of symptomatic choledocholithiasis were scanned, pre- and post-IVGA using the half-Fourier, single shot, turbo-spin-echo (HASTE) sequence. Maximum intensity projections (optimised for the extra-hepatic biliary tree and ampulla of Vater) were reviewed blindly by three consultant radiologists. The CBD images were graded (0-3) according to the length of duct seen. The ampullary images were graded according to whether to it was visualised clearly (1), or not (0). RESULTS: Following IVGA the CBD was visualised at grade 3 (75-100% of length seen) in 14 additional patients compared with images prior to IVGA. Furthermore, ampullary visualisation was considered diagnostic in 18 additional patients post-IVGA. No glucagon-associated adverse effects were observed. CONCLUSION: These results demonstrate that IVGA improved visualisation of the CBD and ampulla of Vater during magnetic resonance cholangiopanctreatography. This may reduce the requirement for repeat investigation or recourse to invasive diagnostic procedures (e.g. endoscopic retrograde cholangiopancreatography (ERCP)).

Adult↗
PubMed2005

Endoscopic retrograde cholangiopancreatography management of common bile duct stones in a surgical unit.

BACKGROUND: Choledocholithiasis, if left untreated, can lead to significant morbidity and mortality. The management of such a problem has progressed tremendously but controversy still exists as to ideal management, laparoscopic exploration or endoscopic retrograde pancreatography with sphincterotomy. The purpose of this study is to evaluate the results of endoscopic retrograde cholangiopancreatography (ERCP) in a surgical unit. METHODS: We performed a retrospective review on 336 patients who underwent ERCP between 1997-2000. RESULTS: We achieved a successful cannulation rate of 98% and stone clearance rate exceeding 90%. Morbidity has been minimal and there was no mortality in our study. CONCLUSION: We conclude that ERCP is an effective and safe surgical alternative for the management of choledocholithiasis.

Adult↗
PubMed2004

Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones.

BACKGROUND: Choledocholithiasis and intrahepatic bile duct stones pose a significant health hazard, especially in the elderly. The large stone not removable with conventional endoscopic techniques, can be effectively and safely managed with electrohydraulic lithotripsy (EHL). METHODS: This study is a retrospective review of consecutive patients at the Wellesley Central Hospital and St. Michael's Hospital, who underwent peroral endoscopic fragmentation of bile duct stones with EHL under direct cholangioscopic control using a "mother-baby" endoscopic system between October 1990 and March 2002. RESULTS: To date, 111 patients have been analyzed. Of the 111 patients reviewed, 94 patients have had complete records and were included in this study. Mean follow-up was 26.2 months (range 0-80). Prior to EHL, 93 of 94 patients (99%) had endoscopic retrograde cholangiopancreatography (ERCP) and failed standard stone extraction techniques (mean 1.9 ERCPs/patient, range 0-5). Indications for EHL were large stones (81 patients) or a narrow caliber bile duct below a stone of average size (13 patients). Successful fragmentation (61 complete, 28 partial) was achieved in 89 of 93 patients (96%) (1 patient was excluded from analysis due to a broken endoscope). Fragmentation failures were due to targeting problems (2 patients) and hard stones (2 patients). Seventy-six percent of patients required 1 EHL session, 14% required 2 sessions, and 10% required 3 or more. All patients with successful stone fragmentation required post-EHL balloon or basket extraction of fragments. Complications included: cholangitis and/or jaundice (13 patients); mild hemobilia (1 patient); mild post-ERCP pancreatitis (1 patient); biliary leak (1 patient); and bradycardia (1 patient). There were no deaths related to EHL. Final stone clearance was achieved in 85 of 94 patients (90%). CONCLUSIONS: EHL via peroral endoscopic choledochoscopy is a highly successful and safe technique for use in the management of difficult choledocholithiasis and intrahepatic stones. This study has shown a stone fragmentation rate of 96% (89 of 93 patients), and a final stone clearance rate of 90% (85 of 94 patients).

Adult↗
PubMed2005

Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis.

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.

Acute Disease↗
PubMed2005

Intraoperative cholangiography can be safely omitted during laparoscopic cholecystectomy: a prospective study of 413 consecutive patients.

BACKGROUND AND AIMS: The aim of the study was to show that laparoscopic cholecystectomy (LC) can be performed safely without intraoperative cholangiography (IOC). MATERIAL AND METHODS: We conducted a prospective study of 413 consecutive patients with symptomatic gallstone disease, who underwent LC. According to the preoperative clinical, laboratory and ultrasound criteria, 38 patients (9.2%) were selected for preoperative endoscopic retrograde cholangiography (ERC). All patients were followed postoperatively for symptoms and signs of common bile duct (CBD) stones. RESULTS: Preoperative ERC allowed to make a diagnosis of choledocholithiasis in 22 (58%) of the 38 selected patients. Stone clearance was achieved with endoscopic sphincterotomy (ES) in all cases. Three patients (7.9%) had an episode of mild self-limited pancreatitis after the procedure. Eight patients (1.9%) of 413 required conversion from LC to open cholecystectomy. There were no CBD injuries and no death cases. Of the postoperative complications, 1.5% were recorded during hospital stay. During the follow-up period, for at least 2 years after surgery, retained CBD stones were verified in 6 patients (1.5%); however, the supposed rate of residual stones was 2.4%. CONCLUSIONS: This study demonstrates that performance of selective preoperative ERC with ES when necessary, followed by LC, is an appropriate and safe approach to the treatment of patients with cholecystolithiasis and unsuspected choledocholithiasis. This approach allows to omit IOC and to perform LC safely without biliary duct injuries, ensuring low rate of retained CBD stones in the late follow-up period.

Adolescent↗
PubMed2005

Cholecystectomy after endoscopic sphincterotomy for common bile duct stones: is surgery necessary?

It has been more than 30 years since the introduction of endoscopic sphincterotomy for the management of choledocholithiasis. Once introduced, this endoscopic intervention subsequently enabled clinicians to witness the natural history of leaving the gallbladder in situ once the common duct calculi were removed. Because many people were free of symptoms once the common bile duct was cleared of stones, patients and physicians alike soon questioned whether it was necessary to remove the gallbladder at all. Despite more than two decades of clinical research and numerous published reports, the answer to this question remains elusive. Similarly, the management algorithm for choledocholithiasis in patients with an intact gallbladder remains controversial. We review the available key data regarding this question. Importantly, there are only three prospective, randomized trials that have examined the need for cholecystectomy after endoscopic sphincterotomy, with case studies constituting most of the published reports. Consequently, the literature on this topic remains inconclusive, weakened by its retrospective approach, considerable variability between the patients studied, inconsistent inclusion and exclusion criteria, and frequently poor patient follow-up. Nonetheless, the preponderance of data favor removing the gallbladder after endoscopically clearing the common bile duct of gallstones because an estimated 25% of patients will experience recurrent symptoms within a 2-year follow up period. Recognizing the existence of various mitigating clinical factors, we advocate adopting a selective wait-and-see approach for high-risk patients, especially those with a life expectancy of less than 2 years or severely debilitating comorbidities.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2005

Benign obstruction of the common hepatic duct (Mirizzi syndrome): diagnosis and operative management.

BACKGROUND: Mirizzi syndrome is a rare complication of prolonged cholelithiasis, characterized by narrowing of the common hepatic duct due to mechanical compression and/or inflammation due to biliary calculus impacted in the infundibula of the gallbladder or in the cystic duct. OBJECTIVES: To describe a series of eight consecutive patients with Mirizzi syndrome, at a single institution, submitted to surgical treatment and to comment on their aspects with emphasis on the diagnosis and treatment. METHODS: Four women and four men, with a mean age of 61.6 years (42 to 82 years), presenting Mirizzi syndrome were operated between 1997 and 2003. The following items were evaluated: clinical presentation, laboratory results, preoperative evaluation, operative findings, presence of choledocholithiasis, type of Mirizzi syndrome according to the classification by Csendes, choice of operative procedures, and complications. RESULTS: The most frequent symptoms were abdominal pain (87.5%) and jaundice (87.5%). All the patients presented altered hepatic function tests. The diagnosis of Mirizzi syndrome was intra-operative in seven (87.5%) patients, and preoperative in one (12.5%). Cholecystocholedochal fistula associated with choledocholithiasis was observed in three (37.5%) cases. Mirizzi syndrome was classified as Csendes type I in five (62.5%) patients, type II in one (12.5%), type III in one (12,5%) and type IV in another (12.5%). Cholecystectomy, as an isolated surgical procedure, was performed in four (50.0%) patients. One (12.5%) patient was submitted to partial cholecystectomy and closure of the fistulous orifice with the central part of the infundibula. Two (25.0%) patients were submitted to cholecystectomy and side-to-side choledochoduodenostomy and another (12.5%) to side-to-side choledochoduodenostomy remaining the gallbladder in situ. Seven (87.5%) patients had an uneventful recovery and were discharged in good conditions. One (12.5%) patient presented a postoperative sepsis due to a sub-hepatic abscess, and was reoperated. There was no operative mortality. CONCLUSION: The preoperative diagnosis of Mirizzi syndrome is difficult and an awarded suspicion is necessary to avoid lesions of the biliary tree. The problem may only become evident during the operation due to firm adherences around Calot's triangle. The success of the treatment is related to a precocious recognition of the condition, even at the time of surgery, and adapting the management considering to the individual characteristics of each case.

Adult↗