Mirizzi Syndrome.

The complete and definitive treatment of patients with Mirizzi syndrome is surgical. The treatment goals are the removal of the gallbladder with the offending stone(s) and the repair of the bile duct defect. A high index of suspicion for early recognition of this condition is paramount to prevent bile duct injury. Biliary anatomy is delineated precisely by preoperative and intraoperative imaging tests. The dissection of the gallbladder is conducted in an antegrade, fundus-first fashion. Extensive dissection of Calot's triangle is avoided. Instead, the gallbladder is opened, the impacted stone(s) is removed backward, and the confirmation of the presence a cholecystocholedochal fistula is established by direct inspection. A coexistent gallbladder carcinoma is excluded by taking frozen sections. In patients without biliary fistula (Mirizzi type I), simple cholecystectomy suffices to relieve the bile duct obstruction. In patients with biliary fistula (Mirizzi type II), the size of the fistula determines the type of repair. In general, small fistulas are repaired by choledochoplasty using a cuff of gallbladder remnant, whereas large bile duct defects require bilioenteric reconstruction (Roux-en-Y hepaticojejunostomy or choledochoduodenostomy). In patients unfit for surgery, biliary decompression is effectively accomplished by placement of stents using endoscopic or percutaneous techniques. Lithotripsy and removal of the offending stone can also be carried out in patients with Mirizzi type II. In general, nonsurgical treatment of Mirizzi syndrome is incomplete and places the patients on a path of intensive follow-up, multiple procedures, and the risk to continue suffering from complications of symptomatic gallstone disease. However, nonsurgical treatment allows for valuable time to prepare high-risk patients for a more elective and safer operation.