Management of the Mirizzi syndrome and the surgical implications of cholecystcholedochal fistula.

Several methods of handling the residual choledochal defects encountered during operation for type II Mirizzi syndrome have been described. Early experience with eight patients treated by a variety of procedures including direct suture and flap techniques led to disappointingly high morbidity and mortality rates. Since 1986 a standardized surgical approach has been used in four patients without complications or mortality. Essential to management are preoperative diagnosis by ultrasonography and endoscopic retrograde cholangiopancreatography and classification of the Mirizzi syndrome into two types as proposed by McSherry. Mirizzi type I consists of an extrinsic compression of the hepatic duct by a calculus impacted in the cystic duct or in Hartmann's pouch. This is treated by cholecystectomy with or without common bile duct exploration. In the more difficult Mirizzi type II, the stone has eroded into the hepatic duct causing a cholecystcholedochal fistula. This is treated by partial cholecystectomy and a cholecystcholedochoduodenostomy. This management strategy prevents inadvertent bile duct injury and has yielded satisfactory results.