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【摘要】 目的 总结Mirrizi综合征的诊断和治疗经验。方法 对22例经手术证实的Mirrizi综合征进行回顾分析。结果 22例病人在术前均未能确诊，经术中证实后行保留颈部的胆囊大部切除术5例;胆囊切除，瘘口直接修补10例;胆囊大部切除加胆囊瓣瘘口修补术5例;胆肠吻合2例。结论 Mirrizi综合征术前诊断困难，确诊率低;术中应根据不同情况，选择合适术式。
关键词 Mirrizi综合征 诊断 治疗
Experience in diagnosis and treatment of22cases of Mirrizi syndrome
Zhang Jun，Qiao Qilu，Zhao Jianxun，et al.
Department of General Surgery，First Hospital of Peking University，Beijing100034.
【Abstract】 Objective To summarize the experience in diagnosis and treatment of Mirizzi syndrome.Methods 22cases of Mirizzi syndrome proved by operation were respectively analyzed.Results No case was definitely diagˉnosed before operation.Of the22cases，5were treated with subtotal cholecystectomy，10with cholecystectomy and cloˉsure of the fistula，5with subtotal cholecystectomy and choledochoplasty with remnant of the gallbladder，2with choleˉcystectomy plus Roux-en-Y hepaticojejunostomy.Conclusion It’s difficult to diagnose Mirizzi syndrome preoperaˉtively，and appropriate procedures should be selected according to different types of Mirizzi syndrome.Key words Mirizzi syndrome diagnosis treatment Mirrizi syndrome is defined as the cholangitis，obstructive jaundice and disorder of liver function caused by external comprsˉsion of common hepatic duct by a stone impacted in the cystic duct or in the neck of the gallbladder with or without inflammation.It is a rare disease that Baer ［1］ described it occured in0.7%～1.1%of all patients having operations for cholelithiasis.Here，we report the clinical characteristics，diagnostic methods，surgical manageˉment in22patients with Mirizzi syndrome collected from1996to2002who were treated at the First Hospital of Peking University.
1 Material and Methods
1.1 General material 22cases with Mirizzi syndrome representˉed approximately0.56%of all cholecystolithiasis.The study popuˉlation consisted of5men and17women with a mean age of56.4years old（range，31to68years）.
1.2 Main clinical manifestation 13patients only complained of abdominal pain in the right upper quadrant，7patients accompanyˉing with fever，1patient with obstructive jaundice，and1case had triad of cholangitis.
1.3 Lab findings Preoperative levels of serum BIL，GPT，AKP and GTTwere higher than normal value in10，9，8and11cases respectively.There was no significant specificity.
1.4 Ultrasonography All patients showed cholelithiasis.Eˉchogenic focus with acoustic shadow in the neck of the gallbladder or in the cystic duct was observed in9cases.7of them revealed the diameter of the stones exceeding2cm.Gallbladder atropgy was detected with7patients.Ultrasonographic examination alsodemonstrated dilated hepatic duct in7cases.“Three duct sign”was not obtained.
1.5 ERCP ERCP was not performed in all patients.
1.6 PTC One patient underwent PTC examination.It showed dilated biliary duct and partial obstruction in middle segment of common bile duct.Tumor or stone was not differetiated by PTC imaging.
1.7 Csendes classes 22cases were classified among the Csendes classes as illustrated in Table1.
Table1 csendes classes of twenty-two cases略
1.8 Surgical management All patients were resolved with surgiˉcal intervention.Of the22cases，5were treated with subtotal cholecystectomy，10with cholecystectomy and closure of the fistuˉla，5with subtotal cholecystectomy and choledochoplasty with remˉnant of the gallbladder，2with cholecystectomy plus Roux-en-Y hepaticojejunostomy.
2 Results
The mortality was zero in this series.Two complications ocˉcurred in2patients.Percutaneous USG-guided aspiration and drainage was done for the bile leakage after removing T-tube at the14 ［th］ days postoperatively.In another patient，bleeding from the upper digestive tract occurred in3weeks after operation and conˉservative therapy was performed.
3 Discussion
3.1 Mechanism Mirizzi described in1984firstly a partial or a spastic obstruction of the common hepatic duct due to an impacted stone in the cystic duct or infundibulum of the gallbladder ［2］ .The modern deriniton of Mirizzi syndrome is thought to include four components ［3］ :cystic duct runs parallel to the common hepatic duct;impaction of a stone in the cystic duct or neck of the gallˉbladder;mechanical obstruction of the common hepatic duct by the stone itself or by secondary inflammation;intermittent or constant jaundice causing possible recurrent cholangitis，if longstanding，or secondary biliary cirrhosis.In present series，however，a cystic duct running parallel to the hepatic duct was noticed in only1patient intraoperatively.This finding was not a common phenomenon.Furˉthermore，The impacted stones（77.8%）were mostly larger than2cm that alllowed them to easily compacted in the neck of the cysts and difficult to move.
3.2 Diagnosis Preoperative confirmation for Mirizzi syndrome is usually difficult due to lack of specific symptoms.Fransisco reportˉed only as many as24%of patients could be ruled out before opˉeration. ［4］ No case in this series was elucidated preoperatively.Onˉly one patientwas considered the possibility of the Mirizzi syndrome based on a PTC findings.Currently，the first choice of workup was BUS.The diagnosis of Mirizzi syndrome should be suspected when the ultra
sonography showed a gallbladder atrohpy and echogenic foˉcus in the infundibulum of the cyst and dilated hepatic duct.Given ERCP has an advantage to indicate biliary tree directly and show the deformation of bile duct structure clearly.Wang Yongqiang ［5］ and Tian Yifeng ［6］ proposed it was the most useful method to diagˉnosis Mirizzi syndrome.There was no patient in our entire cohort to undergo ERCP due to the absense of obstructive jaundice which inˉcreased difficulty to identify Mirizzi syndrome preoperatively.Therefore，in order to elucidate the disease prior to operation，an ERCP should be performed when ultrasonography shows dilated hepatic duct even though in case of absence of obviously obstrucˉtion of the bile tract.Wang Wei ［7］ et al reported it was difficult for PTC to indicate cystic duct and bile duct under the obstruction site clerrly.1case in our patient performing PTC confirms this point.
3.3 Surgical management The treatment principle of Mirizzi syndrome is to dissect the cyst，remove the obstruction，repair，reˉpair the fistula and set up the drainage.An attempt at complete disˉsection in the area of the triangle of Calot is very dangerous due to severe adhesion and fibrosis.Proper operative management based on the classification of Mirizzi syndrome is important to avoid bile duct injury.Partial cholecystectomy is considered to be a safe and definitive surgical treatment in typeⅠlesions.CBD exploration just for bile duct stenosis is mostly unnecessary.Bile spilling from the site where the impacted stone is removed could indicate the presence of a bile fistula.The best surgical method of fistula repair varies according to the size of the fistula existed.The common hepˉatic duct can be sutured directly for typeⅡ.Partial cholecystectoˉmy and choledoplasty with remmant of the gall bladder is an indiˉcation for typeⅢ.A T-tube should be inserted into the CBD through a separate incision to provide maximum safety of the suture line.Setting T-tube through the fistula always results in stenosis of the bile duct.We remored the T-tube at the postoperative14 ［th］ days without any complication related stenosis.If the fistula can not be closed primarily，just as type4，bilio-digestive by pass may be the best choice of treatment.This approach is essential to avoid early and later complications.In addition，the relationship beˉtween Mirizzi syndrome is more and more concerned.Mirizzi synˉdrome had elevated CA19-9is demonstrated by Lee ［8］ .Redaelli and Shilling MK ［9］ reported the incidence of malignancy in patients withMirizzi syndrome was significantly higher than the incidence in longstanding gallstone disease（27%vs2%，respectively）.Although gallladder cancer has not been found in and of our patients，we suggest frozen sections should be done when the diagnosis ofMirizzi syndrome is identified during the surgical procedure to determine the operative management.
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作者单位:100034北京大学第一医院普通外科
（收稿日期:2004-07-20） （编辑毅 文）