What are the potential solutions for a Mirizzi syndrome type 2 (choledocholithiasis with partial obstruction of the common bile duct)?

From the Guidelines

Mirizzi Type 2 syndrome requires surgical management as the primary solution to minimize morbidity, mortality, and improve quality of life. The recommended approach typically involves cholecystectomy with repair of the bile duct defect. Specific surgical options include laparoscopic or open subtotal cholecystectomy with removal of stones, followed by closure of the cholecystobiliary fistula. For larger defects (less than 50% of duct circumference), a choledochoplasty using the gallbladder remnant may be performed. Alternatively, Roux-en-Y hepaticojejunostomy is recommended for extensive defects exceeding 50% of the bile duct circumference.

Preoperative ERCP with stent placement may be used to decompress the biliary system before definitive surgery, as it has been shown to be effective in managing acute cholangitis, a potential complication of Mirizzi syndrome 1. Intraoperative cholangiography is essential to define the biliary anatomy. Postoperatively, patients require close monitoring for bile leaks and strictures. The surgical approach is necessary because Type 2 Mirizzi syndrome involves a cholecystobiliary fistula with erosion into the bile duct caused by impacted gallstones, which cannot be adequately addressed with conservative management alone.

Some studies suggest that endoscopic biliary decompression by nasobiliary catheter or indwelling stent can be effective for patients with acute suppurative cholangitis caused by bile duct stones 1. However, for Mirizzi Type 2 syndrome, surgical management is still the primary solution. The use of a biliary stent as sole treatment for CBDS should be restricted to a selected group of patients with limited life expectancy and/or prohibitive surgical risk 1.

Key considerations in the management of Mirizzi Type 2 syndrome include:

• Surgical management as the primary solution
• Cholecystectomy with repair of the bile duct defect
• Preoperative ERCP with stent placement for biliary decompression
• Intraoperative cholangiography to define biliary anatomy
• Close monitoring for bile leaks and strictures postoperatively
• Restricting the use of biliary stents to patients with limited life expectancy or prohibitive surgical risk.

From the Research

Potential Solutions for Mirizzi Type 2

The potential solutions for Mirizzi Type 2 include:

• Primary closure over a T-tube 2
• Bilio-digestive anastomosis, preferably Roux-en-Y 2
• Laparoscopic treatment, which is a feasible and safe procedure, especially in specialist units 3, 4
• Mucosal approach, which may decrease the risk of bile duct injury, biliary tract infection, and blood loss 5
• Exploration of the bile duct through the cholecystocholedochal fistula, followed by drainage with a T-tube through the fistula 4

Surgical Approaches

Surgical approaches for Mirizzi Type 2 include:

• Open surgery, which is the current standard for managing patients with Mirizzi syndrome 6
• Laparoscopic surgery, which can be used to treat Mirizzi syndrome, but is generally considered a contraindication due to the increased risk of morbidity and mortality 6, 3
• Mucosal approach, which is a novel surgical approach that has been used to treat Type 2 Mirizzi syndrome with successful results 5

Treatment Outcomes

Treatment outcomes for Mirizzi Type 2 include:

• Low morbidity rate, with a reported rate of 32% 2
• No mortality, with a reported series of 25 patients 2
• Symptom-free and normal liver function, with a reported follow-up of 1 to 96 months 2
• Postoperative complications, such as bile leakage and postoperative intra-abdominal collection, which can occur in up to 16.7% of patients 5