Treatment of Mirizzi Syndrome with Intrahepatic Bile Duct Dilatation
For Mirizzi syndrome with intrahepatic bile duct dilatation, endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy and plastic stent placement is the first-line treatment, followed by definitive surgical management with cholecystectomy once biliary drainage is established and inflammation subsides. 1, 2, 3
Initial Management: Biliary Decompression
The priority is immediate biliary drainage to relieve obstruction and prevent cholangitis:
ERCP with biliary sphincterotomy and removable plastic stent placement is the recommended initial therapeutic procedure for patients with dilated intrahepatic bile ducts from biliary obstruction. 4, 2, 3
If the impacted cystic duct stone can be mobilized into the common bile duct during ERCP, perform mechanical basket lithotripsy and stone extraction with a balloon catheter. 5
When complete stone extraction is not possible during the initial procedure, temporary stenting ensures adequate biliary drainage and allows for definitive treatment within 4-6 weeks. 1, 3
For patients with acute cholangitis or septic shock who fail antibiotic therapy, urgent biliary decompression with endoscopic stone extraction and/or biliary stenting is mandatory. 4, 2
Diagnostic Confirmation
ERCP serves dual purposes as both diagnostic gold standard and therapeutic intervention:
ERCP delineates the cause, level, and extent of biliary obstruction, identifies the presence of cholecystobiliary fistula, and allows classification of Mirizzi syndrome type. 6, 7
Endoscopic ultrasound can identify the impacted cystic duct stone causing extrinsic compression of the common hepatic duct, confirming the diagnosis when ERCP cannulation is difficult. 5
MRCP should complement initial imaging to obtain exact visualization and classification of the biliary anatomy before definitive surgical planning. 2, 6
Definitive Surgical Management
After successful biliary drainage and resolution of acute inflammation (minimum 3 weeks):
Cholecystectomy remains the mainstay of definitive treatment for Mirizzi syndrome. 6, 8, 9
Open cholecystectomy is the current standard, with good short- and long-term results and low mortality and morbidity when performed after adequate biliary drainage. 6, 9
Laparoscopic cholecystectomy is feasible for Type I Mirizzi syndrome (without cholecystobiliary fistula) in experienced hands, with preoperative ERCP diagnosis being crucial to prevent bile duct injury. 9, 7
For Type II-IV Mirizzi syndrome (with cholecystobiliary fistula), additional procedures may be required including common bile duct exploration, choledochoplasty, or bilioenteric anastomosis. 8, 9
Subtotal cholecystectomy should be performed if total cholecystectomy cannot be completed safely due to dense adhesions and distorted anatomy at Calot's triangle. 8
Alternative Approach: Percutaneous Drainage
If ERCP fails or is not possible:
Percutaneous transhepatic biliary drainage (PTBD) is the second-line option for biliary decompression, though it carries a 2.5% bleeding complication rate. 4
PTBD is contraindicated in patients with uncorrected coagulopathy (INR >2.0 or platelet count <60K). 4
A rendezvous technique combining percutaneous and endoscopic approaches can be used for difficult cases. 1
Special Considerations for High-Risk Patients
For elderly patients or those with multiple comorbidities who are poor surgical candidates:
Endoscopic treatment alone (ERCP with stone extraction and stenting) can serve as definitive treatment, avoiding surgery entirely. 5, 6
This approach is particularly appropriate when surgical risk outweighs benefits, though it does not address the underlying gallbladder pathology. 6
Critical Pitfalls to Avoid
Never attempt laparoscopic cholecystectomy without preoperative diagnosis of Mirizzi syndrome, as the distorted anatomy and dense adhesions significantly increase the risk of bile duct injury. 8, 9, 7
Do not perform surgery during the acute inflammatory phase; allow minimum 3 weeks for inflammation to subside after biliary drainage. 2
Avoid percutaneous approaches in patients with moderate to massive ascites due to bleeding risk and ascitic fluid leakage. 4, 3
Endoscopic sphincterotomy carries significantly higher complication rates (up to 19%) in elderly patients compared to younger patients. 1