Is choledochoduodenostomy the preferred primary operation for patients with Mirizzi syndrome, or should cholecystectomy with common‑bile‑duct repair (or Roux‑en‑Y hepaticojejunostomy for high‑grade fistulas) be performed?

Choledochoduodenostomy for Mirizzi Syndrome

Choledochoduodenostomy is NOT the preferred primary operation for Mirizzi syndrome; instead, cholecystectomy with common bile duct repair (for low-grade fistulas) or Roux-en-Y hepaticojejunostomy (for high-grade fistulas with tissue loss) should be performed. 1, 2

Surgical Approach Based on Mirizzi Syndrome Type

Type I Mirizzi Syndrome (External Compression Without Fistula)

• Cholecystectomy alone is the procedure of choice when the common bile duct integrity can be confirmed intraoperatively 3, 4
• If there is any uncertainty about bile duct security, add common bile duct exploration and/or T-tube drainage 3
• Laparoscopic cholecystectomy may be attempted by experienced surgeons, though conversion to open is common due to dense adhesions and distorted anatomy at Calot's triangle 5, 6, 7

Type II-III Mirizzi Syndrome (Cholecystobiliary Fistula)

• Partial cholecystectomy with primary repair of the fistula using gallbladder or cystic duct remnant is the recommended approach 7, 4
• The gallbladder portion around the fistula margin should be left in place and used to oversew the defect 7, 4
• Choledochoplasty may be needed for larger defects 4
• Direct repair with or without T-tube placement may be considered for minor bile duct injuries without tissue loss 1, 2

Type IV Mirizzi Syndrome (Large Fistula with Tissue Loss)

• Roux-en-Y hepaticojejunostomy is the procedure of choice when there is extensive tissue loss, questionable vascularity of the hepatic duct, or tissues inadequate for primary repair 7, 4
• Hepaticojejunostomy should be considered as the treatment of choice for major bile duct injuries (Strasberg E injuries) 1, 2
• This reconstruction provides superior long-term outcomes compared to primary repair when significant tissue loss is present 1, 8

Why Choledochoduodenostomy Is Not Recommended

Technical and Anatomical Limitations

• Choledochoduodenostomy is contraindicated in patients who may require future endoscopic access to the biliary tree 9
• The procedure is only appropriate for distal common bile duct injuries without associated vascular injury, which is not the typical anatomical location affected in Mirizzi syndrome 9
• Mirizzi syndrome involves the common hepatic duct or proximal common bile duct at the level of the cystic duct insertion, making choledochoduodenostomy anatomically inappropriate 6, 7

Evidence from Clinical Series

• In a multi-institutional review of 11 Mirizzi syndrome cases, no choledochoduodenostomies were performed; instead, partial cholecystectomy with fistula repair or Roux-en-Y hepaticojejunostomy was used based on severity 7
• A large series of 198 Mirizzi syndrome patients demonstrated that cholecystectomy (for Type I), partial cholecystectomy with choledochoplasty (for Types II-III), and hepaticojejunostomy (for Type IV) were the standard approaches 4
• One older series reported using choledochoduodenostomy for Type II patients, but this approach has not been validated in modern guidelines and is not supported by current expert consensus 3

Critical Surgical Principles

Preoperative Planning

• Exhaustive preoperative work-up is mandatory for patients with suspected Mirizzi syndrome to discuss and balance the risks/benefits ratio of the procedure 1
• MRCP and ultrasonography combined can achieve diagnostic sensitivity of 77-82% 4
• Intraoperative choledochoscopy is effective to confirm the diagnosis and extent of fistula during surgery 4

Intraoperative Decision-Making

• Open surgery is the current standard for managing Mirizzi syndrome due to dense adhesions and distorted anatomy 7, 4
• Laparoscopic approach should be confined to Type I cases with very strict patient selection 4
• When major bile duct injury is encountered, referral to an HPB center should be considered if sufficient expertise is not available locally 1, 2
• The opinion of another surgeon should be considered when bile duct injury is suspected 1

Reconstruction Requirements

• Any bilioenteric anastomosis must be tension-free with good mucosal apposition between healthy, well-vascularized tissues 9, 8
• All scar tissue and devitalized tissue must be removed from the bile duct before anastomosis 8
• For hepaticojejunostomy, create a Roux-en-Y jejunal limb of 40-60 cm to prevent reflux 8

Common Pitfalls to Avoid

• Do not attempt end-to-end bile duct anastomosis when tissue loss is present, as this is associated with significantly higher failure rates 1, 8
• Avoid performing anastomosis on ischemic, inflamed, or scarred bile duct tissue, as this guarantees failure 8
• Do not attempt laparoscopic cholecystectomy if dense adhesions and inability to delineate structures in Calot's triangle are encountered; convert to open immediately 7
• The repair of complex vasculobiliary injuries should be delayed and not attempted intraoperatively, even by expert HPB surgeons 1, 2