Mirizzi syndrome with cholecystocholedochal fistula: preoperative diagnosis and management.

Gallstone obstruction of the cystic duct with resulting repeated attacks of inflammation and pressure necrosis leads to the formation of cholecystocholedochal fistulas (Mirizzi syndrome type II). Obstructive jaundice and cholangitis are the common presentations of the condition. These fistulas are often not recognized before operation and constitute a high risk of damage to the common duct during a formal cholecystectomy. A high index of suspicion is required to diagnose the condition. We report five patients with cholecystocholedochal fistulas diagnosed by endoscopic retrograde cholangiography that delineated the fistula and the obstructing stone. The plan of management was formulated before surgery, and persistent attempt to dissect the Calot's triangle was avoided. In three patients the common duct defect was closed with the use of a gallbladder flap. Hepaticojejunostomy was required for the two difficult cases with large common duct defects and inflamed tissue.