Chatzoulis George, Kaltsas Andreas, Danilidis Lazaros, Dimitriou John, Pachiadakis Ioannis
Department of Surgery, 424 Military Hospital Thessaloniki, Greece.
BMC Surg. 2007 May 27;7:6. doi: 10.1186/1471-2482-7-6.
Mirizzi syndrome is a rare complication of prolonged cholelithiasis with presence of large, impacted gallstone into the Hartman's pouch, causing chronic extrinsic compression of common bile duct (CBD). Fistula formation between the CBD and the gallbladder may represent an outcome of that condition. According to Mirizzi's classification and Csendes's subclassification, Mirizzi syndrome type IV represents the most uncommon type (4%). Spontaneous biliary-enteric fistulas have also been rarely reported (1.2-5%) in a large series of cholecystectomies. Cholecystocolic fistula is the most infrequent biliary enteric fistula, causing significant morbidity and representing a diagnostic challenge.
We describe a very rare, to our knowledge, combination of Mirizzi syndrome type IV and cholecystocolic fistula. A 52 year old male, presented to our clinic complaining of episodic diarrhea (monthly episodes lasting 16 days), high temperature (38 degrees C-39 degrees C), right upper quadrant pain without jaundice. The definitive diagnosis was made intraoperatively. Magnetic Resonance Imaging (MRI) and Endoscopic Retrograde Cholangiopancreatography (ERCP) demonstrated the presence of Mirizzi syndrome with cholecystocolic fistula formation. The patient was operated upon, and cholecystectomy, cholecystocolic fistula excision and Roux-en-Y biliary-enteric anastomosis were undertaken with excellent post-operative course.
Appropriate biliary tree imaging with ERCP and MRI/MRCP is essential for the diagnosis of Mirizzi syndrome and its complications. Cholecystectomy, fistula excision and biliary-enteric anastomosis with Roux-en-Y loop appears to be the most appropriate surgical intervention in order to avoid damage to Calot's triangle anatomic elements. Particularly in our case, ERCP was a valuable diagnostic tool that Mirizzi syndrome type IV and cholecystocolic fistula.
Mirizzi综合征是长期胆石症的一种罕见并发症，巨大嵌顿性胆结石位于Hartmann袋内，导致胆总管（CBD）慢性外部受压。胆总管与胆囊之间形成瘘管可能是该病症的一个后果。根据Mirizzi分类和Csendes亚分类，IV型Mirizzi综合征是最罕见的类型（4%）。在大量胆囊切除术中，自发性胆肠瘘的报道也很少见（1.2 - 5%）。胆囊结肠瘘是最罕见的胆肠瘘，会导致严重的发病率，也是一个诊断难题。
据我们所知，我们描述了一例非常罕见的IV型Mirizzi综合征与胆囊结肠瘘的组合病例。一名52岁男性到我们诊所就诊，主诉发作性腹泻（每月发作，持续16天）、高热（38摄氏度至39摄氏度）、右上腹疼痛且无黄疸。术中做出了明确诊断。磁共振成像（MRI）和内镜逆行胰胆管造影（ERCP）显示存在Mirizzi综合征并伴有胆囊结肠瘘形成。对该患者进行了手术，实施了胆囊切除术、胆囊结肠瘘切除术和Roux - Y胆肠吻合术，术后恢复良好。
采用ERCP以及MRI/MRCP对胆管树进行适当成像对于Mirizzi综合征及其并发症的诊断至关重要。胆囊切除术、瘘管切除术以及采用Roux - Y袢的胆肠吻合术似乎是最合适的手术干预方式，以避免损伤胆囊三角的解剖结构。特别是在我们的病例中，ERCP是诊断IV型Mirizzi综合征和胆囊结肠瘘的一种有价值的诊断工具。
