Bartone Giovanni, Castriconi Maurizio, Romagnuolo Giuseppe, Maglio Mauro Natale Domenico, Monte Giovanni, Zito Enzo Saverio, Chianese Francesco, Giuliano Maria Elena, De Sena Guido
Unità Operativa a Struttura Complessa, di Chirurgia Generale del Dipartimento di Emergenza Azienda Ospedaliera di Rilievo Nazionale, Cardarelli, Napoli.
Chir Ital. 2008 Jan-Feb;60(1):55-62.
The authors report their experience in the management of patients with Mirizzi Syndrome (MS) admitted, over a period of 15 years, at the General Surgery of Emergency Department of Cardarelli Hospital, Naples, Italy. All patients were admitted and surgically treated in emergency save for one. Out of 12 patients, cholecystectomy was performed in 7 cases. In others 5 patients, with cholecystocholedochal fistula, cholecystectomy with positionig of T-Tube was performed in 4 cases (MS-II); finally, 1 patient with MS type III undewrwent choledochojejunostomy. According to literature, the diagnostic protocol included abdominal ultrasonography and CT scan of the abdomen for all patients; in one case, a cholangio-MRI was performed to clarify the diagnosis. The preoperative diagnosis is essential to reduce risk of iatrogenic injuries. The cholangio-MRI, used to this extent, clarifies the site of obstruction, shows the anatomy of the biliary tree and allows to make all the possible differential diagnoses in order to exclude the presence of biliary tumors before surgery. The intraoperative cholangiography remains mandatory to clarify the anatomy of the biliary tree. In the cases we have treated, ERCP was never performed. We believe that ERCP has limited indications and unsatisfactory outcomes for both diagnosis and treatment of MS. Pathological examination of the fresh-frozen surgical specimens was always performed intraoperatively to exclude the presence of concomitant cancer of the gallbladder. The traditional treatment of patients with MS is surgery, as confirmed by our experience. We perform cholecystectomy for MS type I and cholecystectomy with direct repair of the biliary fistula over aT tube for MS type II. Patients with MS type III usually undergo a tailored operation based on the intraoperative findings, while choledochojejunostomy is mandatory for patients with MS type IV. Laparoscopic surgery is indicated only for MS type I and II. It seems to carry a higher risk for the patient and we do not use this approach in the emergency settings.
作者报告了他们在意大利那不勒斯卡雷利医院急诊科普通外科对Mirizzi综合征（MS）患者进行治疗的15年经验。除1例患者外，所有患者均在急诊情况下入院并接受手术治疗。在12例患者中，7例行胆囊切除术。在其他5例存在胆囊胆管瘘的患者中，4例行胆囊切除术并放置T管（MS-II型）；最后，1例III型MS患者接受了胆总管空肠吻合术。根据文献，诊断方案包括对所有患者进行腹部超声检查和腹部CT扫描；1例患者进行了磁共振胰胆管造影（MRCP）以明确诊断。术前诊断对于降低医源性损伤风险至关重要。在此种情况下使用的MRCP可明确梗阻部位，显示胆管树的解剖结构，并有助于进行所有可能的鉴别诊断，以便在手术前排除胆管肿瘤的存在。术中胆管造影对于明确胆管树的解剖结构仍然是必需的。在我们治疗的病例中，从未进行过内镜逆行胰胆管造影（ERCP）。我们认为，ERCP在MS的诊断和治疗方面适应证有限且效果不佳。术中始终对新鲜冷冻手术标本进行病理检查，以排除胆囊合并癌的存在。正如我们的经验所证实的，MS患者的传统治疗方法是手术。对于I型MS，我们行胆囊切除术；对于II型MS，行胆囊切除术并通过T管直接修复胆瘘。III型MS患者通常根据术中发现进行个体化手术，而IV型MS患者则必须行胆总管空肠吻合术。腹腔镜手术仅适用于I型和II型MS。它似乎对患者具有较高风险，我们在急诊情况下不采用这种方法。
