Selection of the Method of Treatment of Mirizzi Syndrome

The dissertation addresses the problem of selecting the optimal method of treatment of Mirizzi syndrome, a rare complication of gallstone disease in which stones in the region of the gallbladder neck or cystic duct compress or injure the common hepatic duct. The work is aimed at comparing the short-term results of surgical and combined (endoscopic, laparoscopic and open) methods of treatment of type I and type II Mirizzi syndrome, and at developing an algorithm for diagnosis and operative treatment that takes into account the variant of the pathology. Based on analysis of clinical material and comparison of ultrasound and endoscopic retrograde cholangiopancreatography data, the author evaluates the informativeness of preoperative methods, substantiates indications for laparoscopic cholecystectomy and criteria for conversion to laparotomy, and proposes a classification of Mirizzi syndrome that distinguishes types I, II A and II B.

The practical significance of the work lies in the possibility of reducing the frequency of injuries to the hepaticocholedochus during laparoscopic cholecystectomy and of expanding indications for minimally invasive interventions in patients with this syndrome. The results of the investigation have been introduced into the practice of surgical departments of city clinical hospitals in Khabarovsk and are used in the educational process at the departments of surgery of AGMA and DVGMU.

Relevance of the problem. At present, laparoscopic cholecystectomy (LCE) for chronic calculous cholecystitis is regarded by the majority of surgeons as the operation of choice due to its high efficacy and low rate of postoperative complications (Yu. I. Gallinger et al., 1995; V. V. Grubnik et al., 1996; N. A. Maistrenko, V. V. Stukalov, 2000; O. V. Galimov et al., 2004; G. M. Larson et al., 1992; G. M. Fried et al., 1995). In recent years, an increasing number of publications have appeared in the literature attesting to the effectiveness of laparoscopic cholecystectomy not only in chronic but also in acute cholecystitis (S. S. Slesarenko et al., 1995; A. S. Balalykin, 1996; V. V. Egorov, 1997; O. E. Lutsevich et al., 2003; B. K. Shurkalin et al., 2004; E. Trondsen et al., 1994).

Among the few drawbacks of laparoscopic cholecystectomy one should note the necessity in a number of cases of conversion to laparotomy and the higher frequency of injuries to the hepaticocholedochus compared with "open" cholecystectomy. Thus, according to data of B. K. Shurkalin et al. (2003), D. M. Krasilnikov et al. (2003), S. I. Tokpanov et al. (2003), A. Cuschieri et al. (1991), W. Meyers, 1991; G. Larson et al. (1992), D. Crist, T. Gadacz (1993), D. Deziel et al. (1993), the frequency of injuries to the hepaticocholedochus in "open" cholecystectomy varies from 0.1 to 0.4%, and in laparoscopic cholecystectomy — from 0.3 to 0.9% of cases. In the opinion of E. I. Galperin (1984), A. E. Borisov (1994), V. U. Radnaev (1996), I. V. Fedorov et al., 1998; N. A. Maistrenko and V. V. Stukalov (2000), K. Rust et al. (1991), J. Moser et al. (1993), R. Peterli et al. (1995), Desai et al. (1997), Sare et al. (1998), S. Contini et al. (1999), H. Dorrance et al. (1999); S. Chiappalone et al. (2000), F. Gotz, A. Pier (2001); L. Johnson et al. (2001), in the majority of cases injury to the hepaticocholedochus is associated with the presence of Mirizzi syndrome, and therefore they class this pathology among the absolute or relative contraindications to laparoscopic cholecystectomy.

According to data of many authors, the frequency of Mirizzi syndrome varies from 0.4 to 3.6% of cases (I. R. Lazarovskis, 1981; Z. A. Topchiashvili, 1988; A. N. Smirnova, 1994; V. U. Radnaev, 1996; V. S. Savelyev, V. I. Revyakin, 2003; M. Curet et al., 1994; G. Silecchia et al., 1995; T. Nagakawa et al., 1997; E. Targarona et al., 1997; A. Sharma et al., 1998; H. Dorrance et al. (1999), L. Johnson et al. (2001) O. Shah et al., 2001). As investigations testify, this pathology is relatively rarely diagnosed before surgery, despite the use of such modern methods of investigation as ultrasound examination (USE), computed tomography and endoscopic retrograde cholangiopancreatography (ERCP), as evidenced by the works of many authors (V. U. Radnaev et al. 1996; A. Scendes et al., 1989; S. Contini et al., 1999). According to data of J. Bagia et al. (2001), Shah et al. (2001), USE permitted the preoperative diagnosis of this pathology in only 15–22% of cases, while ERCP — in 33–50%. Preoperative diagnosis of Mirizzi syndrome makes it possible not only to avoid injury to the hepaticocholedochus, but also to predict a high probability of conversion to laparotomy during laparoscopic cholecystectomy. For instance, the rate of conversion to "open" operation in the course of laparoscopic cholecystectomy varies from 3.6% to 6.9% of cases (I. A. Gilenko (1994), Yu. I. Gallinger et al., 1995; A. G. Krieger, 1997; A. Cuschieri et al., 1991; G. Larson et al., 1992; W. Meyers, 1991; D. Crist, T. Gadacz, 1993; D. Deziel et al., 1993; B. Absill, 1994), while in patients with Mirizzi syndrome this index increases to 20–40% (A. L. Andreev, 2000; N. A. Maistrenko, V. V. Stukalov, 2000; G. Silecchia et al., 1995; H. Dorrance et al. (1999), L. Johnson et al. (2001), J. Bagia et al., 2001).

Despite the obvious relevance of the problem of diagnosis and treatment of Mirizzi syndrome, the literature contains only a few monographic and dissertation studies devoted mainly to the diagnosis and surgical treatment of Mirizzi syndrome (T. O. Smirenskaya, 2000; A. V. Selivanenko, 2002; V. S. Savelyev, V. I. Revyakin, 2003). As regards the endosurgical treatment of Mirizzi syndrome, only isolated studies based on a small number of observations are devoted to this question (V. N. Egiev et al., 1997; A. L. Andreev, 2000; M. Sare et al., 1998; P. Chowbey et al., 2000), which does not permit the authors to draw generalising conclusions. In addition, the literature does not clearly define the place of laparoscopic surgery within the spectrum of methods of treatment of various variants of Mirizzi syndrome.

Thus, analysis of the literature data attests to the necessity of further study of the possibilities of improving preoperative diagnosis and the selection of the optimal method of treatment of various variants of Mirizzi syndrome.

The aim of the investigation consists in performing a comparative assessment of the short-term results of surgical and combined (endoscopic, laparoscopic and surgical) methods of treatment of type I and type II Mirizzi syndrome.

Proceeding from this, the following tasks were solved in the investigation:

1. To study the informativeness of USE and ERCP in the diagnosis of type I and type II Mirizzi syndrome.

2. To develop an algorithm for the surgical treatment of type I and type II Mirizzi syndrome.

3. To develop principles for performing laparoscopic cholecystectomy in Mirizzi syndrome that increase the efficacy and safety of this intervention.

4. To study the influence of expanding the indications for laparoscopic cholecystectomy in Mirizzi syndrome on the frequency of injuries to the hepaticocholedochus in patients with gallstone disease.

5. To carry out a comparative assessment of the short-term results of predominantly surgical and combined methods of treatment of gallstone disease.

Scientific novelty of the investigation

An original classification of Mirizzi syndrome is proposed. An algorithm has been developed for the treatment of patients with types I, II A and II B Mirizzi syndrome, facilitating the selection of the optimal method of operation.

Principles for performing LCE have been developed that increase its safety in different types of Mirizzi syndrome. Indications for conversion to laparotomy during laparoscopic cholecystectomy in types I, II A and II B Mirizzi syndrome have been elaborated.

It has been proved that expansion of the indications for laparoscopic cholecystectomy in Mirizzi syndrome does not lead to an increase in the frequency of injuries to the hepaticocholedochus.

It has been established that the use of combined treatment, based on the indicated application of EPST, LCE and "open" operations in different types of Mirizzi syndrome, improves the short-term results of treatment of this pathology.

Practical significance of the investigation consists in the fact that the study of various aspects of the diagnosis and treatment of Mirizzi syndrome made it possible to reduce the frequency of injuries to the hepaticocholedochus in the course of laparoscopic cholecystectomy and to expand the indications for minimally invasive (endoscopic and laparoscopic) treatment of this pathology.

Main propositions submitted for defence

1. Clinical-laboratory and ultrasound diagnosis of Mirizzi syndrome is of low informativeness. More informative methods of preoperative diagnosis of Mirizzi syndrome are radiocontrast methods of investigation. The final diagnosis of Mirizzi syndrome is established during the operative intervention.

2. Laparoscopic cholecystectomy in Mirizzi syndrome is a complex intervention and should be performed by an endosurgeon possessing extensive experience in laparoscopic removal of the gallbladder and mastering the technique of endosurgical suture. Laparoscopic cholecystectomy in Mirizzi syndrome should be accompanied by a low threshold of conversion to laparotomy in connection with the high risk of wounding the common hepatic and bile ducts.

3. Surgical correction of the revealed variants of cholecystocholedochal fistula should be performed according to the principles of treatment of high strictures and injuries of the hepaticocholedochus.

Approbation of the work

The materials of the dissertation were reported at the VIII Russian–Japanese Symposium in Blagoveshchensk (2000), at the III scientific–practical conference "New Technologies in Surgery" in Khabarovsk (2001), at the city scientific–practical conference "Selected Questions of Surgical Practice" in Khabarovsk (2005) and at the First Far Eastern District scientific–practical conference "New Technologies in Endoscopic Diagnosis and Treatment" in Vladivostok (2005).

On the topic of the dissertation 6 printed works have been published.

Personal contribution of the author to the development of the topic

The author personally performed 2 laparoscopic cholecystectomies in patients with type I Mirizzi syndrome and assisted at laparoscopic cholecystectomies and "open" operations in 11 patients with different variants of this pathology.

Implementation of the work in practical public health

Laparoscopic cholecystectomy in Mirizzi syndrome is widely used in the everyday practice of surgical departments No. 1 and No. 2 of MUZ GKB No. 11 in Khabarovsk and in the surgical department of hospital No. 3 of MUZ GKB No. 3 in Khabarovsk. The materials of the dissertation are used in the educational process at the departments of surgery of AGMA and DVGMU. On the topic of the dissertation 6 works have been published in the scientific–practical literature.

Volume and structure of the dissertation