A case of mirizzi syndrome: diagnostic and therapeutic challenges in a high-risk surgical patient

Abstract

Mirizzi Syndrome is a rare complication of long-standing cholelithiasis, characterized by extrinsic compression of the common hepatic duct by an impacted gallstone in the cystic duct or Hartmann's pouch. Its preoperative diagnosis remains challenging due to its mimicry of malignant biliary obstruction, and its management often requires a complex, multi-modal approach. The case of a 66-year-old female presented with multiple comorbidities who presented with obstructive jaundice and was ultimately diagnosed and treated for Type II Mirizzi Syndrome. This case highlights the critical role of endoscopic retrograde cholangiopancreatography (ERCP) in both diagnosis and initial management, the potential for complications, and the necessity for a tailored surgical strategy in high-risk patients. Mirizzi Syndrome, first described by Pablo Luis Mirizzi in 1948, is an uncommon sequela of chronic cholelithiasis, with an estimated incidence of 0.7-1.4% in patients undergoing biliary surgery. It occurs when a gallstone becomes impacted in the cystic duct or infundibulum of the gallbladder, leading to chronic inflammatory changes, fistula formation, and mechanical obstruction of the common hepatic duct. The condition is classified using the Csendes classification: Type I involves external compression of the common hepatic duct without a fistula, while Types II-V involve the presence of a cholecystobiliary fistula of varying sizes. The clinical presentation is often insidious and non-specific, featuring jaundice, right upper quadrant pain, and weight loss, which can be mistaken for pancreaticobiliary malignancies. Accurate preoperative diagnosis is crucial for surgical planning but is often achieved only intraoperatively due to overlapping radiological features with other pathologies. Management is primarily surgical; however, the approach must be highly individualized, considering the patient's comorbidities, the extent of inflammation, and the presence of a fistula. Endoscopic intervention with ERCP plays a vital role in preoperative biliary decompression and stenting, facilitating a safer subsequent surgical procedure. The objective of this case report is to illustrate the diagnostic journey, interdisciplinary management, and successful treatment of a complex case of Type II Mirizzi Syndrome in a patient with significant cardiopulmonary comorbidities. We aim to emphasize the importance of a high index of suspicion, the utility of advanced endoscopic techniques, and the adaptation of surgical techniques to minimize morbidity in high-risk surgical candidates.