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Mirizzi syndrome (MS) is one of the least understood concepts in bile duct surgery. This is
due to the rarity of this pathology. This disease occurs according to the literature, from 0.5 to 5%
among all patients operated on for gallstone disease [6, 12, 13, 17]. In connection with the pro-
gress of biliary tract surgery, an increase in the incidence of cholelithiasis, interest in this problem
has increased in recent years. However, there is still no consensus on the diagnosis and tactics of
surgical treatment [1, 2, 7, 15]. MS is often diagnosed only during surgery, which increases the
percentage of access conversion and the risk of trauma to the common bile duct [9, 18].
The main clinical manifestations of MS are pain in the right hypochondrium, jaundice and
fever as a result of associated cholangitis [4, 8, 12]. It is practically difficult to isolate the clinical
symptoms that distinguish this syndrome from others that occur with obstructive jaundice. Differ-
ential diagnosis is carried out with such diseases and conditions as choledocholithiasis, common
bile duct cancer, gallbladder cancer, pancreatic cancer, pseudotumorous pancreatitis, compression
of the common bile duct with metastatic lymph nodes, sclerosing cholangitis, etc. [3, 18]. Diagno-
sis of MS is developing in parallel with the progress of technical equipment in medicine. If at the
origins of the description of the syndrome is only intraoperative cholangiography, now all new
technologies are coming to the aid of the surgeon. Ultrasound examination (ultrasound) of the ab-
dominal cavity is a routine method for detecting pathology of the pancreato-duodenal zone. This
method is also a screening method for MS. But, according to different authors, the sensitivity of
this method is quite low and varies from 4 to 46% [7, 8, 20, 21, 25]. Such characteristics according
to the results of ultrasound, such as a shrunken gallbladder in the presence of dilated intrahepatic
ducts with a normal size of the distal common bile duct, allow one to suspect SM at the initial
stage of the examination [16, 20].
Methods of direct contrast enhancement of bile ducts have been the standard in preoperative
diagnosis of MS for several decades. Among them, the most commonly used endoscopic retro-
grade cholangiopancreatography (ERCP) [1, 5, 7]. Hakim H. A. N. et al. (2020) indicate 100%
sensitivity of this method in the diagnosis of Hassan R. et al. (2019) believe that the differential
DOI: 10.38095/2181-466X-2021992-157-160 UDC 616.366-003.7[612.357.64]
MODERN METHODS OF DIAGNOSIS AND TREATMENT OF PATIENTS WITH
MIRIZZI SYNDROME
N. A. Qurbonov
1
, S. S. Davlatov
2
, M. M. Amonov
3
1
Samarkand State Medical Institute, Samarkand, Uzbekistan
2
Bukhara State Medical Institute, Bukhara, Uzbekistan
3
Sultan Zaynal Abidin University, Terengganu, Malaysia.
Ключевые слова:
синдром Мириззи, желчные протоки, диагностика, компьютерная томография, ретроград-
ная холангиопанкреатография.
Таянч сўзлар:
Мириззи синдроми, ўт йўллари, диагностика, компьютерли томография, ретроград панкреато-
холангиография.
Key words:
Mirizzi syndrome, bile ducts, diagnostics, computed tomography, retrograde cholangiopancreatography.
МИРИЗЗИ СИНДРОМ БИЛАН БЕМОРЛАРНИ ЗАМОНАВИЙ
ДИАГНОСТИКА ВА ДАВО УСУЛЛАРИ
Н. А. Курбонов
1
, С. С. Давлатов
2
, М. М. Амонов
3
1
Самарқанд давлат тиббиѐт институти, Самарқанд, Ўзбекистон
2
Бухоро давлат тиббиѐт институти, Бухоро, Ўзбекистон
3
Султан Зайнал Абидин университети, Теренггану, Малайзия.
СОВРЕМЕННЫЕ МЕТОДЫ ДИАГНОСТИКИ И ЛЕЧЕНИЯ ПАЦИЕНТОВ
С СИНДРОМОМ МИРИЗЗИ
Н. А. Курбонов
1
, С. С. Давлатов
2
, М. М. Амонов
3
1
Самаркандский государственный медицинский институт, Самарканд, Узбекистан
2
Бухарский государственный медицинский институт, Бухара, Узбекистан
3
Университет Султан Зайнал Абидин, Теренггану, Малайзия
N. A. Qurbonov, S. S. Davlatov,...
Доктор ахборотномаси № 2 (99)—2021
158
diagnosis between compression of the proximal part of the common bile duct and its stricture is of
great importance for the choice of the scope of the operation. To exclude the tumor nature of the
disease, the authors propose to use a set of techniques, consisting of endoscopic papillotomy per-
formed for diagnostic purposes, instrumental revision of the biliary tract and selective cholangi-
ography of the deformed part of the duct. At the same time, the authors emphasize that the use of
additional diagnostic techniques in general increases the invasiveness of the study, and therefore
the indications for their implementation must be limited. Other methods of direct contrasting of the
bile ducts, such as percutaneous transhepatic cholangiography (PTSC), cholecysto-
cholangiography, are less relevant in the diagnosis of MS due to their higher invasiveness. In addi-
tion, when performing PTCG, difficulties arise in visualizing the distal common bile duct due to
an obstacle located above [13, 14].
Despite the fact that ERCP plays a leading role in the preoperative diagnosis of SM, it
should not be forgotten that approximately 6–22% of patients fail to cannulate the large duodenal
papilla or achieve visualization of the entire common bile duct [1, 7]. Also, after ERCP and endo-
scopic retrograde papillosphincterotomy (EPST), there is a risk of severe complications such as
pancreatitis, cholangitis, bleeding, and sepsis [7, 9, 30]. And although the likelihood of them is
quite low, nevertheless, the risk of performing ERCP can be life-threatening. All this forces re-
searcher to look for new, effective and safer methods. In recent years, non-invasive methods of
preoperative diagnosis of MS, such as spiral computed tomography, magnetic resonance cholangi-
opancreatography, have been developing [9, 12]. Nagakawa T. et al. (1997) note that computed
tomography (CT) does not provide any additional information in comparison with abdominal ul-
trasound or ERCP [21]. Only 79% of stones that are detected in the gallbladder by ultrasound can
be visualized with CT [21]. However, this research method plays a significant role in the differen-
tial diagnosis with cholangiocarcinoma, gallbladder cancer, compression of the common bile duct
by metastases in the hepatic hilus [9, 20]. There is another point of view on this research method.
Nagakawa T. et al. (1997) in their work noted the high sensitivity, specificity and accuracy, 93%,
98% and 94%, respectively, of spiral computed tomography after performing infusion cholangi-
ography.
Magnetic resonance cholangiopancreatography is a new and still poorly studied method for
diagnosing MS. A number of authors consider this research method as the most promising for the
verification of this syndrome [9, 21]. E.C.H. Budzinskiy S. A. et al. (2019) in their work talk about
the advantages of laparoscopic ultrasound of the pancreatoduodenal region [9]. During surgery, if
MS is suspected, this diagnostic method allows real-time construction of a multi-plane image of
the bile ducts at different angles, but at present it remains inaccessible and insufficiently studied.
In general, despite the variety of diagnostic methods, it is often not possible to diagnose MS before
surgery. Such a situation during the operation can disorient the surgeon and create the danger of
injury to the common bile duct, mistakenly considered to be the gallbladder or a wide cystic duct.
Thus, the lack of universal preoperative methods for examining MS calls for the development of
optimal diagnostic tactics. There are two main directions in the treatment of MS in modern sur-
gery: X-ray endoscopic methods, surgical interventions. X-ray endoscopic techniques can be used
as the first stage of a surgical procedure as a preoperative preparation or as an independent method
of treating patients with MS in the case of a high anesthetic risk [2, 11]. Among the disadvantages
of REV, the authors distinguish the following: radiation exposure to patients and staff; high cost of
endoscopic and X-ray equipment; the impossibility of eliminating the narrowing of the lumen of
the proximal common bile duct [2, 24].
According to the literature, the methods of operative access and options for operations in
Mirizzi syndrome vary greatly: for example, some authors attribute this syndrome to absolute con-
traindications to laparoscopic cholecystectomy [1, 2, 13]. Lledó J. B. et al. (2014) in a review of
the literature on the use of the laparoscopic technique in MS indicates 40% conversion of access,
20% of complications, and 6% of reoperations [19]. However, there are a number of publications,
the authors of which indicate the possibility of using the laparoscopic technique under certain con-
Обзор литературы
Доктор ахборотномаси № 2 (99)—2021
159
ditions. So, Lai E. C. H., Lau W. Y. (2006) indicate the possibility of using the laparoscopic ap-
proach by an experienced surgeon only in the first type of MS [17].
The most common operation for the first type of MS is cholecystectomy, supplemented by
drainage of the common bile duct [2, 17, 18]. In the presence of a biliary fistula, it is necessary to
separate it with the subsequent restoration of the integrity of the common bile duct. As one of the
options for closing the common bile duct defect, used by most surgeons, is the elimination of the
common bile duct wall defect with a specially left part of the gallbladder [2, 10, 15] However,
Waisberg J. et al. (2005) suggest that it is theoretically logical that the retained gallbladder tissue
may increase the risk of developing residual choledocholithiasis [27].
Pugaev A. V. et al. (2019) in the presence of a cholecystobiliary fistula, it is recommended
to perform plasty of the common bile duct with temporary stents. The authors explain the need for
temporary stenting by the presence of long-term inflammatory changes in the area of the hepatodu-
odenal ligament, due to which MS can be considered as a "model of damage to the bile ducts."
With significant damage to the wall of the common bile duct involved in the fistula, a number of
surgeons indicate the need to form a biliodigestive anastomosis: choledocho-duodenoanastomosis,
choledocho-jejunonastomosis, cholecysto-choledochojejunoanastomosis [22, 23].
During operations for MS, there remains a high risk of developing intra- and postoperative
complications [1, 2, 6]. The most common complication after surgery for MS is stricture of the
common bile duct. According to Zhang J., Perera P., Beard R. (2020) of 46 patients operated on
with MS, stricture of the common hepatic duct developed in 6.5%. The results of operations on the
so-called lost drainage, performed in four patients with the first form of MS ("stenosing" form),
Vorobey A. V. et al. (2018) is rated as positive [27]. However, the reasons for the removal of
drains from the ducts are immediately given, such as the development of jaundice, obstruction of
the drains caused by the formation of small stones, the deposition of salts on the walls of the drain-
ages and the accumulation of putty detritus, which leads to repeated attacks of cholangitis. The
greatest difficulty for surgical treatment is presented by patients with significant destruction of the
common bile duct wall. It is noted that the higher the degree of destruction of the common bile
duct wall (III – IV type MS according to C.K. McSherry et al., 1982), the higher the level of post-
operative mortality [2, 6, 26]. In type III – IV MS, most surgeons adhere to the position of the
need to apply choledochojejunostomy.
Thus, today MS is one of the complications of gallstone disease, in the diagnosis and surgi-
cal tactics of which there are a number of unresolved issues. Despite a wide range of surgical tech-
niques for this syndrome, the results of treatment to date are not entirely satisfactory. The presence
of MS in a patient during surgery increases the risk of intra- and postoperative complications. Dif-
ficulties in diagnosing Mirizzi's syndrome, the danger of damage to the bile duct, few observa-
tions, as well as a fairly wide range of surgical treatment methods determine the relevance of stud-
ying this problem. The introduction of modern methods for diagnosing MS and the development
of rational surgical tactics, depending on the type of syndrome, will make it possible to improve
the treatment of patients with this complication of cholelithiasis.
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