Mirizzi Syndrome: Optimal Timing and Management

IntroductionMirizzi syndrome is uncommon with an incidence of 0.3% to 1.4% of all cholecystectomies and remains challenging given the potential need for biliary reconstruction. Standardized surgical guidelines are lacking, which continues to hinder the establishment of optimal operative strategies tailored to disease severity.ObjectiveEvaluate postoperative outcomes based on timing of diagnosis (preoperative vs intraoperative), timing of cholecystectomy (index vs delayed), and surgical subspecialty performing the operation.MethodsA multi-center retrospective review was conducted of all cholecystectomies performed between 2014 and 2023 across 3 Los Angeles County hospitals. Patients with Mirizzi syndrome were identified and stratified according to the Csendes classification. Primary outcomes included bile duct injury, bile leak, biloma, abscess, need for postoperative drainage or reoperation, and readmission. Comparisons were performed using Fisher's exact test.ResultsAmong 14 486 cholecystectomies performed during the study period, 65 patients (0.45%) met inclusion criteria. Complications were significantly lower in patients with preoperative diagnosis compared with intraoperative diagnosis, 25% vs 57% (P = 0.05). Most patients underwent index-admission cholecystectomy, 52/65 (80%). In advanced disease (types II-Va), complication rates did not differ between index and delayed surgery, 55% vs 38% (P = 0.67). Overall complication rates were similar between acute care surgery and hepatopancreatobiliary surgery, 24% vs 40% (P = 0.28). For type I disease, outcomes were comparable between services.ConclusionsPreoperative diagnosis of Mirizzi syndrome is associated with improved postoperative outcomes. Type I disease can be safely managed by either acute care or hepatopancreatobiliary surgeons, while delayed surgery in advanced cases appears safe to facilitate specialized care.