MIRIZZI SYNDROME TYPE III: A CASE REPORT AND REVIEW OF SURGICAL MANAGEMENT

Abstract

Introduction. Mirizzi syndrome is a rare complication of chronic gallstone disease, defined by extrinsic compression or fistulization of the common bile duct by a stone impacted in the gallbladder infundibulum or the cystic duct. Type III of the Csendes classification involves a cholecystocholedochal fistula affecting between one third and two thirds of the duct circumference and requires ductal reconstruction rather than simple closure. A preoperative diagnosis is rarely established.

Case presentation. A 77-year-old patient was admitted for right upper quadrant pain, xerostomia and asthenia, with severe cardiovascular comorbidity. Ultrasonography showed chronic calculous cholecystitis with a contracted gallbladder and a stone impacted at the neck. Laboratory tests revealed mild anaemia (haemoglobin 110 g/L), an erythrocyte sedimentation rate of 34 mm/h and serum amylase of 235.6 U/L with normal lipase, whereas bilirubin and transaminases remained normal. Intraoperatively, a cholecystocholedochal fistula involving two thirds of the duct circumference was confirmed. Subtotal cholecystectomy, choledochotomy with stone extraction, repair of the defect with a gallbladder cuff and external biliary drainage by the Robson-Vișnevski procedure were performed. Histopathology showed chronic calculous cholecystitis with acute exacerbation. The postoperative course was uneventful and the patient was discharged on the seventh day.

Conclusion. Type III Mirizzi syndrome remains a diagnostic and reconstructive challenge. The absence of jaundice does not exclude the diagnosis, and correct intraoperative classification determines the choice of technique. In an elderly patient at high cardiac risk, choledochoplasty with a gallbladder cuff over external biliary drainage was followed by a favorable postoperative course during hospitalization.