Hello Friends, Today we present a case of Type 5 Mirizzi Syndrome (Modified Csendes Classification) - a 85 years old lady was diagnosed to have Cholecystoduodenal Fistula without gallstone ileus with Multiple stones in CBD,CHD, Right and left Hepatic ducts & Cholelithiasis with Chronic Calculous Cholecystitis presented to us with clinical features of Cholangitis.
She was managed with Laparoscopic CBD-CHD Exploration, Stones retrieval assisted with Foley’s Balloon with Cholecystectomy & Choledocho-Duodenostomy.
Biliary fistulas are defined as chronic pipe-like ulcers. They can connect the gallbladder with the biliary tree and rarely involve the gastrointestinal tract (internal fistulas) and the abdominal wall (external fistulas). Biliary fistulas are rare complications of lithiasis or neoplasia & are classified as primary & secondary.
Internal fistulas are always caused by inflammation and occur mainly as late complications of gallstone or hydatid diseases, like biliobronchial fistulas.
External fistulas are related to the iatrogenic injury of the biliary tract and are infrequent compared to primary fistulas.
The incidence of the primary biliary fistulas is ranged from 1 to 2%, in symptomatic patients; The widespread use of ultrasonography and the early treatment for patients with gallstone disease with laparoscopic surgery reduce the incidence of biliary fistulas. However, the laparoscopic cholecystectomy has slightly increased the secondary fistulas in comparison with open surgery (0.3–0.4% to 0.6%).
In 2008, Beltran et al proposed the inclusion of the cholecystoenteric fistulas in the Mirizzi’s Syndrome’s classification as type 5: every type of lesion, plus cholecystoenteric fistula, without gallstone ileus (5a), and with gallstone ileus (5b). Bilioenteric fistulas are classified as-
(i) cholecystoduodenal fistulas: 40%;
(ii) cholecystocolic fistulas: 28%;
(iii) cholecystogastric: 32%.
Large stones, recurrent cholangitis, female sex, and old age are risk factors for bilioenteric fistulas. In the absence of stones, a bilioduodenal or more complex fistula can be caused by peptic ulcer or hydatid disease.