Mirizzi syndrome: report of a case and the challenge of management in our environment.

Background: Mirizzi Syndrome is a rare complication of cholelithiasis reported to occur in 1% of all patients with gall stones and an incidence of 0.7-1.4% in all cholecystectomies. It is characterized by an impaction of a large calculus in the Hartman's pouch of the gall bladder (GB) or in the cystic duct, causing an extrinsic obstruction of the common hepatic duct. This can, with time, result in varying degrees of fistula formation between the duct and the GB. Types I, IIa, b and c have been described depending on the circumference of the duct involved in the cholecysto-choledochal fistula. This syndrome presents clinically as surgical jaundice. The preoperative diagnosis is difficult as well as the surgical management of the type II subtypes. The aim of this paper is to draw attention to this clinicopathological entity as it occurs with the same frequency in our environment as in the environment with high incidence of cholelithiasis.

Method: We report a case in our practice (Mirizzi Type IIa) and discuss the difficulties encountered in pre-operative diagnosis and subsequent management. The literature is also reviewed

Results: The diagnosis of Type IIa Syndrome was made on the operating table. The on-table cholangiogram was inconclusive. A choledochoplasty was performed over a T-tube and this was removed after 12 weeks. Patient has done well thereafter.

Conclusion: The local surgeon is advised to have a high index of suspicion about this condition so as not to be caught unawares.