Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : PR01 - PR04 Full Version

Management of Mirizzi Syndrome in a Tertiary Care Centre of Southern India- A Series of 10 Cases


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51530.16068
Rohith Muddasetty, Sivakumar Kalyanashanmugam, Prabhakaran Raju, Sugumar Chidambaranathan, Naganathbabu Obla Lakshmanamoorthy

1. Postgraduate Student, Institute of Surgical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India. 2. Assistant Professor, Institute of Surgical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India. 3. Associate Professor, Institute of Surgical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India. 4. Professor, Institute of Surgical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India. 5. Director and Professor, Institute of Surgical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India.

Correspondence Address :
Naganathbabu Obla Lakshmanamoorthy,
Director and Professor, Institute of Surgical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India.
E-mail: naganathbabu@gmail.com

Abstract

Mirizzi syndrome is a rare condition characterised by obstructive jaundice due to compression of Common Hepatic Duct (CHD) by a stone impacted in the neck of gall bladder. Incidence is around 1-2% in patients with symptomatic cholelithiasis. Preoperative diagnosis and management is challenging. Authors have retrospectively analysed the records of patients undergoing cholecystectomy in our institute for the past five years and selected those patients who had final diagnosis of Mirizzi syndrome were reviewed and following results were arrived. From January 2016 to February 2021, 446 patients underwent cholecystectomy. Out of these, 10 (2.24%) patients had final diagnosis of Mirizzi syndrome. Male:Female ratio was 3:7. Mean age at presentation was 49.5 years. Most common presenting symptoms were pain abdomen and jaundice. Mirizzi syndrome was preoperatively diagnosed only in 3 (30%) patients. Others were diagnosed during surgery. Type I in four patients, type II in three patients, type III in two patients and type IV in one patient. These patients were treated with either total or subtotal cholecystectomy. Open approach was used in 8 (80%) patients and laparoscopic approach in 2 (20%) patients. Biliary drainage procedure was done in all patients, T-tube drainage in 5 (50%); Roux-en-Y Hepaticojejunostomy (HJ) in 3 (30%) and Hepaticoduodenostomy in 2 (20%) patients. Thus, the authors concluded Mirizzi syndrome being one of a rare complication of long standing cholelithiasis, which poses a challenging task for diagnosis and management. High index of suspicion is required to identify and treat Mirizzi syndrome in order to avoid bile duct injuries.

Keywords

Choledocholithiasis, Cholelithiasis, Hepaticojejunostomy, Hepaticoduodenostomy

Pablo Luis Mirizzi, Argentinean Surgeon described “Common Hepatic Duct (CHD) syndrome” in 1948 which was later named after him as Mirizzi syndrome (1). Mirizzi syndrome can occur up to 0.7-1.4% of patients undergoing biliary surgeries. Incidence may be around 2.7% in high risk population (2). The pathophysiology is explained by McSherry C and Csendes A et al., (3),(4). Gall stone impacted at the cystic duct or infundibulum or neck of gall bladder lead to compression and obstruction of the CHD. Inflammation sets in the area secondary to pressure ulcer. Eventually stone erodes the common wall leading to formation of fistula (3),(4).

Various classifications systems have been described namely Sherry, Puestow, Corlette and Beltran based on the extent of CHD compression or fistulisation. Modified Csendes classification is widely accepted and followed, as it describes the degree of CHD involvement and also includes cholecystectoenteric fistula (5).

Type I: External compression of bile duct by a large stone impacted in the cystic duct of Hartmann’s pouch.

Type II: Erosion of bile duct wall by gall stones, involving less than one third of its circumference.

Type III: Erosion of bile duct wall by gall stones, involving up to two third of its circumference.

Type IV: Complete destruction of bile duct wall with gall bladder completely fused to bile duct forming single structure.

Type Va: Cholecystoenteric fistula without gall stone ileus.

Type Vb: Cholecystoenteric fistula with gall stone ileus.

Incidence of various types as described by Csendes, Type I: 10.5-78%; Type II: 15-41%; Type III: 3-44%; Type IV: 1-4%; Type V: 29% (6).

Diagnosis is usually done by MRI abdomen with cholangiogram reconstruction. It shows largestones impacted in the gall bladder neck or cystic duct, inflammation gall bladder with proximal dilatation of biliary ducts.

Mirizzi syndrome is a challenge, not only in the diagnosis but also intraoperative management. It can mimic malignancy (6). It is associated with high risk of bile duct injury and incidence was found to be 0-22% in various reports (6),(7).

Standard treatment guidelines have not been established due to rarity and complexity of the disease. Hereby, authors discuss the management of Mirizzi syndrome in the Institute.

Case Report

Authors have retrospectively analysed records of patients undergoing cholecystectomy in the Institute between January 2016 and February 2021. Among these patients we studied those who had final diagnosis of Mirizzi syndrome. Following data were reviewed: sex, age, symptoms, preoperative imaging, blood investigations, intraoperative findings and procedure done. The diagnosis of Mirizzi syndrome was on the intraoperative finding of CHD compression or fistulisation. Classification was based on Modified Csendes classification (5).

Total of 446 cholecystectomies were performed during this period. Total 10 patients were diagnosed to have Mirizzi syndrome with incidence of 2.24%. Among them three were male and seven were female (M:F=3:7). Mean age of presentation was 49.5±10.86 years. Pain abdomen and jaundice were most common presenting symptoms seen in 9 patients (90%). Fever was present in 6 patients (60%). Loss of appetite was present in 4 patients (40%). On routine investigations, total counts were elevated in seven patients with mean value of 12,997 cells/mm3. Elevated bilirubin values were seen in 8 patients (80%) with mean values total bilirubin 7.08 mg/dL and direct bilirubin 5.25 mg/dL. Serum alkaline phosphatase was elevated in 8 patients (80%) with mean value of 459.2 IU/L. All patients had undergone MRCP evaluation in the preoperative period. Among the 10 patients with final diagnosis of Mirizzi syndrome, findings of MRCP were as follows- gall bladder stones identified in 10 patients, dilated CHD in 10 patients and dilated Common Bile Duct (CBD) in two patients, choledocholithiasis in seven patients. MRCP was suggestive of Mirizzi syndrome in three out of 10 patients (30%) with one patient each having type I, II and III (Table/Fig 1). Endoscopic Retrograde Cholangiography (ERC) and stone retrieval was successful in three patients who had choledocholithiasis, but ERC was not suggestive of Mirizzi syndrome. One patient had imaging suggestive of gall bladder malignancy in which CA19-9 was 199 U/L, however, intraoperative finding lead to diagnosis of Mirizzi syndrome.

All 10 patients underwent surgery. Eight went for open procedure and two patients for laparoscopic procedure. Total cholecystectomy was done in five patients and subtotal cholecystectomy was done in five patients (50% each). All patients had calculi in gall bladder neck or cystic duct compressing CHD. Size of stone ranged 6-20 mm. Cholecystobiliary fistula was identified in six patients. CBD exploration was done in all the patients and choledocholithiasis was present in six patients. Primary repair of CBD over a T-tube was done in five patients, hepaticoduodenostomy in two patients and Roux-en-Y HJ in three patients. Based on the above findings and in concurrence with Modified Csendes classification (5), Mirizzi syndrome was classified as Type I in four patients; Type II in two patients; Type III in three patients; Type IV in one patient [Table/Fig 2].

All patients had uneventful postoperative course in hospital. T-tube cholangiogram was performed after six weeks and removed after confirming no residual CBD stones. MRCP image and intraoperative picture of a patient in the present series described in [Table/Fig 3]. Summary of all patients presented in (Table/Fig 4).

Discussion

Mirizzi syndrome is a rare complication of gall stone disease. Incidence of Mirizzi syndrome in the present study is 2.24% which was comparable to incidence mentioned in various literature 1-2% (2) and 4.7% (8). The mean age of presentation varies between 53-70 years and has a female preponderance (70% patients in literature) (6). Mirizzi syndrome commonly presents with obstructive jaundice (60-100% patients) and abdomen pain (50-100% patients) (6). Biochemical investigations routinely show elevated bilirubin and serum alkaline phosphatase values. Cancer Antigen (CA)19-9 values have also been found elevated in Mirizzi syndrome due to proliferating biliary epithelium due to inflammation (9).

Ultrasonography is initial investigation; it shows a contracted gall bladder with stone in the infundibulum or cystic duct, atrophied gall bladder wall and upstream dilation of CHD. Common bile duct may be normal (10). Computed tomography scans mainly help to rule out malignant tumours (6),(10). MRCP is the preferred modality of imaging; it shows presence of stone at infundibulum compressing the biliary tree with upstream dilation. However, MRCP cannot effectively localise fistula (10). The diagnostic accuracy of MRCP is only 50% (10),(11). Endoscopic Retrograde Cholangiopancreatography (ERCP) being and invasive procedure can identify the compression of CHD and also presence of fistula. Diagnostic accuracy of ERCP reaches 55-90% (11),(12). In up to 50% of the cases diagnosis of Mirizzi Syndrome will be done intraoperatively, where findings of shrunken gall bladder, distorted Calot’s triangle, stone impacted in the neck or cystic duct, reflux of bile as the impacted stone is removed are seen (7). In the present case series, only 30% of patients had preoperative diagnosis of Mirizzi syndrome.

Type I Mirizzi syndrome is most common type to be encountered, 10.5-78% incidence. Followed by type II and III; 15-41% and 3-44%, respectively. Comparison of various parameters with literature data has been tabulated in (Table/Fig 5) (2),(6),(8),(10),(11). Treatment of Mirizzi syndrome is always surgical. It has increased risk of bile duct injury due to tissue oedema, inflammation, dense adhesions and distorted anatomy (13). Open approach is preferred, however, as advances in laparoscopy are made, it is also an alternative (14). Subtotal cholecystectomy and removal of impacted stone is the treatment of choice. In the presence of fistula, reconstruction of bile duct would be necessary. It can be done as primary repair over T-tube or choledochoplasty with remnant gall bladder wall or bilio-enteric anastomosis. Baer HU et al., have described cholecysto-Choledochoduodenostomy for Mirizzi syndrome type II or higher (13). Safioleas M et al., have described cholecysto-choledocho-jejunostomy (15). Standard Roux-en-Y HJ is also advocated. All patients should undergo CBDE since, there is high chance of choledocholithiasis.

In the present series, type I cases were treated with total or subtotal cholecystectomy and bile duct drained over a T-tube. In both type II cases, subtotal cholecystectomy was done and hepaticoduodenostomy was done. In type III cases, total or subtotal cholecystectomy was done with Roux-en-Y HJ as preferred method of drainage. In type IV case, total cholecystectomy and Roux-en-Y HJ was done. These patients had uneventful postoperative period.

Conclusion

Mirizzi syndrome is one of the rare complications of long standing cholelithiasis. High index of suspicion is required in diagnosis especially in elderly females presenting with obstructive jaundice or cholangitis. Elevated tumour marker may mislead us to diagnose malignancy. Hence, it should be carefully considered in presence of jaundice. Imaging studies may miss the diagnosis in more than half of cases. Meticulous surgery can prevent inadvertent bile duct injury and spare patients from long term morbidity.

Acknowledgement

Authors would like to acknowledge the help of all our colleagues of the Institute in publication of the present article.

References

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MCSherry C. The Mirizzi syndrome: Suggested classification and surgical therapy. Surg Gastroenterol. 1982;1:219-25.
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Beltrán MA. Mirizzi syndrome: History, current kMarcelo A Beltránnowledge and proposal of a simplified classification. World J Gastroenter. 2012;14;18(34):4639-50. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3442202/. [crossref] [PubMed]
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Chen H, Siwo EA, Khu M, Tian Y. Current trends in the management of Mirizzi Syndrome: A review of literature. Medicine (Baltimore). 2018;97(4):e9691. [crossref] [PubMed]
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Safioleas M, Stamatakos M, Safioleas P, Smyrnis A, Revenas C, Safioleas C. Mirizzi Syndrome: An unexpected problem of cholelithiasis. Our experience with 27 cases. Int Semin Surg Oncol. 2008;5:12. [crossref] [PubMed]
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Boutallaka H, Seddik H, Mrabti S, Addajou T, Sair A, Benhamdane A, et al. Role of ERCP in diagnosis and treatment of Type I Mirizzi Syndrome: A case series with review of literature. J Gastroenterol Hepatol Res. 2020;9(1):3071-76. [crossref]
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DOI and Others

DOI: 10.7860/JCDR/2022/51530.16068

Date of Submission: Jul 23, 2021
Date of Peer Review: Nov 15, 2021
Date of Acceptance: Jan 05, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 26, 2021
• Manual Googling: Nov 13, 2021
• iThenticate Software: Jan 04, 2022 (6%)

ETYMOLOGY: Author Origin

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