Therapeutic Approach in Grade Iv Mirizzi Syndrome in the Context of Chronic Cholelithiasis: A Rare Complication

Mirizzi syndrome is a rare but significant complication of chronic cholelithiasis characterized by extrinsic compression or erosion of the common hepatic duct caused by impacted stones in the gallbladder infundibulum or cystic duct. The Csendes classification stratifies the syndrome into five grades according to the extent of biliary involvement, from external compression without fistula (Grade I) to extensive cholecystoenteric fistulas (Grade V). Grade IV, the most severe form, involves a wide cholecystobiliary fistula with destruction of more than two-thirds of the diameter of the common hepatic duct, posing significant surgical challenges. This case report describes a 56-year-old female patient with chronic cholelithiasis presenting with right upper quadrant abdominal pain. Imaging studies initially suggested choledocholithiasis; however, during surgery, Grade IV Mirizzi syndrome with a broad cholecystobiliary fistula and significant bile duct destruction was found. Management included preoperative endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction, followed by laparoscopic cholecystectomy converted to open surgery due to complex biliary anatomy. Reconstruction was performed via Roux-en-Y hepaticojejunostomy, with favorable postoperative evolution. This case highlights the importance of high clinical suspicion, advanced imaging techniques, and surgical expertise for appropriate diagnosis and management of Mirizzi syndrome, especially in its advanced forms, to prevent complications and optimize patient outcomes.