Jose Pulido, MD, Eduardo Garcia-flores, MD, Jeronimo Monterrrubio, MD, Ulises Caballero, MD, Luis Zavala, MD, Marco Juarez, MD, Christian Cussin, MD. Christus Muguerza – Udem.
Cholecystoenteric fistula is a rare complication of cholelithiasis, it´s a spontaneous track with bile flow between an inflamed gallbladder and one or more adjacent structures (3). It’s associated with chronic cholelithiasis, peptic ulcer, and neoplasia (5).
Cholecystoduodenal fistula accounts for 80% of cholecystoenteric fistulas, and for 0.5-1.9% of biliary diseases (2). Incidence of 3-5% in patients with cholelithiasis (4). More common in geriatric female population (3).
Clinical manifestations nausea, fever, vomiting, backache, flatulence, intolerance to fatty meals, right superior quadrant pain, and jaundice (4). It’s an occasional intraoperative finding during laparoscopic cholecystectomy (3)
US findings include gallbladder with thickened wall, calculi, adhesions to the duodenum and intra and extra hepatic pneumatosis (2).
During laparoscopy a thick-walled contracted gallbladder stuck firmly to adjoining viscera in a patient with long history of gallstone disease should alert the surgeon of the presence of a fistula (4).
The treatment of choice is by laparoscopy. The most commonly used technique is the endoscopic stapling (1); another option is the visceral hand-sewn repair after detaching the fistula (4).
59-year-old female, with surgical history of hysterectomy and oophorectomy 13 years ago. With a 10 month right upper quadrant colicky pain.
Physical examination: Abdomen soft, depressible, normal peristaltic movements, pain at palpation of right hipocondrium, and positive Murphy’s sign.
Laboratory tests: Hb: 14.1 g/dL, WC 6,340 K/uL, N: 57%, AST: 18 U/L, ALT: 137 U/L, AP: 420 U/L, GGT: 430 U/L. LDH: 174 U/L.
External ultrasound: presence of vesicular lithiasis.
We observed multiple adherences to duodenum, a scleroatrophic gallbladder, with a cholecystoduodenal fistula.
Posteriorly we liberated and resected the fistula, repaired the defect on the duodenum with inverted 3-0 polyglactin 910 sutures and Lembert stitches with silk.
Pneumatic, methylene blue test, and cholangiography without evidence of leaks.
Cholecystectomy was realized and a # 19 Blake drain was introduced. Operative time of the procedure was of 127 min without complications.
Patient was admitted to surgical ward, with NPO and 5 days of TPN, started oral liquids at the sixth day, and discharged at the seventh day. The drain presented a daily average of 90 cc of serous discharge and was removed at the tenth day.
The ability of a surgeon to identify intraoperatively fistulas is very important for it’s correct management. Even tough the endoscopic stapling is the standard of care; the laparoscopic hand-sewn technique is feasible and secure, like it was demonstrated in this case.