Praneetha Narahari, MD. Saint Agnes Medical Provider, Fresno, CA
Gallbladder disease can be confounding with diverse manifestations. Cholecysto-enteric fistula has an incidence of < 1%, with or without a contracted gallbladder. Cholecystocolonic fistula is stated to be about 20% of all cholecysto enteric fistula. They are challenging due to a higher risk of complications from recurrent inflammation causing fibrosis in the calot's triangle and an almost 10% risk of ductal injury. I report a case of Laparoscopic repair of cholecystocolic fistula and a concomitant laparoscopic CBD exploration.
62 yr old male, presented with epigastric pain for several years, jaundice and fever for few days. CT revealed Pneumobilia and absent gallbladder. Gallbladder not visualized on US either. Patient did not have any abdominal surgeries. MRCP confirmed the same with small calculi in distal CBD. The cholangitis improved with antibiotics and he was scheduled for elective surgery in a week, as he was on plavix.
Laparoscopic cholecystectomy with laparoscopic CBD exploration was performed. All inflammatory adhesions were taken down and the contracted GB was identified with colon( identified by presence of tenia coli) adhesed to it. The fistula tract between the two was stapled with an echelon stapler and Gallbladder removed. A choledochotomy was made in the CBD and a choledochoscope inserted through it and the CBD was cleared of debris. No major stones identified. Choledochotomy closed with intracorporeal sutures. Drain placed. Discharged on POD 1. Drain was non bilious and removed on day 5. Patient did well and his symptoms of several years improved.
Laparoscopy provides higher magnification and high definition resolution. This greatly improves visualization and dissection in the presence of inflammation. The recovery is quicker as physiologic homeostasis is maintained in this high risk population. The patients have less reserve from sepsis, inflammation and jaundice and other age related co morbidities. Laparoscopy is a good alternative to minimize post op morbidity and should be considered.
2. stapling of the fistula
3.CBD exposed for choledochotomy
4. CBD cleared with choledochoscopy
5. MRCP with distal intraluminal defects
6. CT with pneumobilia