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Cholecystoenteric fistula with and without gallstone ileus: A case series
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Cholecystoenteric fistula with and without gallstone ileus: A case series Mauricio Gonzalez-Urquijo , Mario Rodarte-Shade , Gerardo Lozano-Balderas , Gerardo Gil-Galindo PII: DOI: Reference:
S1499-3872(19)30255-3 https://doi.org/10.1016/j.hbpd.2019.12.004 HBPD 245
To appear in:
Hepatobiliary & Pancreatic Diseases International
Received date: Accepted date:
12 July 2019 17 December 2019
Please cite this article as: Mauricio Gonzalez-Urquijo , Mario Rodarte-Shade , Gerardo Lozano-Balderas , Gerardo Gil-Galindo , Cholecystoenteric fistula with and without gallstone ileus: A case series, Hepatobiliary & Pancreatic Diseases International (2019), doi: https://doi.org/10.1016/j.hbpd.2019.12.004
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.
Manuscript type: Original Article/Biliary Running title: Cholecystoenteric fistula Title: Cholecystoenteric fistula with and without gallstone ileus: A case series
Authors: Mauricio Gonzalez-Urquijo1,2,*, Mario Rodarte-Shade1,2, Gerardo LozanoBalderas1, Gerardo Gil-Galindo1,2 Abbreviated name: Gonzalez-Urquijo M, Rodarte-Shade M, Lozano-Balderas G, GilGalindo G City: Monterrey, México
Author Affiliations 1. Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Dr. Ignacio Morones Prieto O 3000, Monterrey 64710, México 2. Department of Surgery, Hospital Metropolitano “Dr. Bernardo Sepúlveda”, Secretaria de Salud de Nuevo León, Adolfo López Mateos No. 4600, San Nicolás de los Garza 66400, México * Corresponding author Mauricio Gonzalez- Urquijo, Dr. Ignacio Morones Prieto O 3000. Monterrey 64710, México (E-mail address: [email protected]) Received 12 July 2019 Accepted 17 December 2019 Acknowledgments: Research group of Bioengineering and Regenerative Medicine from Tecnologico de Monterrey. Credit authorship contribution statement: Mauricio Gonzalez-Urquijo: Conceptualization, data curation, writing original draft Mario Rodarte-Shade: Data curation, formal analysis, investigation, methodology Gerardo Lozano-Balderas: Project administration, software, supervision Gerardo Gil-Galindo: Validation, Writing-review & editing
Funding: None. Ethical approval: This study was approved by the Ethics Committee of Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud. The study protocol was approved by the Institutional Review Board of our Institution (approval No. 031). Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Abstract Background: A cholecystoenteric fistula (CEF) is an uncommon complication of gallstone disease. The aim of this study was to present our experience of a series of patients with CEF, presenting with or without gallstone ileus, along with their surgical outcomes. Methods: From 2015 to 2018, 3245 consecutive patients underwent cholecystectomy for gallbladder disease at our institution, of which 15 were diagnosed with a CEF. All electronic medical records were retrospectively reviewed. Results: Fifteen patients presented with CEF. Ten patients presented cholecystoduodenal fistula, four patients cholecystocolonic, and one patient cholecystogastric counterparts. Twelve patients were female. The median patient age was 61 years (range 33–86 years). Five patients presented with gallstone ileus treated by laparotomy and enterolithotomy. In ten patients, a laparoscopic approach was attempted, but conversion to open surgery was necessary for eight of them. The median operative time was 140 min (range 60–240 min), and the median operative blood loss was 50 mL (range 10–600 mL). The procedure-related morbidity and mortality rates were 13.3% and 6.7%, respectively. Conclusions: There is no consensus on the best treatment modality for a CEF, as the treatment outcome is mostly dependent on the surgeon’s expertise and the patient’s
condition. Not all CEFs are accompanied by gallstone ileus. For such case, the main purpose is to resolve the intestinal obstruction and, unless necessary, avoidance of the gallbladder area. Keywords: Cholecystoenteric fistula; Gallbladder disease; Biliary-enteric fistula; Gallstone ileus; Intestinal obstruction
Introduction A cholecystoenteric fistula (CEF) first described by Bartholin in 1654, is relatively rare. This type of fistula, is a well-recognized complication of biliary disease, with a reported incidence of 3%–5% in patients with cholelithiasis, and is designated as a spontaneous anomalous tract between any part of the gallbladder and a segment of the surrounding gastrointestinal tract, the most frequent localization being the duodenum, accounting for 75%–80% of all such fistulas, followed by the colon and stomach [1–4]. Because of the lack of particular symptoms, as compared with cholecystitis, it is difficult to diagnose a CEF preoperatively. Previously, CEF was always an incidental finding during surgery, but with the improvement of imaging modalities, such as computed tomography (CT) and magnetic resonance imaging, along with the application of endoscopic technology, the preoperative diagnosis of a CEF has been significantly improved, but is achieved in only 8%–17% of cases [4,5]. The common causes of CEF include chronic cholelithiasis, peptic ulceration, malignant neoplasms, Crohn’s disease, among others [5–8]. The present study aims to present a case series of patients with CEFs due to chronic cholelithiasis and to display our personal surgical experience treating this uncommon type of biliary disease, along with their surgical outcomes.
Methods The Institutional Review Board approved the study protocol (approval No. 031). From 2015 to 2018, 3245 consecutive patients underwent cholecystectomy for gallbladder disease at our institution. Among them, 15 patients were diagnosed with a CEF, either preoperatively or intraoperatively. We searched the surgical database for all patients diagnosed with this type of fistula and retrospectively reviewed all electronic medical records. The patient demographics, clinical characteristics, diagnostic methods, surgical procedures, treatment outcomes, and follow-ups were all documented and organized. All patients underwent a physical examination, laboratory testing, and evaluation of the gallbladder either by ultrasonography (US) or CT. Based on the patient’s condition, other imaging modalities, such as magnetic resonance cholangiopancreatography (MRCP), or endoscopic
retrograde
cholangiopancreatography
(ERCP),
were
performed.
If
choledocholithiasis was encountered, the patient underwent ERCP with subsequent cholecystectomy. Laparoscopic cholecystectomy under general anesthesia with a standard four-port technique was attempted in most patients. Conversion to open surgery was left to the discretion of the surgeon. When dense adhesions to adjacent organs and impacted stones in Hartmann’s pouch rendered access to Calot’s triangle difficult, a fundus-first dissection technique was applied, and subtotal cholecystectomy was performed. All patients were followed up in the outpatient clinic within the first week, the first month, and then yearly. Patients were examined clinically, and liver function was evaluated at each follow-up visit. Statistical analysis Continuous variables were reported as the median, and range while categorical variables were reported as frequencies and percentages. Data analysis was performed with a
combination of Excel 16.0 (Microsoft Corporation, Redmond, WA, USA) and R software 3.4 (R Core Team, Auckland, New Zealand).
Results In our series, 12 patients were women, and three were men. The median age was 61 years (range 33–86 years). Ten patients had cholecystoduodenal fistula (CDF), four patients cholecystocolonic fistula (CCF), and one patient cholecystogastric fistula (CGF). Five patients had concomitant diabetes mellitus (DM) and systemic arterial hypertension (SAH), four had only SAH, and two had only DM. All patients had >2-year history of abdominal pain, with a median time of exacerbation of pain in the right upper quadrant before surgical treatment of 3 days (range 1–10 days). Only two patients had jaundice due to choledocholithiasis at presentation. Four patients presented with an elevated white blood cell count, with a median value of 8.3× 109 cells/L (range 5.0×109-15.6×109 cells/L). Liver function test results were detailed in Table 1. The US was the initial imaging modality in 11 patients, which revealed gallstones and features of acute cholecystitis in all cases, with a median gallbladder wall thickness of 4.0 mm (range 1.5–11.0 mm). Two patients presented with choledocholithiasis, detected by US, resolved with ERCP. During the ERCP, visualization of a CDF was seen in one of the patients, while there was no fistulous opening in the other. Both patients underwent sphincterotomy with the placement of a common duct stent in the patient with a CDF. Overall, a preoperative diagnosis of CEF was achieved in six patients, one with an initial diagnosis of choledocholithiasis by ERCP and five with a CT scan (Fig. 1). Of the 10 patients with CDF, four converted from laparoscopy to open procedure, performing partial cholecystectomies. Primary closure of the duodenum and a Graham
patch was achieved in two patients each, respectively. In one patient, a laparoscopic procedure was auspiciously completed, and total cholecystectomy was completed while performing a Graham patch on the second portion of the duodenal wall. Laparotomy was performed for four patients with gallstone ileus, completing an enterolithotomy in the terminal ileum. Furthermore, in half of those patients (n=2) dismantling of the fistula was accomplished by total cholecystectomy and primary closure of the duodenum. The fistula was left intact in the other two patients, and only the intestinal obstruction was resolved. An open approach was completed in one patient, during which the common bile duct (CBD) was found to be firmly adhered to the duodenum along with the fundus of the gallbladder; hence, partial cholecystectomy with T-tube insertion within the CBD and a Graham patch on the duodenum was done. Of the four patients with CCF, a laparoscopic approach was attempted in three of them, with conversion to open surgery in two patients. In one patient, a colostomy at the site of the fistula was performed, and a partial cholecystectomy was achieved. Two patients were treated with primary closure of the transverse colon. In one patient, conversion to open surgery was needed, performing a partial cholecystectomy, and in the other a laparoscopic cholecystectomy was auspiciously performed. One patient was treated with enterolithotomy alone, for intestinal obstruction due to sigmoid gallstone ileus. One patient presented a CGF on the lesser curvature, treated with a partial cholecystectomy. An omental patch was placed at the site of the defect in the lesser curvature. The patient characteristics and surgical outcomes were summarized in Table 2. In global, trans-operative cholangiography was performed in six of the 12 patients who previously underwent cholecystectomy, but no filling defect of the biliary tract was
detected. Each had anomalous communications from the gallbladder to the duodenum, colon or stomach. In the 12 patients, a tube drain was left in the subhepatic space and was removed within a median of 3.5 days (range 2–10 days). The median operative time was 140 min (range 60–240 min), and the median intraoperative blood loss was 50 mL (range 10–600 mL). Regarding the site of the fistula, on the gallbladder side, the fundus was the site of the fistula in six patients, the body in four, the Hartmann pouch in two, and in three patients, the site was uncertain due to firm adhesion and a significant fibrotic process. Overall, procedure-related morbidity and mortality were found in two patients and one patient, respectively. One patient had a remaining stone within the CBD that was treated 4 days after the initial procedure with ERCP, which achieved an outstanding outcome, another patient presented paralytic ileus on postoperative day (POD) 3 treated with prokinetic agents, and one geriatric patient died from septic shock due to intestinal obstruction secondary to gallstone ileus. Only enterolithotomy was performed, but the patient did not recover from renal failure and died on POD 20 in the intensive care unit. The median length of hospital stay was 7 days (range 3–20 days). Fourteen patients were currently followed up in our clinic, with a median follow-up period of 14 months (range 8– 40 months). All are symptom-free with normal liver function. None of the three patients with gallstone ileus, for whom the gallbladder area was not addressed, have reported colicky biliary pain. Final histopathological analysis revealed chronic cholecystitis in all patients.
Discussion A CEF is a rare clinical condition that occurs primarily in the female geriatric population [9]. In the present study, more than half of the patients were geriatric, and 80% of the population were female. CEF has been reported to occur in 3%–5% of patients with cholelithiasis and 0.15%–4.8% of all who undergo surgery to the biliary tract. The incidence (0.46%) in the present study was lower than in early reports [9,10], and was almost the same as that reported by Li et al. [4], Duzgun et al. [5] and Chowbey et al. [2]. The most frequent type of biliary fistula is CDF, followed by CCF and CGF [1,3]. In our patients, 66.7%, 26.7%, and 6.7% presented with these types of fistulas, respectively. An inflamed, contracted gallbladder stuck firmly to contiguous viscera in a patient with a long history of chronic cholecystitis should alert the surgeon to the possibility of a cholecystoenteric fistula [2]. Li et al. [4] advised that a long history of cholecystolithiasis, especially >5 years, should increase suspicion for the presence of CEF when encountering the gallbladder firmly adhered to a part of the gastrointestinal tract. The clinical presentation of this condition is mostly chronic. In this series, all patients had a history of abdominal pain for a minimum of 24 months, and these symptoms (i.e., epigastric or right upper quadrant pain, nausea, and vomiting) were not discernable from the symptoms of most gastrointestinal conditions, such as cholelithiasis or acute cholecystitis [5,11]. In our series, seven patients had an initial diagnosis of acute cholecystitis, and one patient had a diagnosis of cholelithiasis, which was operated in an elective manner. We made the preoperative diagnosis of CEF in 40% of our patients, making it higher than other series, where a preoperative diagnosis was achieved in 8%-31% [4,12].
The majority of the diagnoses are made intraoperatively, unless the biliary tract is involved, which consequently causes jaundice, cholangitis, or pancreatitis [13]. Most studies report that the fistulas are revealed incidentally by other radiologic studies to investigate biliary conditions, pancreatic diseases, or intestinal obstructions [5]. Intestinal obstructions are easily detected by CT, which is also useful to exclude neoplastic lesions located at the hepatic hilum or into the liver. Pneumobilia may be evident by CT, being highly suggestive of a biliary-enteric fistula [12,14]. The patients who presented with signs and symptoms of intestinal obstruction underwent CT scans, showing gallstone ileus in all cases (n=5), with pneumobilia present in four of them. MRCP has superior diagnostic accuracy in about 50% of cases, thereby providing better information about the structure and contents of the biliary tree [15]. The diagnostic accuracy of ERCP for a biliary fistula varies from 55% to 90%, but this modality also offers the advantage of a therapeutic role [12,16,17]. In this series, to achieve a preoperative diagnosis, MRCP was not applied in any of our patients, but ERCP was used for two patients, which detected a CDF in one patient who underwent sphincterotomy and placement of a biliary stent. The stent was removed at 2 months post-cholecystectomy. For the other patient, a stone was extracted from the CBD, and sphincterotomy was effectively achieved, although no fistula was observed. There are two possible explanations for the nature of a CEF. The first theory is based on the erosion of stones through the injured wall of the gallbladder into the duodenum, colon, or stomach, causing a gallstone ileus (Fig. 2) [10,18]. Furthermore, since the gallbladder is decompressed, and if no stone remains, the patient may become asymptomatic. If the patient is exceedingly ill due to electrolyte imbalance, sepsis, or other disorders caused by the intestinal obstruction due to a gallstone ileus, under no
circumstances should the fistula be repaired or closed because of the increased risk of additional contamination from further dissection in the area of the gallbladder. We only repaired the fistulas of two of the five patients with gallstone ileus because the gallbladder was not firmly adhered to the duodenum and unruffled dissection was feasible. For the other three patients, the inflammatory process caused significant derangement of the anatomy of Calot’s triangle, so we opted to leave the fistulas untreated. The second theory of the formation of this type of fistula involves acute inflammation with obstruction of the cystic duct, causing the gallbladder to stretch and swell, sometimes rubbing the gastrointestinal tract and forming adhesions between two organs with subsequent gangrenous changes with eventual erosion, thereby establishing a lasting anomalous communication [5]. The standard treatment when encountering a CEF is cholecystectomy, and repair of the fistulous opening, either by a laparoscopic, or an open approach, depending on the experience of the surgeon and the condition of the patient [2]. Whenever difficult dissection or significant bleeding is encountered in a laparoscopic method, intestinal suturing might be challenging along with an increased risk of injury to the biliary tree, in which cases, conversion to open surgery might be necessary [4]. The conversion rate from the laparoscopic approach in the current study was 80% due to trouble visualizing the anatomy of the gallbladder area in most cases and because of significant hemorrhage from Calot´s triangle in one case, which occurred during dissection of the inflamed tissue around the gallbladder and duodenal area, but there was no damage to any significant vascular structure. A defect on the duodenum can be closed with sutures [4] or a Graham patch [19], while leaving a T-tube during duodenostomy after previous repair attempts had failed [20].
We suggest the use of the first two techniques to restore the duodenal anatomy since there was no leakage with either of these methods in this series. On the patients where the colon was involved, we performed on two of them, partial cholecystectomies, and on one a completed counterpart. On two patients we performed primary closure of the transverse colon, and on another, a colostomy was achieved with colonic reconnection auspiciously implemented 20 weeks later. We encountered a 49-yearold female patient with a gallstone ileus on the sigmoid colon along with a CCF, opting for conservative management, achieving only an enterolithotomy, with positive outcomes. This unusual site of impaction of the stone is exceptionally infrequent, occurring only in around 5% of all patients with gallstone ileus [3]. In this series, one patient developed jaundice and abdominal pain on POD 2. He presented with a stone within the CBD, as observed during MRCP. On POD 3, the stone (diameter, 4 mm) was extracted under ERCP guidance, and sphincterotomy was performed. Another patient developed paralytic ileus treated medically without complications. The only death was an 86-year-old female patient who presented with gallstone ileus, severe abdominal distension, and acute renal failure. Laparotomy with enterolithotomy was performed, but the patient succumbed to kidney failure on POD 20. Hence, the mortality rate in this study was 6.7%, which was lower than the rate of 25% in a series of 12 patients reported by Duzgun et al. [5] and lower than that in another study of 15%–22% among patients with a CEF [9]. In conclusion, CEF is an infrequent finding during cholecystectomy, implying a surgical challenge for the surgeon. When the US demonstrates a shrunken gallbladder with a thick wall of a patient with a long history of cholecystolithiasis, a supplemental image study is recommended (CT, MRCP, or ERCP) in order to rule out any other biliary disease.
During surgery, if the gallbladder area is fixed by extensive inflammatory tissue and is stringently attached to the gastrointestinal tract, the surgeon should be highly suspicious of the presence of a CEF. There is no consensus on the best treatment for this condition, as the outcome is dependent on the surgeon’s expertise and the condition of the patient. A CEF is not always accompanied by gallstone ileus. For such cases, the primary purpose is to repair the intestinal obstruction, while avoiding the gallbladder area, unless there is definite proof of gallstones in the biliary tree.
References: [1]
Glenn F, Reed C, Grafe WR. Biliary enteric fistula. Surg Gynecol Obstet 1981;153:527–531.
[2]
Chowbey PK, Bandyopadhyay SK, Sharma A, Khullar R, Soni V, Baijal M. Laparoscopic management of cholecystoenteric fistulas. J Laparoendosc Adv Surg Tech A 2006;16:467-472
[3]
Costi R, Randone B, Violi V, Scatton O, Sarli L, Soubrane O, et al. Cholecystocolonic fistula: Facts and myths. A review of the 231 published cases. J Hepatobiliary Pancreat Surg 2009;16:8–18.
[4]
Li XY, Zhao X, Zheng P, Kao XM, Xiang XS, Ji W. Laparoscopic management of cholecystoenteric fistula: A single-center experience. J Int Med Res 2017;45:1090– 1097.
[5]
Duzgun AP, Ozmen MM, Ozer MV, Coskun F. Internal biliary fistula due to cholelithiasis: A single-centre experience 2007;13:4606–4609.
[6]
Safaie-Shirazi S, Zike WL, Printen KJ. Spontaneous enterobiliary fistulas. Surg Gynecol Obstet 1973;137:769–772.
[7]
Jones TA, Davis ME, Glantz AI. Bouveret’s syndrome presenting as upper gastrointestinal hemorrhage without hematemesis. Am Surg 2001;67:786–789.
[8]
Topal U, Savci G, Sadikoglu MY, Tuncel E. Choledochoduodenal fistula secondary to duodenal peptic ulcer. A case report. Acta Radiol 1997;38:1007–1009.
[9]
Atli AO, Coşkun T, Ozenç A, Hersek E. Biliary enteric fistulas. Int Surg 1997;82:280–283.
[10] Zwemer FL, Coffin-kwart VE, Conway MJ. Biliary enteric fistulas. Management of 47 cases in native Americans. Am J Surg 1979;139:301–304. [11] Piedad OH, Wels PB. Spontaneous internal biliary fistula, obstructive and nonobstructive types: Twenty-year review of 55 cases. Ann Surg 1972;175:75–80. [12] Crespi M, Montecamozzo G, Foschi D. Diagnosis and treatment of biliary fistulas in the laparoscopic era. Gastroenterol Res Pract 2016;2016:6293538. [13] Angrisani L, Corcione F, Tartaglia A, Tricaricio F, Rendano R, Vincenti M, et al. Cholecystoenteric fistula (CF) is not a contraindication for laparoscopic surgery. Surg Endosc 2001;15:1038–1041. [14] Pickhardt PJ, Friedland JA, Hruza DS, Fisher AJ. Findings in Bouveret ’ s Syndrome. Am J Roentgenol 2003;180:1033–1035. [15] 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. [16] Inal M, Oguz M, Aksungur E, Soyupak S, Börüban S, Akgül E. Biliary - enteric fistulas: report of five cases and review of the literature. Eur Radiol 1999;1151:1145–1151. [17] Yonetci N, Kutluana U, Yilmaz M, Sungurtekin U, Tekin K. The incidence of
Mirizzi syndrome in patients undergoing endoscopic retrograde cholangiopancreatography. Hepatobiliary Pancreat Dis Int 2008;7:520–524. [18] Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: A review. Mt Sinai J Med 2006;73:1132–1134. [19] Hill BC, Burke LH, Ertl CW. Cholecystoduodenal fi stula in a patient post-Roux-enY gastric bypass. BMJ Case Rep 2013:2013. [20] Kutlu OC, Garcia S, Dissanaike S. The successful use of simple tube duodenostomy in large duodenal perforations from varied etiologies. Int J Surg Case Rep 2013;4:279–282.
Table 1. Paraclinical characteristics Laboratories values
Data
WBC (×109 cells/L)
8.3 (5-15.6)
Total bilirubin (mg/dL)
0.64 (0.33–9.48)
Direct bilirubin (mg/dL)
0.38 (0.21–7.37)
Indirect bilirubin (mg/dL)
0.30 (0.08–2.11)
AST (U/L)
56 (12–212)
ALT (U/L)
68 (13–285)
AP (U/L)
120 (60–672)
GGT (U/L)
147 (20–1133)
Ultrasound Gallbladder wall (mm)
4 (1.5-11)
CBD (mm)
6 (3-10)
Computed Tomography Pneumobilia
4 (2.7%)
AST: aspartate aminotransferase; ALT: alanine aminotransferase; AP: alkaline phosphatase; CBD: common bile duct ; GGT: gamma-glutamyltransferase; WBC: white blood count
Table 2. Patient characteristics, surgical treatments, and outcomes No.
Comorbidities Preoperative diagnosis
1
Sex/Age (yr) F/61
DM, SAH
Acute cholecystitis/US
Operative findings CDF
2
F/39
None
Acute cholecystitis/US
CDF
3
F/44
None
GI + CDF/US, CT scan
4
F/57
DM, SAH
Acute cholecystitis/US
CDF + GI in IC valve CDF
5
F/33
DM
Acute cholecystitis/ US
CDF
6
M/61
DM
CDF
7
F/82
SAH
Choledocholithiasis/US, ERCP GI + CDF/CT scan
8
F/86
None
GI + CDF/CT scan
CDF + GI in IC valve
9
M/73
SAH
GI + CDF/CT scan
CDF + GI in IC valve
10
F/55
DM, SAH
CDF
11
F/49
SAH
Choledocholithiasis + CDF/US, ERCP GI + CCF /CT scan
12
F/71
DM, SAH
Acute cholecystitis/US
CCF + GI in the sigmoid colon CCF
13
M/51
None
Acute cholecystitis/US
CCF
14
F/79
SAH
Cholelithiasis/US
CCF
15
F/61
DM, SAH
Acute cholecystitis/US
CGF
CDF + GI in IC valve
Surgical procedures Conversion + partial cholecystectomy + Graham patch on the duodenum Conversion + partial cholecystectomy + primary closure on the duodenum
Hospital stay (d) 7
Postoperative course NC
7
Laparotomy + enterolithotomy
6
Stone on CBD, treated with ERCP NC
Conversion + partial cholecystectomy + Graham patch on the duodenum Conventional partial cholecystectomy + T-tube insertion + Graham patch on the duodenum Conversion + partial cholecystectomy + primary closure on the duodenum Laparotomy + enterolithotomy + cholecystectomy + primary closure on the duodenum Laparotomy + enterolithotomy
7
NC
8
NC
4
NC
7
NC
20
Laparotomy + enterolithotomy + cholecystectomy + primary closure on the duodenum LC + primary closure on the duodenum Laparotomy + enterolithotomy
3
Sepsis, renal failure, death NC
5
NC
5
NC
Conversion + partial cholecystectomy + primary closure on the transverse colon Conversion + partial cholecystectomy + colostomy LC + primary closure on the transverse colon Conversion + partial cholecystectomy + Graham patch on the lesser curvature
7
NC
10
Paralytic ileus
4
NC
7
NC
CDF: cholecystoduodenal fistula; CCF: cholecystocolonic fistula; CGF: cholecystogastric fistula; CT: computed tomography; DM: diabetes mellitus; GI: gallstone ileus; IC: ileocecal; LC: laparoscopic cholecystectomy; NC: no complications; SAH: systemic arterial hypertension;
US:
ultrasonography;
ERCP:
cholangiopancreatography; CBD: common bile duct.
endoscopic
retrograde
Figure legends
Fig. 1. CT of the abdomen with intravenous contrast of a 61-year-old female patient. The black arrow identifies the gallbladder with aerobilia. Red arrow identifies the duodenal stump. The gallbladder is in communication with the duodenum. A: Coronal view; B: Axial view.
Fig. 2. Diagram exposing the process of a cholecystoduodenal fistula creation. A: Adherence formation and inflammatory tissue surrounding the gallbladder in touch with the duodenum; B: Erosion of the gallbladder’s wall into the duodenum, creating an anomalous communication.
Cholecystoenteric fistula with and without gallstone ileus: A case series Mauricio Gonzalez-Urquijo , Mario Rodarte-Shade , Gerardo Lozano-Balderas , Gerardo Gil-Galindo PII: DOI: Reference:
S1499-3872(19)30255-3 https://doi.org/10.1016/j.hbpd.2019.12.004 HBPD 245
To appear in:
Hepatobiliary & Pancreatic Diseases International
Received date: Accepted date:
12 July 2019 17 December 2019
Please cite this article as: Mauricio Gonzalez-Urquijo , Mario Rodarte-Shade , Gerardo Lozano-Balderas , Gerardo Gil-Galindo , Cholecystoenteric fistula with and without gallstone ileus: A case series, Hepatobiliary & Pancreatic Diseases International (2019), doi: https://doi.org/10.1016/j.hbpd.2019.12.004
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.
Manuscript type: Original Article/Biliary Running title: Cholecystoenteric fistula Title: Cholecystoenteric fistula with and without gallstone ileus: A case series
Authors: Mauricio Gonzalez-Urquijo1,2,*, Mario Rodarte-Shade1,2, Gerardo LozanoBalderas1, Gerardo Gil-Galindo1,2 Abbreviated name: Gonzalez-Urquijo M, Rodarte-Shade M, Lozano-Balderas G, GilGalindo G City: Monterrey, México
Author Affiliations 1. Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Dr. Ignacio Morones Prieto O 3000, Monterrey 64710, México 2. Department of Surgery, Hospital Metropolitano “Dr. Bernardo Sepúlveda”, Secretaria de Salud de Nuevo León, Adolfo López Mateos No. 4600, San Nicolás de los Garza 66400, México * Corresponding author Mauricio Gonzalez- Urquijo, Dr. Ignacio Morones Prieto O 3000. Monterrey 64710, México (E-mail address: [email protected]) Received 12 July 2019 Accepted 17 December 2019 Acknowledgments: Research group of Bioengineering and Regenerative Medicine from Tecnologico de Monterrey. Credit authorship contribution statement: Mauricio Gonzalez-Urquijo: Conceptualization, data curation, writing original draft Mario Rodarte-Shade: Data curation, formal analysis, investigation, methodology Gerardo Lozano-Balderas: Project administration, software, supervision Gerardo Gil-Galindo: Validation, Writing-review & editing
Funding: None. Ethical approval: This study was approved by the Ethics Committee of Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud. The study protocol was approved by the Institutional Review Board of our Institution (approval No. 031). Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Abstract Background: A cholecystoenteric fistula (CEF) is an uncommon complication of gallstone disease. The aim of this study was to present our experience of a series of patients with CEF, presenting with or without gallstone ileus, along with their surgical outcomes. Methods: From 2015 to 2018, 3245 consecutive patients underwent cholecystectomy for gallbladder disease at our institution, of which 15 were diagnosed with a CEF. All electronic medical records were retrospectively reviewed. Results: Fifteen patients presented with CEF. Ten patients presented cholecystoduodenal fistula, four patients cholecystocolonic, and one patient cholecystogastric counterparts. Twelve patients were female. The median patient age was 61 years (range 33–86 years). Five patients presented with gallstone ileus treated by laparotomy and enterolithotomy. In ten patients, a laparoscopic approach was attempted, but conversion to open surgery was necessary for eight of them. The median operative time was 140 min (range 60–240 min), and the median operative blood loss was 50 mL (range 10–600 mL). The procedure-related morbidity and mortality rates were 13.3% and 6.7%, respectively. Conclusions: There is no consensus on the best treatment modality for a CEF, as the treatment outcome is mostly dependent on the surgeon’s expertise and the patient’s
condition. Not all CEFs are accompanied by gallstone ileus. For such case, the main purpose is to resolve the intestinal obstruction and, unless necessary, avoidance of the gallbladder area. Keywords: Cholecystoenteric fistula; Gallbladder disease; Biliary-enteric fistula; Gallstone ileus; Intestinal obstruction
Introduction A cholecystoenteric fistula (CEF) first described by Bartholin in 1654, is relatively rare. This type of fistula, is a well-recognized complication of biliary disease, with a reported incidence of 3%–5% in patients with cholelithiasis, and is designated as a spontaneous anomalous tract between any part of the gallbladder and a segment of the surrounding gastrointestinal tract, the most frequent localization being the duodenum, accounting for 75%–80% of all such fistulas, followed by the colon and stomach [1–4]. Because of the lack of particular symptoms, as compared with cholecystitis, it is difficult to diagnose a CEF preoperatively. Previously, CEF was always an incidental finding during surgery, but with the improvement of imaging modalities, such as computed tomography (CT) and magnetic resonance imaging, along with the application of endoscopic technology, the preoperative diagnosis of a CEF has been significantly improved, but is achieved in only 8%–17% of cases [4,5]. The common causes of CEF include chronic cholelithiasis, peptic ulceration, malignant neoplasms, Crohn’s disease, among others [5–8]. The present study aims to present a case series of patients with CEFs due to chronic cholelithiasis and to display our personal surgical experience treating this uncommon type of biliary disease, along with their surgical outcomes.
Methods The Institutional Review Board approved the study protocol (approval No. 031). From 2015 to 2018, 3245 consecutive patients underwent cholecystectomy for gallbladder disease at our institution. Among them, 15 patients were diagnosed with a CEF, either preoperatively or intraoperatively. We searched the surgical database for all patients diagnosed with this type of fistula and retrospectively reviewed all electronic medical records. The patient demographics, clinical characteristics, diagnostic methods, surgical procedures, treatment outcomes, and follow-ups were all documented and organized. All patients underwent a physical examination, laboratory testing, and evaluation of the gallbladder either by ultrasonography (US) or CT. Based on the patient’s condition, other imaging modalities, such as magnetic resonance cholangiopancreatography (MRCP), or endoscopic
retrograde
cholangiopancreatography
(ERCP),
were
performed.
If
choledocholithiasis was encountered, the patient underwent ERCP with subsequent cholecystectomy. Laparoscopic cholecystectomy under general anesthesia with a standard four-port technique was attempted in most patients. Conversion to open surgery was left to the discretion of the surgeon. When dense adhesions to adjacent organs and impacted stones in Hartmann’s pouch rendered access to Calot’s triangle difficult, a fundus-first dissection technique was applied, and subtotal cholecystectomy was performed. All patients were followed up in the outpatient clinic within the first week, the first month, and then yearly. Patients were examined clinically, and liver function was evaluated at each follow-up visit. Statistical analysis Continuous variables were reported as the median, and range while categorical variables were reported as frequencies and percentages. Data analysis was performed with a
combination of Excel 16.0 (Microsoft Corporation, Redmond, WA, USA) and R software 3.4 (R Core Team, Auckland, New Zealand).
Results In our series, 12 patients were women, and three were men. The median age was 61 years (range 33–86 years). Ten patients had cholecystoduodenal fistula (CDF), four patients cholecystocolonic fistula (CCF), and one patient cholecystogastric fistula (CGF). Five patients had concomitant diabetes mellitus (DM) and systemic arterial hypertension (SAH), four had only SAH, and two had only DM. All patients had >2-year history of abdominal pain, with a median time of exacerbation of pain in the right upper quadrant before surgical treatment of 3 days (range 1–10 days). Only two patients had jaundice due to choledocholithiasis at presentation. Four patients presented with an elevated white blood cell count, with a median value of 8.3× 109 cells/L (range 5.0×109-15.6×109 cells/L). Liver function test results were detailed in Table 1. The US was the initial imaging modality in 11 patients, which revealed gallstones and features of acute cholecystitis in all cases, with a median gallbladder wall thickness of 4.0 mm (range 1.5–11.0 mm). Two patients presented with choledocholithiasis, detected by US, resolved with ERCP. During the ERCP, visualization of a CDF was seen in one of the patients, while there was no fistulous opening in the other. Both patients underwent sphincterotomy with the placement of a common duct stent in the patient with a CDF. Overall, a preoperative diagnosis of CEF was achieved in six patients, one with an initial diagnosis of choledocholithiasis by ERCP and five with a CT scan (Fig. 1). Of the 10 patients with CDF, four converted from laparoscopy to open procedure, performing partial cholecystectomies. Primary closure of the duodenum and a Graham
patch was achieved in two patients each, respectively. In one patient, a laparoscopic procedure was auspiciously completed, and total cholecystectomy was completed while performing a Graham patch on the second portion of the duodenal wall. Laparotomy was performed for four patients with gallstone ileus, completing an enterolithotomy in the terminal ileum. Furthermore, in half of those patients (n=2) dismantling of the fistula was accomplished by total cholecystectomy and primary closure of the duodenum. The fistula was left intact in the other two patients, and only the intestinal obstruction was resolved. An open approach was completed in one patient, during which the common bile duct (CBD) was found to be firmly adhered to the duodenum along with the fundus of the gallbladder; hence, partial cholecystectomy with T-tube insertion within the CBD and a Graham patch on the duodenum was done. Of the four patients with CCF, a laparoscopic approach was attempted in three of them, with conversion to open surgery in two patients. In one patient, a colostomy at the site of the fistula was performed, and a partial cholecystectomy was achieved. Two patients were treated with primary closure of the transverse colon. In one patient, conversion to open surgery was needed, performing a partial cholecystectomy, and in the other a laparoscopic cholecystectomy was auspiciously performed. One patient was treated with enterolithotomy alone, for intestinal obstruction due to sigmoid gallstone ileus. One patient presented a CGF on the lesser curvature, treated with a partial cholecystectomy. An omental patch was placed at the site of the defect in the lesser curvature. The patient characteristics and surgical outcomes were summarized in Table 2. In global, trans-operative cholangiography was performed in six of the 12 patients who previously underwent cholecystectomy, but no filling defect of the biliary tract was
detected. Each had anomalous communications from the gallbladder to the duodenum, colon or stomach. In the 12 patients, a tube drain was left in the subhepatic space and was removed within a median of 3.5 days (range 2–10 days). The median operative time was 140 min (range 60–240 min), and the median intraoperative blood loss was 50 mL (range 10–600 mL). Regarding the site of the fistula, on the gallbladder side, the fundus was the site of the fistula in six patients, the body in four, the Hartmann pouch in two, and in three patients, the site was uncertain due to firm adhesion and a significant fibrotic process. Overall, procedure-related morbidity and mortality were found in two patients and one patient, respectively. One patient had a remaining stone within the CBD that was treated 4 days after the initial procedure with ERCP, which achieved an outstanding outcome, another patient presented paralytic ileus on postoperative day (POD) 3 treated with prokinetic agents, and one geriatric patient died from septic shock due to intestinal obstruction secondary to gallstone ileus. Only enterolithotomy was performed, but the patient did not recover from renal failure and died on POD 20 in the intensive care unit. The median length of hospital stay was 7 days (range 3–20 days). Fourteen patients were currently followed up in our clinic, with a median follow-up period of 14 months (range 8– 40 months). All are symptom-free with normal liver function. None of the three patients with gallstone ileus, for whom the gallbladder area was not addressed, have reported colicky biliary pain. Final histopathological analysis revealed chronic cholecystitis in all patients.
Discussion A CEF is a rare clinical condition that occurs primarily in the female geriatric population [9]. In the present study, more than half of the patients were geriatric, and 80% of the population were female. CEF has been reported to occur in 3%–5% of patients with cholelithiasis and 0.15%–4.8% of all who undergo surgery to the biliary tract. The incidence (0.46%) in the present study was lower than in early reports [9,10], and was almost the same as that reported by Li et al. [4], Duzgun et al. [5] and Chowbey et al. [2]. The most frequent type of biliary fistula is CDF, followed by CCF and CGF [1,3]. In our patients, 66.7%, 26.7%, and 6.7% presented with these types of fistulas, respectively. An inflamed, contracted gallbladder stuck firmly to contiguous viscera in a patient with a long history of chronic cholecystitis should alert the surgeon to the possibility of a cholecystoenteric fistula [2]. Li et al. [4] advised that a long history of cholecystolithiasis, especially >5 years, should increase suspicion for the presence of CEF when encountering the gallbladder firmly adhered to a part of the gastrointestinal tract. The clinical presentation of this condition is mostly chronic. In this series, all patients had a history of abdominal pain for a minimum of 24 months, and these symptoms (i.e., epigastric or right upper quadrant pain, nausea, and vomiting) were not discernable from the symptoms of most gastrointestinal conditions, such as cholelithiasis or acute cholecystitis [5,11]. In our series, seven patients had an initial diagnosis of acute cholecystitis, and one patient had a diagnosis of cholelithiasis, which was operated in an elective manner. We made the preoperative diagnosis of CEF in 40% of our patients, making it higher than other series, where a preoperative diagnosis was achieved in 8%-31% [4,12].
The majority of the diagnoses are made intraoperatively, unless the biliary tract is involved, which consequently causes jaundice, cholangitis, or pancreatitis [13]. Most studies report that the fistulas are revealed incidentally by other radiologic studies to investigate biliary conditions, pancreatic diseases, or intestinal obstructions [5]. Intestinal obstructions are easily detected by CT, which is also useful to exclude neoplastic lesions located at the hepatic hilum or into the liver. Pneumobilia may be evident by CT, being highly suggestive of a biliary-enteric fistula [12,14]. The patients who presented with signs and symptoms of intestinal obstruction underwent CT scans, showing gallstone ileus in all cases (n=5), with pneumobilia present in four of them. MRCP has superior diagnostic accuracy in about 50% of cases, thereby providing better information about the structure and contents of the biliary tree [15]. The diagnostic accuracy of ERCP for a biliary fistula varies from 55% to 90%, but this modality also offers the advantage of a therapeutic role [12,16,17]. In this series, to achieve a preoperative diagnosis, MRCP was not applied in any of our patients, but ERCP was used for two patients, which detected a CDF in one patient who underwent sphincterotomy and placement of a biliary stent. The stent was removed at 2 months post-cholecystectomy. For the other patient, a stone was extracted from the CBD, and sphincterotomy was effectively achieved, although no fistula was observed. There are two possible explanations for the nature of a CEF. The first theory is based on the erosion of stones through the injured wall of the gallbladder into the duodenum, colon, or stomach, causing a gallstone ileus (Fig. 2) [10,18]. Furthermore, since the gallbladder is decompressed, and if no stone remains, the patient may become asymptomatic. If the patient is exceedingly ill due to electrolyte imbalance, sepsis, or other disorders caused by the intestinal obstruction due to a gallstone ileus, under no
circumstances should the fistula be repaired or closed because of the increased risk of additional contamination from further dissection in the area of the gallbladder. We only repaired the fistulas of two of the five patients with gallstone ileus because the gallbladder was not firmly adhered to the duodenum and unruffled dissection was feasible. For the other three patients, the inflammatory process caused significant derangement of the anatomy of Calot’s triangle, so we opted to leave the fistulas untreated. The second theory of the formation of this type of fistula involves acute inflammation with obstruction of the cystic duct, causing the gallbladder to stretch and swell, sometimes rubbing the gastrointestinal tract and forming adhesions between two organs with subsequent gangrenous changes with eventual erosion, thereby establishing a lasting anomalous communication [5]. The standard treatment when encountering a CEF is cholecystectomy, and repair of the fistulous opening, either by a laparoscopic, or an open approach, depending on the experience of the surgeon and the condition of the patient [2]. Whenever difficult dissection or significant bleeding is encountered in a laparoscopic method, intestinal suturing might be challenging along with an increased risk of injury to the biliary tree, in which cases, conversion to open surgery might be necessary [4]. The conversion rate from the laparoscopic approach in the current study was 80% due to trouble visualizing the anatomy of the gallbladder area in most cases and because of significant hemorrhage from Calot´s triangle in one case, which occurred during dissection of the inflamed tissue around the gallbladder and duodenal area, but there was no damage to any significant vascular structure. A defect on the duodenum can be closed with sutures [4] or a Graham patch [19], while leaving a T-tube during duodenostomy after previous repair attempts had failed [20].
We suggest the use of the first two techniques to restore the duodenal anatomy since there was no leakage with either of these methods in this series. On the patients where the colon was involved, we performed on two of them, partial cholecystectomies, and on one a completed counterpart. On two patients we performed primary closure of the transverse colon, and on another, a colostomy was achieved with colonic reconnection auspiciously implemented 20 weeks later. We encountered a 49-yearold female patient with a gallstone ileus on the sigmoid colon along with a CCF, opting for conservative management, achieving only an enterolithotomy, with positive outcomes. This unusual site of impaction of the stone is exceptionally infrequent, occurring only in around 5% of all patients with gallstone ileus [3]. In this series, one patient developed jaundice and abdominal pain on POD 2. He presented with a stone within the CBD, as observed during MRCP. On POD 3, the stone (diameter, 4 mm) was extracted under ERCP guidance, and sphincterotomy was performed. Another patient developed paralytic ileus treated medically without complications. The only death was an 86-year-old female patient who presented with gallstone ileus, severe abdominal distension, and acute renal failure. Laparotomy with enterolithotomy was performed, but the patient succumbed to kidney failure on POD 20. Hence, the mortality rate in this study was 6.7%, which was lower than the rate of 25% in a series of 12 patients reported by Duzgun et al. [5] and lower than that in another study of 15%–22% among patients with a CEF [9]. In conclusion, CEF is an infrequent finding during cholecystectomy, implying a surgical challenge for the surgeon. When the US demonstrates a shrunken gallbladder with a thick wall of a patient with a long history of cholecystolithiasis, a supplemental image study is recommended (CT, MRCP, or ERCP) in order to rule out any other biliary disease.
During surgery, if the gallbladder area is fixed by extensive inflammatory tissue and is stringently attached to the gastrointestinal tract, the surgeon should be highly suspicious of the presence of a CEF. There is no consensus on the best treatment for this condition, as the outcome is dependent on the surgeon’s expertise and the condition of the patient. A CEF is not always accompanied by gallstone ileus. For such cases, the primary purpose is to repair the intestinal obstruction, while avoiding the gallbladder area, unless there is definite proof of gallstones in the biliary tree.
References: [1]
Glenn F, Reed C, Grafe WR. Biliary enteric fistula. Surg Gynecol Obstet 1981;153:527–531.
[2]
Chowbey PK, Bandyopadhyay SK, Sharma A, Khullar R, Soni V, Baijal M. Laparoscopic management of cholecystoenteric fistulas. J Laparoendosc Adv Surg Tech A 2006;16:467-472
[3]
Costi R, Randone B, Violi V, Scatton O, Sarli L, Soubrane O, et al. Cholecystocolonic fistula: Facts and myths. A review of the 231 published cases. J Hepatobiliary Pancreat Surg 2009;16:8–18.
[4]
Li XY, Zhao X, Zheng P, Kao XM, Xiang XS, Ji W. Laparoscopic management of cholecystoenteric fistula: A single-center experience. J Int Med Res 2017;45:1090– 1097.
[5]
Duzgun AP, Ozmen MM, Ozer MV, Coskun F. Internal biliary fistula due to cholelithiasis: A single-centre experience 2007;13:4606–4609.
[6]
Safaie-Shirazi S, Zike WL, Printen KJ. Spontaneous enterobiliary fistulas. Surg Gynecol Obstet 1973;137:769–772.
[7]
Jones TA, Davis ME, Glantz AI. Bouveret’s syndrome presenting as upper gastrointestinal hemorrhage without hematemesis. Am Surg 2001;67:786–789.
[8]
Topal U, Savci G, Sadikoglu MY, Tuncel E. Choledochoduodenal fistula secondary to duodenal peptic ulcer. A case report. Acta Radiol 1997;38:1007–1009.
[9]
Atli AO, Coşkun T, Ozenç A, Hersek E. Biliary enteric fistulas. Int Surg 1997;82:280–283.
[10] Zwemer FL, Coffin-kwart VE, Conway MJ. Biliary enteric fistulas. Management of 47 cases in native Americans. Am J Surg 1979;139:301–304. [11] Piedad OH, Wels PB. Spontaneous internal biliary fistula, obstructive and nonobstructive types: Twenty-year review of 55 cases. Ann Surg 1972;175:75–80. [12] Crespi M, Montecamozzo G, Foschi D. Diagnosis and treatment of biliary fistulas in the laparoscopic era. Gastroenterol Res Pract 2016;2016:6293538. [13] Angrisani L, Corcione F, Tartaglia A, Tricaricio F, Rendano R, Vincenti M, et al. Cholecystoenteric fistula (CF) is not a contraindication for laparoscopic surgery. Surg Endosc 2001;15:1038–1041. [14] Pickhardt PJ, Friedland JA, Hruza DS, Fisher AJ. Findings in Bouveret ’ s Syndrome. Am J Roentgenol 2003;180:1033–1035. [15] 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. [16] Inal M, Oguz M, Aksungur E, Soyupak S, Börüban S, Akgül E. Biliary - enteric fistulas: report of five cases and review of the literature. Eur Radiol 1999;1151:1145–1151. [17] Yonetci N, Kutluana U, Yilmaz M, Sungurtekin U, Tekin K. The incidence of
Mirizzi syndrome in patients undergoing endoscopic retrograde cholangiopancreatography. Hepatobiliary Pancreat Dis Int 2008;7:520–524. [18] Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: A review. Mt Sinai J Med 2006;73:1132–1134. [19] Hill BC, Burke LH, Ertl CW. Cholecystoduodenal fi stula in a patient post-Roux-enY gastric bypass. BMJ Case Rep 2013:2013. [20] Kutlu OC, Garcia S, Dissanaike S. The successful use of simple tube duodenostomy in large duodenal perforations from varied etiologies. Int J Surg Case Rep 2013;4:279–282.
Table 1. Paraclinical characteristics Laboratories values
Data
WBC (×109 cells/L)
8.3 (5-15.6)
Total bilirubin (mg/dL)
0.64 (0.33–9.48)
Direct bilirubin (mg/dL)
0.38 (0.21–7.37)
Indirect bilirubin (mg/dL)
0.30 (0.08–2.11)
AST (U/L)
56 (12–212)
ALT (U/L)
68 (13–285)
AP (U/L)
120 (60–672)
GGT (U/L)
147 (20–1133)
Ultrasound Gallbladder wall (mm)
4 (1.5-11)
CBD (mm)
6 (3-10)
Computed Tomography Pneumobilia
4 (2.7%)
AST: aspartate aminotransferase; ALT: alanine aminotransferase; AP: alkaline phosphatase; CBD: common bile duct ; GGT: gamma-glutamyltransferase; WBC: white blood count
Table 2. Patient characteristics, surgical treatments, and outcomes No.
Comorbidities Preoperative diagnosis
1
Sex/Age (yr) F/61
DM, SAH
Acute cholecystitis/US
Operative findings CDF
2
F/39
None
Acute cholecystitis/US
CDF
3
F/44
None
GI + CDF/US, CT scan
4
F/57
DM, SAH
Acute cholecystitis/US
CDF + GI in IC valve CDF
5
F/33
DM
Acute cholecystitis/ US
CDF
6
M/61
DM
CDF
7
F/82
SAH
Choledocholithiasis/US, ERCP GI + CDF/CT scan
8
F/86
None
GI + CDF/CT scan
CDF + GI in IC valve
9
M/73
SAH
GI + CDF/CT scan
CDF + GI in IC valve
10
F/55
DM, SAH
CDF
11
F/49
SAH
Choledocholithiasis + CDF/US, ERCP GI + CCF /CT scan
12
F/71
DM, SAH
Acute cholecystitis/US
CCF + GI in the sigmoid colon CCF
13
M/51
None
Acute cholecystitis/US
CCF
14
F/79
SAH
Cholelithiasis/US
CCF
15
F/61
DM, SAH
Acute cholecystitis/US
CGF
CDF + GI in IC valve
Surgical procedures Conversion + partial cholecystectomy + Graham patch on the duodenum Conversion + partial cholecystectomy + primary closure on the duodenum
Hospital stay (d) 7
Postoperative course NC
7
Laparotomy + enterolithotomy
6
Stone on CBD, treated with ERCP NC
Conversion + partial cholecystectomy + Graham patch on the duodenum Conventional partial cholecystectomy + T-tube insertion + Graham patch on the duodenum Conversion + partial cholecystectomy + primary closure on the duodenum Laparotomy + enterolithotomy + cholecystectomy + primary closure on the duodenum Laparotomy + enterolithotomy
7
NC
8
NC
4
NC
7
NC
20
Laparotomy + enterolithotomy + cholecystectomy + primary closure on the duodenum LC + primary closure on the duodenum Laparotomy + enterolithotomy
3
Sepsis, renal failure, death NC
5
NC
5
NC
Conversion + partial cholecystectomy + primary closure on the transverse colon Conversion + partial cholecystectomy + colostomy LC + primary closure on the transverse colon Conversion + partial cholecystectomy + Graham patch on the lesser curvature
7
NC
10
Paralytic ileus
4
NC
7
NC
CDF: cholecystoduodenal fistula; CCF: cholecystocolonic fistula; CGF: cholecystogastric fistula; CT: computed tomography; DM: diabetes mellitus; GI: gallstone ileus; IC: ileocecal; LC: laparoscopic cholecystectomy; NC: no complications; SAH: systemic arterial hypertension;
US:
ultrasonography;
ERCP:
cholangiopancreatography; CBD: common bile duct.
endoscopic
retrograde
Figure legends
Fig. 1. CT of the abdomen with intravenous contrast of a 61-year-old female patient. The black arrow identifies the gallbladder with aerobilia. Red arrow identifies the duodenal stump. The gallbladder is in communication with the duodenum. A: Coronal view; B: Axial view.
Fig. 2. Diagram exposing the process of a cholecystoduodenal fistula creation. A: Adherence formation and inflammatory tissue surrounding the gallbladder in touch with the duodenum; B: Erosion of the gallbladder’s wall into the duodenum, creating an anomalous communication.