- Email: [email protected]
Spontaneous cholecystocutaneous fistula
Cirugía y Cirujanos. 2015; 83(1): 61-64
CIRUGÍA y CIRUJANOS Órgano de difusión científica de la Academia Mexicana de Cirugía Fundada en 1933 www.amc.org.mx
www.elservier.es/circir
CLINICAL CASE
6SRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXOD☆ Fernando Guardado-Bermúdeza,*, Araceli Aguilar-Jaimesa, Fernando Josafat Ardisson-Zamoraa, Luis Alberto Guerrero-Silvaa, Estefanie Villanueva-Rodríguezb and Nubia Alondra Gómez-de Leijac a Servicio de Cirugía General, Departamento de Cirugía, Hospital Civil de Ciudad Madero, Ciudad Madero, Tamaulipas, México
Servicio de Medicina Interna, Departamento de Cirugía, Hospital Civil de Ciudad Madero, Ciudad Madero, Tamaulipas, México b
Servicio de Medicina General, Departamento de Cirugía, Hospital Civil de Ciudad Madero, Ciudad Madero, Tamaulipas, México
c
Received 10 June 2013; accepted 21 January 2014
KEYWORDS %LOLDU\ÀVWXOD Cholecystocutaneous; Fistulogram
Abstract Background: 6SRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXODLVGHÀQHGDVDJDOOEODGGHUFRPPXQLFDWLRQZLWK WKHH[WHUQDOHQYLURQPHQWWKURXJKWKHDEGRPLQDOZDOOUXSWXUH7KHÀUVWUHSRUWVZHUHZULWWHQLQWKH seventeenth century by Thilesus. During the past 50 years, 25 cases have been reported. Clinical case: 7KHFDVHLVSUHVHQWHGRID\HDUROGZRPDQZKRKDGDÀYH\HDUKLVWRU\RIELOLDU\ FROLF6L[PRQWKVSULRUWRKHUPHGLFDODVVHVVPHQWWKHUHZDVDOHDNRIELOLDU\PDWHULDODQGJDOOVWRQHV VSRQWDQHRXVO\LQWKHULJKWXSSHUTXDGUDQW)LVWXORJUDPZDVSHUIRUPHGZLWKQRHYLGHQFHRIREVWUXFWLRQ$FKROHF\VWHFWRP\DQGUHVHFWLRQRIWKHÀVWXODZDVVXEVHTXHQWO\SHUIRUPHG Discussion: 7KHELOLDU\ÀVWXODVDUHDQDEQRUPDOFRPPXQLFDWLRQIURPWKHJDOOEODGGHULQWRDQRWKHU VXUIDFH,WLVDUDUHFRQGLWLRQQRZDGD\VDVLWRQO\RFFXUVLQRISDWLHQWVZLWKJDOOEODGGHUOLWKLDVLV $OWKRXJKWKHFOLQLFDOVLJQVRIVSRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXODFOLQLFDUHPRUHWKDQHYLGHQW LWLVLPSHUDWLYHWRSHUIRUPVWXGLHVOLNHXOWUDVRXQGWRPRJUDSK\DQGDÀVWXORJUDP7KHPDLQVWD\RI WUHDWPHQWLVFKROHF\VWHFWRP\UHVHFWLRQRIWKHÀVWXODDQGUHSDLURIDEGRPLQDOZDOOGHIHFW Conclusion:7KHLQFLGHQFHRIFKROHF\VWRFXWDQHRXVÀVWXODWRGD\LVPLQLPDODQGLWVHHPVWKDWWKHFXUrent trend is to become an entity anecdotal. The subcostal abdominal examination approach remains DVWKHÀUVWFKRLFH7KHODSDURVFRSLFDSSURDFKLVDQRSWLRQUHVHUYHGIRUWKHH[SHULHQFHGVXUJHRQ © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
☆ Please cite this article as: Guardado-Bermúdez et al. Fístula colecistocutánea espontánea. Cirugía y Cirujanos. 2015; 83: 61-64. *Corresponding author: Calle Miguel Ramos 606, Col. Luna Luna. C.P. 89519, Ciudad Madero, Tamaulipas, México. Teléfono: 01 (833) 1265 579. E-mail address: [email protected] (F. Guardado Bermúdez).
2444-0507 0009-7411/© 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
62
F. Guardado-Bermúdez et al.
PALABRAS CLAVE Fístula biliar Colecistocutánea; Fistulograma
Fístula colecistocutánea espontánea Resumen Antecedentes:6HGHÀQHODItVWXODFROHFLVWRFXWiQHDHVSRQWiQHDFRPRODFRPXQLFDFLyQGHODYHsícula biliar con el medio externo a través de la rotura de la pared abdominal; los primeros reportes escritos datan del siglo XVII por Thilesus. Durante los últimos 50 años, se han reportado 25 casos. Caso clínico:6HWUDWDGHXQSDFLHQWHIHPHQLQRGHDxRVFRQFyOLFRELOLDUGHDxRVGHHYROXFLyQ PHVHVSUHYLRVDVXYDORUDFLyQSUHVHQWDVDOLGDGHPDWHULDOELOLDUDVtFRPROLWRVGH PDQHUDHVSRQWiQHDHQHOKLSRFRQGULRGHUHFKR6HUHDOL]DXQÀVWXORJUDPDVLQHYLGHQFLDGHREVWUXFFLyQ SRVWHULRUPHQWHVHUHDOL]DFROHFLVWHFWRPtDDVtFRPRUHVHFFLyQGHOWUD\HFWRÀVWXORVR Discusión: /DVItVWXODVELOLDUHVVRQXQDFRPXQLFDFLyQDQyPDODGHODYHVtFXODKDFLDRWUDVXSHUÀFLH HVXQDSDWRORJtDUDUDHQQXHVWURVGtDV\DTXHVRORVHSUHVHQWDHQXQGHORVSDFLHQWHV con colecistopatía litiásica, si bien la clínica de la fístula colecistocutánea espontánea es más que evidente, es indispensable realizar estudios complementarios, como ultrasonido, tomograItD\ÀVWXORJUDPD/DEDVHGHOWUDWDPLHQWRFRQVLVWHHQODFROHFLVWHFWRPtDDVtFRPRHQODUHVHFFLyQGHOWUD\HFWRÀVWXORVR\ODUHSDUDFLyQGHOGHIHFWRHQODSDUHGDEGRPLQDO Conclusión: La incidencia de fístulas colecistocutáneas en la actualidad es mínima y parece que ODWHQGHQFLDDFWXDOHVDFRQYHUWLUVHHQXQDHQWLGDGDQHFGyWLFD ODYtDGHDERUGDMHSDUDODH[SORUDFLyQDEGRPLQDOHVODYtDVXEFRVWDOFRPRSULPHUDRSFLyQ(ODFFHVRODSDURVFySLFRHVXQD RSFLyQUHVHUYDGDSDUDHOFLUXMDQRH[SHULPHQWDGR © 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background 6SRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXODLVGHÀQHGDVWKH OLQNEHWZHHQWKHJDOOEODGGHUZLWKWKHH[WHULRUE\PHDQV RIDUXSWXUHLQWKHDEGRPLQDOZDOOOD\HUVDOORIZKLFK VWUHQJWKHQVWKHÀVWXORXVWUDFW(YHQWKRXJKWKHUHLVHYLGHQFHRIWKHDSSHDUDQFHRIFKROHF\VWRFXWDQHRXVÀVWXODV by putting the patient in ventral decubitus position in order to treat gallbladder disease, more than 2,000 years ago, the ÀUVWZULWWHQUHSRUWVZHUHIRXQGLQWKHVHYHQWHHQWKFHQWXU\ E\7KLOHVXVZKRGHVFULEHGWKLVFRQGLWLRQIRUWKHÀUVWWLPH 7RZDUGVWKHQLQHWHHQWKFHQWXU\&RXUYRLVLHUSUHVHQWHGKLV series of 499 patients. During the past century, 70 cases have been reported and 25 of them in the last 50 years. Such tendency of reduction in the appearance of this nosoORJLFFRQGLWLRQLVGXHWRSURPSWGLDJQRVLVDVZHOODVWKHGHYHORSPHQWLQWKHWKHUDS\XVHGIRUWUHDWPHQWLQWKHODVWWZR centuries. We submit the clinical case of a patient start-
Fig. 1 ([WHUQDORULÀFHRIFKROHF\VWRFXWDQHRXVÀVWXOD
LQJKHUIRXUWKGHFDGHZLWKQRSULRUPHGLFDOKLVWRU\RIWKH FRQGLWLRQZKRGHYHORSHGDORQJWHUPHYROXWLRQFKROHF\VWR FXWDQHRXVÀVWXOD1-4.
Clinical case 7KHSDWLHQWZDVD\HDUROGZRPDQZLWKQRFKURQLFGHJHQHUDWLYHRUVXUJLFDOKLVWRU\ZLWKPXOWLSOHSUHJQDQFLHV ZKRVXIIHUHGIURPSDLQLQWKHULJKWK\SRFKRQGULXPRI years of evolution, treated as acid peptic disease. 6 months before the assessment, she presented a lesion of 2 cm in the right hypochondrium, characterised by increased YROXPHDQGHIIXVLRQRISXUXOHQWPDWHULDO6KHZDVWUHDWHG in an ambulatory manner at the general medicine service DVDSUREDEOHFXWDQHRXVDEVFHVVZLWKORFDOGHUPDWRORJLFDO PDQDJHPHQW KRZHYHUDIWHUPRQWKVWKHSDWLHQWSUHVHQWHGDVSRQWDQHRXVHIIXVLRQRIELOLDU\PDWHULDODVZHOO
Fig. 2 8OWUDVRXQGRIDEGRPLQDOZDOO
6SRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXOD
ZDVFRQGXFWHGGU\LQJWKHFRUUHVSRQGLQJVSLQGOHRIÀVWXlous tract (Figs. 4 and 5). An exploration of the bile duct ZDVFDUULHGRXWLQDWUDQVF\VWLFPDQQHUZLWKRXWHYLGHQFH RIGLODWLRQRUREVWUXFWLRQV WKHZRXQGKHDOHGDQGWKHHYHQW concluded. 7KHSDWLHQWSUHVHQWHGVDWLVIDFWRU\HYROXWLRQZLWKRXW SRVWRSHUDWLYHFRPSOLFDWLRQVDQGZDVGLVFKDUJHGDIWHU KRXUV'XULQJPHGLXPDQGODWHSRVWRSHUDWLYHWKHUHZDV SURSHUKHDOLQJZLWKQRLQIRUPDWLRQUHJDUGLQJFRPSOLFDWLRQV WRWKHSURFHGXUHDQGDVVLVWDQFHÀQDOLVHG
Discussion
DVFDOFXOXVZKLFKVXGGHQO\FRQQHFWVWKHELOHGXFWWRWKH outside (Fig. 1). Subsequently, she returned for assessment at the general VXUJHU\VHUYLFHZKHUHVWXG\SURWRFROZDVLQLWLDWHG6KHXQGHUZHQWDQXOWUDVRQRJUDSK\ZLWKHYLGHQFHRIÀVWXORXVWUDFW WKURXJKDEGRPLQDOZDOOWKLFNQHVVDQGZLWKFROOHFWLRQDW the subcutaneous cellular level (Fig. 2). 7KHWUDFWZDVFDQQXODWHGDQGDILVWXORJUDSK\ZDVSHUIRUPHGZLWKSUHVHQFHRIFRPPXQLFDWLRQWRWKHJDOOEODGGHU ZLWKRXWREVWUXFWLRQRIWKHELOHGXFW )LJ $VXUJLFDOH[SORUDWLRQZDVSURJUDPPHGHOHFWLYHO\XVLQJ D.RVKHUDSSURDFK$WVXEKHSDWLFOHYHOLWZDVSRVVLEOHWR REVHUYHJDOOEODGGHUDGKHUHQFHVWRWKHFRORQZDOOOLYHUDQG greater omentum. A retrograde dissection of the gallbladder
6SRQWDQHRXVELOLDU\ÀVWXODVDUHDQRPDORXVFRQQHFWLRQVRI the gallbladder to another surface. It is a rare pathology QRZDGD\VDVLWLVRQO\SUHVHQWLQRISDWLHQWVZLWKJDOOEODGGHUOLWKLDVLV'HVSLWHWKHIDFWWKDWVXFKFDVHVDUHIHZ they are predominant in female patients under 60 years1,3. %LOLDU\ÀVWXODVDUHFODVVLÀHGLQWRWZRJURXSV LQWHUQDODQG external; the latter present communication to any part of WKHDQWHULRUVXUIDFHRIWKHWUXQN KRZHYHUWKH\DUHH[tremely rare because, in recent decades, less than 100 cases have been reported in medical literature. In the case RILQWHUQDOÀVWXODVDUHFRQQHFWHGWRWKHGXRGHQXP WRFRORQDQGWRMHMXQXPVWRPDFKRUEURQFKL1,2. 7KHDSSHDUDQFHRIFKROHF\VWRFXWDQHRXVÀVWXODKDVDGLverse etiopathogenesis. Among the causes there are gallbladder neoplasia, anatomic anomalies and, of course, post-surgery causes. Nevertheless, most cases are associatHGWRYHVLFXODUOLWKLDVLVZKHUHWKHLQFUHDVHRILQWUDOXPLQDO SUHVVXUHFRPSURPLVHVZDOOFLUFXODWLRQOHDGLQJWRLVFKHPLD necrosis, bacterial translocation and, eventually, abscesses, ZKLFKFRPPXQLFDWHWRWKHDEGRPLQDOZDOO7KHUHLVDJUHDWHUDVVRFLDWLRQEHWZHHQWKHFKROHF\VWRFXWDQHRXVÀVWXODDQG WKHREVWUXFWLRQRIWKHELOHGXFWE\FDOFXOXV+RZHYHURXU patient did not have that feature1,3-6. Clinical presentation of spontaneous cholecysto-cutaneRXVÀVWXODLVDQLQVLGLRXVFRQGLWLRQZLWKORQJWHUPHYROXtion, and biliary colic as a main feature that lasts years. Subsequently, there is also a cutaneous lesion that develops LQWRDQDEVFHVVLQWKHULJKWK\SRFKRQGULXPULJKWÁDQNRU HYHQWKHXPELOLFDOVFDUZKLFKLIWKHUHLVQRFDUHIXOH[ploration and effective examination, can be treated as a GHUPDWRORJLFDOSDWKRORJ\ZLWKRXWVXFFHVV)LQDOO\RQFHWKH
Fig. 4 )LVWXORXVWUDFWUHVHFWLRQLQDEGRPLQDOZDOO
Fig. 5 *DOOEODGGHUZLWKDEGRPLQDOZDOOVHJPHQW
Fig. 3 Fistulogram.
64 tract is consolidated, the effusion of biliar material and calFXOXVLVDGGHGE\PHDQVRIWKHÀVWXOD5,7-9. (YHQWKRXJKWKHÀVWXODFOLQLFLVPRUHHYLGHQWLWLVYHU\ important to conduct extension studies, such as: ultrasound to establish bile duct characteristics, tomography to search IRUDEVFHVVHVDQGRIFRXUVHDÀVWXORJUDPLQRUGHUWRHVtablish the lesion aetiology and the presence of bile duct obstructions8,10-13. &KROHF\VWRFXWDQHRXVÀVWXODPDQDJHPHQWPXVWEHFRPprehensive; even though surgical management is the basis for treatment, conservative management must be considHUHGEDVHGRQÁXLGWKHUDS\DQGDQWLPLFURELDOVLQWKRVH SDWLHQWVLQZKLFKWKHRYHUDOOFRQGLWLRQLVFRPSURPLVHG GXULQJDQDHVWKHWLFRUVXUJLFDOSURFHGXUHV/LNHZLVHLI there is evidence of obstruction in the bile duct during WKHÀVWXORJUDPRQHRIWKHRSWLRQVZLWKOHVVFRPRUELOLW\ rate is the retrograde endoscopic choliopancreatography. 7KDWZLWKVWDQGLQJZHFDQQRWVHWDVLGHWKHIDFWWKDWWKH SDWLHQWVKRXOGXQGHUJRVXUJLFDOLQWHUYHQWLRQDVÀQDOWKHUapy. The use of endoscopic retrograde cholangiopancreatography drains the bile duct, contributing to intraluminal SUHVVXUHUHGXFWLRQLQWKHJDOOEODGGHUDQGUHGXFLQJÀVWXOD ZHDU9,12,14-18. The surgical procedure consists of the cholecystectomy, DVZHOODVILVWXORXVWUDFWUHVHFWLRQDQGUHSDLURIWKHDEGRPLQDOZDOOGHIHFW7KHÀVWXORJUDSK\HVWDEOLVKHVELOHGXFW SHUPHDELOLW\ZKLFKVKRXOGEHYHULÀHGGXULQJVXUJHU\DFcording to the surgeon’s criteria. The preferable approach is usually the conventional; that is to say, by means of a ULJKWVXEFRVWDOLQFLVLRQZLWKVSLQGOHUHVHFWLRQRIWKHWUDFW LQWKHZDOO/DSDURVFRS\DFFHVVLVFXUUHQWO\GHVFULEHG +RZHYHUWKHSURFHVVXQOHDVKHGE\WKHSDWKRORJ\LVUHODWHGWRFKURQLFDQGVHYHUHJDOOEODGGHULQÁDPPDWLRQ,W DOVRMHRSDUGL]HVELOHGXFWVWUXFWXUHVZLWKPLQLPDOLQYDsion12,14,16,19,20.
Conclusions 7KHUHLVFXUUHQWO\DORZLQFLGHQFHRIFKROHF\VWRFXWDQHRXV ÀVWXODDQGLWVHHPVWKDWWKHFXUUHQWWUHQGLVIRULWWREHFRPHDQDQHFGRWDOFRQGLWLRQ+RZHYHUVXUJHRQVVKRXOG NHHSLWLQPLQGE\DVRQHRIWKHFRPSOLFDWLRQVRIELOLDU\ related pathologies. Even though the efforts of health systems in establishing a prompt diagnosis and treatment for gallbladder diseases has accomplished the reduction of seYHUHFRPSOLFDWLRQVVXFKDVÀVWXODWLRQLQWKHORZHVWVRFLDO strata of the population there is still a small percentage WKDWGRHVQRWKDYHDFFHVVWRVXFKEHQHÀWVDQGWKDWLVUHIHUUHGWRDVXUJLFDOVHUYLFHZLWKSDWKRORJLHVDVGHVFULEHG in this text. There must be a preoperative comprehensive assessment WKDWLQIRUPVWKHÀVWXODDQDWRP\DVDELOHGXFWLQRUGHUWR stablish an optimal surgical plan. As regards the approach, abdominal exploration by subcostal means remains as the ÀUVWRSWLRQGXHWRWKHHWKLRORJLFDOIHDWXUHVRIWKHFRQGLWLRQ and since laparoscopic access is an alternative reserved for H[SHUWVXUJHRQVDVZHOODVWKHSDWLHQFHQHHGHGWRWUHDWWKH pathology comprehensively via this access.
F. Guardado-Bermúdez et al.
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Bibliography 1. 9DOGLYLD**&ROHFLWLWLVDJXGD\FUyQLFD$VRFLDFLyQ0H[LFDQD de Cirugía General A.C. Academia Mexicana de Cirugía General A.C. Tratado de cirugía general. 2.ª ed. Editorial Manual Moderno; 2008. p. 941-948. 2. ,RDQQLGLV23DUDVNHYDV*.RWURQLV$&KDW]RSRXORV6.RQVWDQtara A, Papadimitriou N, et al. Spontaneous cholecystocutaneRXVÀVWXODGUDLQLQJIURPDQDEGRPLQDOVFDUIURPSUHYLRXVVXUJLcal drainage. Ann Ital Chir. 2012;83(1):67-69. 3. Flora HS, Bhattacharya S. Case report spontaneous cholecystoFXWDQHRXVÀVWXOD+3% 4. 5RMDV5**yPH]&;:HLVVHU-)&KRXVOHE.$&HUYDQWHV&- Ochoa GJR, et al. Fístula colecisto-cutánea espontánea. Informe de un paciente. Cir Gen. 2002;24(1):53-56. 5. (O6KHKU\$+%LOLDU\ÀVWXODV(-6 6. %LUFK%5&R[6-6SRQWDQHRXVH[WHUQDOELOLDU\ÀVWXODXQFRPplicated by gallstones. Postgrad Med J. 1991;67(786):391-392. 7. Cruz JR Jr, Nahas J, de Figueiredo LF. Spontaneous cholecystoFXWDQHRXVÀVWXOD $UDUHFRPSOLFDWLRQRIJDOOEODGGHUGLVHDVH Sao Paulo Med J. 2006;124(4):234-236. 8. Ijaz S, Lidder S, Mohamid W, Thompson HH. CholecystocutaneRXVÀVWXODVHFRQGDU\WRFKURQLFFDOFXORXVFKROHF\VWLWLV&DVH Rep Gastroenterol. 2008;2(1):71-75. 9. Dutriaux C, Maillard H, Prophette B, Catala M, Célerier P. SponWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXOD$QQ'HUPDWRO9HQHUHRO 2005;132(5):467-469. 10. Vasanth A, Siddiqui A, O’Donnell K. Spontaneous cholecystocuWDQHRXVÀVWXOD6RXWK0HG- 11. 0DOLN$+1DGHHP02FNULP-&RPSOHWHODSDURVFRSLFPDQDJHPHQWRIFKROHF\VWRFXWDQHRXVÀVWXOD8OVWHU0HG- 166-167. 12. Khan AA, Azhar MZ, Khan AA, Rasheed A, Khan KN. SpontaneRXVFKROHF\VWRFXWDQHRXVÀVWXOD-&ROO3K\VLFLDQV6XUJ3DN 2005;15(11):726-727. 13. *RVVDJH-$)RUVKDZ0-6WHSKHQVRQ-0DVRQ56SRQWDQHRXV FKROHF\VWRFXWDQHRXVÀVWXOD-6XUJ 14. 3H]]LOOL5%DUDNDW%&RULQDOGHVL5&DYD]]D06SRQWDQHRXV FKROHF\VWRFXWDQHRXVÀVWXOD&DVH5HS*DVWURHQWHURO 4(3):356-360. 15. 8JDOGH6HUUDQR36RODU*DUFtD/0L\DUGH/HyQ$*RQ]DOH] Pinto AI, González Pinto I, González González J. Fistula colecisWRFXWiQHDFRPRIRUPDGHSUHVHQWDFLyQGHODGHQRFDUFLQRPD de vesícula biliar. Cir Esp. 2013;91(6):396-397. doi:10.1016/ j.ciresp. 2011.12.009. 16. .DSRRU<6LQJK*.KRNKDU06SRQWDQHRXVFKROHF\VWRFXWDQHRXV ÀVWXOD³QRWDQROGWLPHVWRU\,QGLQDQ-6XUJ 6XSSO 188-191. DOI: 10.1007/S12262-012-0560-2. 17. <FH\DU6(UWUN6.DUDELoDN,2QXU($\GRÿDQ)6SRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXODSUHVHQWLQJZLWKDQDEVFHVV containing multiple gallstones: a case report. Mt Sinai J Med. 2005;72(6):402-404. 18. 0HWVHPDNHUV :- 4XDQWHQ , 9DQKRHQDFNHU ) 6SLHVVHQV 7 Spontaneous cholecystocutaneous abscess. JBR-BTR. 2010; 93(4):198-200. 19. Tallon AL, Lopez PM, Molina GD, Bustos JM, Tamayo LM. CholeF\VWRFXWDQHRXVÀVWXOD $UDUHFRPSOLFDWLRQRIJDOOVWRQHV*DVtroenterol Hepatol. 2010;33:553-554. 20. 5DQNLQ/0(JHU6$%RXUODQG+66SRQWDQHRXVH[WHUQDOELOLDU\ ÀVWXOD$Q6XUJ
CIRUGÍA y CIRUJANOS Órgano de difusión científica de la Academia Mexicana de Cirugía Fundada en 1933 www.amc.org.mx
www.elservier.es/circir
CLINICAL CASE
6SRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXOD☆ Fernando Guardado-Bermúdeza,*, Araceli Aguilar-Jaimesa, Fernando Josafat Ardisson-Zamoraa, Luis Alberto Guerrero-Silvaa, Estefanie Villanueva-Rodríguezb and Nubia Alondra Gómez-de Leijac a Servicio de Cirugía General, Departamento de Cirugía, Hospital Civil de Ciudad Madero, Ciudad Madero, Tamaulipas, México
Servicio de Medicina Interna, Departamento de Cirugía, Hospital Civil de Ciudad Madero, Ciudad Madero, Tamaulipas, México b
Servicio de Medicina General, Departamento de Cirugía, Hospital Civil de Ciudad Madero, Ciudad Madero, Tamaulipas, México
c
Received 10 June 2013; accepted 21 January 2014
KEYWORDS %LOLDU\ÀVWXOD Cholecystocutaneous; Fistulogram
Abstract Background: 6SRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXODLVGHÀQHGDVDJDOOEODGGHUFRPPXQLFDWLRQZLWK WKHH[WHUQDOHQYLURQPHQWWKURXJKWKHDEGRPLQDOZDOOUXSWXUH7KHÀUVWUHSRUWVZHUHZULWWHQLQWKH seventeenth century by Thilesus. During the past 50 years, 25 cases have been reported. Clinical case: 7KHFDVHLVSUHVHQWHGRID\HDUROGZRPDQZKRKDGDÀYH\HDUKLVWRU\RIELOLDU\ FROLF6L[PRQWKVSULRUWRKHUPHGLFDODVVHVVPHQWWKHUHZDVDOHDNRIELOLDU\PDWHULDODQGJDOOVWRQHV VSRQWDQHRXVO\LQWKHULJKWXSSHUTXDGUDQW)LVWXORJUDPZDVSHUIRUPHGZLWKQRHYLGHQFHRIREVWUXFWLRQ$FKROHF\VWHFWRP\DQGUHVHFWLRQRIWKHÀVWXODZDVVXEVHTXHQWO\SHUIRUPHG Discussion: 7KHELOLDU\ÀVWXODVDUHDQDEQRUPDOFRPPXQLFDWLRQIURPWKHJDOOEODGGHULQWRDQRWKHU VXUIDFH,WLVDUDUHFRQGLWLRQQRZDGD\VDVLWRQO\RFFXUVLQRISDWLHQWVZLWKJDOOEODGGHUOLWKLDVLV $OWKRXJKWKHFOLQLFDOVLJQVRIVSRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXODFOLQLFDUHPRUHWKDQHYLGHQW LWLVLPSHUDWLYHWRSHUIRUPVWXGLHVOLNHXOWUDVRXQGWRPRJUDSK\DQGDÀVWXORJUDP7KHPDLQVWD\RI WUHDWPHQWLVFKROHF\VWHFWRP\UHVHFWLRQRIWKHÀVWXODDQGUHSDLURIDEGRPLQDOZDOOGHIHFW Conclusion:7KHLQFLGHQFHRIFKROHF\VWRFXWDQHRXVÀVWXODWRGD\LVPLQLPDODQGLWVHHPVWKDWWKHFXUrent trend is to become an entity anecdotal. The subcostal abdominal examination approach remains DVWKHÀUVWFKRLFH7KHODSDURVFRSLFDSSURDFKLVDQRSWLRQUHVHUYHGIRUWKHH[SHULHQFHGVXUJHRQ © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
☆ Please cite this article as: Guardado-Bermúdez et al. Fístula colecistocutánea espontánea. Cirugía y Cirujanos. 2015; 83: 61-64. *Corresponding author: Calle Miguel Ramos 606, Col. Luna Luna. C.P. 89519, Ciudad Madero, Tamaulipas, México. Teléfono: 01 (833) 1265 579. E-mail address: [email protected] (F. Guardado Bermúdez).
2444-0507 0009-7411/© 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
62
F. Guardado-Bermúdez et al.
PALABRAS CLAVE Fístula biliar Colecistocutánea; Fistulograma
Fístula colecistocutánea espontánea Resumen Antecedentes:6HGHÀQHODItVWXODFROHFLVWRFXWiQHDHVSRQWiQHDFRPRODFRPXQLFDFLyQGHODYHsícula biliar con el medio externo a través de la rotura de la pared abdominal; los primeros reportes escritos datan del siglo XVII por Thilesus. Durante los últimos 50 años, se han reportado 25 casos. Caso clínico:6HWUDWDGHXQSDFLHQWHIHPHQLQRGHDxRVFRQFyOLFRELOLDUGHDxRVGHHYROXFLyQ PHVHVSUHYLRVDVXYDORUDFLyQSUHVHQWDVDOLGDGHPDWHULDOELOLDUDVtFRPROLWRVGH PDQHUDHVSRQWiQHDHQHOKLSRFRQGULRGHUHFKR6HUHDOL]DXQÀVWXORJUDPDVLQHYLGHQFLDGHREVWUXFFLyQ SRVWHULRUPHQWHVHUHDOL]DFROHFLVWHFWRPtDDVtFRPRUHVHFFLyQGHOWUD\HFWRÀVWXORVR Discusión: /DVItVWXODVELOLDUHVVRQXQDFRPXQLFDFLyQDQyPDODGHODYHVtFXODKDFLDRWUDVXSHUÀFLH HVXQDSDWRORJtDUDUDHQQXHVWURVGtDV\DTXHVRORVHSUHVHQWDHQXQGHORVSDFLHQWHV con colecistopatía litiásica, si bien la clínica de la fístula colecistocutánea espontánea es más que evidente, es indispensable realizar estudios complementarios, como ultrasonido, tomograItD\ÀVWXORJUDPD/DEDVHGHOWUDWDPLHQWRFRQVLVWHHQODFROHFLVWHFWRPtDDVtFRPRHQODUHVHFFLyQGHOWUD\HFWRÀVWXORVR\ODUHSDUDFLyQGHOGHIHFWRHQODSDUHGDEGRPLQDO Conclusión: La incidencia de fístulas colecistocutáneas en la actualidad es mínima y parece que ODWHQGHQFLDDFWXDOHVDFRQYHUWLUVHHQXQDHQWLGDGDQHFGyWLFD ODYtDGHDERUGDMHSDUDODH[SORUDFLyQDEGRPLQDOHVODYtDVXEFRVWDOFRPRSULPHUDRSFLyQ(ODFFHVRODSDURVFySLFRHVXQD RSFLyQUHVHUYDGDSDUDHOFLUXMDQRH[SHULPHQWDGR © 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background 6SRQWDQHRXVFKROHF\VWRFXWDQHRXVÀVWXODLVGHÀQHGDVWKH OLQNEHWZHHQWKHJDOOEODGGHUZLWKWKHH[WHULRUE\PHDQV RIDUXSWXUHLQWKHDEGRPLQDOZDOOOD\HUVDOORIZKLFK VWUHQJWKHQVWKHÀVWXORXVWUDFW(YHQWKRXJKWKHUHLVHYLGHQFHRIWKHDSSHDUDQFHRIFKROHF\VWRFXWDQHRXVÀVWXODV by putting the patient in ventral decubitus position in order to treat gallbladder disease, more than 2,000 years ago, the ÀUVWZULWWHQUHSRUWVZHUHIRXQGLQWKHVHYHQWHHQWKFHQWXU\ E\7KLOHVXVZKRGHVFULEHGWKLVFRQGLWLRQIRUWKHÀUVWWLPH 7RZDUGVWKHQLQHWHHQWKFHQWXU\&RXUYRLVLHUSUHVHQWHGKLV series of 499 patients. During the past century, 70 cases have been reported and 25 of them in the last 50 years. Such tendency of reduction in the appearance of this nosoORJLFFRQGLWLRQLVGXHWRSURPSWGLDJQRVLVDVZHOODVWKHGHYHORSPHQWLQWKHWKHUDS\XVHGIRUWUHDWPHQWLQWKHODVWWZR centuries. We submit the clinical case of a patient start-
Fig. 1 ([WHUQDORULÀFHRIFKROHF\VWRFXWDQHRXVÀVWXOD
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Clinical case 7KHSDWLHQWZDVD\HDUROGZRPDQZLWKQRFKURQLFGHJHQHUDWLYHRUVXUJLFDOKLVWRU\ZLWKPXOWLSOHSUHJQDQFLHV ZKRVXIIHUHGIURPSDLQLQWKHULJKWK\SRFKRQGULXPRI years of evolution, treated as acid peptic disease. 6 months before the assessment, she presented a lesion of 2 cm in the right hypochondrium, characterised by increased YROXPHDQGHIIXVLRQRISXUXOHQWPDWHULDO6KHZDVWUHDWHG in an ambulatory manner at the general medicine service DVDSUREDEOHFXWDQHRXVDEVFHVVZLWKORFDOGHUPDWRORJLFDO PDQDJHPHQW KRZHYHUDIWHUPRQWKVWKHSDWLHQWSUHVHQWHGDVSRQWDQHRXVHIIXVLRQRIELOLDU\PDWHULDODVZHOO
Fig. 2 8OWUDVRXQGRIDEGRPLQDOZDOO
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ZDVFRQGXFWHGGU\LQJWKHFRUUHVSRQGLQJVSLQGOHRIÀVWXlous tract (Figs. 4 and 5). An exploration of the bile duct ZDVFDUULHGRXWLQDWUDQVF\VWLFPDQQHUZLWKRXWHYLGHQFH RIGLODWLRQRUREVWUXFWLRQV WKHZRXQGKHDOHGDQGWKHHYHQW concluded. 7KHSDWLHQWSUHVHQWHGVDWLVIDFWRU\HYROXWLRQZLWKRXW SRVWRSHUDWLYHFRPSOLFDWLRQVDQGZDVGLVFKDUJHGDIWHU KRXUV'XULQJPHGLXPDQGODWHSRVWRSHUDWLYHWKHUHZDV SURSHUKHDOLQJZLWKQRLQIRUPDWLRQUHJDUGLQJFRPSOLFDWLRQV WRWKHSURFHGXUHDQGDVVLVWDQFHÀQDOLVHG
Discussion
DVFDOFXOXVZKLFKVXGGHQO\FRQQHFWVWKHELOHGXFWWRWKH outside (Fig. 1). Subsequently, she returned for assessment at the general VXUJHU\VHUYLFHZKHUHVWXG\SURWRFROZDVLQLWLDWHG6KHXQGHUZHQWDQXOWUDVRQRJUDSK\ZLWKHYLGHQFHRIÀVWXORXVWUDFW WKURXJKDEGRPLQDOZDOOWKLFNQHVVDQGZLWKFROOHFWLRQDW the subcutaneous cellular level (Fig. 2). 7KHWUDFWZDVFDQQXODWHGDQGDILVWXORJUDSK\ZDVSHUIRUPHGZLWKSUHVHQFHRIFRPPXQLFDWLRQWRWKHJDOOEODGGHU ZLWKRXWREVWUXFWLRQRIWKHELOHGXFW )LJ $VXUJLFDOH[SORUDWLRQZDVSURJUDPPHGHOHFWLYHO\XVLQJ D.RVKHUDSSURDFK$WVXEKHSDWLFOHYHOLWZDVSRVVLEOHWR REVHUYHJDOOEODGGHUDGKHUHQFHVWRWKHFRORQZDOOOLYHUDQG greater omentum. A retrograde dissection of the gallbladder
6SRQWDQHRXVELOLDU\ÀVWXODVDUHDQRPDORXVFRQQHFWLRQVRI the gallbladder to another surface. It is a rare pathology QRZDGD\VDVLWLVRQO\SUHVHQWLQRISDWLHQWVZLWKJDOOEODGGHUOLWKLDVLV'HVSLWHWKHIDFWWKDWVXFKFDVHVDUHIHZ they are predominant in female patients under 60 years1,3. %LOLDU\ÀVWXODVDUHFODVVLÀHGLQWRWZRJURXSV LQWHUQDODQG external; the latter present communication to any part of WKHDQWHULRUVXUIDFHRIWKHWUXQN KRZHYHUWKH\DUHH[tremely rare because, in recent decades, less than 100 cases have been reported in medical literature. In the case RILQWHUQDOÀVWXODVDUHFRQQHFWHGWRWKHGXRGHQXP WRFRORQDQGWRMHMXQXPVWRPDFKRUEURQFKL1,2. 7KHDSSHDUDQFHRIFKROHF\VWRFXWDQHRXVÀVWXODKDVDGLverse etiopathogenesis. Among the causes there are gallbladder neoplasia, anatomic anomalies and, of course, post-surgery causes. Nevertheless, most cases are associatHGWRYHVLFXODUOLWKLDVLVZKHUHWKHLQFUHDVHRILQWUDOXPLQDO SUHVVXUHFRPSURPLVHVZDOOFLUFXODWLRQOHDGLQJWRLVFKHPLD necrosis, bacterial translocation and, eventually, abscesses, ZKLFKFRPPXQLFDWHWRWKHDEGRPLQDOZDOO7KHUHLVDJUHDWHUDVVRFLDWLRQEHWZHHQWKHFKROHF\VWRFXWDQHRXVÀVWXODDQG WKHREVWUXFWLRQRIWKHELOHGXFWE\FDOFXOXV+RZHYHURXU patient did not have that feature1,3-6. Clinical presentation of spontaneous cholecysto-cutaneRXVÀVWXODLVDQLQVLGLRXVFRQGLWLRQZLWKORQJWHUPHYROXtion, and biliary colic as a main feature that lasts years. Subsequently, there is also a cutaneous lesion that develops LQWRDQDEVFHVVLQWKHULJKWK\SRFKRQGULXPULJKWÁDQNRU HYHQWKHXPELOLFDOVFDUZKLFKLIWKHUHLVQRFDUHIXOH[ploration and effective examination, can be treated as a GHUPDWRORJLFDOSDWKRORJ\ZLWKRXWVXFFHVV)LQDOO\RQFHWKH
Fig. 4 )LVWXORXVWUDFWUHVHFWLRQLQDEGRPLQDOZDOO
Fig. 5 *DOOEODGGHUZLWKDEGRPLQDOZDOOVHJPHQW
Fig. 3 Fistulogram.
64 tract is consolidated, the effusion of biliar material and calFXOXVLVDGGHGE\PHDQVRIWKHÀVWXOD5,7-9. (YHQWKRXJKWKHÀVWXODFOLQLFLVPRUHHYLGHQWLWLVYHU\ important to conduct extension studies, such as: ultrasound to establish bile duct characteristics, tomography to search IRUDEVFHVVHVDQGRIFRXUVHDÀVWXORJUDPLQRUGHUWRHVtablish the lesion aetiology and the presence of bile duct obstructions8,10-13. &KROHF\VWRFXWDQHRXVÀVWXODPDQDJHPHQWPXVWEHFRPprehensive; even though surgical management is the basis for treatment, conservative management must be considHUHGEDVHGRQÁXLGWKHUDS\DQGDQWLPLFURELDOVLQWKRVH SDWLHQWVLQZKLFKWKHRYHUDOOFRQGLWLRQLVFRPSURPLVHG GXULQJDQDHVWKHWLFRUVXUJLFDOSURFHGXUHV/LNHZLVHLI there is evidence of obstruction in the bile duct during WKHÀVWXORJUDPRQHRIWKHRSWLRQVZLWKOHVVFRPRUELOLW\ rate is the retrograde endoscopic choliopancreatography. 7KDWZLWKVWDQGLQJZHFDQQRWVHWDVLGHWKHIDFWWKDWWKH SDWLHQWVKRXOGXQGHUJRVXUJLFDOLQWHUYHQWLRQDVÀQDOWKHUapy. The use of endoscopic retrograde cholangiopancreatography drains the bile duct, contributing to intraluminal SUHVVXUHUHGXFWLRQLQWKHJDOOEODGGHUDQGUHGXFLQJÀVWXOD ZHDU9,12,14-18. The surgical procedure consists of the cholecystectomy, DVZHOODVILVWXORXVWUDFWUHVHFWLRQDQGUHSDLURIWKHDEGRPLQDOZDOOGHIHFW7KHÀVWXORJUDSK\HVWDEOLVKHVELOHGXFW SHUPHDELOLW\ZKLFKVKRXOGEHYHULÀHGGXULQJVXUJHU\DFcording to the surgeon’s criteria. The preferable approach is usually the conventional; that is to say, by means of a ULJKWVXEFRVWDOLQFLVLRQZLWKVSLQGOHUHVHFWLRQRIWKHWUDFW LQWKHZDOO/DSDURVFRS\DFFHVVLVFXUUHQWO\GHVFULEHG +RZHYHUWKHSURFHVVXQOHDVKHGE\WKHSDWKRORJ\LVUHODWHGWRFKURQLFDQGVHYHUHJDOOEODGGHULQÁDPPDWLRQ,W DOVRMHRSDUGL]HVELOHGXFWVWUXFWXUHVZLWKPLQLPDOLQYDsion12,14,16,19,20.
Conclusions 7KHUHLVFXUUHQWO\DORZLQFLGHQFHRIFKROHF\VWRFXWDQHRXV ÀVWXODDQGLWVHHPVWKDWWKHFXUUHQWWUHQGLVIRULWWREHFRPHDQDQHFGRWDOFRQGLWLRQ+RZHYHUVXUJHRQVVKRXOG NHHSLWLQPLQGE\DVRQHRIWKHFRPSOLFDWLRQVRIELOLDU\ related pathologies. Even though the efforts of health systems in establishing a prompt diagnosis and treatment for gallbladder diseases has accomplished the reduction of seYHUHFRPSOLFDWLRQVVXFKDVÀVWXODWLRQLQWKHORZHVWVRFLDO strata of the population there is still a small percentage WKDWGRHVQRWKDYHDFFHVVWRVXFKEHQHÀWVDQGWKDWLVUHIHUUHGWRDVXUJLFDOVHUYLFHZLWKSDWKRORJLHVDVGHVFULEHG in this text. There must be a preoperative comprehensive assessment WKDWLQIRUPVWKHÀVWXODDQDWRP\DVDELOHGXFWLQRUGHUWR stablish an optimal surgical plan. As regards the approach, abdominal exploration by subcostal means remains as the ÀUVWRSWLRQGXHWRWKHHWKLRORJLFDOIHDWXUHVRIWKHFRQGLWLRQ and since laparoscopic access is an alternative reserved for H[SHUWVXUJHRQVDVZHOODVWKHSDWLHQFHQHHGHGWRWUHDWWKH pathology comprehensively via this access.
F. Guardado-Bermúdez et al.
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