Cholecystoenteric fistula (CF) is not a contraindication for laparoscopic surgery

A rare case of a cholecysto-duodenocolonic fistula secondary to cholelithiasis

Internal biliary fistula is a rare but well-known complication of cholelithiasis. It is a notoriously challenging entity to diagnose and manage. Gallstones are often the causative factor in the formation of a cholecystoenteric fistula, with the most common internal biliary fistula being a cholecystoduodenal fistula followed by a cholecystocolonic fistula. Rarely, do these fistulae exist simultaneously. Here, we present an uncommon case of cholecysto-duodenocolonic fistula.

Duodenocolic and Cholecystocolonic Fistula: A Case Report of an Unusual Presentation

Laparoscopic cholecystectomy is the established standard of care for addressing symptomatic gallstones, typically representing a straightforward and uncomplicated surgical procedure. However, patients exhibiting variant anatomy or local inflammation can present challenges to the surgeon, potentially leading to complications. In this context, we present the case of a 55-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallstone disease at a different medical facility. Postoperatively, she was diagnosed with a case of duodenocolic fistula and cholecystocolonic fistula. Conservative treatment ensued with intravenous antibiotic administration, as well as enteral and parenteral feeding. Diagnosing cholecystocolonic fistula before surgery proves challenging, even with modern diagnostic and imaging tools. Despite its significance, there is limited information in the literature regarding the management of this infrequent finding. The approach to diagnosis and management is elaborated upon in the case report.

Cholecystogastric fistula diagnosed by endoscopic ultrasonography

A case of a patient with symptoms of gastric obstruction secondary to cholecystogastric fistula is presented and a brief review of the literature is done.

An unusual case of gallstone ileus within the cecum and ascending colon: a case report

Gallstone ileus is a rare cause of intestinal obstruction. Due to long-standing inflammation of the gallbladder, fistulization can occur within nearby structures, most commonly to the duodenum or hepatic flexure of the colon. Through these fistulas, a stone can migrate and result in a small bowel obstruction or a large bowel obstruction. This case exemplifies the diagnosis and treatment of gallstone ileus, along with potential complications due to stone migration. Early recognition and treatment of gallstone ileus is important, as stone migration can lead to increased mortality with delayed diagnosis.

Laparoscopic Management of Cholecystoduodenal and Cholecystocolic Fistula: A Clinical Case Report

Biliary fistula is a rare (less than 8%) cholecystectomy complication, internal fistulae being the most common of them (mainly colonic and duodenal). However, the presence of two fistulas at the same time is extremely rare, with a small number of cases reported in the literature to date. Symptoms tend to be non-specific, leading to a difficult preoperative diagnosis. The standard treatment for bilioenteric fistulas is open cholecystectomy and subsequent closure of the fistula. Nonetheless, modern techniques including laparoscopic and endoscopic approaches have been reported lately for their treatment with favorable results. We present a case of concomitant cholecystoduodenal and cholecystocolic fistula successfully treated with subtotal cholecystectomy and primary closure of the fistulous tracts by laparoscopic approach in a female Hispanic patient.

A Rare Case of Cholecystoduodenal and Cholecystocolic Fistula with Gallstone Ileus

Cholecystoduodenal and cholecystocolic fistula (CCF) is a rare condition, occurring in patients with cholelithiasis. Multiple complex fistulas are even rare. This is a case study done to detail such a rare case, very few such cases have been reported in the past studies, with cholecystoduodenal and CCF with gallstone ileus. We present the case of an 80-year-old, female diagnosed with intestinal obstruction. Intraoperatively, the gallbladder (GB) fundus forms a CCF and the body of the GB with the first part of the duodenum forms cholecystoduodenal fistula. Gallstone ileus found impacted in jejunum 35 cm distal to DJ junction. Resection of fistula tracts with primary repair of the transverse colon was done with Graham's patch repair of duodenum and fundus first cholecystectomy. Cholecysto-duodeno-colic fistulas complicated with gallstone ileus are very rare. In the case of gallstone ileus, the surgical treatment is an emergency and the only therapeutic option.

Multiple Cholecystoenteric Fistulae With Bouveret Syndrome and Acute Pancreatitis: A Rare Combination

Multiple cholecystoenteric fistulae, Bouveret syndrome (a form of gallstone ileus), and acute pancreatitis occurring together is very rare. Diagnosis is seldom clinical and is mostly based on computerised tomography (CT) or magnetic resonance imaging (MRI). Endoscopy and minimally invasive surgery have revolutionised the treatment of Bouveret syndrome and cholecystoenteric fistula, respectively, over the last two decades. Laparoscopic repair of cholecystoenteric fistula followed by cholecystectomy is successful on a consistent basis with skilled laparoscopic suturing and advanced laparoscopy. In patients with Bouveret syndrome, when the stone is <4cm and is in the proximal duodenum, it is usually amenable for endoscopic extraction with snares, nets, forceps and lithotripsy. When endoscopy is unavailable or fails, laparoscopic surgery is suitable for these patients. However, stones >4 cm, located in the distal duodenum, multiple fistulae, and associated acute pancreatitis may necessitate open surgery. We present here a case of a 65-year-old Indian female with multiple cholecystoenteric fistulae and Bouveret syndrome with acute pancreatitis with a 6.5 cm gallstone diagnosed on CT scan and MRI and treated successfully by open surgery. We also review the current literature on the management of this complex problem.

Cholecystocolonic fistula following endoscopic ultrasound-guided gallbladder drainage for stump cholecystitis

Cholecystocolonic fistulas are a rare sequela of gallstone disease. Presenting symptoms are variable but a triad of chronic diarrhea, vitamin K malabsorption, and pneumobilia has been proposed. If untreated, recurrent biliary sepsis can occur with substantial morbidity and mortality. Definitive management is surgical although endoscopic treatment has been described in nonsurgical patients. We present a case of a cholecystocolonic fistula following transgastric endoscopic ultrasound-guided gallbladder drainage with a lumen-apposing metal stent for stump cholecystitis. The patient's presenting symptom was diarrhea. Upper endoscopy and cholecystoscopy 4 weeks following gallbladder drainage revealed a cholecystocolonic fistula. The cholecystogastric tract was closed through the scope clips. The patient had no episodes of cholangitis and had a patent biliary tree with a prior biliary sphincterotomy so clinical observation was chosen. Colonoscopy 1 month later confirmed the closure of the fistula and the patient had a resolution of diarrhea. Our case highlights a novel adverse event of endoscopic ultrasound-guided gallbladder drainage caused by direct pressure of the lumen apposing metal and double pigtail stents on an already inflamed gallbladder wall. Endoscopic therapies that aid in transcapillary biliary drainage are viable alternatives to surgery and can result in fistula closure.

Preoperative Diagnosis and Treatment of Cholecystoduodenal Fistula

The case is about an 87-year-old female. While staying at a facility, she had a fever and abdominal pain and visited our hospital for an up-close examination and treatment. An abdominal CT scan revealed gallstones, gallbladder enlargement, and common bile duct stones. Endoscopic retrograde cholangiopancreatography was performed to confirm the presence of common bile duct stones, which were extracted. At that time, she was diagnosed with a duodenal fistula of the gallbladder and underwent surgery in our department. The gallbladder and duodenum were firmly adhered, and gallstones were palpated between the gallbladder and duodenum. The gallbladder was incised at the fundus to check the lumen, and gallstones were lodged in the fistula with the duodenum. After the removal of gallstones, the gallbladder was dissected, and a fistula with the duodenum was identified. After treating the cystic duct, the fistula was removed, and the gallbladder was removed. Because the duodenal wall was fragile due to inflammation and the fistula was large and difficult to close simply, the duodenal bulb was separated with a linear stapler, and the stomach and jejunum were reconstructed with a 25-mm CDH using the Roux-en-Y technique. The patient's postoperative course was good, and she was discharged from the hospital.

Role of Multidetector Computed Tomography in Diagnosis of Acquired Gastrointestinal Fistulas

Introduction Fistulas are abnormal communication between two epithelialized surfaces. Gastrointestinal fistulas are communication between the gut and another epithelialized surface. Fistulas are classified according to anatomic (internal or external), physiologic (output volume), and etiologic characteristics. In the case of clinical suspicion of a fistula, a multidisciplinary approach helps in diagnosing and management. Multidetector computed tomography (MDCT) has an advantage over other imaging modalities due to its ability to reconstruct high-resolution images in seconds, which limits motion or peristalsis artifacts, and is ideal for patients who are uncooperative or who are seriously ill.

Aim Evaluation of MDCT as an initial tool in the diagnosis and characterization of gastrointestinal fistulas.

Methods During this prospective observational study, MDCT was used to assess patients with clinical suspicion of gastrointestinal fistulas. When necessary, contrast agents were used to identify the enteric fistulous tract. The etiology and characterization of the fistulas were determined. Further, the gastrointestinal fistulas were confirmed via endoscopy, cystoscopy, or surgery.

Results The most common type of gastrointestinal fistula is enterocutaneous fistula (ECF) (39%) and the most common cause of gastrointestinal fistulas is postoperative (47%). ECFs were classified according to their etiology, anatomy, and favorable characteristics (85% favorable) along with complexity (64% complex) to aid in the management process. In addition to pancreaticopleural fistulas (22%), biliary (11%), esophageal (8%), and pelvic fistulas (19%) were also observed. There were 19% of fistulas (esophageal and biliary) that were asymptomatic. Endoscopy confirmed such asymptomatic fistulas that were not convincingly detected on CT.

Conclusion In this study, we concluded that with the appropriate clinical history, MDCT can accurately depict enteric fistulas. In addition to characterizing fistulas, MDCT is equally useful for detecting secondary complications like inflammation, obstruction, or abscesses.

Indirect cholecystoduodenal fistula via hepatoduodenal ligament secondary to gangrenous cholecystitis: a case report

BACKGROUND

Cholecystoduodenal fistula is an infrequent complication of gallbladder diseases. In the majority of cases, the fistula is formed by direct communication between the gallbladder and duodenum due to gallstone impaction in the gallbladder neck. We herein report a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis.

CASE PRESENTATION

An 80-year-old woman suspected of having emphysematous cholecystitis by a previous doctor was referred to our hospital for urgent surgery. The initial diagnosis based on additional examinations was gangrenous cholecystitis penetrating the hepatoduodenal ligament. Since she did not complain of signs of peritonitis and was taking an anticoagulant medicine, we avoided surgery and selected percutaneous gallbladder drainage (PTGBD) instead. Contrast imaging of the PTGBD tube and upper endoscopy identified the indirect cholecystoduodenal fistula via the hepatoduodenal ligament. Despite repeated attempts at endoscopic fistula closure using clips, the fistula did not close successfully. We therefore performed laparoscopic cholecystectomy and fistula closure. The postoperative clinical course was uneventful, and she left the hospital on postoperative day 15. The resected gallbladder contained small black stones, and a histological examination revealed gangrenous cholecystitis with no malignant signatures.

CONCLUSION

We encountered a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis that was successfully treated by laparoscopic cholecystectomy and fistula closure. It is important to recognize the possible formation of indirect cholecystoduodenal fistula in cases of gangrenous cholecystitis penetrating the hepatoduodenal ligament.

Cholecystocolic fistula closed using endoscopic therapy alone: A case report

BACKGROUND

Cholecystocolic fistula (CCF) is a known but rare complication of cholelithiasis. Treatment for CCF is generally surgical. As the number of elderly patients has increased in recent years, many cases require non-surgical treatment; therefore, endoscopic treatment has gained importance.

PATIENT CONCERNS AND DIAGNOSIS

An 87-year-old woman presented with impaired consciousness and symptoms of anorexia. Computed tomography showed cholecystitis and a fistula between the gallbladder and transverse colon. Colonoscopy revealed a CCF. The condition was diagnosed as CCF caused by acute cholecystitis.

INTERVENTIONS AND OUTCOMES

The patient declined surgery due to her age. Endoscopic fistula closure was performed using a through-the-scope clip after endoscopic naso-gallbladder drainage. Successful closure of the fistula resulted in improvement of cholecystitis and anorexia. The patient was discharged after one month. It has been more than 18 months since the procedure, there has been no recurrence.

CONCLUSION

This report on successful endoscopic closure of a CCF indicates that it may be useful for patients who decline surgery.

Surgical Management of Cholecystoenteric Fistula in Patients With and Without Gallstone Ileus: An Experience of 29 Cases

Background

Cholecystoenteric fistula (CEF) is an uncommon complication of cholelithiasis. Here, we report our experience on diagnostic methods and surgical management of CEF patients with and without gallstone ileus (GI).

Methods

This is a retrospective cases series over an 11-year period (2011–2022). Data analyzed included preoperative characteristics, ultrasound, imaging features, operation findings and postoperative course.

Results

A total of 29 patients diagnosed with CEF were enrolled, 51.7% (15/29) of whom were female, with a median age of 66 years (range: 35–96 years). With regards to subtype distribution, seventeen patients had cholecystoduodenal fistula (CDF), six had cholecystoconlonic fistula (CCF), three exhibited cholecystogastric fistula (CGF), one CDF combination with CCF and two CDF combination with type I Mirizzi syndrome. Twelve patients presented with gallstone ileus, and received one stage procedure or simple Enterolithotomy. The median operation time and blood loss of 157 min (range: 65–360 min) and 40 ml (range: 10–450 ml), respectively. Surgical complications, evidenced by fistula recurrence, were recorded in three patients (3/22; 13.6%), while four (4/29; 13.8%) and one patient (1/29; 3.4%) presented with wound infection and residual stone in common bile duct, respectively. No deaths were reported in our study.

Conclusion

CEF is a rare complication of gallstone disease that is occasionally found during operation. To date, no consensus has been reached regarding efficacious treatment therapies for CEF patients. For a CEF patient with GI, one stage procedure should be selected prudently, while simple Enterolithotomy would be a mainstream choice for relieving bowel obstruction.

Clinical spectrum and management outcome in gallbladder perforation-a sinister entity: Retrospective study from Sub-Himalayan region of India

Objective: Gallbladder perforation is an infrequent entity seen among surgical patients. Rare occurrence owes to difficulty in diagnosing gallbladder perforations. The aim of the present study was to determine the optimal management strategy that may decrease the morbidity and mortality associated with this potentially life-threatening condition.

Material and Methods: This was a retrospective study from hospital health records wherein the experience of 40 consecutive patients with gallbladder rupture, either spontaneous or secondary to both benign conditions and malignancy, was noted at a tertiary care hospital over 48 months from February 2017 till January 2021. The etiology, clinical presentation, and treatment given were analysed.

Results: Out of 40 patients included, 23 were females and the majority of patients were more than 45 years of age. Twelve patients responded to intravenous antibiotics and analgesics alone while five required an ultrasound-guided pigtail catheter drainage due to non-improving clinical condition. The failure of expectant management led to a delayed laparotomy in seven patients while four patients required emergency laparotomy because of generalized peritonitis. An elective cholecystectomy was offered to 12 patients with cholecystoenteric fistulae after diagnostic laparoscopy in the same admission. Thirty-eight patients were discharged in stable condition and doing well at 30-day follow-up.

Conclusion: Gallbladder perforation is seen more commonly in acute calculous cholecystitis compared to other conditions. It is more evident when the treatment of acute calculous cholecystitis is delayed by more than 6-8 weeks. The spectrum of clinical presentation varies from mild pain and vomiting to generalized peritonitis. The patient often requires a step-up approach to control the ongoing sepsis for an improved outcome.

Cholecystoduodenal Fistula Evading Imaging and Endoscopic Retrograde Cholangiopancreatography: A Case Report

Cholecystoduodenal fistulas are a type of internal biliary fistula that occur due to chronic inflammation of the gallbladder/biliary tree; if left untreated, perforation and necrosis can occur. Cholecystoduodenal fistulas are often difficult to diagnose due to their non-specific signs and symptoms. Since the widespread use of techniques such as magnetic resonance cholangiopancreatography and imaging modalities such as computed tomography, the frequency of reports describing intraoperative cholecystoduodenal fistula has reduced dramatically. Here, we report the case of a 54-year-old female who presented with a two-day history of non-radiating epigastric abdominal pain, initially diagnosed with acute cholecystitis and choledocholithiasis. Upon undergoing laparoscopic cholecystectomy, she was found to have extensive fibrosis of the gallbladder, adhesions, and an impacted gallstone in the wall of the gallbladder. Imaging and endoscopic retrograde cholangiopancreatography performed prior to surgery did not detect a cholecystoduodenal fistula that was discovered intraoperatively. She was treated successfully with laparoscopic cholecystectomy and repair of the duodenum.

Cholecystocolonic fistula as an uncommon cause of diarrhea: a case-report and review of the literature

Bilio-enteric fistulization is the aberrant connection between the biliary and luminal digestive tracts. The cholecystocolonic fistula (CCF) is the second most common bilio-enteric fistula (comprising 20% of cases), after the cholocystoduodenal fistula (comprising 70% of all cases). A CCF may result from malignancy or more benign etiologies, such as gallstones, and is thought to arise from a chronic inflammatory cadence of tissue necrosis, tissue perforation, and fistula creation. The combination of chronic watery diarrhea, vitamin K malabsorption, and radiological evidence of pneumobilia in a patient with history of gallstone disease has been suggested as a pathognomonic triad of CCF. Here, we present a case of a 62-year-old woman exhibiting this triad, who was found to have a CCF as a result of chronic gallstone-related disease. Recognition of this rare etiology of chronic diarrhea can enhance clinicians' diagnostic appraisal and management of this common chief complaint.

The rare entity of cholocystocolonic fistula: a case report

Cholocystocolonic fistulas (CCFs) represent a rare medical entity. Previous inflammatory processes in the abdomen, especially in the gallbladder and surgeries are all related to their appearance. There are not typical findings concerning the clinical image and the therapeutic approach varies between patients. Herein, we present a case of a 46-year-old patient, with a history of perforated duodenal ulcer, suffering from abdominal pain and diarrheas. A computed tomography (CT) demonstrated air inside the biliary system. A laparotomy was conducted to the patient and no complications had occurred. In addition, a review of literature regarding the clinical presentation and the therapeutic options for this disease are discussed in this manuscript in relation to our patient.

Rolling in the Deep: Imaging Findings and Diagnostic Pearls in Gallstone Ileus

Gallstone ileus is a dramatic complication of gallstone disease, uncommon but not exceptional in a busy emergency department. It represents a cause of mechanical intestinal obstruction, which predominantly occurs in elderly and frail patients; this contributes to the high morbidity and mortality rates associated with this condition. The modern radiologist is frequently asked to determine the cause of bowel obstruction and should be aware of the most pictorial features of this unusual disease. Broadly speaking, abdominal radiography and ultrasonography alone are limited in detecting the cause of bowel obstruction, but the sensitivity for the preoperative diagnosis of gallstone ileus may be improved by combining the findings obtained by both techniques. Computed tomography is the modality of choice for the diagnosis of this disease: it may accurately describe the number, size, and location of migrated gallstones and the exact site of bowel obstruction, providing a detailed preoperative planning. Magnetic resonance imaging may be used in selected cases for an exquisite anatomic definition of the fistulous communication.

Cholecystoenteric fistula with and without gallstone ileus: A case series

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.

Operative management of cholecystogastric fistula: case report and literature review

We present a patient who was managed surgically for cholecystogastric fistula. The patient was presented with nonspecific symptoms (upper abdominal pain, belching) and, after being investigated, was proceeded for laparoscopic cholecystectomy for gallbladder stones. Unexpectedly, intraoperative, she was found to have cholecystogastric fistula, which was operated with open single-stage approach. We highlight the incidence of these cases, the difficult preoperative clinical presentation and possible diagnostic imaging; explain further about the different surgical approaches to manage these cases and finally review the literature regarding the presentation and the management of bilioenteric fistulas.

Robotic cholecystectomy and cholecystoenteric fistula closure in a female with remote cholangitis

Cholecystocolic fistula (CCF), a connection between the gallbladder and neighboring colon, is a rare entity with little consensus as to the optimal surgical management. Existing case reports have described both open and laparoscopic repairs. We describe the first reported case of a successful robotic repair of a CCF in a 50-year-old woman diagnosed with cholangitis 5 years prior to surgery. The patient had a longitudinal follow-up by a single surgeon, allowing for early diagnosis and repair. This case also includes radiographic imaging over 5 years during the index hospitalization and preoperative workup. This allows for a glimpse into the natural pathogenesis of this disease. After robotic surgery, the patient made a complete recovery with no postoperative complications.

Cholecystocolonic Fistula

Cholecystocolonic fistula (CCF) is a rare complication of gallstone disease with a variable clinical presentation. It is difficult to diagnose CCF pre-operatively despite modern diagnostic and imaging modalities as they are often asymptomatic or incidentally discovered, often peri-operatively. However, management of this uncommon yet important finding is not very well described in the literature. The most common fistula is the cholecystoduodenal fistula, followed by the cholecystocolonic fistula; the cholecystogastric fistula is reportedly the least commonly reported. We report our experience with three cases of cholecystocolonic fistula discovered on imaging which were subsequently confirmed through surgery.

Cholecystoduodenal fistula caused by aggressive mucinous gallbladder carcinoma with a porcelain gallbladder

Cholecystoduodenal fistula secondary to gallbladder carcinoma (GBC) is extremely rare and develops when the tumor penetrates into the adjacent duodenum. A porcelain gallbladder is also a very rare entity that involves the calcification of the gallbladder wall and can be associated with the development of GBC. Herein, we report an unusual case of a patient with cholecystoduodenal fistula, which has been caused by aggressive mucinous gallbladder carcinoma with a porcelain gallbladder. A 68-year-old man was referred to our department due to significant accumulation near the neck of the gallbladder detected by FDG positron emission tomography/computed tomography (PET/CT), which was performed as a check-up of postpneumonectomy for lung cancer. Abdominal contrast CT and magnetic resonance imaging revealed porcelain-like circumferential calcification of the gallbladder wall and a mass in the region detected by FDG PET/CT. Furthermore, upper endoscopy revealed a submucosal tumor with apical ulceration in the posterior wall of the duodenal bulb. Histopathological examination of its biopsy specimen rendered a diagnosis of adenocarcinoma. The patient was preoperatively diagnosed with either gallbladder cancer or duodenal cancer, and subtotal stomach-preserving pancreatoduodenectomy and radical cholecystectomy with gallbladder bed resection were performed. The resected gallbladder revealed a porcelain gallbladder, which formed the cholecystoduodenal fistula. These specimens were histopathologically diagnosed as mucinous adenocarcinoma of the gallbladder with an abundant mucin production.

Cholecystocolic fistula diagnosis with hepatobiliary scintigraphy: A case report

We report a 62‐year‐old woman who presented with chronic watery diarrhea and weight loss. During evaluation, she was found to have pneumobilia in the absence of gallstones, raising the suspicion of bilioenteric communication. Computed tomography demonstrated adherence of the gallbladder to the adjacent transverse colon. Hepatobiliary scintigraphy demonstrated the presence of a cholecystocolic fistula. A planned uneventful open cholecystectomy with resection of fistulous tract and closure of colonic opening was performed, resulting in the complete resolution of clinical symptoms.

Cholecystoenteric Fistula Masquerading as a Bleeding Subepithelial Mass

An 82-year-old man was referred for endoscopic ultrasound of an ulcerated subepithelial mass in the duodenal sweep. The mass was initially identified during upper endoscopy for coffee-ground emesis. During endoscopic ultrasound, a 21-mm hypoechoic ulcerated subepithelial mass with a duct-like structure was identified. During suction to appose the lesion against the tip of the echoendoscope, the ulceration opened into a fistulous tract with drainage of bile and stones. Subsequent abdominal imaging demonstrated that the mass-like duodenal lesion abutted the gallbladder, which had an air-fluid level. We report a cholecystoenteric fistula masquerading as a subepithelial duodenal mass.

Management dilemma of cholecysto-colonic fistula: Case report

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Cholecystocolonic fistula is different from cholecystoduodenal fistula in that the gallbladder is communicating with the large bowel lumen which has a very high bacterial load.

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Cholecystocolonic fistula is a two-way communication and this carries a significant risk of biliary sepsis development.

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Biliary decompression can facilitate cholecystocolonic fistula resolution and healing.

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Operative intervention in the setting of biliary obstruction after failed decompression should be performed urgently to avoid biliary sepsis.

Introduction

Cholecystocolonic fistula is a rare condition and is found in roughly 1 in every 10,000. It represents 6.3% to 26.5% of all cholecystenteric fistulas (Chowbey et al., 2006; Angrisani et al., 2001; Yamashita et al., 1997). Cholecystocolonic fistula is the second most common intestinal fistula after cholecystoduodenal fistula (Costi et al., 2009). Rarity of this condition, atypical presentation, diagnostic and management challenges, makes it a unique surgical entity.

Case presentation

A 77-year old male presented with progressive abdominal distension and diarrhea. After initial evaluation, a cholecystocolonic fistula was suspected. Further diagnostic studies including Hepatobiliary Imino-Diacetic Acid (HIDA) scan and Endoscopic Retrograde Cholangiography (ERC) revealed complete occlusion of the cystic duct that could not be relieved. Shortly after, the patient developed septic shock likely of biliary origin and required an urgent open partial cholecystectomy and segmental resection of the involved colonic segment.

Discussion

In this particular case, the acute presentation together with the inflammatory features around the gallbladder pointed toward an acute inflammatory process and therefore we have tried to delay any operative intervention to allow the inflammation to subside and avoid operating in an inflamed field. Furthermore, our aim was to relieve any sort of biliary obstruction to allow the fistula −if present- to heal by minimizing bile flow through the fistula. Relieving biliary obstruction was not successful in our patient.

Conclusion

Based on our experience with this particular case, we could safely conclude that an operation for cholecystocolonic fistula presence in the setting of biliary obstruction that failed decompressive attempts should be performed in an urgent fashion to avoid biliary sepsis development.

Gallstone Ileus Caused by a Cholecysto-Duodeno-Colic Fistula, Case Report And Literature Review

Introduction: Complex cholecysto-duodeno-colic fistulas are an extremely rare complication that can occur in patients with cholelithiasis. The aim of this article is to present the case of a pacient with cholecystoduodeno- colic fistula manifested with biliary ileus in a patient known for many years with cholelithiasis. Case report: We present the case of a 62 y/o male that was admitted in our clinic with the diagnosis of gallstone ileus. Emergency surgical intervention was needed. Intraoperatively we discovered a cholecysto-duodenocolic fistula complicated with gallstone ileus. During the operation we practiced retrograde cholecystectomy, closure of the fistulous tract (duodenoraphy, coloraphy), enterotomy and extraction of the calculus located inside the small intestine. The postoperative evolution was favorable. Conclusions: Cholecysto-duodeno-colic fistulas complicated with gallstone ileus are an extremely rare complication that can occur in patients with gallstones. In case of the occurrence of gallstone ileus, the surgical treatment is an emergency, being the only therapeutic technique that can save the patient’s life.

Spontaneous cholecystocolic fistula: an uncommon complication of chronic cholecystitis

Cholecystocolic fistula, a rare complication of long-standing gallstone disease, is a diagnostic challenge owing to nonspecific clinical presentation and lack of accurate preprocedural diagnostic modalities. In case of incidental discovery of the fistula during the surgical procedure, excision of the fistula with repair of the colonic defect is imperative.

Laparoscopic management of cholecystoenteric fistula: A single-center experience

Aim

To report our experience regarding management of cholecystoenteric fistula (CEF) and identify the most effective diagnostic methods and surgical treatment.

Methods

In total, 10,588 patients underwent laparoscopic cholecystectomy for cholecystolithiasis from January 2000 to December 2014 at the Research Institute of General Surgery, Jinling Hospital (Nanjing, China). Twenty-nine patients were diagnosed with CEF preoperatively or intraoperatively. Data were retrospectively collected on demographics, preoperative diagnostics, intraoperative findings, laparoscopic procedures, complications, and follow-up.

Results

Twenty-nine patients (female/male ratio, 2.2; mean age, 68.7 years) with CEF were evaluated. Twenty-three (79.3%) patients had a cholecystoduodenal fistula (CDF), four (13.8%) had a cholecystocolonic fistula (CCF), one (3.4%) had a cholecystogastric fistula, and one (3.4%) had a CDF combined with a CCF. Only nine (31.0%) patients obtained a preoperative diagnosis. All patients initially underwent laparoscopic treatment, but five (17.2%) underwent conversion to open surgery; three of these five developed postoperative morbidity or mortality, and the other two had an uneventful postoperative course. Among patients managed successfully by laparoscopy, the hospital stay ranged from 3 to 6 days (mean, 4 days). All patients were asymptomatic at a mean follow-up of 13 months (range, 3–21 months).

Conclusion

Ultrasound and computed tomography can provide valuable diagnostic clues for CEF. Laparoscopic management of CEF in experienced hands is safe, feasible, and associated with rapid postoperative recovery.

Double Incomplete Internal Biliary Fistula: Coexisting Cholecystogastric and Cholecystoduodenal Fistula

Internal biliary fistula is a rare complication of a common surgical disease, cholelithiasis. It is seen in 0.74% of all biliary tract surgeries and is thought to be a result of repeated inflammatory periods of the gallbladder. In this report we present a case of incomplete cholecystogastric and cholecystoduodenal fistulae in a single patient missed by ultrasonography and endoscopic retrograde cholangiopancreatography and diagnosed intraoperatively. In the literature there is only one report of an incomplete cholecystogastric fistula. To our knowledge this is the first case of double incomplete internal biliary fistulae.

Laparoscopic management of cholecystocolic fistula

Introduction

Cholecystocolic fistula is a rare complication of gallbladder disease. Its clinical presentation is variable and nonspecific, and the diagnosis is made, mostly, incidentally during intraoperative maneuver. Cholecystectomy with closure of the fistula is considered the treatment of choice for the condition, with an increasingly reproducible tendency to the use of laparoscopy.

Aim

To describe the laparoscopic approach for cholecystocolic fistula and ratify its feasibility even with the unavailability of more specific instruments.

Technique

After dissection of the communication and section of the gallbladder fundus, the fistula is externalized by an appropriate trocar and sutured manually. Colonic segment is reintroduced into the cavity and cholecystectomy is performed avoiding the conversion procedure to open surgery.

Conclusion

Laparoscopy for resolution of cholecystocolic fistula isn't only feasible, but also offers a shorter stay at hospital and a milder postoperative period when compared to laparotomy.

Cholecystocolic fistula caused by gallbladder carcinoma: Preoperatively misdiagnosed as hepatic colon carcinoma

Cholecystocolic fistula secondary to gallbladder carcinoma is extremely rare and has been reported in very few studies. Most cholecystocolic fistulae are late complications of gallstone disease, but can also develop following carcinoma of the gallbladder when the necrotic tumor penetrates into the adjacent colon. Although no currently available imaging technique has shown great accuracy in recognizing cholecystocolic fistula, abdominopelvic computed tomography may show fistulous communication and anatomical details. Herein we report an unusual case of cholecystocolic fistula caused by gallbladder carcinoma, which was preoperatively misdiagnosed as hepatic flexure colon carcinoma.

Incidental cholecystojejunal fistula treated with successful laparoscopic management

Internal biliary fistula (IBF) is occurred spontaneously due to the biliary disease in most cases. Bilioenteric, biliobiliary, bronchobiliary, and vasculobiliary type of IBF have been reported in the literature. We herein describe our experience with an incidental cholecystojejunal fistula, a very rare type of bilioenteric fistula in laparoscopic cholecystectomy. A 61-year-old woman with several years' history of intermittent right upper abdominal pain was admitted to Soonchunhyang University Cheonan Hospital. Abdominal CT scan showed the pneumobilia in gallbladder with common bile duct dilatation. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were done. On operative findings, there was a cholecystojejunal fistula. We performed laparoscopic cholecystectomy and fistulectomy with jejunal partial resection. To our knowledge, this is the first report on incidental cholecystojejunal fistula uncombined with any other disease and was treated with laparoscopic procedure.

Spontaneous cholecystocolic fistula: case report

Cholecystocolic fistula is a rare billiary-enteric fistula with variable clinical presentation. Despite modern diagnostic tool a high degree of suspicion is required to diagnose it preoperatively. These fistulae are treated by open as well as laparoscopic surgery, with no difference in intraoperative and postoperative complications. We are describing a 50-year-old female patient with the diagnosis of chronic cholecystitis with cholelithiasis, which was investigated with routine lab investigations, and abdominal ultrasonography but none of these gave us any clue to the presence of fistula, were discovered incidentally during an open surgery and were appropriately treated.

A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula

INTRODUCTION Cystic artery pseudoaneurysms and cholecystoenteric fistulae represent two rare complications of gallstone disease. PRESENTATION OF CASE An 86 year old male presented to the emergency department with obstructive jaundice, RUQ pain and subsequent upper gastrointestinal bleeding. Upper GI endoscopy revealed bleeding from the medial wall of the second part of the duodenum and a contrast-enhanced computed tomography scan revealed a cystic artery pseudoaneurysm, concurrent cholecystojejunal fistula and gallstone ileus. This patient was successfully managed surgically with open subtotal cholecystectomy, pseudoaneurysm resection and fistula repair. DISCUSSION To date there are very few cases describing haemobilia resulting from a bleeding cystic artery pseudoaneurysm. This report is the first to describe upper gastrointestinal bleeding as a consequence of two synchronous rare pathologies: a ruptured cystic artery pseudoaneurysm causing haemobilia and bleeding through a concurrent cholecystojejunal fistula. CONCLUSION Through this case, we stress the importance of accurate and early diagnosis through ultra- sonography, endoscopy, and contrast-enhanced CT imaging and emphasise that haemobilia should be included in the differential diagnosis of anyone presenting with upper gastrointestinal bleeding. We have demonstrated the success of surgical management alone in the treatment of such a case, but accept that consideration of combined therapeutic approach with angiography be given in the first instance, when available and clinically indicated.

Cholecystocolonic fistula mimicking acute cholecystitis diagnosed unequivocally by computed tomography

Cholecystocolonic fistula is an uncommon potential complication of cholecystitis found intraoperatively in 0.06-0.14 % of patients undergoing cholecystectomy and 0.1-0.5 % of autopsy series. Although cholecystocolonic fistula is the second most common cholecystoenteric fistula, second only to cholecystoduodenal fistula, it is diagnosed preoperatively in only 7.9 % of patients. Failure to preoperatively diagnose cholecystocolonic fistula places surgeons in precarious positions, as they may be forced to convert a seemingly routine cholecystectomy to a more sophisticated procedure coupled with adhesiolysis, colonic suturing, or colonic resection. We report a young patient who presented to the emergency department with complaints indicative of acute cholecystitis; however, preoperative ultrasound was suggestive of a cholecystoenteric fistula. Computed tomography and pathology were pathognomonic with clear visualization of the cholecystocolonic fistulous tract.

Cholecystogastric fistula: a brief report and review of the literature

Cholecystogastric fistula is a rare, life-threatening complication of cholelithiasis that presents a difficult challenge to the surgeon when it occurs in elderly and co-morbid patients. Following a case of a 68-year-old female who presented with a short history of epigastric pain and vomiting, and in whom a cholecystogastric fistula was identified on abdominal computed tomography and confirmed on upper gastrointestinal endoscopy, we performed a systematic review of the literature on the management of cholecystogastric fistula. Our patient underwent laparotomy without excision of the fistula nor cholecystectomy and had an uncomplicated post-operative course. Surgical management using an open approach remains the mainstay of treatment of cholecystogastric fistula although laparoscopic techniques are used with increasing success. Surgical closure of the fistula is not always necessary. Improved surgical techniques including the use of laparoscopic surgery have led to improved outcomes in the management of cholecystogastric fistula.

Asymptomatic cholecystocolonic fistula: a diagnostic and therapeutic dilemma

Cholecystocolonic fistulas (CCF) are rare complications of gallstones with a variable clinical presentation. Despite modern diagnostic tools, cholecystocolonic fistulas are often asymptomatic and it is difficult to diagnose them preoperatively. Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is the cholecystoduodenal (70%), followed by the cholecystocolic (10-20%), and the least common is the cholecystogastric fistula. Herein, we report a case of female patient with multiple episodes of acute recurrent cholangitis due to common bile duct and gallbladder stones in which preoperative imaging studies were negative for cholecystocolonic fistula that was incidentally discovered and treated during surgery and was appropriately treated. A review of the literature is reported too.

Diagnosis and Management of Choledochoduodenal Fistula

Recent advances in hepatobiliary imaging techniques have led to the increased detection of choledochoduodenal fistula. However, the diagnosis and treatment of choledochoduodenal fistula is still a challenge. In this study, we summarize how patients were diagnosed and treated for choledochoduodenal fistula at our institution. Sixty-six patients with choledochoduodenal fistula were diagnosed and treated in our department from January 2000 to June 2009. Sixty-one patients were treated operatively, whereas five patients were treated with medicine. Patients with choledochoduodenal fistula were confirmed by endoscopic retrograde cholangiography. Of the 61 patients needing surgical intervention, clinical outcomes were excellent in 57 patients, and five patients underwent successful laparoscopic surgery for repairing the choledochoduodenal fistula. Follow-up of these patients for 6 months to 10 years showed they did not suffer from further cholangitis. A patients’ past history of biliary disease, upper abdominal pain, fever, and jaundice may lead to choledochoduodenal fistula. Operative therapy, including laparoscopic surgery, was the primary treatment for most patients, regardless of the preoperative diagnosis.

Laparoscopic management of cholecystoenteric fistulas

BACKGROUND

Cholecystoenteric fistulas are a rare complication of gallstone disease and affect 3-5% of patients with cholelithiasis. Most fistulas are diagnosed intraoperatively.

MATERIALS AND METHODS

Between January 1997 and June 2003, 12428 patients underwent laparoscopic cholecystectomy at our department. Cholecystoenteric fistula was diagnosed intraoperatively and treated in 63 patients: 45 patients (71.4%) had cholecystoduodenal fistulas, while cholecystogastric and cholecystocolic fistulas were found in 9 patients (14.3%) and 4 patients (6.3%), respectively; and 5 patients (7.9%) were found to have Mirizzi syndrome type I along with a cholecytoenteric fistula. The operation could be completed laparoscopically in 59 patients. An endostapler was used in 47 patients to transect the fistula and in 12 patients the defect in the bowel was repaired with intracorporeal sutures.

RESULTS

Major morbidity occurred in 3 patients (4.76%). One patient developed a loculated subdiaphragmatic collection which was treated by ultrasound guided aspiration and antibiotic therapy. Prolonged biliary drainage occurred in 2 patients. In addition, 7 patients (11.11%) had minor postoperative complications. The mean postoperative hospital stay was 5.2 days. All the patients are asymptomatic at a mean follow-up of 2.4 years.

CONCLUSION

Cholecystoenteric fistula is a difficult problem usually diagnosed intraoperatively. A high degree of suspicion at operation is mandatory. A stapled cholecystofistulectomy may be the procedure of choice since it avoids contamination of the peritoneal cavity. Complete laparoscopic management of cholecystoenteric fistulas is possible in well-equipped high-volume centers.

Pneumobilia, chronic diarrhea, vitamin K malabsorption: A pathognomonic triad for cholecystocolonic fistulas

Cholecystocolonic fistula (CF) is an uncommon type of internal biliary-enteric fistulas, which comprise rare complications of cholelithiasis and acute cholecystitis, with a prevalence of about 2% of all biliary tree diseases. We report a case of a spontaneous CF in a 75-year-old diabetic male admitted to hospital for the investigation of chronic watery diarrhea and weight loss. Massive pneumobilia demonstrated on abdominal ultrasound and computerized tomography, along with chronic, bile acid-induced diarrhea and a prolonged prothrombin time due to vitamin K malabsorption, led to the clinical suspicion of the fistula. Despite further investigation with barium enema and magnetic resonance cholangio-pancreatography, diagnosis of the fistulous tract between the gallbladder and the hepatic flexure of the colon could not be established preoperatively. Open cholecystectomy with fistula resection and exploration of the common bile duct was the preferred treatment of choice, resulting in an excellent postoperative clinical course. The incidence of biliary-enteric fistulas is expected to increase due to the parallel increase of iatrogenic interventions to the biliary tree with the use of endoscopic retrograde cholangio-pancreatography and the increased rate of cholecystectomies performed. Taking into account that advanced imaging techniques fail to demonstrate the fistulas tract in half of the cases, and that CFs usually present with non-specific symptoms, our report could assist physicians to keep a high index of clinical suspicion for an early and valid diagnosis of a CF.

Cholecystocolic fistula: a diagnostic enigma

Cholecystocolic fistula is a rare biliary-enteric fistula with a variable clinical presentation. Despite modern diagnostic tools, a high degree of suspicion is required to diagnose it preoperatively. Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is a cholecystoduodenal (70%), followed by cholecystocolic (10-20%), and the least common is the cholecystogastric fistula accounting for the remainder of cases. These fistulae are treated by open as well as laparoscopic surgery, with no difference in intraoperative and postoperative complications.We report here a case of obstructive jaundice, which was investigated with a plain film of the abdomen, abdominal ultrasonography, and endoscopic retrograde cholangiopancreatography, but none of these gave us any clue to the presence of the fistula was discovered incidentally during an open surgery and was appropriately treated.

Cholecystocolonic fistula: facts and myths. A review of the 231 published cases

BACKGROUND

Cholecystocolonic fistula (CCF) is the second most common cholecystoenteric fistula and is often discovered intraoperatively, resulting in a challenging situation for the surgeon, who is forced to switch to a complex procedure, often in old, unfit patients. Management of this uncommon but possible finding is still ill defined.

METHODS

An extensive review of 160 articles published from 1950 to 2006 concerning 231 cases of CCF was performed.

RESULTS

CCF is mostly an affliction of women in their sixth to seventh decades and is rarely diagnosed preoperatively. Chronic diarrhea is the key symptom in nonemergency patients, but, in one-fourth of cases, CCF presents with an acute onset, mostly biliary ileus. In one-fourth of patients, a second hepatobiliary abnormality is present, including gallbladder cancer in 2% of cases. In uncomplicated cases, diverting colostomy is not performed anymore, and laparoscopy treatment has been described in specialized centers. Symptomatic treatment of concomitant biliary ileus (without treating CCF) is a feasible option. Resolution of colonic biliary ileus by interventional endoscopy is reported.

CONCLUSION

CCF should be considered in differential diagnosis of diarrhea, especially in old, female patients. A possible second hepatobiliary abnormality should be always investigated. Extemporaneous frozen section should be performed if gallbladder cancer is suspected. Depending on clinical presentation, different treatments for CCF are indicated, ranging from minimally invasive procedures to extensive resection.

Internal biliary fistula due to cholelithiasis: A single-centre experience

AIM: To discuss about the perioperative problems encountered in patients with internal biliary fistula (IBF) caused by cholelithiasis.

METHODS: In our hospital, 4 130 cholecystectomies were carried out for symptomatic cholelithiasis from January 2000 to March 2004 and only 12 patients were diagnosed with IBF. The perioperative data of these 12 IBF patients were analyzed retrospectively.

RESULTS: The incidence of IBF due to cholelithiasis was nearly 0.3%. The mean age was 57 years. Most of the patients presented with non-specific complaints. Only two patients were considered to have IBF when gallstone ileus was observed during the investigations. Nine patients underwent emergency laparotomy with a pre-operative diagnosis of acute abdomen. In the remaining three patients, elective laparoscopic cholecystectomy was converted to open surgery after identification of IBF. Ten patients had cholecystoduodenal fistula and two patients had cholecystocholedochal fistula. The mean hospital stay was 13 d. Two wound infections, three bile leakages and three mortalities were observed.

CONCLUSION: Cholecystectomy has to be performed in early stage in the patients who were diagnosed as cholelithiasis to prevent the complications like IBF which is seen rarely. Suspicion of IBF should be kept in mind, especially in the case of difficult dissection during cholecystectomy and attention should be paid in order to prevent iatrogenic injuries.