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Laparoscopic management of cholecystoenteric fistulas
Pradeep K Chowbey1, Samik K Bandyopadhyay, Anil Sharma
1Department of Minimal Access Surgery, Sir Ganga Ram Hospital, New Delhi, India. chowbey1@vsnl.com
Insights
Cholecystoenteric fistulas, a rare gallstone complication, are often diagnosed during surgery. Laparoscopic treatment, including stapled cholecystofistulectomy, is feasible and effective in high-volume centers.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Hepatobiliary Surgery
Background:
- Cholecystoenteric fistulas are uncommon complications of gallstone disease, affecting 3-5% of patients.
- Diagnosis is typically made intraoperatively during abdominal surgeries.
Purpose of the Study:
- To evaluate the feasibility and outcomes of laparoscopic management for cholecystoenteric fistulas.
- To assess the efficacy of stapled cholecystofistulectomy in treating these complex cases.
Main Methods:
- A retrospective review of 12,428 laparoscopic cholecystectomies between 1997 and 2003.
- Identification and surgical management of 63 patients diagnosed with cholecystoenteric fistulas, including cholecystoduodenal, cholecystogastric, and cholecystocolic types.
- Use of endostaplers for fistula transection and intracorporeal sutures for bowel repair in laparoscopic procedures.
Main Results:
- Laparoscopic surgery was completed in 59 of 63 patients.
- Major morbidity was low (4.76%), with complications including subdiaphragmatic collection and prolonged biliary drainage.
- Mean postoperative hospital stay was 5.2 days, with all patients asymptomatic at a mean follow-up of 2.4 years.
Conclusions:
- Cholecystoenteric fistulas present a surgical challenge, necessitating high intraoperative suspicion.
- Stapled cholecystofistulectomy is a recommended technique to minimize peritoneal contamination.
- Laparoscopic management is achievable in specialized, high-volume surgical centers.
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.
