Biliobiliary fistula: review of nine cases

We have reviewed nine cases of biliobiliary fistula operated during 1983-85. Two of these patients also had a high hepatic duct stricture, an association not highlighted before. Eight of these patients had jaundice. A classical cholecystectomy in the presence of biliobiliary fistula entails grave risk to the integrity of the upper biliary tract. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography can detect these rare fistulae. It is proposed that all patients with cholelithiasis associated with jaundice be screened by sonography for evidence of biliobiliary fistula. They should then have an ERCP to detect and delineate the biliobiliary fistula. At surgery, all of these patients have a fused gall bladder with obliteration of the Calot's triangle. Both retrograde and antegrade cholecystectomy is hazardous in these cases. Instead, the gall bladder should be opened inferiorly and evacuated of all stones, followed by a partial cholecystectomy and common hepatic duct repair over a T-tube. In the presence of an associated high or low biliary stricture, a suitable bilioenteric anastomosis may be required.