Cholecystocholedocal Fistula

Abstract

Purpose: The purpose of this study is to evaluate the treatment of cholecystocholedocal fistula as evidenced by a case study. Methods: A patient with elevated transaminases and alkaline phosphatase was preoperatively evaluated for Mirizzi Syndrome type II using both ultrasound and endoscopic retrograde cholangiopancreatography (ERCP). Figure A is an ERCP image highlighting a contracted gallbladder (arrow) with complete obliteration of the cystic duct. Intraoperatively, a cholangiogram was performed to further resolve the anatomy, revealing a completely obliterated cystic duct. To address the cholecystobiliary fistula, a Roux-en Y hepatojejunostomy was performed.FigureResults: The management of Mirizzi Syndrome requires a good surgical strategy if preoperative diagnosis is made, due to the dangers in dissecting the triangle of Calot. Early recognition of Mirizzi syndrome during laparotomy is essential to avoid complications. The diagnosis of Mirizzi syndrome is initially suggested by an impacted stone in the neck or infundibulum of gallbladder by ultrasound. Computed tomography is obtained to exclude malignancy. Neither of these tests are sufficiently sensitive or specific for the diagnosis of Mirizzi syndrome. The syndrome is best diagnosed by ERCP. Conclusions: The management of this disease is best accomplished by an open approach. Csendes type I is typically successfully managed by an open cholecystectomy, removal of the stone and closure of the gallbladder cuff. In more severe cases of the disease (types II&III), a partial cholecystectomy with oversew of the defect (with or without flaps) in the common hepatic duct and T-tube placement may be required. Csendes type IV, as in the present case, is best managed by a choledochocojueunostomy or a hepaticojejunostomy. Gallbladder carcinoma should be excluded in all cases of Mirizzi syndrome. [figure 1]