Diagnosis and treatment of cholecystoenteric fistula

Abstract

Objective To summarize the clinical characteristics and effective preoperative diagnosis of cholecystoenteric fistula (CEF), and investigate clinical effect of laparoscopic surgery. Methods The retrospective descriptive study was adopted. The clinical data of 29 patients with CEF who were admitted to the Nanjing General Hospital of Nanjing Military Command from January 2000 to December 2014 were collected. All the 29 patients received upper abdominal ultrasonography, and other accessory examinations were selected according to the condition of individual patient. All the patients received laparoscopic surgery initially. If locally dense adhesions around the gallbladder, difficulty of laparoscopic suture or massive bleeding were encountered intraoperatively, patients were then converted to open surgery. The clinical features, results of accessory examina-tions and preoperative diagnosis, intraoperative status (operation method, operation time, volume of blood loss), postoperative status (time to anal exsufflation, drainage-tube removal time, duration of hospital stay, complica-tions) and follow-up status were recorded. The follow-up including long-term complication was performed by telephone interview and outpatient examination till September 2015. Measurement data with normal distribution were presented as average (range). Measurement data with skewed distribution were presented as M (range). Results (1) Clinical features: all the 29 patients had pain in right hypochondriac region or epigastric region. (2) Preoperative accessory examinations and diagnostic results: preoperative ultrasound examination of all the 29 patients demostrated gallbladder wall thickening in 17 patients, atrophic cholecystitis in 12 patients, gallbladder wall thickening combined with atrophic cholecystitis in 5 patients and pneumobilia in 2 patients. Of 15 patients receiving preoperative abdominal computed tomography (CT) examination, 15 had unclear boundary between gall bladder and gastrointestinal tract and 5 had pneumobilia. Of 7 patients receiving ERCP examination, 4 patients had sinus tract opening and bile spillage and (or) showed sinus tract after injection of contrast agent into common bile duct. Of 5 patients receiving gastroscopy, 1 patient showed sinus tract opening and calculus. Of 3 patients receiving colonoscopy, 1 patient showed sinus tract opening and bile spillage, 2 patients had inflammatory reaction at hepatic flexure of the colon. Nine patients were definitely diagnosed before operation with a preoperative diagnostic rate of 31.0%(9/29), including 6 cases of cholecystoduodenal fistula, 2 cases of cholecystocolic fistula and 1 case of cholecysto-gastric fistula. (3) Intraoperative status: of 29 patients with CEF, 24 patients underwent successfully laparoscopic surgery with average operation time of 85 minutes (range, 50-130 minutes) and intraoperative volume of blood loss of 45 mL (range, 30-110 mL). Five patients were converted to open surgery, with average operation time of 150 minutes (range, 120-200 minutes) and intraoperative volume of blood loss of 120 mL(range, 60-250 mL). (4) Postoperative status: the average time to anal exsufflation, drainage-tube removal time and duration of hospital stay were 2 days (range, 1-3 days), 3 days (range, 2-4 days) and 4 days (range, 3-6 days) in 24 patients undergoing laparoscopic surgery. Two patients had postoperative compli-cations and recovered after symptomatic treatment. One of 5 patients converted to open surgery died of multiorgan failure. The average time to anal exsufflation, drainage-tube removal time, duration of hospital stay were of the rest 4 patients were 5 days (range, 3-6 days), 6 days (range, 3-7 days), 14 days (range, 11-19 days). Two patients had postoperative complications and recovered after symptomatic treatment. (5) Follow-up status: 25 patients were followed up for a median time of 25 months (range, 13-38 months) with a follow-up rate of 89.3%(25/28). There were no long-term complications during the follow-up. Conclusions Pain in right hypochondriac region and (or) epigastric region is common symptom of CEF. Ultrasonography and CT provide valuable diagnostic clues to CEF. Laparoscopic surgery is safe, effective and feasible to treat CEF for experienced laparoscopic surgeons. Key words: Cholecystoenteric fistula; Clinical features; Diagnosis; Laparoscopy