Multiple Cholecystoenteric Fistulas and Choledochal Cyst Identified during Laparoscopic Cholecystectomy: An Interesting Case

Abstract

Introduction: Cholecystoenteric fistula is a rare complication of gallbladder disease and cholelithiasis, and are typically discovered incidentally during cholecystectomy. Identification and proper management with division and closure of the fistula is of paramount importance. Type I choledochal cysts are the most common type of choledochal cysts and carry a risk of malignancy. Here, we report a rare case of a patient with cholelithiasis who during laparoscopy was found to have both cholecystoduodenal and cholecystocolonic fistulas, as well as a Type I choledochal cyst. We describe an algorithmic approach to definitive management. Case description: A 55-year-old female presented with cholelithasis. During laparoscopy, a cholecystocolonic fistula, a cholecystoduodenal fistula, and a Type I choledochal cyst were found. Take-down of fistulae and cholecystectomy were performed followed by definitive biliary resection and reconstruction in a staged approach. To our knowledge, this is the first case of a patient with two incidentally discovered cholecystoenteric fistulae and concurrent choledochal cyst. Furthermore, as avoiding definitive biliary bypass in the presence of a septic focus, we describe a step-wise approach to management. Discussion: In patients with acute cholecystitis or choledocholithiasis, imaging frequently does not show evidence of gallbladder fistulas. Most commonly, these processes are only identified intra-operatively. We present a rare case of a patient with multiple cholecystoenteric fistulae and a Type I choledochal cyst discovered intra-operatively. This case report highlights an algorithmic approach to the management of not only dual or multiple cholecystoenteric fistulas, but also a concurrent Type 1 choledochal cyst.