OGBN P10 Laparoscopic management of cholecystoduodenal and cholecystocolic fistulas: technical considerations and postoperative outcomes
Authors: Khan Khurram , Nassar Ahmad H M 
Published: December 2022

Abstract

Background
Cholecystoduodenal and cholecystocolic fistulas are rare complications of gallstone disease. They are usually diagnosed intraoperatively, posing significant surgical challenges. The aim of this study is to review the incidence, presentations, difficulty grading, technical aspects and their management outcomes on a unit adopting a policy of index admission cholecystectomy for all comers with biliary emergencies.

Methods
A prospectively maintained database of all laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) performed over a 30 years period between 1992 to 2022 by a single surgeon was reviewed. All biliary emergencies who were fit for anaesthesia were managed with an intention to treat during the index admission. Procedures involving cholecystoenteric fistulas or suspicious attachments were analysed. The clinical presentation, imaging, operative findings and outcomes were analysed. All suspicious cholecystoenteric attachments were dissected and encircled, confirming a fistula was achieved by access through the gallbladder lumen and, in most cases, obtaining either a duodenography or a colonography before disconnecting and repairing the fistula. Although staplers were not used in this series the technique may enhance the security of closure and prevent occasional complications resulting from minor intraoperative or postoperative leakage.

Results
59/6000 (1%) patients had cholecystoduodenal and cholecystocolic fistulas (46) or dense fibrous attachments (13) where careful dissection revealed no obvious fistula. 67.8% were female and the median age was 68 years. 33 (56%) were emergency admissions, including 20 jaundiced and 8 with acute cholecystitis. Of 26 admitted electively 6 had previous acute cholecystitis. 32 (54.2%) had risk factors for CBD stones. ERCP was done in 5 and of cross sectional imaging in 15 patients only one suspected a cholecystocolic fistula.
LCs were classified difficulty grade IV (28) or V (31). 29 (49.15) required LCBDE: 11 (18.6%) by trancystic exploration and 18 (30.5%) via choledochotomy. 12 patients had Mirizzi abnormalities and 3 had gallbladder, biliary or duodenal cancers. Subhepatic drains were used in 54 (91.5%). Median operative time was 145 minutes (range 35–375). One patient was converted to open due to significant adhesions.
Perioperative complications occurred in 32%: 4 t-tube complications, 3 bile leaks, 3 chest infections, 3 intraabdominal collections requring relaparoscopy and 6 miscellaneous. The rate of complications specific to the presence of such fistulas was only 12%. There were 2 deaths with respiratory infection. Median hospital stay was 10 days (range 1–160).

Conclusions
When dense fibrosis and adhestions to bowel loops are encountered, a high index of suspicion is particularly important as 44% present electively with chronic symptoms. When an attachment is suspected to be a fistula it should be isolated, approached through the gallbladder lumen to confirm a fistula. Ligation is carried out before division and appropriately securing the fistula using seromuscular sutures. The laparoscopic approach to managing cholecystoduodenal and cholecystocolic fistulas is not currently widely practiced as the operative findings results in a low threshold for open conversion. However, laparoscopic resolution is feasible with appropriate training and experience thus avoiding conversion to open surgery which may help reduce the relatively high morbidity associated with such encounters.