Preoperative Diagnosis And Laparoscopic Management Of Cholecystoenteric Fistula

Background:Cholecystoenteric fistula(CEF)is a rare and late complication of cholecystolithiasis and defined as a spontaneous track between an inflamed gallbladder and one or more parts of surrounding gastrointestinal tract.The CEF usually develops insidiously.Impacted gallstones may produce an obstruction of the cystic duct or directly destroy the gallbladder mucosa by pressure necrosis.Then empyema of the gallbladder with subsequent gangrene may develop.While this process is going on,adhesions of the gallbladder wall to the contiguous organs,frequently the duodenum,are gradually formed.If the gangrene continues,dense adhesions facilitate the rupture of the offending gallstone through the gallbladder wall,and the erosion of the intestinal wall.Eventually,a fistula is formed.The preoperative diagnosis of CEF is very difficult.One potential reason is that CEF lacks specific symptoms compared to cholecystitis.Another potential reason is that even though radiological examinations can detect the connecting part between gallbladder and neighboring gastrointestinal tract,they cannot show the fistula exactly.So it is always an accidental finding during operation,which may be challenging to the surgeon and cause catastrophic damage to the patients.Since the late 1980s,laparoscopic cholecystectomy(LC)has been a widely accepted method for treating gallbladder disease.It provides a great deal of advantages over open cholecystectomy of markedly decreased pain and shorter recovery time.In addition,LC does not increase mortality or morbility apparently.At the beginning era of the laparoscopy,CEF was considered as a contraindication for LC.Fortunately,with increasing technical ability and management experience of laparoscopic surgeons,CEF has been successfully managed laparoscopically in several cases.However,bleeding,severe local adhesions and technical difficulties for intestinal suture are usually encountered when performing laparoscopy.So,the rate of conversion to open surgery is still very high.Objective:To analyse the clinical characteristics and effective diagnostic methods of CEF.To investigate the role of laparoscopy in the surgical treatment of CEF.Methods:From January 2000 to December 2014,29 patients were identified as having CEF.Clinical materials of these patients were retrospectively collected.All 29 CEF patients received upper abdominal ultrasound(US),other accessory examinations were selected according to the patients' conditions.All of these patients accepted laparoscopic treatment initially,if dense adhesions around the gallbladder,difficulty of laparoscopic suture or massive bleeding was encountered,patients were then converted to open surgery.The follow-up was performed by telephone interview and outpatient examination till September 2015,which mainly concerned late complications.Results:The mean age of 29 CEF patients was 68.7 years,with a female/male ratio 2.2.23 patients(79.3%)had cholecystoduodenal fistula(CDF),4 patients(13.8%)had cholecystocolic fistula(CCF),1 patient(3.4%)had cholecystogastric fistula(CGF),and the remaining one(3.4%)had CDF combined with CCF.All these patients were assessed by US,a thick-walled gallbladder was reported in 17 patients(58.6%),atrophic cholecystitis was reported in 12 patients(41.4%),a thick-walled gallbladder combined with atrophic cholecystitis was reported in 5 patients(17.2%),and pneumobilia was reported in 2 patients(6.9%).15 patients were assessed by computed tomography(CT),close connection between gallbladder and infected organs was presented on all of them(100.0%),and pneumobilia was presented on 5 patients(33.3%).9 patients(31.0%)obtained preoperative diagnosis.For 24 patients managed successfully by laparoscopy,the postoperative hospital stays ranged from 3 to 6 days,2 patients experienced postoperative complications.For 5 patients converted to open surgery,1 'patient died,the postoperative hospital stays of the remaining four patients ranged from 11 to 19 days,2 patients experienced postoperative complications.25 patients were followed up without any late relative complications.Conclusion:US and CT can provide valuable diagnostic clues to CEF.Laparoscopic method should be standard treatment for experienced laparoscopic surgeon.