Laparoscopic approach in cholecystogastric fistula with cholecystectomy and omental patching: A case report and review.

Cholecystoenteric fistulas are rare complications of cholelithiasis, with cholecystogastric fistulas (CGFs) being the rarest. Recommended treatment is surgery; however, select asymptomatic patients can be managed conservatively. The population frequently involved is old age with multiple comorbidities. Open surgery comes with its added morbidities, especially in this subgroup and hence laparoscopic surgery might be beneficial. Sometimes, these fistulas can be incomplete. Here, we describe a case of incomplete CGF managed by laparoscopic cholecystectomy and omental patching along with a brief review of the literature.

INTRODUCTION

Cholecystectomy is one of the most commonly performed abdominal surgeries, with the procedure being managed laparoscopically in most cases. Cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis and a situation wherein conversion to open surgery is high. The incidence of CEF has been reported to be around 0.5%–0.9%[12] among patients undergoing laparoscopic cholecystectomy. Of these, cholecystoduodenal fistula (CDF) is the most common (75%–80%), followed by cholecystocolonic fistula (CCF) and rarely cholecystogastric fistula (CGF).[2]

Previously, CEF was always an incidental finding during surgery and a contraindication for the laparoscopic approach. However, with the advent of advanced instruments, stapling devices, improved laparoscopic suturing skills and higher pre-operative diagnosis rate, nowadays, more and more patients are being managed laparoscopically.[1] The literature regarding laparoscopic management of CGF is sparse. Here, we describe a case of CGF being managed by laparoscopic cholecystectomy with omental patching of the involved gastric site.

CASE REPORT

A 85 year old female, known hypertensive, presented with pain in the right upper abdomen and fever for 20 days. There was no history of vomiting, jaundice, abdominal distension, haematemesis, melaena or shortness of breath. She was being managed conservatively for the same elsewhere for the last 10 days and was referred to us. On examination, her vitals were stable, and general examination findings were within normal limits. On abdominal examination, tenderness was present in right hypochondrium. Contrast-enhanced computed tomography (CT) (conducted prior to consulting us) suggested complicated cholecystitis, intramural and pericholecystic contained collections, spilled gallstones, impacted neck calculus with a prominent CBD and wall oedema in the stomach. Blood investigations and magnetic resonance cholangiopancreatography (MRCP) were done. MRCP revealed dilated CBD (12 mm) with small distal CBD calculi, gallbladder was thick walled and distended with multiple calculi and cholecystoduodenal/gastric fistula with stones outside the gallbladder (GB) adjoining the tract [Figure 1]. Oesophago-gastro-duodenoscopy (OGD) suggested an ulcer (<1 cm) in the antrum with central depression and raised edges (biopsy: inflammatory granulation tissue). The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stenting, which was followed by laparoscopic cholecystectomy with omental patching of fistula site after 2 days of ERCP. Post-operative recovery was uneventful, and liquids were introduced on POD 2. The patient was discharged on POD 4 with drain in situ, which was removed on the first outpatient department follow-up after a week. Histopathological examination of the GB suggested acute on chronic calculus cholecystitis while that of the tissue at the pyloric fistula site came as inflammatory granulation tissue. The patient has been doing fine at 5 months of follow-up.

Figure 1

Magnetic resonance cholangiopancreatography image showing fistulous communication of gallbladder to stomach

Surgical procedure

Four ports for standard laparoscopic cholecystectomy were made. Initial step included release of omentum from the falciform, gallbladder and liver using suction tip and harmonic. On further releasing the omentum, fistula tract approximately 6 mm in diameter was visualised [Figure 2a] and two small stones were noted [Figure 2b]. Gallbladder was opened at the site of fistula and all the stones inside [Figure 2c] were placed in an endobag. This helped in grasping the infundibulum easily. Omentum was released further, and duodenal adhesions along the anterior aspect released. A 5 mm instrument was introduced through an extra port along the left midclavicular line to retract the duodenum down. As Calot's triangle could not be delineated clearly, GB was cut all around at the site of fistula and plane was created along the liver bed. Further dissection was proceeded in a semi top-down approach until the neck of gallbladder [Figure 2d] which was looped with no. 1 chromic catgut endoloop. Thereafter, gastric site of the fistula [Figure 3a] was inspected thoroughly and tissue was taken for biopsy. However, no obvious opening was noted, and an air leak test was also negative. In view of diseased surface of the gastric wall, two Vicryl 2-0 stay sutures were taken across the site of fistula [Figure 3b] and omental patching [Figure 3c] was done. Another loop of PDS 1-0, endoloop was placed just above the catgut loop at the neck of GB and distal infundibulum was trimmed off. Remaining GB was dissected off from the liver bed and specimen retrieved in endobag. Procedure was completed [Figure 3d] with placement of drain in the sub-hepatic space.

Figure 2

(a) Fistula tract approximately 6 mm in diameter as visualised during dissection. (b) Stones adjoining the fistula tract. (c) Gallbladder opened and the stones inside removed. (d) Neck of gallbladder being looped with no. 1 chromic catgut endoloop

Figure 3

(a) Gastric surface being inspected at the site of fistula. (b) Stay sutures being taken using Vicryl 2-0. (c) Omental patching being done. (d) Image of the abdomen after completion of surgery. Ports used can be seen

DISCUSSION

CEFs are rare complication of long-standing gallstone disease with recurrent episodes of inflammation. These episodes lead to destruction of the gallbladder wall and adjacent viscus with erosion of tissues and fistulisation.

Further, patient population presenting with CEFs are usually older in age with multiple comorbidities. This has implications both in the progress of the disease and management. As these patients have less marked symptoms, initial attacks of inflammation due to gallstones are missed and most of the patients will present with complications including CEFs. Further conversion rate to open cholecystectomy is higher in CEFs, which leads to greater post-operative morbidity and mortality, particularly in this group of patients.[3] Initially a contraindication for the laparoscopic approach[4] today with advanced laparoscopic skills and technology most of the surgeries for CEF can be accomplished laparoscopically as evident in literature albeit few will need conversion to open. Another issue with CEFs is difficulty in obtaining a pre-operative diagnosis. A pre-operative diagnosis of CEF was obtained only in 5/63 (8%) patients in the series published by Chowbey et al.,[1] while in the 29 patient series by Li et al.,[3] pre-operative diagnosis was obtained in 9 (31%), suggesting an increasing rate of pre-operative diagnosis of CEFs. Ultrasonography, CT, MRCP/magnetic resonance imaging, endoscopy, colonoscopy, and ERCP are the available diagnostic options and should be used in a case-to-case basis. In our patient, although CT and OGD were done, fistula was confirmed on MRCP.

CEFs have also been reported to be formed by peptic ulcer, malignant tumour, trauma and Crohn's disease. In addition, malignancy needs to be ruled out as a cause of fistula and frozen sections should be performed if there is a suspicion of malignancy intraoperatively.

Of the CEFs, CGF is the least reported in literature. Surgical approach for CGFs remains the same as for other CEFs, i.e., initial meticulous adhesiolysis, take down of fistula, cholecystectomy and primary suture closure of the defect in viscus. Fistula tract can be transected with stapler as well or can be divided after securing either end with ligatures.[5] Sometimes, patients with CGF/CDF may present with gastric outlet obstruction[6] (Bouveret's syndrome) or ileus, which may need an emergency surgery, gastrostomy/enterotomy and stone removal, followed by surgery for CEF simultaneously or at a later date depending on patient status. At times, CEF can be incomplete: repeated inflammation results in the destruction of the wall of GB and adjacent viscus but yet to penetrate through the mucosa or sometimes mucosa may heal spontaneously. Beksac et al.[7] reported such a case with incomplete CGF and CDF in the same patient. The authors repaired the seromuscular defects primarily and cholecystectomy was performed. Our patient also had an incomplete fistula with only the outer layers involved as leak test was negative. Air leak test is useful in such and other cases where viscus opening is not clearly visualised as was used by us. Further, till date, primary suture closure and staplers have been reported to repair the viscus side of fistula. We suggest that omental patching can also be used for closure of involved gastric site. Furthermore, subtotal cholecystectomy is a safe and effective surgical procedure whenever there is a threat to important structures including CBD.

CONCLUSION

This report highlights a rare complication of CGF along with feasibility of a minimally invasive approach to this condition, which has better results in this patient population. Proper preoperative workup and preparedness along with meticulous dissection under direct vision, experience in laparoscopic suturing and use of subtotal cholecystectomy if needed are some of the basic principles for a successful CEF surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.