Elsevier

The Surgeon

Volume 8, Issue 2, April 2010, Pages 67-70
The Surgeon

Bilo-enteric fistula (BEF) at laparoscopic cholecystectomy: Review of ten year's experience

https://doi.org/10.1016/j.surge.2009.10.010Get rights and content

Abstract

Introduction

BEF is a rare complication of gallstone disease with reported incidence of up to 4.8%. Most are diagnosed intra-operatively and often requires conversion to open surgery. This review assesses the feasibility of laparoscopic management of BEF found at the time of laparoscopic cholecystectomy over ten-year period.

Method

All patients undergoing elective laparoscopic cholecystectomy by a single surgeon (PK) between 1996 and 2006 were prospectively entered in a database and analysed.

Results

Out of 824 laparoscopic cholecystectomy, ten cases of BEF were identified at operation (1.2%, age 14–88 years, median = 62). These were cholecysto-duodenal (7), cholecysto-colonic (1), cholecysto-choledocho-duodenal (1) and choledocho-duodenal (1). Two out of ten were converted to open surgery (20%) compared to overall conversion rate of 2.8% (23/824). Eight cases were successfully completed laparoscopically; endostapler was used in six patients to transect the fistula and two patients had the defect repaired by intra-corporeal sutures. No major complications were seen. One patient had a prolonged hospital stay for social reason.

Conclusion

BEF is often detected intra-operatively and most can be managed laparoscopically successfully. Endostapling avoids peritoneal contamination and reduces operative time.

Introduction

Since the late 1980s, laparoscopic management of gallstone disease has become the standard of care.1 With increasing experience, surgeons have learnt to tackle more complex biliary pathology laparoscopically. Bilo-enteric fistula (BEF) is an uncommon finding at surgery for gallstones disease, with a reported incidence of 0.15%–4.8%.2 Calculus cholecystitis accounts for 90% of all causes of BEF and they are often diagnosed intra-operatively in patients undergoing laparoscopic cholecystectomy.3 Patients' symptoms are often sub-clinical and pre-operative radiological detection of BEF is low.4

BEF were previously considered to be a relative contraindication to laparoscopic surgery due to technical difficulties.5 However, with the advent of laparoscopic stapling devices and increasing technical ability of laparoscopic surgeons, BEF have been successfully managed laparoscopically with excellent results.6 Our study assesses the feasibility of laparoscopic management of BEF found at the time of laparoscopic cholecystectomy.

Section snippets

Method

All patients undergoing elective laparoscopic cholecystectomy for gallstone disease by a single surgeon between 1996 and 2006 were prospectively entered in a database. Demographics, intra-operative findings, operative outcome and post-operative care were analysed.

A detailed clinical history was taken and examination carried out in every patient. All had ultrasound scans of the biliary tree to confirm the presence of gallstones as a minimum imaging modality of pre-operative investigation. If

Results

A total of 824 elective laparoscopic cholecystectomies were performed in the 10-year study period. Age range was between 14 and 88 years old (median = 62). 518 (62.9%) and 306 (37.1%) cases were female and male respectively. Twenty one cases (2.5%) had to be converted to open cholecystectomy due to lack of progress for various reasons.

There were ten cases (1.2%) of BEF identified. Age range was between 45 and 87 years old (median 73.5). None of these cases had a pre-operative diagnosis of BEF.

Discussion

Patients with BEF often present with symptoms of cholecystitis. As mentioned, pre-operative diagnosis is often not possible. Surgeons performing laparoscopic cholecystectomies regularly should be alert to the possibility of BEF and be able to manage these suitably.7

The exact aetiology of BEF secondary to gallstone disease is unclear. Glenn et al. 8 proposed that acute inflammation of the gallbladder with obstruction of the cystic duct allows adhesion of the gallbladder to the contiguous viscus,

Conclusion

BEF is uncommon but a surgically challenging complication of gallstone disease. It is frequently diagnosed intra-operatively during laparoscopic cholecystectomy. Laparoscopic management is feasible and safe, with preference to using endo-stapling device to avoid peritoneal contamination.

References (13)

  • A. Cuschieri et al.

    The European experience with laparoscopic cholecystectomy

    Am J Surg

    (1991)
  • L. Angrisani et al.

    Cholecystoenteric fistula is not a contraindication for laparoscopic surgery

    Surg Endosc

    (2001)
  • O. Tantia et al.

    Pericholecystic fistula: a study of 64 cases

    Int Surg

    (2002)
  • F. Gaillard et al.

    Cholecystocolonic fistula diagnosed with CT-intravenous cholangiography

    Australas Radiol

    (2006)
  • I. Macintyre et al.

    Laparoscopic cholecystectomy

    Br J Surg

    (1993)
  • I. Martin et al.

    Safe laparoscopic cholecystectomy in the presence of a cholecystoenteric fistula

    Dig Surg

    (2000)
There are more references available in the full text version of this article.

Cited by (0)

The abstract was initially presented at the annual meeting of the Association of Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI) at Colchester, November 2008.

View full text