Bilo-enteric fistula (BEF) at laparoscopic cholecystectomy: Review of ten year's experience☆
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.
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Cited by (0)
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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.