Fístula colecistocolónica: abordaje dual endoscópico. Reporte de un caso

Abstract

Cholecystocolonic fistula is an unusual and late complication of cholelithiasis. The symptoms usually are nonspecific and most cases are diagnosed intraoperatively. Our patient was a female, 75 years old, smoker, with a severe aortic stenosis history. She had a 6-month evolution diarrhea associated with weight loss, coagulopathy and aerobilia in abdominal ultrasound. On behalf of the clinic manifestations, cholecystocolonic fistula was suspected so an abdominal computer tomography scan and a cholangioresonance confirmed this suspicion. Given the patient comorbidities, we decided not to perform a surgical approach. An endoscopic retrograde cholangiography with extraction of choledocolithiasis and placement of a fully covered self-expanding metallic stent was associated with a video colonoscopy and closure of the colonic fistula with a clip device. The patient had a favourable evolution and was discharged on the second day post-procedure. After 3 months of follow-up, she did not present diarrhea and has recovered her weight loss and nutritional status. Given the unusual nature of the case and the significance of the preoperative diagnosis, which allowed us to carry out a minimally invasive treatment, we believe that its report is useful. We place special emphasis on the aerobic triad, alteration of the prothrombin concentration and chronic diarrhea that allowed us to suspect the diagnosis.

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“…FCC is the second FCE after cholecystoduodenal ones, 2,3 and it is an infrequent and late complication of cholelithiasis, with an incidence of 1/1000 cholecystectomies. 1 Its etiology may be related to a longlasting inflammatory process of the gallbladder, caused by stones.…”

“…5 Pneumobilia has been considered to be associated with FCC, especially if the gallbladder is shrunken and in close proximity to the intestine on CT. Despite all these studies, preoperative diagnosis is only achieved in 8-17% of cases 3,8 and in general they are identified during surgery. Therefore we can say that the intraoperative diagnosis prevails in the published series where a high suspicion helps its correct diagnosis, where intraoperative cholangiography helps its better diagnosis, however in our case the fundus of the gallbladder was opened, gas leaking out through it which confirmed our suspicion.…”

“…Therefore, the ideal treatment for suspected biliary-enteric fistula should be an open cholecystectomy with closure of the fistula. A very small number of reports 3,[6][7][8][9] have explored laparoscopic management of FCC. Although the authors have advocated for the practicality of the laparoscopic approach, they have also raised concerns about long operating times and the need to convert it to an open procedure due to complications such as iatrogenic colonic perforation.…”

“…5,7 Surgical treatment presents controversies such as the need or not for a colostomy or the feasibility of closing the CCF by laparoscopy. Currently, the initial approach is laparoscopic, although long operating times and a considerable number of conversions have been reported 1,3 due to haemorrhages, severe local adhesions, and technical difficulties in intestinal suture; 1,6 running the risk of causing complications such as iatrogenic perforation of the colon and fecal peritonitis. 1 At the same time, if the anatomical structure is not clear, cholecystectomy is safe and effective.…”

“…1 At the same time, if the anatomical structure is not clear, cholecystectomy is safe and effective. 3 For all these reasons, some authors state that the treatment should be an open cholecystectomy with closure of the fistula. 1 On the other hand, if the patient has electrolyte imbalance, sepsis, or other disorders caused by intestinal obstruction, under no circumstances should the fistula be repaired or closed, due to the increased risk of additional contamination from extra dissection in the BV area, 1,2 so only enterotomy and stone extraction is recommended.…”