Reduced port laparoscopic subtotal cholecystectomy for Mirizzi syndrome with a bilio-biliary fistula: A case report.

A 65-year-old male diagnosed with Mirizzi syndrome with a bilio-biliary fistula was referred to our department and underwent single-incision laparoscopic surgery with an assistant trocar. As typical laparoscopic cholecystectomy could not be performed due to the coexistence of a bilio-biliary fistula, we performed laparoscopic subtotal cholecystectomy as a bail-out procedure according to the recommendation of the recent Tokyo Guidelines (TG18). The neck of the remnant gallbladder could be easily sutured with the effective use of an assistant trocar, and the surgery was completed without any complications. The patient was discharged 5 days after surgery without any complications. While little has been reported on the efficacy of reduced port surgery for Mirizzi syndrome, our surgical approach, i.e. reduced port surgery with an assistant trocar, enabled secure and easy suturing as a bail-out procedure and seemed to be an efficient method that is both less-invasive and safe.

Outcome of combined pancreatic and biliary fistulas after pancreatoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) as well as postoperative biliary fistula (POBF) are considered the main source of postoperative morbidity and mortality after pancreatoduodenectomy (PD). However, little is known about the incidence and complications of combined POPF/POBF compared to isolated POPF or POBF. METHODS: This single-center study investigated retrospectively the incidence and postoperative outcome of combined POPF/POBF compared to isolated fistulas following PD in a tertiary German pancreatic center between 2009 and 2018. RESULTS: A total of 678 patients underwent PD for benign and malignant periampullary lesions. Combined fistulas occurred in 6%, isolated POPF in 16%, and isolated POBF in 2%. Pancreatic ductal adenocarcinoma and chronic pancreatitis had a protective effect on the occurrence of combined fistulas, whereas serous cystadenoma and pancreatic metastasis were risk factors. Morbidity (Grade C fistula, post-pancreatectomy hemorrhage, revisional surgery) and mortality was significantly higher in patients with combined fistulas than in those with isolated fistula. Moreover, the duration of ICU stay was longer. CONCLUSIONS: A combined POPF/POBF is associated with a significant increase of morbidity and mortality compared to isolated fistulas after PD. Early surgical revision in these patients may improve the postoperative survival rate.

Spontaneous cholecystocutaneous fistula secondary to xanthogranulomatous cholecystitis: a case report.

BACKGROUND: Xanthogranulomatous cholecystitis, a rare variant of cholecystitis, may infrequently be complicated by spontaneous cholecystocutaneous fistula. CASE PRESENTATION: We report the case of a 75-year-old Saudi Arabian man who presented with "a painful area of redness" (cellulitis) over his right upper abdomen. Abdominal computed tomography revealed multiple collections, which were drained surgically. A discharging sinus was identified, and a fistulogram revealed cholecystocutaneous fistula during his follow-up visit. The patient underwent laparoscopic management and recovered uneventfully. Final histopathological evaluation confirmed acute-on-chronic xanthogranulomatous cholecystitis . CONCLUSIONS: Although rare, surgeons should consider cholecystocutaneous fistula in the differential diagnosis of anterior abdominal wall abscesses, particularly in patients with concurrent or background symptoms of gallbladder disease. We report the first case of laparoscopic management for cholecystocutaneous fistula in Saudi Arabia.

Diagnosis of Traumatic Bronchobiliary Fistula With Late 99m Tc-Mebrofenin SPECT/CT.

ABSTRACT: Bronchobiliary fistula (BBF) represents a rare disorder; it consists of abnormal interconnection between the biliary tract and bronchial trees. A 22-year-old woman with persistent chest pain, jaundice, and biliptysis was referred for hepatobiliary scintigraphy under clinical suspicion of a BBF. Patient medical history was consistent with biliary tree reconstruction secondary to an iatrogenic injury during cholecystectomy 4 years ago. Previous complementary studies (CT and MR cholangiopancreatography) were equivocal for diagnosis. Planar dynamic images of hepatobiliary scintigraphy in the first hour were inconclusive. A 24-hour SPECT/CT was performed and confirmed the BBF in a minimally invasive way.

Iatrogenic arterio-biliary fistula and peripheral hepatic artery pseudoaneurysm after transjugular liver biopsy: complication management using a microvascular plug.

This study aimed to report on complication management in a 58-year-old woman referred for transjugular biopsy for the evaluation of unknown liver disease. After an initial uneventful biopsy procedure, the patient complained of severe upper abdominal pain. Laboratory tests revealed increasing liver enzymes. Imaging studies depicted an iatrogenic pseudoaneurysm associated with an arterio-biliary fistula originating from the right peripheral hepatic artery. Angiography and percutaneous transarterial superselective embolotherapy was performed by means of a microcatheter and microvascular plug. Precise device positioning allowed for successful closure of the bleeding site without compromising the hepatic vasculature.

Choledochoduodenal fistula: a rare complication of acute peptic ulcer bleeding.

A 75-year-old man presented with a 3-week history of melaena and right upper quadrant pain. This was on a background of significant alcohol intake and a complex medical history. He was haemodynamically unstable with investigations indicating a new iron-deficiency anaemia. After resuscitation, urgent intervention was required under general anaesthesia. This involved a triple phase abdominal CT, followed by emergency oesophagogastroduodenoscopy. This revealed deep ulceration with extension to the pancreatic head and common bile duct. There was also evidence of pneumobilia on CT, secondary to a choledochoduodenal fistula. Treatment encompassed an invasive and medical approach. Following treatment, the patient was stable, with follow-up endoscopy exhibiting good duodenal mucosal healing.

Bouveret´s syndrome: a rarest complication of cholelithiasis. A case report and literature review.

Bouveret´s syndrome refers to the condition of gastric outlet obstruction caused by the impaction of a large gallstone into the duodenum after passage through a cholecystoduodenal fistula. Many endoscopic and surgical techniques have been described in the management of this syndrome, however the morbidity and mortality are still very high. We present the case of a 67-year-old female patient with Bouveret´s syndrome, with successful resolution with surgical treatment after two failed endoscopic treatments.

El síndrome de Bouveret se refiere a la obstrucción de la salida gástrica causada por un lito grande impactado en el duodeno que pasó a través de una fístula colecistoduodenal. Se han descrito varias técnicas endoscópicas y quirúrgicas para tratar esta entidad, pero la morbimortalidad es aún muy elevada. Se presenta el caso de una paciente femenina de 67 años con síndrome de Bouveret, con exitosa resolución mediante tratamiento quirúrgico posterior a dos tratamientos endoscópicos fallidos.

The curious case of biliary emesis and bowel obstruction from Bouveret syndrome.

Bouveret syndrome is a rare complication of biliary lithiasis. This sequela is caused by the passage of the gallstone via a bilioenteric fistula, resulting in an impacted gallstone in the duodenum or stomach. The common presentation of non-specific symptoms contributes to the diagnostic uncertainty and delay, which is strongly associated with adverse outcomes. We report an uncomplicated stone extraction via open gastrotomy in an elderly man afflicted with bowel obstruction and biliary vomit secondary to Bouveret syndrome.

Massive upper gastrointestinal bleeding: a rare complication of cholecystoduodenal fistula.

A biliary fistula which may occur spontaneously or after surgery, is an abnormal communication from the biliary system to an organ, cavity or free surface. Spontaneous biliary-enteric fistula is a rare complication of gallbladder pathology, with over 90% of them secondary to cholelithiasis. Approximately 6% are due to perforating peptic ulcers. Symptoms of biliary-enteric fistula varies widely and usually non-specific, mimicking any chronic biliary disease. Cholecystoduodenal fistula causing severe upper gastrointestinal (UGI) bleed is very rare. Bleeding cholecystoduodenal fistula commonly requires surgical resection of the fistula and repair of the duodenal perforation. We describe the case of a previously healthy older patient who initially presented with symptoms suggestive of UGI bleeding. Bleeding could not be controlled endoscopically. When a laparotomy was performed, a cholecystoduodenal fistula was discovered and bleeding was noted to originate from the superficial branch of cystic artery.

Percutaneous Bronchial Embolization to Treat Intractable Bronchobiliary Fistula.

Sixty-four-year-old female who underwent hemi-hepatectomy for intrahepatic cholangiocarcinoma a year ago presented with biliary sputum, cough and fever. Cross-sectional imaging showed a recurred tumor involving right diaphragmatic area and an abscess formation in liver dome with adjacent right lower lobe of lung. Percutaneous transhepatic biliary drainage and percutaneous drainage of lung abscess were performed. Tubogram showed connections between the lung abscess cavity and multiple distal bronchi, suggesting bronchobiliary fistulas. Two weeks of drainage treatment did not relieve symptoms. We successfully treated intractable bronchobiliary fistula via image-guided percutaneous access to closest distal bronchi near abscess with subsequent tandem placement of vascular plugs.