What is the incidence of choledochoduodenal fistula?

From the Guidelines

Choledochoduodenal fistulas are relatively rare, with an estimated incidence of 3-5% among all biliary-enteric fistulas, as reported in the most recent study 1. The incidence of choledochoduodenal fistulas is not explicitly stated in the provided guidelines 1, but according to the study by BioScience Trends 1, the incidence of bile duct injury (BDI) associated with open cholecystectomy (OC) is 0.125-0.3%, and up to 0.4-0.6% for cases that underwent laparoscopic cholecystectomy (LC).

• The true incidence of choledochoduodenal fistulas may be underreported due to the asymptomatic nature of many cases, with fistulas often discovered incidentally during imaging or surgery for other conditions.
• Risk factors for choledochoduodenal fistulas include a history of recurrent biliary infections, chronic duodenal ulcers, and previous biliary tract interventions.
• The pathophysiology typically involves inflammation and erosion of the bile duct wall into the adjacent duodenum, creating the abnormal communication. The management of bile duct injury, including choledochoduodenal fistulas, remains a considerable challenge in hepatobiliary surgery, with a significant impact on the patient's quality of life, as reported by 1.
• The definitive repair surgery remains the mainstay of treatment for BDI and traumatic biliary stricture.
• However, even in a high volume biliary surgery center with extensive experience, the incidence of stricture after repair surgery of BDI still reaches 10-20%.
• Delayed referral to a specialist center increases morbidity, highlighting the importance of timely and appropriate management of choledochoduodenal fistulas.

From the Research

Incidence of Choledochoduodenal Fistula

• The incidence of choledochoduodenal fistula is extremely rare, even in populous nations 2.
• A review of 728 cases in Mainland China found that more than half of the cases were female, with an average age of 57.3 years 2.
• Another study found that 66 patients were diagnosed and treated for choledochoduodenal fistula over a period of 9 years, indicating a relatively low incidence 3.
• A retrospective study found an incidence of cholecystoduodenal fistula similar to that reported in the medical literature, with only 4 patients identified over a 3-year period 4.

Causes and Symptoms

• Choledochoduodenal fistula is usually caused by cholelithiasis, with 573 out of 728 cases attributed to this cause 2.
• Epigastric pain and cholangitis are the most common symptoms of choledochoduodenal fistula, occurring in 589 and 395 out of 728 cases, respectively 2.
• Other symptoms may include jaundice, fever, and upper abdominal pain 3, 5.

Diagnosis and Treatment

• Choledochoduodenal fistula is usually detected and confirmed by endoscopic retrograde cholangiopancreatography (ERCP) 2, 3.
• Treatment options range from conservative therapy for small fistulas to surgical biliary reconstruction for larger fistulas 2, 3.
• Operative therapy, including laparoscopic surgery, is the primary treatment for most patients, regardless of the preoperative diagnosis 3.