From the Guidelines
The key learning points from a young female patient who underwent laparoscopic cholecystectomy and was found to have two separate cholecystoenteric fistulae are the importance of thorough preoperative assessment, robust contingency planning, and effective communication between healthcare providers. This case highlights an extremely rare finding of simultaneous cholecysto-colic and cholecysto-duodenal fistulae in a young female patient with a relatively short history of gallstone disease. Despite being selected as a straightforward case for an offsite surgical list, the patient had experienced multiple flare-ups of cholecystitis following her initial presentation, which were not communicated to the surgical team. This underscores the importance of treating all laparoscopic cholecystectomies with caution, as seemingly low-risk cases can harbor unexpected complexities. The case also emphasizes the need for robust contingency planning when performing procedures at offsite locations, including adequate emergency equipment availability and clear postoperative follow-up pathways. According to the 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis 1, laparoscopic cholecystectomy is generally considered the standard technique for the removal of gallstones, and local inflammation, especially in gangrenous and emphysematous ACC, has been considered to increase the risk of bile duct injuries, blood loss, operative time, general morbidity and mortality rates in comparison with open surgery. However, evidence has clearly shown the safety of laparoscopic cholecystectomy in ACC, with a lower complication rate and a shorter hospital stay compared to open surgery 1. In cases of difficult gallbladder, subtotal cholecystectomy may be a viable option, with morbidity rates comparable to those reported for total cholecystectomy in straightforward cases 1. Moreover, the management of spilled gallstones during laparoscopic cholecystectomy is crucial, as it can lead to complications of severe morbidity, and standardization of the management of spilled gallstones is needed urgently 1. Therefore, thorough preoperative assessment, effective communication, and robust contingency planning are essential in managing patients with gallstone disease, particularly those with rare anatomical variants like cholecystoenteric fistulae.
From the Research
Key Learning Points
- The presence of cholecystoenteric fistulae, including cholecysto-colic and cholecysto-duodenal fistulae, can be a challenging condition to diagnose and manage, as evidenced by the low preoperative diagnostic rates in several studies 2, 3, 4.
- Laparoscopic management of cholecystoenteric fistulae is a feasible and safe procedure, with successful outcomes reported in multiple case series and studies 3, 5, 4.
- The key to successful laparoscopic management of cholecystoenteric fistulae lies in the surgeon's experience and skill in advanced laparoscopic techniques, such as duodenal mobilization and intracorporeal suturing and knotting 5.
- Preoperative diagnosis of cholecystoenteric fistulae can be improved with the use of advanced imaging techniques, such as contrast-enhanced CT scans and endoscopic retrograde cholangiopancreatography (ERCP) 2, 3.
- The following factors can predict a difficult laparoscopic cholecystectomy:
- Acutely inflamed or gangrenous gallbladder
- Dense adhesions at Calot's triangle
- Fibrotic and contracted gallbladder
- Cholecystoenteric fistula
- Age ≥50 years
- History of hospitalization for acute cholecystitis
- Body mass index of 25 kg/m2 and more
- Abdominal scar
- Palpable gallbladder
- Gallbladder wall thickness ≥4 mm
- Pericholecystic collection
- Impacted stone
- Endoscopic retrograde cholangiopancreatography and pancreatitis 6
- A scoring system can be used to preoperatively predict the difficulty level of laparoscopic cholecystectomy, which can help decide the surgical approach, counsel patients, and reduce complication rates, conversion rates, and overall medical costs 6.