Management of Cholecystohepatic Fistula
Cholecystohepatic fistula should be managed surgically with cholecystectomy and fistula closure, using either laparoscopic or open approach depending on the degree of inflammation and surgeon expertise, with the fistula tract transected using an endoscopic stapler or repaired with intracorporeal sutures. 1, 2
Initial Assessment and Stabilization
Start broad-spectrum antibiotics immediately if there is evidence of biliary fistula, biloma, or bile peritonitis, targeting Gram-negative enteric bacteria. 3
Obtain complete imaging of the biliary tree using MRCP, CT with contrast, or percutaneous transhepatic cholangiography to define the anatomy and extent of injury before definitive repair. 3
If the patient presents with signs of acute cholangitis (fever, jaundice, abdominal pain), grade severity using Tokyo Guidelines and manage accordingly with urgent biliary drainage for severe cases or early drainage within 24 hours for moderate cases. 4
Surgical Management Approach
Laparoscopic Management (Preferred When Feasible)
Laparoscopic cholecystectomy with fistula closure can be completed successfully in experienced hands and should be attempted as the initial approach. 1, 2
Use an endoscopic stapler (Endo-GIA) to transect the fistula tract in 75-80% of cases, as this avoids contamination of the peritoneal cavity and provides secure closure. 1, 2
Alternatively, repair the defect in the liver with intracorporeal sutures using 5-0 or 6-0 absorbable or non-absorbable sutures if the fistula cannot be stapled. 1, 5
Conversion to open cholecystectomy should be performed if laparoscopic visualization is inadequate, there is severe inflammation obscuring anatomy, or if the surgeon lacks sufficient laparoscopic expertise. 1, 2
Open Surgical Management
Open cholecystectomy with fistula transection and repair remains the preferable option when severe inflammation is present or laparoscopic approach is not feasible. 6
Perform cholecystectomy and transect the fistula tract, then repair the hepatic defect with interrupted sutures. 6
The fundamental principle is that anastomosis and reconstruction must use healthy, non-ischemic, non-inflamed, and non-scarred tissue—attempting repair on inflamed or ischemic tissue leads to failure. 3, 5
Timing of Definitive Repair
If the fistula is discovered intraoperatively and there is minimal inflammation, immediate repair by an experienced biliary surgeon is appropriate. 3
If there is significant abdominal infection, biliary peritonitis, or severe inflammation, delay definitive repair for 4-6 weeks after controlling bile leakage and infection with percutaneous drainage and antibiotics. 3, 5
During the delayed period, manage with percutaneous drainage of any fluid collections, broad-spectrum antibiotics, and nutritional support. 5
Postoperative Management
Continue antibiotics for 7-10 days total, or extend to 2 weeks if Enterococcus or Streptococcus is isolated to prevent infectious endocarditis. 4
Place a drain intraoperatively to monitor for bile leak, which occurs in approximately 5-10% of cases and can be managed conservatively if output decreases. 5
Monitor for complications including prolonged biliary drainage (3-5% of cases), subdiaphragmatic collections requiring drainage, and anastomotic leak. 1
Common Pitfalls and Caveats
High index of suspicion is mandatory as most cholecystoenteric fistulas are diagnosed intraoperatively rather than preoperatively, with preoperative diagnostic rates around 50%. 2
Do not attempt repair on ischemic or thermally injured tissue—the boundaries of thermal injury from electrocautery are often unclear early, and operating on ischemic bile ducts is the main cause of anastomotic leakage and stricture. 5
Avoid using scarred bile duct wall or surrounding tissue for reconstruction as this inevitably leads to surgical failure. 5, 3
If specialist hepatobiliary expertise is unavailable, provide drainage and refer the patient to a tertiary center rather than attempting complex repair. 3, 5