Cholecystocutaneous Fistula Treatment & Management

  • Author: Cherry Ee Peck Koh, FRACS, MBBS, MS; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Aug 5, 2011
 

Medical Therapy

All patients should be treated with antibiotics because of associated sepsis, cholecystitis, or empyema. However, antibiotics are an adjunctive therapy and should not be the only treatment.

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Surgical Therapy

Both the gallbladder and fistula need to be resected to achieve a cure. However, as this condition commonly occurs in elderly patients who may have multiple medical comorbidities, surgical treatment must be tailored depending on the patient's fitness for surgery.

Surgery

Several decisions must be made at the time of surgery, including whether to use a one-stage versus staged procedure (drainage of abscess with surgical excision of gallbladder and fistula or drainage of abscess to control sepsis followed with definitive treatment of gallbladder disease and fistula). Other considerations include the incision site, whether to incorporate the external opening into the incision, and which method of closure to use (see Intraoperative details).

Drainage of the cholecystocutaneous abscess prior to spontaneous discharge turns the abscess into a fistula and allows control of sepsis. Appropriate intravenous antibiotics should be initiated as well. A drainage tube may be inserted into the fistula to keep the track patent. However, only an experienced physician should perform this maneuver, as a nonfibrous tract can easily be perforated. The tract can also be gently dilated to allow the passage of forceps to remove stones within the gallbladder. Drainage of the abscess also offers temporizing care while transfer to a specialized institution is underway should further expertise be required.

In the definitive treatment of the underlying gallbladder disease or fistula, either a laparoscopic approach or an open approach can be considered. A laparoscopic approach is less invasive and has been described; however, the conversion rate may be high depending on the intra-abdominal findings, such as adhesions to the surrounding tissue.[63] Port placement may also need to be altered depending on adhesions to the surrounding tissue and the course of the fistula tract. An open approach should be used if an underlying malignancy is suspected.

Conservative treatment

Definitive surgical excision of both the gallbladder and the tract is the treatment of choice. However, in the surgically prohibitive patient, conservative management can be considered. Indications for conservative management include the patient's inability to tolerate anesthesia that permits definitive surgical treatment or a poor prognosis (eg, coexisting advanced malignancy) such that surgical intervention is not warranted. With progress in the safety of surgery and anesthesia, there are in fact very few absolute contraindications, and management options depend on local expertise and tailored treatment to suit the patient’s clinical status.

In conservative management, spontaneous healing of the fistula can occur provided there is no distal biliary tree obstruction.[5, 64] In the review by Henry and Orr in 1949, of 37 patients within their series, spontaneous healing occurred in 6 (16%) patients.[5] Incision and drainage of the cholecystic abscess without definitive excision of the tract or gallbladder led to spontaneous healing in 3 more patients. While this report demonstrates that simple drainage and conservative treatment can lead to healing in a substantial number of patients (24%) with spontaneous cholecystocutaneous fistula, it also shows that most require formal surgical intervention.

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Preoperative Details

Prior to surgery, an infective or inflammatory process should be adequately treated with antibiotics. Bacteriologic studies are helpful in guiding antibiotic therapy.

Consider performing ultrasonography and fistulography (see Imaging Studies).

Patient consent should be obtained for an open excision of the gallbladder and fistula. For patients with choledocholithiasis, open common bile duct exploration should be discussed, although a separate, endoscopic procedure can also be performed.

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Intraoperative Details

Considerations include the incision site, whether to incorporate the external opening into the incision, and method of closure. The procedure can be performed via a midline laparotomy or a subcostal incision. Many choose to close the muscle and fascia at the fistula site but leave the skin to heal by secondary intention.

In attempting this procedure laparoscopically, perform the gallbladder dissection in the usual fashion to reveal the cystic artery and duct. Following ligation of both cystic duct and artery, the gallbladder must be mobilized off the liver bed and abdominal wall fistula or abscess. Significant edema and thickening of the gallbladder hilum may complicate laparoscopic dissection.

In either technique, a drain should be inserted in the subhepatic space if a subhepatic collection is found.

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Follow-up

If the patient's wounds are allowed to heal through secondary intention, he or she should be observed until healing is complete.

Patients who are treated conservatively should be observed to ensure tract closure and adequate skin care to prevent skin irritation.

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Complications

  • Cholecystocutaneous fistula is a complication of neglected cholelithiasis.
  • Prior to discharge of the fistula, the patient may be septic. Necrotizing fasciitis of the anterior abdominal wall due to sepsis has been reported.[54]
  • Following discharge of the fistula, bilious discharge can cause skin irritation and dermatitis.
  • Chronic untreated fistulae can lead to dysplasia and subsequent malignant change similar to Marjolin ulcer. This is rare, and a review of the literature has revealed only one case of adenocarcinoma arising from a biliary fistula tract.[65]
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Outcome and Prognosis

Prognosis is generally good. However, as most patients with this condition are elderly, potential coexisting medical problems may complicate surgical intervention.

Malignant change in the fistulous tract is rare and generally occurs only after 10-20 years.[65]

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Contributor Information and Disclosures
Author

Cherry Ee Peck Koh, FRACS, MBBS, MS  Surgical Registrar, Department of General Surgery, Alfred Hospital, Bayside Health

Cherry Ee Peck Koh, FRACS, MBBS, MS is a member of the following medical societies: Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

David Merenstein, MBBS, FRACS  Consulting Staff, General and Endocrine Surgery, Department of Surgery, Monash Medical Centre, Faculty of Medicine, Nursing and Health Services; Consulting Staff, Sandringham and District Hospital, William Angliss Hospital and West Gippsland Hospital

David Merenstein, MBBS, FRACS is a member of the following medical societies: Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Simon Roger Berry, MBBS  General, UGI, and HPB Surgeon, Surgical Consulting Group, Cabrini Hospital, Australia

Simon Roger Berry, MBBS is a member of the following medical societies: Australian Medical Association, Australian Medical Association, International Hepato-Pancreato-Biliary Association, and Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor, Associate Program Director, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David L Morris, MD, PhD, FRACS  Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

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A 90-year-old man referred with abdominal wall abscess in the right upper quadrant.
Computed tomography (CT) scan demonstrating a grossly inflamed gallbladder with a stone within the gallbladder, with partial gallbladder herniation into overlying abdominal wall musculature, marked overlying tissue inflammation, and fistulous tract.
Table. Case Reports of Cholecystocutaneous Fistula in the Past 50 Years From 1961 to 2011
Author(s)Year PublishedNumber of CasesCountry of Origin
Gordon et al[6] 20111United States of America
Sayed et al[7] 20101United Kingdom
Pezzilli et al[8] 20101Italy
Metsemakers et al[9] 20101Belgium
Tallon Aquilar et al[10] 20101Spain
Hawari et al[11] 20101United Kingdom
Gandhi et al[12] 20091New Zealand
Murphy et al[13] 20081United Kingdom
Ijaz et al[14] 20081United Kingdom
Chatterjee et al[15] 20071India
Malik et al[16] 20071United Kingdom
Nagral et al[17] 20071India
Marwah et al[18] 20071India
Shrestha et al[19] 20061United Kingdom
Cruz et al[20] 20061Brazil
Salvador-Izquierdo et al[21] 20061Spain
Yuceyar et al[22] 20051Turkey
Khan et al[23] 20051Saudi Arabia
Dutriaux et al[24] 20051France
Gossage et al[25] 20041United Kingdom
Vasanth et al[26] 20041United States of America
Mathonnet et al[27] 20021France
Chang et al[28] 20021Taiwan
Flora et al[29] 20011United Kingdom
Ramos Rincon et al[30] 20011Spain
Nicholson et al[31] 19991United States of America
Avital et al[32] 19981Israel
Kumar[33] 19981United States of America
Andley et al[34] 19961India
Birch et al[35] 19911United Kingdom
Carragher et al[36] 19901United Kingdom
Rosario et al[37] 19901United States of America
Sevonius et al[38] 19881Sweden
Gibson et al[39] 19871United Kingdom
Bilanovic et al[40] 19871Croatia
Tuna et al[41] 19861United States of America
Hakaim et al[42] 19861United States of America
Rye et al[43] 19851Denmark
Kulicki et al[44] 19841Poland
Davies et al[45] 19841United Kingdom
Abril et al[46] 19841United States of America
Nayman[47] 19831Australia
Ulreich et al[48] 19831United States of America
Hoffman et al[49] 19821United States of America
Fitchett et al[50] 19701United States of America
Callen[51] 19791United States of America
Orr[52] 19791Australia
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