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Cholecystocutaneous Fistula Treatment & Management

  • Author: Cherry Ee Peck Koh, MBBS, MS, FRACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Oct 08, 2013
 

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.[40] 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.[6, 67] In the review by Henry and Orr in 1949, of 37 patients within their series, spontaneous healing occurred in 6 (16%) patients.[6] 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.[68]

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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, MBBS, MS, FRACS Colorectal and General Surgeon, Royal Prince Alfred Hospital, Australia

Cherry Ee Peck Koh, MBBS, MS, FRACS 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: International Hepato-Pancreato-Biliary Association, Australian Medical Association, Australian Medical Association, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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: Received none from RFA Medical for director; Received none from MRC Biotec for director.

Chief Editor

John Geibel, MD, DSc, MSc, 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; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, 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, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

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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 52 Years from 1961 to 2013
Author(s) Year Published Number of Cases Country of Origin
Sodhi et al[1] 2012 1 India
Ozdemir et al[7] 2012 1 Turkey
Andersen and Friis-Andersen[8] 2012 1 Denmark
Ioannidis et al[9] 2012 1 Italian
Baty et al[10] 2011 1 Australia
Cheng et al[11] 2011 1 Taiwan
Khan et al[12] 2011 1 Ireland
Gordon et al[13] 2011 1 United States of America
Sayed et al[14] 2010 1 United Kingdom
Pezzilli et al[15] 2010 1 Italy
Metsemakers et al[16] 2010 1 Belgium
Tallon Aquilar et al[17] 2010 1 Spain
Hawari et al[18] 2010 1 United Kingdom
Gandhi et al[19] 2009 1 New Zealand
Murphy et al[20] 2008 1 United Kingdom
Ijaz et al[21] 2008 1 United Kingdom
Chatterjee et al[22] 2007 1 India
Malik et al[23] 2007 1 United Kingdom
Nagral et al[24] 2007 1 India
Marwah et al[25] 2007 1 India
Shrestha et al[26] 2006 1 United Kingdom
Cruz et al[27] 2006 1 Brazil
Salvador-Izquierdo et al[28] 2006 1 Spain
Yuceyar et al[29] 2005 1 Turkey
Khan et al[30] 2005 1 Saudi Arabia
Dutriaux et al[31] 2005 1 France
Gossage et al[32] 2004 1 United Kingdom
Vasanth et al[33] 2004 1 United States of America
Mathonnet et al[34] 2002 1 France
Chang et al[35] 2002 1 Taiwan
Flora et al[36] 2001 1 United Kingdom
Ramos Rincon et al[37] 2001 1 Spain
Nicholson et al[38] 1999 1 United States of America
Avital et al[39] 1998 1 Israel
Kumar[40] 1998 1 United States of America
Andley et al[41] 1996 1 India
Birch et al[42] 1991 1 United Kingdom
Carragher et al[43] 1990 1 United Kingdom
Rosario et al[44] 1990 1 United States of America
Sevonius et al[45] 1988 1 Sweden
Gibson et al[46] 1987 1 United Kingdom
Bilanovic et al[47] 1987 1 Croatia
Tuna et al[48] 1986 1 United States of America
Hakaim et al[49] 1986 1 United States of America
Rye et al[50] 1985 1 Denmark
Kulicki et al[51] 1984 1 Poland
Davies et al[52] 1984 1 United Kingdom
Abril et al[53] 1984 1 United States of America
Nayman[54] 1983 1 Australia
Ulreich et al[55] 1983 1 United States of America
Hoffman et al[56] 1982 1 United States of America
Fitchett et al[57] 1970 1 United States of America
Callen[58] 1979 1 United States of America
Orr[59] 1979 1 Australia
             
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