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.
Surgical Therapy
Both the gallbladder and fistula must be resected to achieve a cure. However, given that this condition commonly occurs in elderly patients who may have multiple medical comorbidities, surgical treatment must be tailored according to the patient's fitness for surgery.
Choice of surgical approach
Several decisions must be made at the time of surgery, including whether to use a one-stage or a staged procedure (drainage of abscess with surgical excision of gallbladder and fistula vs drainage of abscess to control sepsis followed by 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 Operative Details below).
Drainage of the cholecystocutaneous abscess prior to spontaneous discharge turns the abscess into a fistula and allows control of sepsis. Appropriate intravenous (IV) antibiotics should be initiated as well. A drainage tube may be inserted into the fistula to keep the tract patent. However, only an experienced physician should perform this maneuver; 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 under way should further expertise be required.
For definitive treatment of the underlying gallbladder disease or fistula, either a laparoscopic or an open approach can be considered. A laparoscopic approach is less invasive; however, the conversion rate may be high, depending on the intra-abdominal findings (eg, adhesions to the surrounding tissue). [48] Port placement may also have 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 vs definitive excision
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 that there is no distal biliary tree obstruction. [12, 69] In the 1949 series from Henry et al, six of 37 patients (16%) experienced spontaneous healing. [12] Incision and drainage of the cholecystic abscess without definitive excision of the tract or gallbladder led to spontaneous healing in three more. Whereas 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.
Preparation for surgery
Before surgical treatment, an infective or inflammatory process should be adequately treated with antibiotics. Bacteriologic studies are helpful in guiding antibiotic therapy.
Ultrasonography (US) and fistulography should be considered (see Imaging Studies). [68]
Patient consent should be obtained for an open excision of the gallbladder and fistula. For patients with choledocholithiasis, open common bile duct (CBD) exploration should be discussed, though a separate endoscopic procedure can also be performed.
Operative 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 the laparoscopic version of the procedure, the gallbladder dissection is performed in the usual fashion to reveal the cystic artery and duct. After ligation of both the cystic duct and the cystic 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.
Complications
Cholecystocutaneous fistula is a complication of neglected cholelithiasis. [2, 10]
Prior to discharge of the fistula, the patient may be in a septic state. Necrotizing fasciitis of the anterior abdominal wall due to sepsis has been reported. [62]
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. [70]
Long-Term Monitoring
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 to confirm that adequate skin care is provided to prevent skin irritation.
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A 90-year-old man referred with abdominal wall abscess in the right upper quadrant.
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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.
Tables
Author(s) |
Year Published |
Number of Cases |
Country of Origin |
|||
Sodhi et al [14] |
2012 |
1 |
India |
|||
Ozdemir et al [15] |
2012 |
1 |
Turkey |
|||
Andersen et al [16] |
2012 |
1 |
Denmark |
|||
Ioannidis et al [17] |
2012 |
1 |
Italian |
|||
Baty et al [18] |
2011 |
1 |
Australia |
|||
Cheng et al [19] |
2011 |
1 |
Taiwan |
|||
Khan et al [20] |
2011 |
1 |
Ireland |
|||
Gordon et al [21] |
2011 |
1 |
United States of America |
|||
Sayed et al [22] |
2010 |
1 |
United Kingdom |
|||
Pezzilli et al [23] |
2010 |
1 |
Italy |
|||
Metsemakers et al [24] |
2010 |
1 |
Belgium |
|||
Tallon Aquilar et al [25] |
2010 |
1 |
Spain |
|||
Hawari et al [26] |
2010 |
1 |
United Kingdom |
|||
Gandhi et al [27] |
2009 |
1 |
New Zealand |
|||
Murphy et al [28] |
2008 |
1 |
United Kingdom |
|||
Ijaz et al [29] |
2008 |
1 |
United Kingdom |
|||
Chatterjee et al [30] |
2007 |
1 |
India |
|||
Malik et al [31] |
2007 |
1 |
United Kingdom |
|||
Nagral et al [32] |
2007 |
1 |
India |
|||
Marwah et al [33] |
2007 |
1 |
India |
|||
Shrestha et al [34] |
2006 |
1 |
United Kingdom |
|||
Cruz et al [35] |
2006 |
1 |
Brazil |
|||
Salvador-Izquierdo et al [36] |
2006 |
1 |
Spain |
|||
Yuceyar et al [37] |
2005 |
1 |
Turkey |
|||
Khan et al [38] |
2005 |
1 |
Saudi Arabia |
|||
Dutriaux et al [39] |
2005 |
1 |
France |
|||
Gossage et al [40] |
2004 |
1 |
United Kingdom |
|||
Vasanth et al [41] |
2004 |
1 |
United States of America |
|||
Mathonnet et al [42] |
2002 |
1 |
France |
|||
Chang et al [43] |
2002 |
1 |
Taiwan |
|||
Flora et al [44] |
2001 |
1 |
United Kingdom |
|||
Ramos Rincon et al [45] |
2001 |
1 |
Spain |
|||
Nicholson et al [46] |
1999 |
1 |
United States of America |
|||
Avital et al [47] |
1998 |
1 |
Israel |
|||
Kumar [48] |
1998 |
1 |
United States of America |
|||
Andley et al [49] |
1996 |
1 |
India |
|||
Birch et al [50] |
1991 |
1 |
United Kingdom |
|||
Carragher et al [51] |
1990 |
1 |
United Kingdom |
|||
Rosario et al [52] |
1990 |
1 |
United States of America |
|||
Sevonius et al [53] |
1988 |
1 |
Sweden |
|||
Gibson et al [54] |
1987 |
1 |
United Kingdom |
|||
Bilanovic et al [55] |
1987 |
1 |
Croatia |
|||
Tuna et al [56] |
1986 |
1 |
United States of America |
|||
Hakaim et al [57] |
1986 |
1 |
United States of America |
|||
Rye et al [58] |
1985 |
1 |
Denmark |
|||
Kulicki et al [59] |
1984 |
1 |
Poland |
|||
Davies et al [60] |
1984 |
1 |
United Kingdom |
|||
Abril et al [61] |
1984 |
1 |
United States of America |
|||
Nayman [62] |
1983 |
1 |
Australia |
|||
Ulreich et al [63] |
1983 |
1 |
United States of America |
|||
Hoffman et al [64] |
1982 |
1 |
United States of America |
|||
Fitchett et al [65] |
1970 |
1 |
United States of America |
|||
Callen [66] |
1979 |
1 |
United States of America |
|||
Orr [67] |
1979 |
1 |
Australia |
|||
