A case of biliary gastric fistula following percutaneous radiofrequency thermal ablation of hepatocellular carcinoma

Percutaneous radiofrequency thermal ablation （RFA） is an effective and safe therapeutic modality in the management of liver malignancies, performed with ultrasound guidance. Potential complications of RFA include liver abscess, ascites, pleural effusion, skin burn, hypoxemia, pneumothorax, subcapsular hematoma, hemoperitoneum, liver failure, tumour seeding, biliary lesions. Here we describe for the first time a case of biliary gastric fistula occurred in a 66-year old man with a Child＇s class A alcoholic liver cirrhosis as a complication of RFA of a large hepatocellular carcinoma lesion in the nl segment. In the light of this case, RFA with injection of saline between the liver and adjacent gastrointestinal tract, as well as laparoscopic RFA, ethanol injection （PEI）, or other techniques such as chemoembolization, appear to be more indicated than percutaneous RFA for large lesions close to the gastrointestinal tract.

Bronchobiliary fistula in a patient with liver cancer

Bronchobiliary fistula(BBF) is a pathologic channel between the biliary tract and bronchial tree. In general, congenital BBF is relatively rare in adult patients. There are a few case reports suggesting that BBF is mainly secondary to hepatobiliary diseases, such as biliary obstruction, tumor, surgery, or liver abscess, and liver tumor is the predominant causative factor [1]. In addition, with the increasing number of liver and biliary surgeries and interventional therapies in recent years, more cases of BBF were reported as a postoperative complication [ 2, 3 ]. In this case, we presented a patient who underwent interventional treatment for liver tumor and was treated for his respiratory symptoms but diagnosed with BBF finally. Here, we summarized the clinical features and main diagnostic procedures of the case, aiming to provide evidence for early identification and diagnosis of BBF.

Arterio-biliary fistula as rare complication of chemoradiation therapy for intrahepatic cholangiocarcinoma

Significant hemobilia due to arterio-biliary fistula is a very rare complication of chemoradiation therapy(CRT) for unresectable intrahepatic cholangiocarcinoma(ICC).Here we report a case of arterio-biliary fistula after CRT for unresectable ICC demonstrated by angiographic examinations.This fistula was successfully treated by endovascular embolization.Hemobilia is a rare complication,but arterio-biliary fistula should be considered after CRT of ICC.

Biliary fistula after treatment for hydatid disease of the liver:When to intervene

AIM:To determine the outcome of patients with biliary fistula(BF)after treatment for hydatid disease of the liver. METHODS:Between January 2000 and December 2010,out of 301 patients with a diagnosis of hydatid cyst of the liver,282 patients who underwent treatment [either surgery or puncture,aspiration,injection and reaspiration(PAIR)procedure]were analysed.Patients were grouped according to the presence or absence of postoperative biliary fistula(PBF)(PBF vs no-PBF groups,respectively).Preoperative clinical,radiological and laboratory characteristics,operative characteristics including type of surgery,peroperative detection of BF,postoperative drain output,morbidity,mortality and length of hospital stays of patients were compared amongst groups.Multivariate analysis was performed to detect factors predictive of PBF.Receiver operative characteristics(ROC)curve analysis were used to determine ideal cutoff values for those variables found to be significant.A comparison was also made between patients whose fistula closed spontaneously(CS)and those with intervention in order to find predictive fac-tors associated with spontaneous closure. RESULTS:Among 282 patients[median(range)age, 23(16-78)years;77.0%male];210(74.5%)were treated with conservative surgery,33(11.7%)radical surgery and 39(13.8%)underwent percutaneous drainage with PAIR procedure A PBF developed in 46(16.3%) patients,all within 5 d after operation.The maximum cyst diameter and preoperative alkaline phosphatase levels(U/L)were significantly higher in the PBF group than in the no-PBF group[10.5±3.7 U/L vs 8.4±3.5 U/L(P<0.001)and 40.0±235.1 U/Lvs 190.0±167.3 U/L(P=0.02),respectively].Hospitalization time was also significantly longer in the PBF group than in the no-PBF group[37.4±18.0 d vs 22.4±17.9 d(P< 0.001)].A preoperative high alanine aminotransferase level(>40 U/L)and a peroperative attempt for fistula closure were significant predictors of PBF development (P=0.02,95%CI:-0.03-0.5 and P=0.001,95%CI:0.1-0.4),respectively.Comparison of patients whose PBF CS or with biliary intervention(BI)revealed that the mean diameter of the cyst was not significantly different between CS and BI groups however maximum drain output was significantly higher in the BI group(81.6± 118.1 cm vs 423.9±298.4 cm,P<0.001).Time for fistula closure was significantly higher in the BI group(10.1 ±3.7 d vs 30.7±15.1 d,P<0.001).The ROC curve analysis revealed cut-off values of a maximum bilious drainage<102 mL and a waiting period of 5.5 postoperative days for spontaneous closure with the sensitivity and specificity values of(83.3%-91.1%,AUC:0.90)and (97%-91%,AUC:0.95),respectively.The multivariate analysis demonstrated a PBF drainage volume<102 mL to be the only statistically significant predictor of spontaneous closure(P<0.001,95%CI:0.5-1.0). CONCLUSION:Patients with PBF after hydatid surgery often have complicated postoperative course with serious morbidity.Patients who develop PBF with an output <102 mL might be managed expectantly.

Internal biliary fistula due to cholelithiasis:A single-centre experience

AIM： To discuss about the perioperative problems encountered in patients with internal biliary fistula （IBF） caused by cholelithiasis.METHODS： In our hospital, 4 130 cholecystectomies were carried out for symptomatic cholelithiasis from January 2000 to March 2004 and only 12 patients were diagnosed with IBF. The perioperative data of these 12 IBF patients were analyzed retrospectively.RESULTS： The incidence of IBF due to cholelithiasis was nearly 0.3%. The mean age was 57 years. Most of the patients presented with non-specific complaints. Only two patients were considered to have IBF when gallstone ileus was observed during the investigations. Nine patients underwent emergency laparotomy with a pre-operative diagnosis of acute abdomen. In the remaining three patients, elective laparoscopic cholecystectomy was converted to open surgery after identification of IBF. Ten patients had cholecystoduodenal fistula and two patients had cholecystocholedochal fistula. The mean hospital stay was 23 d. Two wound infections, three bile leakages and three mortalities were observed.CONCLUSION： Cholecystectomy has to be performed in early stage in the patients who were diagnosed as cholelithiasis to prevent the complications like IBF which is seen rarely. Suspicion of IBF should be kept in mind, especially in the case of difficult dissection during cholecystectomy and attention should be paid in order to prevent iatrogenic injuries.

Combined radiologic and endoscopic treatment(using the “rendezvous technique”) of a biliary fistula following left hepatectomy

Despite the ongoing decrease in the frequency of complications after hepatectomy, biliary fistulas still occur and are associated with high morbidity and mortality rates. Here, we report on an unusual technique for managing biliary fistula following left hepatectomy in a patient in whom the right posterior segmental duct joined the left hepatic duct. The biliary fistula was treated with a combined radiologic and endoscopic procedure based on the "rendezvous technique". The clinical outcome was good, and reoperation was not required.

Colonic perforation with duodenal-colic fistula formation by a biliary stent in a liver transplant recipient

Endoscopic retrograde cholangio-pancreatography (ERCP) is increasing utilized in the setting of liver transplantation for a number of post-operative related biliary issues. Although ERCP represents an excellent technology, it is not without attendant risk including sepsis, bleeding and perforation. In this case report, the first of its kind, is described the occurrence of a migrated biliary stent induced duodenal-colic fistula formation in a liver transplantation patient who had required dual biliary stenting given post-operative biliary structuring. The placement of dual stents and their size are likely implicated in the cause of perforation. The enteric anatomy and the medical immunosuppression likely contributed to a delay in diagnosis and worse outcome.

Endoscopic management of postcholecystectomy biliary leakage

BACKGROUND: Biliary leak is an uncommon but significant complication following cholecystectomy. Endotherapy is an established method of treatment. However, the optimal intervention is not known. METHOD: Eighty-five patients with postcholecystectomy biliary leaks from July 2000 to March 2009 were retrospectively evaluated. RESULTS: The study population was 20 males and 65 females with a mean age of 42.47 years. Patients presented with abdominal pain (46), jaundice (23), fever (23), abdominal distension (42), or bilious abdominal drain (67). Endoscopic retrograde cholangiopancreatography detected a leak at the cystic duct stump in 45 patients, stricture with middle common bile duct leak in 4, leak from the right hepatic duct in 3, and a ligated common bile duct in 32. Twelve also had bile duct stones. One had a broken T-tube with stones Endotherapy was possible in 53 patients. Three patients with stones, one with a broken T-tube with stones, and 4 with stricture of the common bile duct with a leak were managed with sphincterotomy and stenting. Eight patients with a cystic duct stump leak with stones were managed with sphincterotomy and stone extraction. Three outpatients and 12 inpatients with a cystic duct stump leak were managed with sphincterotomy and stent and sphincterotomy and nasobiliary drain, respectively. Five patients with a cystic duct stump leak were managed with stenting. Sixteen with coagulopathy were managed with only nasobiliary drain (9) or stent (7). Leak closure was achieved in 100% patients Four developed mild pancreatitis which improved with conservative treatment.CONCLUSIONS: Endoscopic intervention is a safe and effective method of treatment of postcholecystectomy biliary leaks. However, management should be individualized based on factors such as outpatients or inpatients, presence of stone, stricture, ligature, or coagulopathy.

Management of perianal fistulas in Crohn's disease:An upto-date review

Perianal disease is one of the most disabling manifestations of Crohn's disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagnosis,based on endoscopy,magnetic resonance imaging,endoanal ultrasound and examination under anesthesia,is crucial for perianal fistula treatment.Available medical and surgical therapies are discussedin this review,including new local treatment modalities that are under investigation.

Biliary phytobezoar resulting in intestinal obstruction

Phytobezoar is the most common type of bezoar.It is composed of indigestible vegetable matter and is usually found in the stomach.Biliary phytobezoar is extremely rare and difficult to diagnose preoperatively.The pathogenesis is not clear,and there have been only a few reports of biliary bezoars associated with sphincteric impairmentat the ampulla of Vater.Here,we present a report of biliary bezoar that resulted in jejunal obstruction.We were unable to identifythe bezoar in the extrahepatic bile duct until it obstructed the small bowel lumen.To our knowledge,this is the first report of small bowel obstruction resulting frommigration of a biliary bezoar.

Biliary leakage following pancreaticoduodenectomy:Prevalence,risk factors and management

Background: Few studies investigated biliary leakage after pancreaticoduodenectomy(PD) especially when compared to postoperative pancreatic fistula(POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management. Methods: We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group(1) included patients who developed biliary leakage and group(2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed. Results: The study included 555 patients. Forty-four patients(7.9%) developed biliary leakage. Ten patients(1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography(ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients(90.9%). Only 4 patients(9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group(6.8% vs 3.9%, P = 0.05). Conclusions: Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases.

Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent

AIM: To highlight the fatal complication caused by expanding biliary stents and the importance of avoiding use of expanding stent in potentially curable diseases.METHODS: Arteriobiliary fistula is an uncommon cause of haemobilia. We describe a case of right hepatic artery pseudoaneurysm causing arteriobiliary fistula and presenting as severe malena and cholangitis, in a patient with a mesh metal biliary stent. The patient had lymphoma causing bile duct obstruction.RESULTS: Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolisation of the pseudo aneurysm successfully controlled the bleeding.CONCLUSION: Bleeding from the pseudo aneurysm of the hepatic artery can be fatal. Mesh metal stents in biliary tree can cause this complication as demonstrated in this case.So mesh metal stent insertion should be avoided in potentially benign or in curable conditions. Difficulty in diagnosis and management is discussed along with the review of the literature.

Influence of bile contamination for patients who undergo pancreaticoduodenectomy after biliary drainage

BACKGROUND The influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy(PD)has not been thoroughly evaluated.AIM To evaluate the effect of preoperative biliary drainage and bile contamination on the outcomes of patients who undergo PD.METHODS The database of 4101 patients who underwent PD was reviewed.Preoperative biliary drainage was performed in 1964 patients(47.9%),and bile contamination was confirmed in 606 patients(14.8%).RESULTS The incidence of postoperative infectious complications was 37.9%in patients with preoperative biliary drainage and 42.4%in patients with biliary contamination,respectively.Patients with extrahepatic bile duct carcinoma,ampulla of Vater carcinoma,and pancreatic carcinoma had a high frequency of preoperative biliary drainage(82.9%,54.6%,and 50.8%)and bile contamination(34.3%,26.2%,and 20.2%).Bile contamination was associated with postoperative pancreatic fistula(POPF)Grade B/C,wound infection,and catheter infection.A multivariate logistic regression analysis revealed that biliary contamination(odds ratio 1.33,P=0.027)was the independent risk factor for POPF Grade B/C.The three most commonly cultured microorganisms from bile(Enterococcus,Klebsiella,and Enterobacter)were identical to those isolated from organ spaces.CONCLUSION In patients undergoing PD,bile contamination is related to postoperative infectious complication including POPF Grade B/C.The management of biliary contamination should be standardised for patients who require preoperative biliary drainage for PD,as the main microorganisms are identical in both organ spaces and bile.

Total closure of pancreatic section for end-to-side pancreaticojejunostomy decreases incidence of pancreatic fistula in pancreaticoduodenectomy

BACKGROUND： Postoperative pancreatic fistula （POPF） is a serious complication and results in prolonged hospitalization and high mortality. The present study aimed to evaluate the safety and effectiveness of total closure of pancreatic section for end-to-side pancreaticojejunostomy in pancreaticoduodenectomy （PD）. METHODS： This was a prospective randomized clinical trial comparing the outcomes of PD between patients who un- derwent total closure of pancreatic section for end-to-side pancreaticojejunostomy （Group A） vs those who underwent conventional pancreaticojejunostomy （Group B）. The primary endpoint was the incidence of pancreatic fistula. Secondary endpoints were morbidity and mortality rates. RESULTS： One hundred twenty-three patients were included in this study. The POPF rate was significantly lower in Group A than that in Group B （4.8% vs 16.7%, P〈0.05）. About 38.3% patients in Group B developed one or more complications; this rate was 14.3% in Group A （P〈0.01）. The wound/abdomi- nal infection rate was also much higher in Group B than that in Group A （20.0% vs 6.3%, P〈0.05）. Furthermore, the average hospital stays of the two groups were 18 days in Group A, and 24 days in Group B, respectively （P〈0.001）. However, there was no difference in the probability of mortality, biliary leakage,delayed gastric emptying, and pulmonary infection between the two groups. CONCLUSION： Total closure of pancreatic section for end-to- side pancreaticojejunostomy is a safe and effective method for pancreaticojejunostomy in PD.

Choledochoduodenal fistula caused by migration of endoclip after laparoscopic cholecystectomy

The wide use of surgical endoclips in laparoscopic surgery has led to a variety of complications.Postcholecystectomy endoclips migrating into the common bile duct after laparoscopic cholecystectomy is rare.A migrated endoclip can cause obstruction,serve as a nidus for stone formation,and cause cholangitis.While the exact pathogenesis is still unknown,it is probably related to improper clip application,subclinical bile leak,inflammation,and subsequent necrosis,allowing the clips to erode directly into the common bile duct.We present a case of endoclip migrating into the common bile duct and duodenum,resulting in choledochoduodenal fistula after laparoscopic cholecystectomy and a successful reconstruction of the biliary tract by a hepaticojejunostomy with a Roux-en-Y procedure.This case shows that surgical endoclips can penetrate into the intact bile duct wall through serial maceration,and it is believed that careful application of clips may be the only way to prevent their migration after laparoscopic cholecystectomy.

Biliopleural fistula: A rare complication of percutaneous transhepatic gallbladder drainage

A 79-year-old previously healthy man presented with acute acalculous cholecystitis with obstruction of the biliary tract. He was successfully treated with antibiotics and percutaneous transhepatic gallbladder drainage, but returned to the hospital two days after discharge with a rare complication of this technique, biliopleural fistula. A thoracostomy tube was inserted to drain the pleural effusion, and the patient’s previous antibiotics reinstated. After two weeks of drainage and antibiotics, the fistula healed spontaneously without the need for further intervention.

Cholecystoenteric fistula with and without gallstone ileus: A case series

Background: A cholecystoenteric stula (CEF) is an uncommon complication of gallstone disease. The aim of this study was to present our experience of a series of patients with CEF, presenting with or without gallstone ileus, along with their surgical outcomes. Methods: From 2015 to 2018, 3245 consecutive patients underwent cholecystectomy for gallbladder disease at our institution, of which 15 were diagnosed with a CEF. All electronic medical records were retrospectively reviewed. Results: Fifteen patients presented with CEF. Ten patients presented cholecystoduodenal stula, four pa- tients cholecystocolonic, and one patient cholecystogastric counterparts. Twelve patients were female. The median patient age was 61 years (range 33 86 years). Five patients presented with gallstone ileus treated by laparotomy and enterolithotomy. In ten patients, a laparoscopic approach was attempted, but conversion to open surgery was necessary for eight of them. The median operative time was 140 min (range 60 240 min), and the median operative blood loss was 50 mL (range 10600mL). The procedure-related morbidity and mortality rates were 13.3% and 6.7%, respectively. Conclusions: There is no consensus on the best treatment modality for a CEF, as the treatment outcome is mostly dependent on the surgeon’s expertise and the patient’s condition. Not all CEFs are accompanied by gallstone ileus. For such case, the main purpose is to resolve the intestinal obstruction and, unless necessary, avoidance of the gallbladder area.

Another new variant of Bouveret's syndrome

Although Bouveret's syndrome,i.e.gastric outlet obstruction by a large gallstone impacted in the proximal duodenum secondary to a cholecystoduodenal fistula,is rare,its pathogenesis and clinical features are well characterized.However,existence of variant forms of the syndrome are not well known,and as far as we know,only two cases of variant Bouveret's syndrome have been described in the English-language literature.We present a case of another new variant of Bouveret's syndrome in a 54-year-old Korean woman.

Cholecystoenteric fistula in a patient with advanced gallbladder cancer: A case report and review of literature

BACKGROUND Cholecystoenteric fistula(CEF)involves the formation of a spontaneous ano-malous tract between the gallbladder and the adjacent gastrointestinal tract.Chronic gallbladder inflammation can lead to tissue necrosis,perforation,and fistulogenesis.The most prevalent cause of CEF is chronic cholelithiasis,which rarely results from malignancy.Because the symptoms and laboratory findings associated with CEF are nonspecific,the condition is often misdiagnosed,pre-senting a challenge to the surgeon when detected intraoperatively.Therefore,a preoperative diagnosis of CEF is crucial.We present the case of a 57-year-old male with advanced gallbladder cancer(GBC)who arrived at the emergency room with persistent vomiting,abdominal pain,and diarrhea.An abdominopelvic computed tomography scan revealed a contracted gallbladder with bubbles in the fundus connected to the second por-tion of the duodenum and transverse colon.We suspected that GBC had invaded the adjacent gastrointestinal tract through a cholecystoduodenal fistula(CDF)or a cholecystocolonic fistula(CCF).He underwent multiple examinations,including esophagogastroduodenoscopy,an upper gastrointestinal series,colo-noscopy,and magnetic resonance cholangiopancreatography;the results of these tests con-firmed a diagnosis of synchronous CDF and CCF.The patient underwent a Roux-en-Y gastrojejunostomy and loop ileostomy to address the severe adhesions that were previously observed to cover the second portion of the duodenum and hepatic flexure of the colon.His symptoms improved with supportive treatment while hospitalized.He initiated oral targeted therapy with lenvatinib for further anticancer treatment.CONCLUSION The combination of imaging and surgery can enhance preoperative diagnosis and alleviate symptoms in patients with GBC complicated by CEF.

Cholecystoduodenal fistula presenting with upper gastrointestinal bleeding: A case report

BACKGROUND Cholecystoduodenal fistula is a rare complication of cholelithiasis.Symptoms are usually non-specific and often indistinguishable from those of etiologic diseases,but it rarely presents as severe gastrointestinal bleeding.Bleeding associated with cholecystoduodenal fistula usually requires surgery because significant bleeding from the cystic artery is unlikely to be resolved by conservative management or endoscopic hemostasis.CASE SUMMARY We report a case of cholecystoduodenal fistula that presented with hematemesis which was diagnosed by endoscopy and computed tomography.Endoscopic hemostasis could not be achieved,but surgical treatment was successful.Additionally,we have presented a literature review.CONCLUSION Cholecystoduodenal fistula should be considered as differential diagnosis when a patient with history of gallstone disease presents with gastrointestinal bleeding.