Perforated acute cholecystitis complicated by a fistula to the appendix
Hugo Bonatti
Meritus Surgical Specialists, Hagerstown, MD, USA
Date of Decision 25-Mar-2022
Date of Acceptance 26-Mar-2022
Date of Web Publication 17-Jun-2022
Meritus Surgical Specialists, 11110 Medical Campus Road, Suite 147, Hagerstown, MD 21742
DOI: 10.4103/wjsi.wjsi_4_22
Fistulas between the gallbladder (GB) and intestinal tract are rare but require surgical repair. The most commonly involved alimentary tract segments are the duodenum and the hepatic colon flexure. An 80-year-old obese male with multiple comorbid conditions presented with acute right upper quadrant pain, weakness, and signs of sepsis; computed tomography (CT) scan showed a perihepatic phlegmon and pneumobilia suspicious for contained GB perforation. He was not a surgical candidate at this time; antibiotics were started and a percutaneous cholecystostomy tube was placed. Magnetic resonance cholangiopancreatography (MRCP) showed choledocholithiasis and he underwent endoscopic retrograde cholangiopancreatography revealing GB perforation and tracking of contrast toward the right lower quadrant; stone extraction was done and a biliary stent was placed. After 2 months of rehabilitation and clinical improvement, he underwent laparoscopic interval cholecystectomy. The appendix was fused with the GB creating a cholecystoappendiceal fistula. The appendix was stapled at the cecal base. Thereafter, the cholecystectomy was done. The GB fundus was fused to the hepatic duct, and during dissection, an anterior wall injury to the hepatic duct occurred, which was successfully managed by laparoscopic T-tube insertion. The patient recovered well and removed the T-tube himself after 4 weeks. An MRCP showed no evidence of a leak or stenosis. To the best of our knowledge, this is the first reported case of a cholecystoappendiceal fistula, which explains the pneumobilia on the initial CT scan. In a retrospective study, the cholangiogram showed the pathology but was not recognized. Combined laparoscopic appendectomy and cholecystectomy was done.
Keywords: Cholecystoenteric fistula, laparoscopic appendectomy, laparoscopic cholecystectomy
Bonatti H. Perforated acute cholecystitis complicated by a fistula to the appendix. World J Surg Infect 2022;1:43-5
Bonatti H. Perforated acute cholecystitis complicated by a fistula to the appendix. World J Surg Infect [serial online] 2022 [cited 2023 Jan 29];1:43-5. Available from: https://www.worldsurginfect.com/text.asp?2022/1/1/43/347768
Acute cholecystitis and appendicitis are among the most commonly encountered conditions in general surgery. Laparoscopic cholecystectomy and appendectomy are rarely performed at the same time.[1],[2]
Fistulas between the gallbladder (GB) and intestinal tract are rare and frequently require surgical intervention.[3] Due to the anatomical proximity, the duodenum and the hepatic colon flexure are most commonly involved in such cholecystoenteric fistulas, whereas other segments of the intestine are rarely involved. In case of a cholecystoduodenal fistula, migration of gallstones into the alimentary tract may occur, and if a large stone is passed, this may lead to gallstone ileus.[4] In most cases, the foreign body gets lodged in the terminal ileum and requires surgical intervention. Usually, the stone is extracted, but the GB does not need to be removed in most cases.[5] If the hepatic flexure of the colon is involved in the fistula, colonic obstruction from a large stone may develop; however, in most cases, the GB becomes chronically inflamed as gas and potentially fecal matter travels into the GB, causing chronic infection.[6],[7] Gas may also ascend into the biliary system causing cholangitis and on imaging, aerobilia can be seen. In these cases, laparoscopic cholecystectomy with fistula closure is the best option, but in some cases, a segmental colectomy may be necessary.[8],[9] Whereas in the vast majority, GB disease causes the fistula, also colonic disorders such as diverticulitis or malignancies eroding into the GB have been reported.[10] We describe a case of the cholecystocolonic fistula in an elderly male patient.
An 80-year-old obese male with multiple comorbid conditions including coronary artery disease and chronic obstructive pulmonary disease presented with acute right upper quadrant (RUQ) pain, weakness, and signs of sepsis to the emergency room. On physical examination, he was found severely debilitated and bedridden. His abdomen was soft, but he complained of significant RUQ tenderness, there was no rebound. A 4 cm reducible umbilical hernia was also noted. He was afebrile with the normal blood pressure but tachycardia up to 120 bpm and an irregular rhythm. White blood count was elevated to 12K/ml; liver enzymes and total bilirubin were within the normal limits. He was started on intravenous fluid and antibiotics (piperacillin/tazobactam at 3750 mg every 8 h). Computed tomography (CT) scan showed a perihepatic phlegmon and pneumobilia suspicious for contained GB perforation or cholecystoenteric fistula [Figure 1]a and [Figure 1]b. Due to the multiple comorbid conditions, mild dementia and poor performance status, he was not considered a surgical candidate at this time. He was admitted, antibiotics were continued, and a percutaneous cholecystostomy tube was placed the next day [Figure 2]a. He clinically improved, but his liver enzymes started to rise, and magnetic resonance cholangiopancreatography (MRCP) showed choledocholithiasis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) revealing GB perforation and tracking of contrast toward the right lower quadrant [Figure 2]b. A sphincterotomy and stone extraction were done and a biliary stent was placed. Cholangiogram during cholecystostomy placement and ERCP both showed contrast tracking toward the right suggesting a perforation but no contrast reached the colon.
Figure 1: Computed tomography scan at admission (a, transverse; b, coronal view). Dense inflammatory changes around the gallbladder, gas in the gallbladder, and pronounced aerobilia
Figure 2: (a) Cholangiogram following cholecystostomy tube placement; (b) Endoscopic retrograde cholangiopancreatography: Cholecystolithiasis; gallbladder fills with contrast; dye is tracking toward the right side (arrow) suggesting contained perforation
He was discharged to a nursing home for aggressive rehabilitation and made a remarkable recovery clinically improving and he was able to ambulate with the help of a walker. He was medically cleared for surgery. Laparoscopic interval cholecystectomy was started by placing 5 mm trocars in the left upper quadrant (x2) and a 10–12 mm port into the umbilical hernia. Dense omental adhesions to the liver and GB were divided with electrocautery and the harmonic scalpel exposing the colon. The cecum was found flipped up with the appendix fused with the GB fundus on the right side creating a cholecystoappendiceal fistula [Figure 3]a. The colon was dissected off, the mesoappendix was divided with the harmonic scalpel, and the appendix was stapled at the cecal base [Figure 3]b. Thereafter, cholecystectomy was continued cutting with the harmonic scalpel through the dense scar tissue at the GB plate [Figure 3]c. The GB fundus on the left side was fused to the hepatic duct, and during dissection, a 1 cm anterior wall injury to the hepatic duct occurred, which was successfully managed by laparoscopic T-tube insertion [Figure 3]d. The specimen (appendix with the GB) was removed through the umbilical hernia site after port removal and the hernia was primarily closed. Pathology showed severe acute and chronic inflammation of the GB extending into the liver parenchyma and a chronically inflamed appendix. He had an uneventful postoperative course. After 2 weeks, CT scan showed postoperative changes but no evidence of abscess or leak, and the biliary stent was endoscopically removed.
Figure 3: Intraoperative findings. (a) The appendix is fused with the gallbladder fundus (arrow). (b) The appendix is stapled at the base (arrow). (c) Cholecystectomy using harmonic scalpel due to dense inflammatory changes; (d) anterior hepatic duct injury managed with T-tube insertion
The patient recovered well in the nursing home, however, showed signs of confusion. After 4 weeks, he was brought emergently from the nursing home to the office after he had removed the T-tube himself expressing that "he did not want and need it anymore." He did clinically well and follow-up MRCP showed no evidence of a leak or stenosis.
Cholecytstoenteric fistulas are rare pathologies and more commonly form between the GB and duodenum than the colon; however, connections to other organs have also been reported.[3] A fistula between the appendix could form in case of a disorder of the appendix or GB if the two organs come close. Either the GB reaches down into the right lower quadrant or the appendix is directed up toward the liver. In our case, the mobile cecum was flipped up bringing the appendix next to the GB. Once acute cholecystitis developed and the GB perforated, the appendix covered the leak and the fistula developed.
On the initial CT scan, pronounced pneumobilia was noted suggestive of a connection to the intestinal tract. In a retrospective study, the cholangiogram showed the cholecystoappendiceal fistula, but the contrast leak was not interpreted as such. However, a correct interpretation of the imaging studies would not have changed the surgical approach. Combined en bloc laparoscopic appendectomy and cholecystectomy was done by first stapling the appendix base and then performing the GB removal. A cecectomy, ileocecal resection, or right hemicolectomy was not indicated in this case. The cholecystectomy was as expected technically challenging given the acute and chronic inflammation, cholecystostomy tube, and previous ERCP. The right side of the fundus harbored the fistula and the left side was fused with the hepatic duct – separation of the GB from the duct was done with the harmonic scalpel and a small injury to the duct was successfully managed by T-tube insertion.
Minimally invasive approach to such fistulas has been shown to be feasible and safe and also robotic-assisted surgery has recently been reported.[11] We report to the best of our knowledge the first case of a cholecystoappendiceal fistula and we were able to manage it successfully with en bloc laparoscopic appendectomy and cholecystectomy.
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[Figure 1], [Figure 2], [Figure 3]
Bonatti H
Cholecystoenteric fistula
laparoscopic cholecystectomy
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