Fstulas Bilio-Digestivas 1. Cir Esp. 2007 Sep;82(3):180-1.

[Gallstones in a retained gastric antrum] [Article in Spanish] Cascales Snchez P, Martnez Moreno A, Usero Rebollo S, Garca Blzquez E, Moreno Resina JM. Servicio de Ciruga General y del Aparato Digestivo, Complejo Hospitalario Universitario de Albacete, Albacete, Espaa. pcascales@sescam.org Retained gastric antrum arises when there is incomplete excision of the gastric antrum during Billroth II gastrectomy for peptic ulcer disease. We report the case of a patient with gallstones in a retained gastric antrum, without biliodigestive fistula. This finding is extremely rare and we have found no previously reported cases in the literature. PMID: 17916291 [PubMed - indexed for MEDLINE] 2. BMC Gastroenterol. 2006 Jan 5;6:1. Development of bile duct bezoars following cholecystectomy caused by choledochoduodenal fistula formation: a case report. Moghaddam JA, Amini M, Adibnejad S. Department of General Surgery, Baqiyatallah Hospital, Baqiyatallah University of Medical Sciences, Mollasadra Street, Tehran, Iran. Akhavan_j@yahoo.com BACKGROUND: The formation of bile duct bezoars is a rare event. Its occurrence when there is no history of choledochoenteric anastomosis or duodenal diverticulum constitutes an extremely scarce finding. CASE PRESENTATION: We present a case of obstructive jaundice, caused by the concretion of enteric material (bezoars) in the common bile duct following choledochoduodenal fistula development. Six years after cholecystectomy, a 60-year-old female presented with abdominal pain and jaundice. Endoscopic retrograde cholangiopancreatography demonstrated multiple filling defects in her biliary tract. The size of the obstructing objects necessitated surgical retrieval of the stones. A histological assessment of the objects revealed fibrinoid materials with some cellular debris. Post-operative T-tube cholangiography (9 days after the operation) illustrated an open bile duct without any filling defects. Surprisingly, a relatively long choledochoduodenal fistula was detected. The fistula formation was assumed to have led to the development of the bile duct bezoar. CONCLUSION: Bezoar formation within the bile duct should be taken into consideration as a differential diagnosis, which can alter treatment modalities from surgery to less invasive methods such as more intra-ERCP efforts. Suspicions of the presence of bezoars

are strengthened by the detection of a biliary enteric fistula through endoscopic retrograde cholangiopancreatography. Furthermore, patients at a higher risk of fistula formation should undergo a thorough ERCP in case there is a biliodigestive fistula having developed spontaneously. PMCID: PMC1351192 PMID: 16396681 [PubMed - indexed for MEDLINE] 3. Nat Clin Pract Gastroenterol Hepatol. 2005 Jul;2(7):331-5; quiz 336. Diagnosis and treatment of a patient with gallstone ileus. Zuber-Jerger I, Kullmann F, Schneidewind A, Schlmerich J. University Hospital of Regensburg, Germany. ina.zuber-jerger@klinik.uni-regensburg.de BACKGROUND: A 79-year-old white woman presented with upper abdominal pain. She had a history of rheumatoid arthritis since she was 19 years old, which was treated with prednisolone, leflunomide, diclofenac and pantoprazole. She also had factor VII deficiency. The patient had been hospitalized 2 months previously with sepsis presumed to be due to urinary infection, and was treated with antibiotics. Sonography at this time revealed a gallbladder with a monstrous thick wall and stones, and the first differential diagnosis was cholecystitis. Cholecystectomy was planned after amelioration of the patient's general state, but her general state worsened. INVESTIGATIONS: Sonography, endoscopy of the upper and lower intestine, and CT scan. DIAGNOSIS: Biliodigestive fistula and gallstone ileus. MANAGEMENT: Enterolithotomy, stenting, endoscopic retrograde cholangiopancreatography, and surgery. PMID: 16265287 [PubMed - indexed for MEDLINE] 4. Khirurgiia (Mosk). 2004;(3):51-5. [Intestinal gallstone obstruction] [Article in Russian] Dobrovolski SR, Ivanov MP, Naga IV. Kafedra gospital'no khirurgii Rossiskogo universiteta druzhby narodov i Gorodskaia bol'nitsa No. 17, Moskva. Three cases of intestinal obstruction due to obturation with gallstones are presented. These patients made 1,3% of all patients operated for acute intestinal obstruction and 0,2% of all patients operated for cholelithiasis. This variant of intestinal obstruction is rare disease and is not characterized with a typical

picture and specific symptoms. Analysis of complaints, anamnesis, additional methods of abdominal examination help to suspect biliary ileus. In emergency cases scope of surgery must be minimal and directed to adequate elimination of intestinal obstruction. Indications for simultaneous disjunction of biliodigestive fistula depend on many factors which must be regarded individually for each patient. PMID: 15097990 [PubMed - indexed for MEDLINE] 5. Klin Khir. 2001 Jan;(1):61-2. [Observation of the complex biliodigestive fistula] [Article in Russian] Kozlov VS, Gavrilenko VG, Lavrov AS, Borisenko VI. PMID: 11475983 [PubMed - indexed for MEDLINE] 6. Ultraschall Med. 2000 Aug;21(4):186-8. [Biliary-digestive fistula with gallstone ileus--a sonographic diagnosis] [Article in German] Rickes S, Neye H, Lochs H, Wermke W. Medizinische Klinik mit Schwerpunkt Gastroenterologie, Hepatologie und Endokrinologie des Universittsklinikums Charit, Berlin. We demonstrate a patient with a fistula between the gallbladder and the small intestine combined with a gallstone ileus of the small bowel, diagnosed by ultrasound. Plain abdominal X-ray only revealed small bowel obstruction. All the typical diagnostic criteria of a biliodigestive fistula could be detected by ultrasound. The patient was operated and discharged a few days later. We demonstrate that biliodigestive fistulas can be diagnosed by ultrasound. PMID: 11008319 [PubMed - indexed for MEDLINE] 7. Scand J Gastroenterol. 2000 Jul;35(7):781-3. Gastric outlet obstruction by gallstone: Bouveret syndrome. Ariche A, Czeiger D, Gortzak Y, Shaked G, Shelef I, Levy I. Dept. of Surgery B, Soroka Medical Center, Ben Gurion University, Beer-Sheva, Israel.

Gallstone has rarely been described as a cause of gastrointestinal obstruction. However, the relative incidence of gallstone ileus increases significantly with age. The gastric outlet is very seldom the location of obstruction by a gallstone. The diagnosis of this condition is not difficult. Nevertheless, if treatment is delayed, high morbidity and mortality rates result. Comprehensive treatment aims to relieve the obstruction, to close the biliodigestive fistula and to prevent further gallbladder complications. The surgeon who deals with this type of illness should tailor the treatment plan according to the age, general condition, and intraoperative findings of the individual patient. This paper presents a case report of an 88-year-old woman with gastric outlet obstruction caused by a gallstone. PMID: 10972185 [PubMed - indexed for MEDLINE] 8. G Chir. 2000 Mar;21(3):110-7. [Spontaneous biliodigestive fistulae. The clinical considerations, surgical treatment and complications] [Article in Italian] Stagnitti F, Mongardini M, Schillaci F, Dall'Olio D, De Pascalis M, Natalini E. Istituto di Clinica Chirurgica d'Urgenza e di Pronto Soccorso, Universit degli Studi La Sapienza, Roma. To reevaluate the current feature of spontaneous bilioenteric fistula we reviewed 81 cases who had been treated for biliary fistula between 1948 and 1998. After a review of the literature on this subject, the multiple problems relate to pathological anatomy, pathogenesis and physiopathology are discussed. Of 81 patients, 55 were women and 26 were men with the average age of 54.5 years. The most common type of fistula was cholecysto-duodenal (55 cases--68%), followed by cholecysto-colonic (11 cases--13.6%), choledocho-duodenal (7 cases--8.6%), cholecysto-gastric (4 cases--4.9%) and duodeno-left hepatic duct fistula (4 cases). The authors have found in 41 cases the gallstone ileus complications, in 12 cases inflammatory disease of biliary three, in 8 cases hemobilia, gallstone ileus with perforation and digestive hemorrhage compliances respectively. All the patients were treated with surgery. A first procedure consists of enterolithotomy, in gallstone ileus cases, followed by biliary surgery. In 14 patient the general or local conditions argued against one-stage procedure and two-stage procedure had been considered. In 63 patients a cholecystectomy was done, 15 were treated with enterolithotomy and 8 with intestinal resection. Seven patients with gastroduodenal ulcer based fistula have required a gastroduodenal resection. The mortality was 13.6% (11 cases). PMID: 10810820 [PubMed - indexed for MEDLINE]

9. J R Coll Surg Edinb. 1997 Oct;42(5):324-8. Complications following cholecystectomy. Roviaro GC, Maciocco M, Rebuffat C, Varoli F, Vergani V, Rabughino G, Scarduelli A. Department of Surgery, University of Milan, S. Giuseppe Hospital, Italy. Laparoscopic cholecystectomy is considered the gold standard for cholelithiasis. Nevertheless possible complications must not be underestimated. In this department, from 1 July 1991 to 30 November 1995, 1005 patients with cholelithiasis underwent videocholecystectomy. There was no peri-operative mortality. In 36 cases (3.6%) the procedure was changed to laparotomy. In four cases (0.4%) conversion was mandatory due to severe complications: in three patients while introducing a trocar (one aortic lesion, one middle colic vein injury and one visceral perforation) and in one patient due to bleeding in the hepatic hilar region. In 32 cases (3.2%) conversion was carried out electively. This was due to technical difficulties or to choledocholithiasis (22 patients), anaesthesiological problems (three cases), biliodigestive fistula (one), bile spillage from accessory hepatic ducts (three), unexpected colonic cancer (one), instrument malfunction (two cases). Twenty-four patients (2.4%) experienced post-operative complications: one with pneumothorax, two with bile leakage (one bile duct damage, and one cystic duct leakage), eight with haemoperitoneum, five with subphrenic abscess, three with anaemia, three with intraparietal collections, one with bilateral basal bronchopneumonia, one with perforated duodenal stress ulcer. Of these, 11 patients (1%) underwent reintervention: five re-laparoscopies, three conversions, and three open laparotomies. This study demonstrates the safety of videolaparocholecystectomy. Complications are relatively rare and can be often dealt with conservative treatment or re-laparoscopy. Complications are often linked to insertion of a blind trocar or to the induction of a closed pneumoperitoneum. Meticulous technique or open laparoscopy minimize these risks. Conversion must not be considered a defeat but a wise decision in the face of major difficulties. Under these principles, videocholecystectomy is safe and represents the best treatment of gallbladder stones. PMID: 9354066 [PubMed - indexed for MEDLINE] 10. Minerva Chir. 1997 Apr;52(4):439-47. [Biliodigestive fistulae. Apropos 2 cases with opposite symptomatology] [Article in Italian] Picucci L, Alibrandi M, Persico Stella L, Bevilacqua M, De Nuntis S, Quondamcarlo C, Valle D. Divisione di Chirurgia, Ospedale Generale di Zona Regina Apostolorum, Albano

Laziale, Roma. Biliodigestive fistulas are the most frequent internal biliary fistulas and occur when a calculus or neoplasia perforates the wall of the biliary tract of intestine at any point. Symptoms vary given that completely asymptomatic cases have been reported in which the findings of a biliodigestive fistula was completely coincidental, but there are also cases in which the severe clinical conditions at onset require immediate surgery. The Authors report two cases with opposing symptoms and underline the importance of diagnostic imaging in the preoperative analysis. They also underline that a correct therapeutic approach is fundamentally important in these cases. PMID: 9265130 [PubMed - indexed for MEDLINE] 11. Minerva Chir. 1996 May;51(5):347-50. [Antropyloric lithiasic obstruction: a variant of Bouveret's syndrome] [Article in Italian] Astolfi A, De Berardinis O, Lalli T, Del Cimmiuo P, Saragani C, Colecchia G. Divisione di Chirurgia Generale, Ospedale Civile S. Liberatore Atri, Teramo. Bouveret's syndrome is a rare complication of a biliodigestive fistula, where a big stone occludes the pyloro-duodenal region. The authors describe a case with obstructive variant at antropyloric level. With the help, of the literature they speak about this matter with particular attention to the clinic symptomatology and diagnostic and therapeutic procedure. PMID: 9072744 [PubMed - indexed for MEDLINE] 12. Gastroenterol Clin Biol. 1995 Dec;19(12):1055-8. [Endoscopic diagnosis of a biliodigestive fistula of tuberculous origin revealing acquired immunodeficiency syndrome] [Article in French] Paupard T, Etienney I, Patey O, Torrent J, Guez C, Bettan L, Emond JP, Lafaix C, Cattan D. Service d'Hpato-Gastroentrologie, Centre Hospitalier, Villeneuve-Saint-Georges. We report the case of a 32-year-old Malian man with abdominal tuberculosis revealing acquired immunodeficiency syndrome. A gastroscopy was made for epigastric pain and showed caseum in a digestive fistula with acid fast bacilli. Mycobacterium tuberculosis infection was confirmed by sputum culture. An early

antituberculous therapy was prescribed. Outcome was good with rapid fistula closing and slower mass diminution of the abdominal lymph nodes. This case report confirms nodal tuberculosis as a possible cause of digestive fistulae. Rapid endoscopic diagnosis of this tuberculous fistula led to diagnosis of acquired immunodeficiency syndrome and early adapted medical treatment without invasive diagnostic methods. PMID: 8729418 [PubMed - indexed for MEDLINE] 13. Aktuelle Traumatol. 1993 May;23(3):144-5. [Biliary fistula after concealed choledochal rupture in a polytraumatized patient] [Article in German] Hubel W, Richter J, Walter E. Unfallchirurgische Klinik, Kreiskrankenhaus Schorndorf. This paper describes the case of a polytraumatised patient. Following primary care, a persistent fistulous wound developed. After initially good healing, the patient progressively deteriorated. Extensive diagnostic workup revealed a maximally elevated bilirubin concentration in the wound secretion. Five years previously, the patient had undergone a cholecystectomy. A leak in the common bile duct caused by the trauma was detected and was treated with a biliodigestive anastomosis with a Roux-Y loop, and bypass of the distal common bile duct. PMID: 8101034 [PubMed - indexed for MEDLINE] 14. J Chir (Paris). 1991 Mar;128(3):127-9. [Post-bulbary ulcers] [Article in French] Albaroudi S, Mjahed A, Ahallat M, Benamar A, Hosni K, Oudanane M, Halhal A, Tounsi A. Clinique chirurgicale C, C.H.U. Avicenne Rabat, Maroc. Authors report 121 cases of post bulbary ulcers between 1969 and 1987. They precise the frequency of complications in this localisations of the ulcerous disease: Hemorrhage: 38% Stenosis: 39.6% Peritonitis through perforation: 9.09% Anatomical reports of the post bulbary area explain the anatomo-pathological aspects made by the above mentioned complications added the biliodigestive fistula and perforations blocked of a surgical treatment. Considering these elements, the authors show the difficulty of a surgical treatment. They suggest

choosing the most simple intervention: Treating the ulcer without approaching the ulceron area; namely; making truncal vagotomy and duodenoplasty, that of Finney being the most adapted in case of haemorrhage. On case of a stenosis, with gastric ditension, exclusion gastrectomy is the adequate intervention. The results are good, except two deaths that occurred by cataclysmic ulcerous haemorrhage. PMID: 2055974 [PubMed - indexed for MEDLINE] 15. Khirurgiia (Mosk). 1991 Feb;(2):45-8. [Tactics in cholelithic intestinal obstruction] [Article in Russian] Kuznetsov VM, Tsybikov EN, Damdinov BCh, Fedorov SI. Tactical manipulations in cholelithic intestinal obstruction are analysed. The authors had 4 cases with cholelithic intestinal obstruction, in one of them obstruction with a gallstone occurred again on the 23rd postoperative day. Relaparotomy, correction of the obstruction, and cholecystectomy with one-stage removal of a biliodigestive fistula had to be conducted. It is pointed out that in obstruction of the intestine with a gallstone correction of the obstruction is a more sparing operation than one-stage cholecystectomy and removal of a biliodigestive fistula. With the use of this tactics there were no fatal outcomes. PMID: 2041347 [PubMed - indexed for MEDLINE] 16. Minerva Chir. 1990 Sep 30;45(18):1195-8. [Spontaneous internal bilio-digestive fistula after cholecystectomy. A clinical report] [Article in Italian] Corsale C, Martini A, Corsale I. Divisione di Chirurgia e Pronto Soccorso, Regione Campania, USL n. 55, Presidio Ospedaliero di Eboli, Salerno. The paper describes a case of spontaneous biliodigestive fistula in a cholecystectomized patient. Following a review of other published reports, the etiopathogenetic, clinical and therapeutic aspects of the case are discussed. PMID: 2287474 [PubMed - indexed for MEDLINE]

17. Chirurg. 1990 May;61(5):392-5. [Gallstone ileus. A report of 104 cases] [Article in German] Hildebrandt J, Herrmann U, Diettrich H. Klinik fr Chirurgie, Medizinischen Akademie Carl Gustav Carus, Dresden. An analysis of 104 cases of gallstone ileus in 102 patients is presented. Biliary stones reach the intestinal tract through a biliodigestive fistula in 80-85% and on natural way in 15-20%. Clinical symptoms depend on mechanism of obstruction. It shows 3 forms of course: peritonitical form (20%), remittent form (30%) and typical intestinal obturation (50%). Roentgenological findings show aerobilia in 36%, dystope radiopaque stones in 8% and signs of obstruction in 97% of investigations. The main concern in gallstone ileus should be to relieve the intestinal obstruction and not cholelithiasis. The mortality rate declined during reported time from 40-50% to 25%. PMID: 2364772 [PubMed - indexed for MEDLINE] 18. Rev Esp Enferm Dig. 1990 Jan;77(1):33-8. [Spontaneous biliodigestive fistula] [Article in Spanish] Palomar de Luis M, Tuba Landaberea JI, Elorza Ore JL. Hospital Ntra. Sra. de Arnzazu, San Sebastin. A retrospective study was made of 23 cases of spontaneous biliodigestive fistulae collected from bile tract surgery performed in our center from 1979 to 1987, representing 1.05% of the total number of cases. The etiology was cholelithiasis in almost all cases and the most frequent connection was to the duodenum. Forty-eight percent of the cases presented as biliary ileus. In each case surgery depended on the etiology, clinical manifestations and status of the patient. The mortality was 8.7% and the morbidity 52%. Results are analyzed and a bibliographic review of the topic is offered. PMID: 2185806 [PubMed - indexed for MEDLINE] 19. Rev Esp Enferm Apar Dig. 1989 Apr;75(4):367-73. [Extrahepatic biliodigestive anastomoses. Analysis of 227 cases] [Article in Spanish]

De Vega DS, Daz MJ, Martnez C, Tamames S, Tamames S. The authors analyze their experience with 227 biliodigestive anastomoses to compare the early and late results. Choledocholithiasis (49%) and cancer of the pancreas (25%) were the most common processes. Choledochoduodenostomy (48%), cholecystojejunostomy (22%), sphincteroplasty (18%) and hepaticojejunostomy (9%) were the techniques most often used. In 61% of cases (90% of the malignant tumors) there was an emergency indication. Twenty-one percent of the patients presented serious complications in the postoperative period (14% of the benign tumors), half of which depended on the bypass. Postoperative peritonitis (2%), external biliary fistula (4%) and acute pancreatitis (2%) were the most significant surgical complications. Hepaticojejunostomy induced the largest number of bypass-dependent complications. There were 12 deaths due to medical causes (5%), these being most numerous in subjects with neoplasms and cholecystojejunostomy, and 8 of surgical origin (4%), half of them in carriers of a hepaticojejunostomy. There was a clear decline in the morbidity of patients operated on in recent years. In the long term, 91% of the patients remained free of discomfort or had minimal symptoms. Choledochoduodenostomy or sphincteroplasty produced the best results. It is concluded that biliodigestive anastomoses yield the best early and late results with minimal secondary effects. PMID: 2740572 [PubMed - indexed for MEDLINE] 20. Rev Esp Enferm Apar Dig. 1989 Feb;75(2):192-7. [Spontaneous cholecystocolonic fistulas. Presentation of 5 cases] [Article in Spanish] Tuba Landaberea JI, Palomar LM, Cormenzana Lizarribar E, Beguiristain Gmez A, Rocandio Cilveti E, Alvarez Caperochipi J. From 1979 to 1987, 5 patients with cholecystocolonic fistula were operated on in our service, which represents 25% of a total of 20 external biliodigestive fistulas complied over this period. Admission was as an emergency in 4 of the 5 patients (80%), and in one for elective programmed surgery. External biliodigestive fistula was suspected in 3 patients (60%) and biliocolonic fistula in one (20%), on observing aerobilia and leakage of contrast into the hepatic angle of the colon. On two occasions (40%) associated choledocholithiasis was detected, by means of echographic study in one case and intraoperative cholangiography in the other. Antecedents of biliary pathology were present in 3 of our 5 observations (60%), with a mean time of evolution of 12 years. PMID: 2711003 [PubMed - indexed for MEDLINE]