Robotic Diagnosis and Management of Acute Cholecystocolonic Fistula

Abstract

Cholecystocolonic fistula (CCF) is a rare complication of biliary tract disease. Increased use of imaging has aided in diagnosing these fistulae preoperatively and has established laparoscopy as a safe alternative to laparotomy. Here, we present a 79-year-old male who presented to the emergency room with abdominal pain and was diagnosed with choledocholithiasis. CT scan revealed a CCF, and he underwent endoscopic retrograde cholangiopancreatography (ERCP). He was followed closely to allow maturation of the fistula, and then, da Vinci® Xi robotic cholecystectomy and ligation were performed. Although current comparisons to laparoscopy have yet to demonstrate a clinical advantage, robotic assistance enhances dexterity, visualization, and ergonomics. Our case is one of the first documented successful operative management of CCF using the da Vinci ® Xi robot.

Robotic management of primary cholecystoduodenal fistula: A case report and brief literature review

“…Cholecystoduodenal fistula (CDF) is a rare complication of chronic cholelithiasis and other long‐term gallbladder pathology, with the overall incidence of any cholecystoenteric fistula (CEF) in biliary disease estimated at 0.9%–3.2% 1 . Up to 70% of these are cholecystoduodenal fistula, with the remaining being cholecystocolic and cholecystogastric 1–3 . Cholecystoduodenal fistulas occur as a result of chronic inflammation of the biliary tree, which can be seen with malignancy, gallstones, trauma, biliary surgery, duodenal ulcers, or inflammatory bowel disease 4–6 .…”

“…Symptoms may be nonspecific and include abdominal pain, fever, nausea/vomiting/diarrhoea, malabsorption, and weight loss, though melena, haematemesis, cholangitis, pancreatitis, or sepsis may occasionally be seen 1,5–7 . Patients often report intermittent symptoms for years prior to diagnosis 1,3,5,7 . Given the varied presentation, CDF can be difficult to diagnose but may come to attention on CT, MRI, MRCP, or intraoperatively 5 .…”

“…Krzeczwsoki et al. recently provided an extensive patient presentation, technique review 1 but to our knowledge no similar report has been published for robotic cholecystoduodenal fistula takedown.…”

“…To our knowledge, this report is one of only 2 papers describing robotic approaches to CDF closure. 1,2 As robotic surgery becomes increasingly available and popular, this report highlights the benefits over laparoscopic or open approaches.…”

“…9,10 Traditionally, CDFs were managed with open surgery until the first laparoscopic approach in 1995. 1 However, the laparoscopic approach continues to have a conversion rate to the open approach of up to 70% 8,11 and the open approach carries a high morbidity rate with serious complications occurring in 17.5% of patients. 12 Robotic surgery offers unique advantages for biliary surgery such as improved visibility, dexterity, stability, and manoeuvrability due to the ability to position the camera and tools at precise angles and around tight corners.…”