We report here a case of a biliary fistula in a 73-year-old man who underwent an urgent open cholecystectomy. The aim of this paper is to assess the treatment of the biliary fistulas in the elderly patients and to compare the result with the international literature.
Materials and methods
A 73-year-old man came to our observation with pain to upper quadrants of the abdomen, fever, signs of peritoneal involvement, leucocytosis, and the increment of cholestasis markers, while US scan showed an acute cholecystitis. The patient underwent a laparoscopic cholecystectomy (LC) but we converted the procedure. We positioned a T-tube and an abdominal drainage. Post-operative bilirubin level began to increase, the abdominal drainage began to drain bile despite the patient's conditions were good. A parenteral nutrition was instituted, deficits of electrolytes and vitamins were corrected and octreotide was delivered. We decided to position a PTHBD on the right biliary emisystem and to perform ERCP to reconstruct biliary tract. Post-operative control showed a well-positioned drainage but a biliary leakage so we decided to perform a hepaticojejunostomy. During the 9th day after hepaticojejunostomy the patient developed a severe episode of hemobilia due to a big pseudoaneurysm on the right hepatic artery, which was covered by stenting. After that general conditions of the patient improved day by day and was discharged after 48 days.
In the case above, conservative treatment had been made immediately because spontaneous closure of the fistula is often usual. Endoscopic treatment of fistula by sphincterotomy, stenting or both is indicated in most patients. Operation is indicated when non-operative measures are not suitable, such as in patients with diffuse bile peritonitis. The increased use of interventional procedures is associated with an increased incidence of vascular injuries and hemobilia. Angiography could detect significant hemobilia in over 90% of patients, and allow the localization of vascular lesions and therapeutic embolization.
Management of bile duct injuries is complex because of physiopathologic effects especially in elderly patients, which present associated co-morbidities. It's most important to assess the adequacy of bile drainage to avoid bile collection and peritonitis. About vascular injuries, transarterial embolization has a high success rate of around 80% to 100%, and the placement of a covered stent may be a valid therapeutic alternative. According to us therapeutic interventional procedures constitute the treatment of choice for diagnosis and treatment in a single session to avoid complex surgical procedures in patients who are often haemodynamically unstable and therefore at high anaesthetic and surgical risk.