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| Journal of the New Zealand Medical Association,
16-July-2010, Vol 123 No 1318
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The most common cause of colovesical fistula in Western
countries is diverticular disease; other common causes include Crohn’s
disease and colonic malignancy.
The patient discussed is one of a handful of reported cases
presenting with colovesical fistula secondary to lost gallstones during
laparoscopic cholecystectomy, since the advent of the procedure in 1987.
Case reportA 54-year-old lady presented to the General Surgical
Outpatient Clinic at Greymouth Hospital in April 2009 for management of a
documented colovesical fistula.
She was an otherwise well lady who had undergone a
laparoscopic cholecystectomy (LC) for symptomatic gallstones in 1995.
Postoperative course was unremarkable until June 2004 when she presented to her
GP with recurrent urinary tract infections. She was investigated over the
following 12 months with no cause found for symptoms.
She continued to be troubled by ongoing suprapubic pain and
urinary symptoms over the next 3 years and was reinvestigated with a computed
tomography (CT) scan of her abdomen in January 2009 which showed evidence of a
colovesical fistula presumed to be secondary to diverticulitis (see Figure 1).
Subsequent colonoscopy in May 2009 demonstrated changes in
the mucosa of the descending colon representing the colovesical
communication.
Figure 1. CT scan showing fistulous
communication between the colon and the bladder
 An elective repair of the colovesical fistula was performed
on 11 June 2009. When the fistula was divided, three small gallstones (see
Figure 2) were identified within the fistula tract.
Figure 2. Gallstones removed from the fistula
tract
 A resection and anastomosis of the distal descending colon
to rectosigmoid was carried out. She went on to have an uneventful
recovery.
Review of the notes from her laparoscopic cholecystectomy
performed in February 1995 state that a large gallbladder containing multiple
stones was encountered. During the dissection one stone had fallen into the
abdomen, and was unable to be retrieved.
DiscussionSince its introduction almost 25 years ago, laparoscopic
cholecystectomy has become the main stay of treatment for symptomatic
gallstones. However two complications are more common compared to the open
procedure: (1) injury to the common bile duct and (2) complications due to lost
gallstones.
As surgeons have become more experienced at laparoscopy, the
risk of common bile duct injury has reduced. The incidence of spilled and lost
gallstones as a result of intraoperative gallbladder perforation has remained
unchanged however.1
There have been a number of hypotheses as to what effect
leaked bile and lost gallstones have on intraperitoneal organs. Several studies
over the past 15 years have looked at this subject, implanting bile and
gallstones in animal models. These studies have shown that gallstones can remain
inert in the abdominal cavity or can be partially reabsorbed causing only mild
local effects.2,3
Gallstones also demonstrate the ability to cause
postoperative adhesions and abscesses.4,5 Risk
factors for septic complications include the number, volume and composition of
stones. Fragmented stones and stones from an acutely infected gallbladder also
leave the patient at higher risk of
complications.3,6
There are a wide variety of complications reported in the
literature from lost gallstones. Intraabdominal abscess formation being the most
common (60%), fistulisation to other intraabdominal organs being the next most
likely (12%).6
Whilst the incidence of long-term complications from lost
gallstones is low at approximately 1.7/1000
LCs,1 the figures are more impressive in the
subset of patients that have intraoperative gallbladder perforation. Woodfield
et al analysed 18,280 LCs showing an incidence of gallbladder perforation in
18.3% of cases.6 This was similar to the
percentage of gallbladder perforations found by Brockman et al at 20% who
analysed approximately 17,000 LCs.7
When the gallbladder was perforated, the incidence of
spilled stones was approximately 40% or 7.3% of all
LC’s.8,9 There have been two studies of
4813 LC’s9,10 and one
review7 looking at 16,869 LCs that have
reported the incidence of spilled stones being unretrieved at 33%. The actual
figure may well be higher given that approximately 20% of stones are lost
without the surgeon realising it.7
The incidence of complications from a stone knowingly
left in the abdominal cavity is approximately
7%-8.5%1,6 but this figure may be higher given
that late complications after end of follow up would not have been included in
the above studies. Data suggests that there is a mean duration of 10.4 months
until definitive intervention is carried out for complications from lost
stones.6
Gallstones are most commonly spilled either during
dissection of the gallbladder off the gallbladder fossa or during removal
through a port site. The general consensus in the literature is that the surgeon
should explore and remove as many of the spilled stones as possible. Conversion
to an open procedure to retrieve lost gallstones is not
recommended.1
As evidenced by the patient that is the subject of this case
report, complications from lost gallstones can occur several years after the
initial operation. The importance of clear documentation and informing the
patient about the lost gallstones cannot be emphasised enough.
Documentation of lost gallstones should include relevant
information on the status of the gallbladder, the number of stones lost and
whether the stones were fragmented, as all these leave the patient at higher
risk of developing late complications. Physicians need to have a high index of
suspicion regarding symptoms that could be a complication from lost stones so
that necessary investigations can be carried out early. Clear documentation and
communication with the patient is important from a medicolegal standpoint if
late diagnosis and/or unnecessary investigations do occur.
Author information: Dinuk L Gooneratne,
Senior House Officer Anaesthetics, Wanganui Hospital, Wanganui
Acknowledgement: The author thanks Mr
Charles Mixter (General Surgeon, Greymouth Hospital) for his assistance.
Correspondence: Dinuk L Gooneratne,
Anaesthetics Department, Wanganui Hospital, 100 Heads Road, Wanganui, New
Zealand. Email: dinukgooneratne@hotmail.com
References:
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