46例自发性胆囊内瘘的回顾性分析

目的总结结石引起的自发性胆囊内瘘的诊治经验。方法对46例胆囊内瘘的病例进行回顾性分析。结果46例胆囊内瘘中胆囊十二指肠瘘29例，胆囊结肠瘘9例，胆囊胆总管、肝总管瘘11例，胆囊胃瘘3例，其中同时有两处瘘7例。术前经B超检查44例，9例提示胆囊积气；1例提示胆囊壁腹腔面消失，右下腹探得结石影。术前7例行腹部平片检查，4例提示小肠梗阻；6例见结石影；2例显示胆道积气。8例行CT检查，其中2例显示胆囊、胆管气体。3例行ERCP检查，其中1例见十二指肠有造影剂异常溢出。术前仅9例考虑到胆囊内瘘的诊断，其余均在术中发现。46例均开腹行胆囊切除或部分切除，39例胆囊胃肠瘘行瘘口修补，其中5例瘘口过大则利用部分胆囊壁来修补；10例胆囊胆管瘘在取尽结石后，经瘘口置T管引流，瘘口较大者亦利用胆囊壁修补，1例切除部分胆囊后行胆囊空肠Roux-Y吻合。术后1例因感染性休克死亡；1例有少量胆漏。经引流治愈，其余均恢复良好。结论萎缩性胆囊炎、胆囊结石应警惕合并胆囊内瘘。出现以下情况提示胆囊内瘘：(1)B超、CT、腹部平片发现胆道积气。(2)CT、腹部X线平片提示肠梗阻。有下列情况可确诊胆囊内瘘：(1)B超发现胆囊腹腔面消失。(2)B超、CT、腹部平片提示原有明确的胆囊结石消失或在异位出现。(3)ERCP、PTC等发现非胆管开口有胆汁或造影剂溢出。(4)口服造影剂或钡剂灌肠见造影剂进入胆囊。治疗时应修补瘘口，瘘口过大可利用部分胆囊壁来修补。     

Principles of the diagnosis and surgical treatment of internal biliary fistulae

On the basis of examination of 58 patients, the main principles of diagnosis and surgical treatment of the internal biliary fistulas are suggested.     

Urogenital fistulae: changing trends and personal experience of 46 cases

A retrospective study of 46 patients with different types of urogenital fistulae treated by the author during the period from January 1997 to December 2006 is presented. Twenty-two (48%) cases had a vesicovaginal fistula of which 16 (73%) were repaired vaginally and 6 (27%) were repaired abdominally. The remaining fistulae were as follows: 14 (30%) unilateral ureterovaginal fistulae, 6 (13%) ureterovesicovaginal fistulae (one bilateral), and 4 (9%) vesicouterine fistulae. All were repaired abdominally except for one patient with ureterovesicovaginal fistula needing continent urinary diversion using Mainz type II pouch. All fistulae were iatrogenic except one case (2%) which was due to neglected obstructed labor. The iatrogenic causes were gynecologically related in 26 (57%) patients and obstetrically related in 19 (41%) cases. There were two (9%) failed repairs in the vesicovaginal cases, one in each group, and both were salvaged by a secondary surgery. In view of this selected retrospective study and in association with other reports, it seems that with the improvement in the basic health-care services in Egypt, there is a change in the etiology of urogenital fistulae with the vast majority being physician related and no more related to neglected obstructed labor. Such shortcoming should be addressed in the current gynecological surgery training and residency programs.     

Management of spontaneous carotid-cavernous fistulae

Fifteen cases of spontaneous carotid-cavernous fistulae, including 4 patients with spontaneous cure and 8 treated with electrothrombosis, are reviewed. Careful angiographic observation will verify closure of the fistula. Aggravation of visual and/or ocular symptoms can also develop with spontaneous carotid-cavernous fistulae. Recurrence of symptoms and development of collaterals were noted, especially after carotid ligation or embolization of the external carotid artery. Electrothrombosis successfully closed the fistulae in 7 patients. The internal carotid artery was occluded in 1 patient who had a preoperative carotid stenosis at the cervical level. The ability to differentiate angiographically between single and multiple fistulae provides a new possibility that spontaneous carotid-cavernous fistulae can be treated with detachable balloon catheters.     

Endoscopic treatment of postoperative biliary fistulae

Postoperative biliary fistulae are difficult to manage, particularly in the face of obstruction or malignancy. We used endoscopic sphincterotomy or endoprosthesis placement to aide fistula closure in 52 patients with postoperative biliary fistulae. Thirty-seven patients with a fistula were treated with endoscopic sphincterotomy alone. Twenty-four of these 37 patients had a history of lithiasis; 21 patients were treated successfully by endoscopic sphincterotomy alone. The fistula closed in 2.4 +/- 1.6 days. Among the other 13 patients without history of stone disease, the fistula closed in seven cases (54%), 8.4 +/- 2 days after endoscopic treatment. Three patients ultimately required surgical intervention. In 15 patients an attempt was made to pass a 10F endoprosthesis above the fistula. Among the eight patients with successful prosthesis insertion, the fistula healed in six patients (75%). In the seven patients in whom a prosthesis could not be passed endoscopically, the percutaneous transhepatic approach was used. Surgical treatment (hepaticojejunal anastomosis) was ultimately required in two of these seven patients. Sphincterotomy alone is the preferred treatment for biliary fistulae-complicating surgery for gallstone disease. Alternatively, when a fistula is large, endoscopic placement of a prosthesis can be proposed as the first treatment. In cases of endoscopic failure, placement of a prosthesis through the percutaneous transhepatic approach is a useful alternative, particularly when the fistula source is located in the intrahepatic biliary tract.