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

Cholecystoduodenal fistula (CDF) arises from persistent biliary tree disorders, causing fusion between the gallbladder and duodenum. Initially, open resection was common until laparoscopic fistula closure gained popularity. However, complexities within the gallbladder fossa yielded inconsistent outcomes. Advanced imaging and robotic surgery now enhance precision and detection.


| MATERIALS AND METHODS
Prior written consent was gathered from the individual(s) for the potential publication of identifiable images or data within this article.
The patient also provided written consent before the drafting of this article.
Our patient is a 62-year-old woman with metabolic syndrome and a history of perforated gallbladder and cholecystoenteric fistula in 2014.Other medical history includes diabetes mellitus type 2, hypertension, thyroid cancer, and bipolar disorder.She initially presented to outpatient hepatology after referral from primary care in November 2021 for non-alcoholic fatty liver disease (NAFLD) evaluation.At that time, review of US and CT from 2019 showed persistent CDF with air and debris in the bile ducts (Figures 1A, 2A, and 3).
The patient reported no symptoms at the time and was counselled on the need for cholecystectomy and fistula repair but strongly desired to avoid surgery.For further workup, she underwent MRI with FibroScan in December 2021, which showed multiple common bile duct (CBD) stones, persistent cholecystoduodenal fistula, and pneumobilia (Figures 1B and 2B).
At follow up visit in February 2022, the patient recalled episodic right upper quadrant pain, fever, and chills for several years that she did not seek care for.Labs at this visit showed elevated liver enzymes with ALT of 144 U/L (normal range 0-50 U/L), AST of 174 U/L (normal range 0-50 U/L), and alkaline phosphatase of 528 U/L (normal range: 0-120 U/L) though total bilirubin was normal at 0.6 mg/dL (normal range 0-1.3 mg/dL) and white blood cell count was 6.1 � 10 9 /L (normal range 3.9-11.7 � 10 9 /L).She was scheduled for ERCP due to the risk of cholangitis from multiple CBD stones, and 27 U/L, respectively.Amylase, lipase, CBC, BMP, and bilirubin were all within normal limits.
Intraoperatively, the duodenum was observed to be tethered to the gallbladder (Figure 4).These adhesions were released with a combination of sharp, blunt, and electrocautery dissection until only the fistula connection to the duodenum remained.The fistula was encircled with umbilical tape to isolate it and a robotic endoGIA stapler was fired across to release it (Figures 5 and 6).The cholecystectomy was then completed using a dome-down approach.The stapled duodenal fistula line was oversewn with 3-0 PDS to prevent leaks (Figure 7) and an omental patch was applied.The cystic plate and cystic duct staple line were also oversewn.Haemostasis was achieved in the gallbladder fossa with electrocautery, Tachosils, and fibrillin glue.Surgical footage can be accessed at https://youtu.be/ weWmC5giTwo.Surgical pathology report revealed a 4.2 � 3.1 � 1.9 cm gallbladder with a cystic duct.There was a full-thickness defect in the inferior body of the gallbladder measuring 0.2 � 0.1 cm but no gallbladder or cystic duct stones.The gallbladder wall measured 0.3-0.5 cm thick.Findings were consistent with chronic cholecystitis and there were no findings indicating malignancy.

| DISCUSSION
A review of the current literature using the search terms 'cholecystoduodenal fistula robot*', 'robotic chole* fistula', 'cholecystoenteric fistula robot*', and 'bilioenteric fistula robot*' was perormed.Eight studies were returned that reported on operative repair of a cholecystoenteric fistula via robotic approach.Of these, only two studies (and three patients in total) reported robotic cholecystectomy with cholecystoduodenal fistula closure. 11,13hers reported cholecystocolic fistula repair or did not specify the type of bilioenteric fistula found.One study by Tschuor et al. reported robotic cholecystectomy in three patients with CDF but does not describe if or how the fistula was treated. 14 videos of intraoperative techniques were not reported in papers reporting robotic CDF closure.A summary of studies is shown in Table 1.
Outcomes were not consistently reported in these studies, but those that did reported complete resolution of symptoms in all patients.None reported future interventions for the patients with CDF.
In all studies, no surgeries were converted to open.
In summary, cholecystoduodenal fistula is a rare condition resulting from chronic gallbladder inflammation and erosion into surrounding structures [4][5][6]8,12 which often presents with nonspecific gastrointestinal symptoms such as abdominal pain, nausea, vomiting, diarrhoea, or weight loss. At tmes it is recognized upon progression to cholangitis, pancreatitis, small bowel obstruction, or sepsis.In the past, CDFs were mostly an unexpected intraoperative finding, but more are being found on imaging with the advancement and increased use of imaging technologies.Additionally, recognition of subtle findings such as pneumobilia on US or CT can provide important clues to the presence of a cholecystoenteric fistula, which is important since left untreated, it can lead to sepsis, recurrent cholangitis, increased risk of gallbladder cancer, and mechanical bowel obstruction.5,8,9 Patients presenting with CDF are more often elderly, present severely or acutely ill, and have numerous comorbidities though our case presents a younger patient with CDF being her primary concern due to chronic pain as well as potential future complications or malignancy.Robotic fistula takedown was determined to be the best option given her presentation to a centre with a high volume of robotic hepatobiliary surgeries.
Historically, CDFs were managed with laparoscopic surgery; however, operating near the gallbladder fossa offers unique challenges in access and visibility.As a result, up to 70% of these operations convert to the open approach. 8Laparoscopic fistula T A B L E 1 Literature review of robotic cholecystoenteric fistula repair.

Authors
Year -5 of 7 closure also carries a morbidity rate of 17%, leading to very careful patient selection and resulting in exclusive enterolithotomy with no treatment of bilioenteric fistula in patients deemed not healthy enough. 8e advantages of robotic surgery are numerous and include ease of manoeuvring, camera and tool stability, 3D visualisation, better access to small spaces, and improved control.
which was successfully completed in March 2022 with removal of CBD stones and placement of two biliary stents.The patient was referred to transplant surgery for discussion of robotic cholecystectomy with fistula closure and after lengthy preoperative discussion and counselling, she agreed to proceed.Pre-operative labs one month prior (one week post-ERCP) were notable for elevated alkaline phosphatase of 220 U/L though AST and ALT were normal at 25 F I G U R E 1 Imaging showing pneumobilia (circle).(A) Coronal view on CT. (B) Coronal view on MRCP.
post-op day 1, labs were notable for AST of 257 U/L and ALT of 144 U/L with normal alkaline phosphatase at 44 U/L.These decreased on post-op day 4 to a normal AST of 44 U/L and ALT of 49 U/L with a normal alkaline phosphatase of 101 U/L.The patient recovered well and was discharged on post-op day 4 after diet advancement, removal of JP drain, and normalisation of liver enzymes.At a 2-week post-follow-up appointment, the patient reported doing well with no fever, chills, nausea, or vomiting.Labs were notable only for mild AST elevation at 55 U/L with normal ALT of 39 U/L and alkaline phosphatase of 94 U/L.She underwent ERCP at 2 months post-op to remove her biliary stents and reported continuing to do well.She remains under the care of hepatology for NAFLD.
Details or F I G U R E 3 Ultrasound long-axis view of the gallbladder showing debris and intraluminal air.F I G U R E 2 CT images showing persistent cholecystoduodenal fistula (CDF; arrow).(A) Coronal view on CT. (B) Coronal view on MRCP, also showing persistent common bile duct stones (adjacent, in circle).F I G U R E 4 Visualisation of cholecystoduodenal fistula (encircled in umbilical tape) after careful dissection.F I G U R E 5 Application of robotic endoGIA stapler to cholecystoduodenal fistula.F I G U R E 6 Stapled cholecystoduodenal fistula stump.(A) Stump held by forceps.(B) larger view with stump encircled.F I G U R E 7 Oversewing of cholecystoduodenal fistula stump.

Study design Patients
a NR, not reported.ALFONSO ET AL.
Higher volume studies or trials comparing open, laparoscopic, and robotic approaches are needed to determine if these preliminarily improved outcomes can be extended to wider patient populations.Given the known and obvious advantages of robotic surgery versus laparoscopic or open surgery, especially in these particular cases, we believe that robotic fistula takedown is most likely to succeed in effectively resolving symptoms with fewer complications and potentially better overall outcomes.Seung Lee was responsible for the conception and design of the study.Data analysis and interpretation were carried out collectively by Kush Savsani, Kimberly N. McFarland, Anjelica Alfonso, and Seung Lee.All authors participated in data collection, analysis, manuscript review and vital revisions.The final manuscript has been reviewed and approved by all authors.