Biliary-enteric communications between the gallbladder and duodenum, or between the
common bile duct and the duodenum, are infrequently reported. They are mainly caused
by perforation of gallstones into an otherwise normal duodenum, or by peptic ulceration
from the duodenum into the biliary tree, respectively [1]
[2]. Iatrogenic fistulas resulting from the passage of bougies or dilators into the
duodenum during exploration of the common bile duct have also been mentioned in the
literature [3]. A 55-year-old man underwent hilar liver resection with left hepatectomy and Roux-en-Y
hepaticojejunostomy for a Klatskin cholangiocarcinoma. Intraoperatively, the duodenum
appeared normal. Uncommon postoperative epigastric symptoms led to a gastroduodenal
endoscopy examination and diagnosis of a duodenal ulcer. The ulcer was attributed
to Helicobacter pylori infection. Eradication therapy was carried out following the Italian schema. The
patient was finally discharged on postoperative day 15. Two months later, the patient
returned, with epigastric pain and signs of cholangitis. A gastroduodenal endoscopy
examination raised a suspicion of a jejunoduodenal fistula between the proximal duodenum
and the Roux limb, probably caused by penetration of the peptic ulcer (Figures [1], [2]). The patient received therapy with ciprofloxacin, ursodeoxycholic acid, and omeprazole.
A 6-week period of endoscopic observation showed that the peptic lesion was healing.
However, the fistula persisted, with the patient having symptoms of relapsing ascending
cholangitis. The duodenal lesion and fistula were therefore finally excised, and direct
closure of the fistula opening on the duodenal wall was carried out. At the time of
writing, a year after the last operation, the patient is living normally and is free
of symptoms. In view of the numbers of Roux-en-Y reconstructions carried out in digestive
tract surgery worldwide [4], the masked clinical presentation of the fistula in the present case should be noted
in order to facilitate the differential diagnosis in cases of unexplained postoperative
epigastric pain associated with cholangitis. Despite an extensive literature search,
no previous reports of a jejunoduodenal fistula after Roux-en-Y reconstruction have
been identified.
Figure 1 Endoscopic image raising a suspicion of fistula.
Figure 2
a Radiological confirmation of the fistula between the proximal duodenum and the Roux
limb. The diagnosis was made by administering contrast through an endoscopic retrograde
cholangiography catheter; an upper gastrointestinal barium study did not demonstrate
the fistula. b Schematic demonstration of the fistula.
Acknowledgement
Dr. Sotiropoulos was supported by the Alexander Onassis Public Benefit Foundation.
