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Background Biliary decompression is a key factor in the treatment of postcholecystectomy bile leak. However, the optimal size of the stent introduced by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is yet to be determined. The aim of the study was to compare the effectiveness of two straight plastic stents with different sizes (10-Fr and 7-Fr) in the treatment of postcholecystectomy bile leak. Methods Between January 2003 and August 2006, 63 patients underwent therapeutic ERCP for postcholecystectomy bile leak. After visualization of the bile duct injury, endoscopic sphincterotomy was performed and the patients were randomized to receive either a 7-Fr (31 subjects, group A) or a 10-Fr (32 subjects, group B) straight plastic stent for four weeks. The success of the endoscopic treatment was determined by the elimination of the symptoms and the removal of the drain without any adverse outcomes. Results The endoscopic intervention was successful in 29 patients of group A (93.54%) and in 31 patients of group B (96.87%). In the remaining two patients of group A, the 7-Fr stent was substituted by a 10-Fr stent after 7 days because the leak remained unaffected, resulting in healing of the leaks. Surgery was required in the remaining one patient of group B. Eight patients developed post-ERCP pancreatitis (5 mild, 2 moderate, 1 severe), which was treated conservatively. Conclusions This trial suggests that the stent size does not affect the outcome of the endoscopic intervention in postcholecystectomy bile leaks due to minor biliary tract injury; however, larger cohorts are required to confirm the optimal stent size in bile leaks due to major bile duct injury.

Cholecystoenteric fistula (CEF) is a rare but well recognized complication of gallstones. Traditionally, surgical management was by open approach. We aim to report on the safety and outcomes of laparoscopic surgery for CEF and present a systematic review of literature. All patients who underwent laparoscopic cholecystectomy in our institution from January 2015 to December 2023 were retrospectively reviewed. We identified all patients with CEF for data collection, including demographics, clinical presentation, operative details, and outcomes. Systematic review of literature reporting on safety and outcomes of laparoscopic surgery for CEF was performed. 4937 patients underwent laparoscopic cholecystectomy over a nine-year period between January 2015 to December 2023.19 patients were diagnosed with CEF. Mean age was 63.7 years. 14 patients (73.7 ​%) were diagnosed intra-operatively. Pneumobilia was a key radiological feature leading to pre-operative diagnosis in three patients. Laparoscopic surgical stapler was most common fistula closure method with six cases (31.6 ​%), followed by laparoscopic handsewn closure in five patients (26.3 ​%). Open conversion rate was 36.8 ​%. Three patients (15.8 ​%) had minor complications, and one patient (5.3 ​%) had bile leak. There was one 30-day readmission. There were zero mortalities in our cohort. Median time to diet and length of stay was 2.5 and 6 days respectively. Following exclusions, the systematic review identified seven studies with a total of 145 patients. Major complication rate was 2.8 ​% and mortality 1.4 ​% among those included. Laparoscopic surgery is safe and feasible in management of cholecystoenteric fistula. It has good outcomes in surgeons familiar with laparoscopic skills. •Cholecystoenteric fistula (CEF) is a rare but well recognized complication of gallstones.•Open surgery has high morbidity rates and longer hospitalization for patients.•Laparoscopic approach improves outcomes, reduces morbidity rates and shorten length of stay.•Our study showed that laparoscopic approach is safe and feasible in management of cholecystoenteric fistula.

PurposeBile duct (BD) complications continue to be the “Achilles’ heel” of liver transplantation, and the utilization of bile duct drainage is still on debate. We describe the results of a less invasive rubber trancystic biliary drainage (TBD) compared to a standard silicone T-tube (TT).MethodsThe transplanted patients (n = 248), over a period of 5 years with a TBD (n = 20), were matched 1:2 with control patients with a TT (n = 40). Primary end points were the overall incidence of BD complications and graft and patient survival. Secondary end points included the complications after the drainage removal.ResultsAlthough the bile duct leakage rates were not significantly different between both groups, the TT group had a significantly higher rate of overall 1-year BD stenosis (40 versus 10 %) (p = 0.036). Three-year patient/graft survival rates were 83.2/80.1 and 84.4/84.4 % for the TT and TBD groups, respectively. The postoperative BD complications, after drainage removal (peritonitis and stenosis), were significantly reduced (p = 0.011) with the use of a TBD.ConclusionThe use of rubber TBD in liver transplant recipients does not increase the number of BD complications compared to the T-tube. Furthermore, less BD anastomotic stenosis and post-removal complications were observed in the TBD group compared to the TT group.

Background Bronchobiliary fistula (BBF) is a rare but fatal disease. Due to its rarity, only a limited number of cases have been reported, leading to a lack of consensus on appropriate treatment strategies. Methods We conducted a retrospective analysis of clinical data of 17 patients diagnosed with BBF between January 1, 2012, and May 30, 2025, focusing on the the presenting symptoms, diagnostic approaches, treatment modalities, and outcomes. Results All 17 patients had cough and pathognomonic biliptysis. Sputum analysis confirmed bile components in all samples from 3 patients, and fiber bronchoscopy revealed yellow-green bilious sputum in 6 patients. Computed tomography (CT) or magnetic resonance imaging (MRI) demonstrated communication between the bile duct and the bronchial tree in 9 patients. Cholangiography showed contrast medium passing through a fistulous tract into the bronchi in 10 patients. Surgical intervention was performed in 6 patients, 3 of whom achieved long-term survival (> 24 months). Minimally invasive interventions provided effective symptomatic palliation in 10 of 11 patients. Among these 10 patients, 3 achieved long-term survival (> 24 months), with an additional 3 remaining alive and under ongoing follow-up (though not yet reaching the 24-month threshold). Of the 8 fatalities, 2 were directly attributed to uncontrolled BBF and its complications (sepsis or hepatic failure). The remaining deaths resulted from progressive malignancy ( n  = 3), postoperative complications (pneumothorax/respiratory failure, n  = 1; hemorrhagic shock/disseminated intravascular coagulation, n  = 1), and post-transplant septic shock ( n  = 1). Conclusions BBF is associated with poor prognosis. Minimally invasive therapies offer effective palliation in malignant cases, whereas surgical intervention may provide curative potential in selected benign cases. Individualized, multidisciplinary management is essential for optimizing outcomes.

Endocystectomy is a conservative surgical approach to managing cystic echinococcosis. Bile leakage is the main complication of this technique. The aim of this study was to evaluate the factors associated with bile leakage and to assess the outcomes and cost efficiency of strategies used to treat bile leakage. Patients who underwent endocystectomy between 2005 and 2020 were included. The preoperative characteristics, intra- and postoperative outcomes, hospital costs, and cost efficiency (the Diagnosis-Related Group reimbursement minus the overall cost) were evaluated prospectively. A total of eighty patients with 142 cysts were included. Postoperative complications occurred in 17 patients (21%), including 11 patients with bile leakage (type A: 1, type B: 6 and type C: 4 patients, total 13%). Bile leakage was more frequent in patients with preoperative MRI signs of cysto-biliary fistulas or intraoperative visible cysto-biliary fistulas (p = 0.03 and p = 0.04, respectively) and in patients with cysts larger than 8 cm (p = 0.03). Patients with bile leakage who underwent reoperation (type C) had significantly shorter hospital stays (9 vs. 16 days, p<0.01) and better cost efficiency than those who received radiologic or endocscopic interventions (€2,072 vs. -€2,097 p = 0.01). No mortality was observed, and recurrence was seen in two patients. Endocystectomy is a safe and efficient technique. Preoperative and intraoperative cysto-biliary fistulas and a cyst diameter larger than 8 cm are correlated to postoperative bile leakage. Early operative management of bile leakage reduces hospital stay and improves cost efficiency compared with radiologic or endoscopic treatments.

Cholecystoenteric fistulas are uncommon complications of chronic gallstone disease and may present insidiously, leading to delayed diagnosis. We describe a male patient in his early 70s who developed biliary ileus secondary to a cholecystoduodenal fistula, initially manifesting as right upper quadrant pain, bilious vomiting and progressive oral intolerance. CT imaging demonstrated pneumobilia, a large ectopic gallstone and small-bowel obstruction consistent with Rigler’s triad. At laparotomy, he underwent partial cholecystectomy, closure of the duodenal defect, pyloric exclusion and decompressive procedures; however, an enteric leak required reoperation with omental patch repair, gastrojejunostomy and enterolithotomy. His recovery was complicated by intra-abdominal sepsis and ventilator-associated pneumonia but improved with intensive care management.This case highlights the diagnostic challenge of gallstone ileus from cholecystoduodenal fistula and the need for prompt CT evaluation and flexible, staged surgical decision-making in patients with significant inflammation or postoperative complications.

Background Bronchobiliary fistula (BBF) is a rare acquired communication between the biliary system and the bronchial tree. Biliptysis (bile-stained sputum) is the most characteristic clinical clue and should prompt evaluation for underlying hepatobiliary pathology, particularly in endemic regions where echinococcosis remains prevalent. Case Presentation A 35-year-old Arab male presented with recurrent biliptysis, right upper quadrant pain, nausea/vomiting, reduced appetite, and mild exertional dyspnea. He had a history of hepatic hydatid cyst surgery 18 years earlier followed by albendazole therapy. Chest imaging showed right lower lobe posterobasal atelectasis/inflammatory consolidation adjacent to the diaphragm, with cystic lesions involving the right hemidiaphragm and multiple cysts at the hepatic dome. Abdominal CT demonstrated a well-defined right hepatic cystic lesion compatible with hydatid disease. Hydatid serology was negative and laboratory tests, including liver enzymes and bilirubin, were within normal limits. Biochemical confirmation of bile was not performed, and bronchoscopy was declined by the patient. Case Discussion Given clinically apparent bile-stained sputum with imaging evidence of right basilar lung involvement and recurrent hydatid disease near the diaphragm, surgical management was pursued. Right posterolateral thoracotomy revealed bile-stained fluid containing hydatid membranes at the presumed fistulous site. As no communication with a main bronchus was identified, a right lower lobe wedge resection was performed. Intraoperative findings suggested erosion into adjacent lung parenchyma and smaller bronchi. Multiple diaphragmatic cysts and a subdiaphragmatic cavity containing daughter cysts were evacuated with scolicidal measures, followed by diaphragmatic repair and drainage. Conclusion Suspected BBF should be considered in patients with biliptysis, even with negative serology or normal liver tests. Definitive management may require a tailored surgical approach addressing both thoracic and hepatobiliary components, particularly in hydatid-related disease. Clinical trial number Not applicable.

BackgroundBiliary fistulas may result as a complication of gallstone disease. According to their tract, abdominal internal biliary fistulas may be classified into cholecystobiliary and bilioenteric fistulas. Surgical treatment is challenging and requires highly trained surgeons with high preoperative suspicion. Conventional surgery is still of choice by most of the authors. However, laparoscopy is emerging as a minimally invasive alternative. We investigated the surgical approach, conversion rate, and outcomes according to the type of biliary fistula.MethodsWe retrospectively reviewed 11,130 laparoscopic cholecystectomies, 31 open cholecystectomies, and 31 surgeries for gallstone ileus at our institution from May 2007 to May 2020. We diagnosed internal biliary fistula in 73 patients and divided them into two groups according to their fistulous tract: cholecystobiliary fistula and bilioenteric fistula. We described demographic characteristics, preoperative imaging modalities, surgical approach, conversion rates, surgical procedures, and outcomes. We additionally revised the literature and compared our results with 13 studies from the past 10 years.ResultsThere were 22 and 51 patients in the cholecystobiliary and bilioenteric groups, respectively. Our preoperative suspicion of a fistula was 80%. We started 88% of procedures by laparoscopic approach. The effectiveness of laparoscopy in the resolution of internal biliary fistula was 40% for cholecystobiliary fistula and 55% for bilioenteric fistulas. The most frequent cause for conversion to laparotomy was the difficulty to identify anatomical features, in addition to the need to perform a Roux en-Y hepaticojejunostomy. Choledocholithiasis was not associated with an increase in conversion rates.ConclusionsLaparoscopic resolution of a biliary fistula is still a matter of controversy. Despite the high conversion rates, we believe that a great number of patients benefit from this minimally invasive technique. A high preoperative suspicion and trained surgeons are vital in the treatment of internal biliary fistulas.