Arputhamary1, Menaga2
Assistant Nursing Superintendent, Kauvery Hospital, Tennur, Trichy
Staff Nurse, Kauvery Hospital, Tennur, Trichy
*Correspondence: Tel: +91 93613 88804; maha@kauveryhospital.com
Cholecysto Cutabeous Fistula, an emerging problem: a challenging outcome
Abstract
A fistula is an abnormal communication between two epithelial surfaces. This abnormal communication can result in a complication of a disease or surgical intervention. The naming of the fistula follows the two surfaces or lumens it connects. A cholecystocutaneous fistula is, therefore an abnormal communication between the gall bladder and the skin. Similarly, enterocutaneous fistula is an abnormal communication between the small bowel and the skin. Reports of spontaneous cholecystocutaneous fistula have been on record since early 17th century. The condition develops as a complication from neglected calculous cholecystitis. However, it occurs extremely infrequently in current surgical practice. With the advancement in diagnostic imaging, biliary tract diseases are diagnosed early nowadays. The availability of efficient and safe surgical treatment has made complications like fistula extremely uncommon.
Case Presentation
A 70-year female was brought to the emergency department with c/o chronic discharge at the Rt Hypochondrial region, of duration 2 years. She had a past surgical history of Cholecystectomy done on April 2020. She has a known history of DM/ HTN / CKD, on regular treatment.
On arrival, the patient was conscious and oriented and afebrile. Vitals: BP: 130/80 mm Hg, PR: 102 min, SpO2: 98% in RA, RR: 20 min.
Relevant investigations were done. Initially, Surgical Gastroenterology advised starting on intravenous fluids, antibiotics, proton pump inhibitors, analgesics and anticoagulants.
USG Abdomen
Post Cholecystectomy status, minimal Rt pleural effusion and ascites. Medical renal disease.
MRI Abdomen
Chronic calculus cholecystitis with Cholecystoculaneous fistula.
Plan: Laparoscopic/fistula tract excision.
High-risk consent was obtained. Nephrologist’s opinion was obtained for elevated RFT and decreased urine output and treated conservatively. Physician opinion obtained for antihypertensive drugs & antidiabetic drugs. Cardiac opinion & Anesthetist opinion obtained for pre-op fitness. Surgery was done and shifted to ward.
Diagnosis: Cholecystocutaneous Fistula
Comorbidities: DM/HTN/CKD
Relevant investigation
Medications
| Urea | 108 mg/dL |
| Creatinine | 3.34 mg dL |
| Bilirubin total | 4.42 mg/dL |
| Bilirubin direct | 3.12 mg/dl |
| Bilirubin indirect | 1.30 mg/dl |
| SGOT/ALT | 55.5 u/l |
| SGPT/AST | 83.7 u/l |
| WBC | 17,300 cells/cumm |
| Alkaline Phosphatase | 17,300 cells/cumm |
| GGT | 57.1 |
| Inj. Magnex Forte | 1.5 GM | 1-0-1 x 5 days |
| Tab. Metrogyl | 500 mg | 1-1-1 x 5 days |
| Tab. Pantocid | 40mg | 1-0-1 x 5 |
| Tab. Cyclopam | 1-0-1 x 5 days | |
| Tab., Urosocol | 300 mg | |
| Tab. Paracetamol | 1 g | 1-1-1 x 5 days |
| Tab. Supradyn | 1-0-0 x 5 days | |
| Neb. Duolin | 1-0-1 x 5 days | |
| Tab. Nicardia R | 20 mg | 1-0-1 x 5 days |
| Tab. Nefrosave | 1-0-1 x 5 days |
Surgical Management
Laparoscopic/Open Cholecystectomy fistula tract excision
Nursing Management
Pre-Operative management
- Patient Assessment
- Understanding of surgery / Consent
- Emotional aspect
- Pre-operative medication
- IV Fluids management
- NPO
- Skin preparation
- Monitoring vital signs
- Antibiotics, prophylaxis given
Post-Operative management
- Instruct effective breathing techniques
- Intake and output monitoring
- Maintain Low fowler’s position and place patient in ‘SIMS’ position
- Support abdomen when coughing,ambulating.
- Encouraging activity
- Promoting wound healing
- Promoting bowel function
- Administer pain medication
- Comfortable position given.
Communication
Patient information was effectively communicated in a language that they could understand. We applied the communication tool (ISBART) for clinical communication and (AIDET) to effectively improve and maintain a good rapport with patients and attendants. At the time of starting shift nurses used to introduce themselves and explain about the patient’s general condition, nursing process related to diet, medication, doctor rounds, investigations report etc. to the patient using (AIDET) tool. Though the doctors were communicating the prognosis to the patient attendants, they insisted on the nurses explaining in detail as they were hesitant to ask the doctor.
Preventive aspects of nursing care
Patient safety goals followed. It was a challenge for nurses to prevent (HAI) in view of all invasive lines. Bundle care practices were strictly adhered to and achieved the best outcome of No (CLABSI), No (CAUTI), No pressure injury throughout the hospital stay also no NOSOCOMIAL infections.
Our team had done risk assessment in each shift and planned and implemented all preventive measures against FALL, DVT, Delining of tubes and pressure injury. Antibiotic Policy was strictly followed.
- We adhered to FASTHUGSBID in critical care units and inwards for the preventive aspects of care.
- F-Feeding/Fluids
- A-Analgesia
- S-Sedation
- T-Thromboprophylaxis
- H- Headup position,
- U- Ulcer prophylaxis
- G-Glycemic control
- S-Spontaneous breathing trial
- B- Bowel Care
- I-Indwelling catheter removal
- D-De-escalation of antibiotics
Nutrition
For any patient to come out of their illness nutrition is very important. Our team provided good nutrition with adequate calories and was supported with IV fluids. To encourage pulses, fruits, vegetables, milk products, Meal, fish and Egg.
Assessment Programme
This assessment sought to answer the following research question posted by the National Institute for health research rough technology.
What is the clinical effectiveness and cost-effectiveness of cholecystectomy for preventing recurrent symptoms and complications from symptomatic gallstones or Cholecystitis?
This condition is rarely seen nowadays due to the greater availability of antibiotic therapy and biliary surgery. Cholecystectomy is the preferred treatment, although in a few patients the fistula may close spontaneously.
Conclusion
Cholecystocutaneous fistula’s diagnosis and management represent one of the surgical challenges that are still encountered from time to time.
We learned through our review different ways of diagnosis and management. Most of them were dependent on surgical experience and advanced medical investigation.
In conclusion, there are no standard ways to diagnose and management of cholecystocutaneous fistula but according to our review, we think that each surgeon should choose the best way to deal with cholecystocutaneous fistula patients depending on patients’ status, available facilities and expert clinical team.
Ms. Arputhamary
Assistant Nursing Superintendent
Ms. Menaga
Senior Staff Nurse