The management of fistulas of the biliary tract after injury to the bile duct during cholecystectomy.

Twelve of 123 patients who were treated for benign stricture of the bile duct after cholecystectomy presented with an external fistula of the biliary tract. Nine of these patients had undergone multiple operations prior to referral, six having undergone earlier attempts at repair of the bile duct. Two patients initially required urgent laparotomy for drainage of infected abdominal collections. Distal obstruction of the bile duct below the origin of the fistula was present in five patients. Repair of the bile duct was undertaken after careful investigation and correction of nutritional, fluid and electrolyte status in five patients who had little prospect of spontaneous closure of the fistula. The other seven patients were initially treated conservatively; in three, the fistula closed at five to nine weeks without complication, and no further surgical treatment has been required (a range of six to 36 months). The remaining four patients required delayed operation after the development of cholangitis or jaundice. The overall median survival time between development of fistula and operative repair was 3.5 months, and all nine of these patients remained asymptomatic with normal results from liver function tests (a median follow-up period of 17 months). The need for careful initial assessment prior to repair of the bile duct and the possibility of conservative treatment for patients with a postcholecystectomy fistula of the biliary tract are emphasized.