right upper quadrant
Knowing Cholecystocutaneous fistulas treatment in India – Overview, Diagnosis and Treatment
With an annual increment rate of about 15%, the number of foreign medical tourists for various medical treatments and surgeries including Cholecystocutaneous fistulas treatment in India are on rise. The reason behind this sudden uphill of foreign patients all across the world is the cost and the quality factor. While comparing the cost and quality of Cholecystocutaneous fistulas treatments in India with the developed nations like the US or UK, it is however, noted that they seems far less going to around 30% of the cost incurred in the west. Interestingly, these medical treatments come with same quality as catered in the western countries sometime exceeds the quality level. The top hospitals in India usually provide an end-to-end service that combines personalized services rendered in the hotel industry to top-of-the-line quality healthcare.
Cholecystocutaneous fistulas an Overview
Cholecystocutaneous fistula was first reported by Thilesus in 1670. Courvoisier documented 499 cases of gallbladder perforation in the late 19th century; 169 of these cases formed cutaneous tracts. Over the past century, there have been fewer accounts of this problem because of prompt and safe management of biliary tract disease. In their review in 1949, Henry and Orr found 36 cases of external biliary fistulas reported after 1890. During the past 50 years, fewer than 20 cases of Cholecystocutaneous fistulas have been reported.
Cholecystocutaneous fistulas are almost always a result of neglected biliary tract disease. Patients with this complication usually do not report a distinct episode of acute cholecystitis in their history, since this would have brought such a patient to medical attention sooner. Patients are usually women over the age of 60. The female predilection is most likely due to the higher incidence of cholecystitis in women than in men. Also, cases have been documented in patients as young as 24 years. Symptoms of underlying Cholecystocutaneous fistulas disease may be neglected by the patient or may be masked by some underlying neuropathy. The fistula usually presents itself as an enlarging mass before spontaneous rupture, and it may be associated with symptoms of upper abdominal colic, dyspepsia, jaundice, or weight loss.
What are Cholecystocutaneous fistulas?
These Cholecystocutaneous fistulas are painless and commonly appear in the right upper quadrant. However, Cholecystocutaneous fistulas have also been observed at the umbilicus, left costal margin, right iliac fossa, right groin, and back. Nicholson et al even reported a case of spontaneous cholecystocutaneous fistula in the right gluteal region. The external opening of such fistulas has also been observed to occur at the site of an abdominal scar from previous surgical drainage. The gallbladder may even herniate beneath subcutaneous tissue before fistula formation. The external opening of the fistula can be confused with a pyogenic granuloma, infected epidermal inclusion cyst, or metastatic carcinoma. The discharge from the Cholecystocutaneous fistulas may be purulent and mucoid if the cystic duct is obstructed by a stone. In cases in which the cystic duct may be patent, bile may drain via the external opening.
The Pathophysiology of Cholecystocutaneous fistulas involves obstruction of the cystic duct, most commonly due to calculi and rarely due to gallbladder carcinoma. Obstruction of the cystic duct causes increased pressure in the gallbladder, leading to impaired blood flow and lymph supply to the gallbladder; this can lead to mural necrosis and perforation. Perforation can occur as
1) acute-free perforation causing peritonitis,
2) Subacute perforation resulting in an abscess around the gallbladder, or
3) Chronic perforation with the formation of an internal or external biliary fistula.
Diagnosis of Cholecystocutaneous fistulas
Imaging plays an important role in the diagnosis of Cholecystocutaneous fistulas. Before fistula formation, the abscess can be diagnosed via ultrasonography, with findings that include a sonolucent mass with echogenic material adjacent to the anterior abdominal wall. The diagnosis of Cholecystocutaneous fistulas is confirmed with a fistulogram, which allows visualization of its origin and course. Ultrasonography and CT imaging can also help in the diagnosis of this complication. A fistulogram was not done in our patient because her clinical presentation, analysis of the fistula drainage, and CT findings yielded a high index of suspicion for a Cholecystocutaneous fistula. Ultimately, our patient had prompt surgical management.
Cholecystocutaneous fistulas Treatment
Management of Cholecystocutaneous fistulas should initially include control of any acute inflammatory process. This can be done by incision and drainage of the sinus abscess, followed by wound cultures and appropriate antibiotic therapy. Our case was unique, since the wound cultures grew methicillin-resistant S. aureus without any coliforms. Surgically, the Cholecystocutaneous fistulas tract can be laid open, with removal of any gallstones present. Intraoperatively the gallbladder usually appears small, contracted, chronically inflamed, and adherent to the parietes. A cholecystectomy should also be done. Some evidence indicates that the excision of the fistula tract decreases the risk for cancer developing in this tissue. Although adenocarcinoma in association with old wounds, scars, draining sinuses, and chronic inflammatory tracts has been well documented, there has been only one reported case of adenocarcinoma in association with a Cholecystocutaneous fistula in particular. In this case, the fistula formation preceded the adenocarcinoma by approximately 20 years. Of the 36 cases of external biliary fistulas recorded between 1890 and 1948 and reviewed by Henry and Orr, spontaneous healing was noted in eight cases. It is plausible that spontaneous healing may be due to the absence or elimination of factors such as persistent gallstones, infection, neoplasia, or epithelialization of the fistula tract, which are known to maintain the patency of a fistula tract. Spontaneous healing may be an option for patients with prohibitive surgical risks.
The possibility of Cholecystocutaneous fistulas should be considered in any patient who has a discharging sinus in the right upper abdominal or chest wall. A fistulogram can make a definitive diagnosis of this complication and thus reduce morbidity via prompt cholecystectomy and excision of the fistula tract. Clinical presentation, analysis of sinus drainage, and radiologic or ultrasound imaging may also provide valuable information in making this diagnosis.
Why India?
The Cholecystocutaneous fistulas treatment in India and other medical treatments for the foreign patients are performed in the most reputed and distinguished hospitals. They provide the patients, quality medical treatment and nursing care, which is at par with the international standards, at a nominal cost. India offers a growing number of private “centers of excellence” where the quality of care is as good as that of big-city hospitals abroad (for instance in the United States or Europe) and that are capable of delivering world class medical services at a remarkably lower cost. The health care industry estimates that several thousand foreign patients are treated in private hospitals in India each year. Patients can avoid lengthy waiting periods and high costs by choosing Cholecystocutaneous fistulas treatment in India and other medical treatment and surgeries.
About the Author
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Laparoscopic perforated cholecystectomy (abscess)
