{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T15:30:04Z","timestamp":1780327804306,"version":"3.54.1"},"reference-count":29,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2023,9,7]],"date-time":"2023-09-07T00:00:00Z","timestamp":1694044800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Introduction: Gallstone disease (GSD) is among the most common disorders worldwide. Gallstones are established in up to 15% of the general population. Laparoscopic cholecystectomy (LC) has become the \u201cgold standard\u201d for treatment of GSD but is associated with a higher rate of certain complications, namely, bile duct injury (BDI). Biliary fistulas (BF) are a common presentation of BDI (44.1% of all patients); however, they are mainly external. Post-cholecystectomy internal BF are exceedingly rare. Case report: a 33-year Caucasian female was admitted with suspected BDI after LC. Strasberg type E4 BDI was established on endoscopic retrograde cholangiopancreatography (ERCP). Urgent laparotomy established biliary peritonitis. Delayed surgical reconstruction was planned and temporary external biliary drains were positioned in the right and left hepatic ducts. During follow-up, displacement of the drains occurred with subsequent evacuation of bile through the external fistula, which resolved spontaneously, without clinical and biochemical evidence of biliary obstruction or cholangitis. ERCP established bilio-duodenal fistula between the left hepatic duct (LHD) and duodenum, with a stricture at the level of the LHD. Endoscopic management was chosen with staged dilation and stenting of the fistulous tract over 18 months until fistula maturation and stricture resolution. One year after stent extraction, the patient remains symptom free. Discussion: Management of post-cholecystectomy BDI is challenging. The optimal approach is determined by the level and extent of ductal lesion defined according to different classifications (Strasberg, Bismuth, Hannover). Type E BDI are managed mainly surgically with a delayed surgical approach generally deemed preferable. Only three cases of choledocho-duodenal fistulas following LC BDI currently exist in the literature. Management is controversial, with expectant approach, surgical treatment (biliary reconstruction), or liver transplantation being described. Endoscopic treatment has not been described; however, in the current paper, it proved to be successful. More reports or larger case series are needed to confirm its applicability and effectiveness, especially in the long term.<\/jats:p>","DOI":"10.3390\/medicina59091621","type":"journal-article","created":{"date-parts":[[2023,9,7]],"date-time":"2023-09-07T09:51:37Z","timestamp":1694080297000},"page":"1621","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Hepatico-Duodenal Fistula Following Iatrogenic Strasberg Type E4 Bile Duct Injury: A Case Report"],"prefix":"10.3390","volume":"59","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2943-1766","authenticated-orcid":false,"given":"Bozhidar","family":"Hristov","sequence":"first","affiliation":[{"name":"Section \u201cGastroenterology\u201d, Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Gastroenterology Clinic, University Hospital \u201cKaspela\u201d, 4001 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7627-0651","authenticated-orcid":false,"given":"Daniel","family":"Doykov","sequence":"additional","affiliation":[{"name":"Section \u201cGastroenterology\u201d, Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Gastroenterology Clinic, University Hospital \u201cKaspela\u201d, 4001 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Desislav","family":"Stanchev","sequence":"additional","affiliation":[{"name":"Section \u201cGastroenterology\u201d, Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Gastroenterology Clinic, University Hospital \u201cKaspela\u201d, 4001 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1155-117X","authenticated-orcid":false,"given":"Krasimir","family":"Kraev","sequence":"additional","affiliation":[{"name":"Department of Propedeutics of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Rheumatology Clinic, St. George University Hospital, 6000 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Petar","family":"Uchikov","sequence":"additional","affiliation":[{"name":"Department of Special Surgery, Faculty of Medicine, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Second Department of Surgery, St. George University Hospital, 4000 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5137-6903","authenticated-orcid":false,"given":"Gancho","family":"Kostov","sequence":"additional","affiliation":[{"name":"Department of Special Surgery, Faculty of Medicine, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Department of Surgery, University Hospital \u201cKaspela\u201d, 4001 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siyana","family":"Valova","sequence":"additional","affiliation":[{"name":"Section \u201cNephrology\u201d, Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Clinic of Nephrology, University Hospital \u201cKaspela\u201d, 4001 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eduard","family":"Tilkiyan","sequence":"additional","affiliation":[{"name":"Section \u201cNephrology\u201d, Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Clinic of Nephrology, University Hospital \u201cKaspela\u201d, 4001 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6433-7970","authenticated-orcid":false,"given":"Katya","family":"Doykova","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Department of Diagnostic Imaging, University Hospital \u201cKaspela\u201d, 4001 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7029-8397","authenticated-orcid":false,"given":"Mladen","family":"Doykov","sequence":"additional","affiliation":[{"name":"Department of Urology and General Medicine, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria"},{"name":"Clinic of Urology, University Hospital \u201cKaspela\u201d, 4001 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,9,7]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1016\/j.gtc.2010.02.003","article-title":"Epidemiology of gallstones","volume":"39","author":"Stinton","year":"2010","journal-title":"Gastroenterol. Clin. N. Am."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1097\/MOG.0000000000000418","article-title":"Incidence of gallstone disease and complications","volume":"34","author":"Shabanzadeh","year":"2018","journal-title":"Curr. Opin. Gastroenterol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1016\/j.gie.2005.12.037","article-title":"Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: Experience at a large tertiary referral center","volume":"65","author":"Khan","year":"2007","journal-title":"Gastrointest. Endosc."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1356","DOI":"10.1002\/bjs.1800831009","article-title":"The west of Scotland laparoscopic cholecystectomy audit group. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: An audit of 5913 cases","volume":"83","author":"Richardson","year":"1996","journal-title":"Br. J. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e2018.00102","DOI":"10.4293\/JSLS.2018.00102","article-title":"Laparoscopic Single-Port Versus Traditional Multi-Port Laparoscopic Cholecystectomy","volume":"23","author":"Casaccia","year":"2019","journal-title":"JSLS"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"4294","DOI":"10.1007\/s00464-016-4745-9","article-title":"Long-term outcomes of patients with common bile duct injury following laparoscopic cholecystectomy","volume":"30","author":"Halbert","year":"2016","journal-title":"Surg. Endosc."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"6293538","DOI":"10.1155\/2016\/6293538","article-title":"Diagnosis and Treatment of Biliary Fistulas in the Laparoscopic Era","volume":"2016","author":"Crespi","year":"2016","journal-title":"Gastroenterol. Res. Pract."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1001\/archsurg.140.10.986","article-title":"Bile Duct Injury During Laparoscopic Cholecystectomy: Results of an Italian National Survey on 56 591 Cholecystectomies","volume":"140","author":"Nuzzo","year":"2005","journal-title":"Arch. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1055\/a-1075-4080","article-title":"ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline","volume":"52","author":"Dumonceau","year":"2020","journal-title":"Endoscopy"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1016\/j.gie.2016.06.051","article-title":"Adverse events associated with ERCP","volume":"85","author":"Chandrasekhara","year":"2017","journal-title":"Gastrointest. Endosc."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1007\/s00464-003-8815-4","article-title":"Bile duct injuries during laparoscopic cholecystectomy: A 1994\u20132001 audit on 13,718 operations in the area of Rome","volume":"18","author":"Gentileschi","year":"2004","journal-title":"Surg. Endosc."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"788","DOI":"10.1111\/j.1445-2197.2006.03868.x","article-title":"Comparison of major bile duct injuries following laparoscopic cholecystectomy and open cholecystectomy","volume":"76","author":"Kaman","year":"2006","journal-title":"ANZ J. Surg."},{"key":"ref_13","first-page":"677","article-title":"Current perspective in the treatment of bile duct injuries","volume":"4","year":"2016","journal-title":"Int. J. Res. Med. Sci."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"786","DOI":"10.1097\/01.sla.0000161029.27410.71","article-title":"Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: Perioperative results in 200 patients","volume":"241","author":"Sicklick","year":"2005","journal-title":"Ann. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1097\/SLA.0000000000002258","article-title":"Long-term impact of bile duct injury on morbidity, mortality, quality of life, and work related limitations","volume":"268","author":"Booij","year":"2018","journal-title":"Ann. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1016\/j.hpb.2016.12.004","article-title":"The morbidity and mortality of hepaticojejunostomies for complex bile duct injuries: A multi-institutional analysis of risk factors and outcomes using NSQIP","volume":"19","author":"Ismael","year":"2017","journal-title":"HPB"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1016\/j.surg.2007.07.008","article-title":"Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies","volume":"142","author":"Walsh","year":"2007","journal-title":"Surgery"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1241","DOI":"10.1007\/s00268-001-0102-8","article-title":"Biliary strictures: Classification based on the principles of surgical treatment","volume":"25","author":"Bismuth","year":"2001","journal-title":"World J. Surg."},{"key":"ref_19","first-page":"101","article-title":"An analysis of the problem of biliary injury during laparoscopic cholecystectomy","volume":"180","author":"Strasberg","year":"1995","journal-title":"J. Am. Coll. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.1002\/bjs.5752","article-title":"Surgical treatment and outcome of iatrogenic bile duct lesions after cholecystectomy and the impact of different clinical classification systems","volume":"94","author":"Bektas","year":"2007","journal-title":"Br. J. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1186\/s13017-021-00369-w","article-title":"2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy","volume":"16","author":"Catena","year":"2021","journal-title":"World J. Emerg. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"43","DOI":"10.4240\/wjgs.v3.i4.43","article-title":"Classification and management of bile duct injuries","volume":"3","author":"Mercado","year":"2011","journal-title":"WJGS"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1111\/j.1477-2574.2009.00096.x","article-title":"Laparoscopic bile duct injuries: Timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes","volume":"11","author":"Stewart","year":"2009","journal-title":"HPB"},{"key":"ref_24","first-page":"29","article-title":"Management of iatrogenic bile duct injury in cholecystectomy: A single centre experience","volume":"4","author":"Sharma","year":"2017","journal-title":"Int. Surg. J."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"508","DOI":"10.1007\/s11684-015-0418-7","article-title":"Bile duct injury repair\u2014Earlier is not better","volume":"9","author":"Kapoor","year":"2015","journal-title":"Front Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1186\/cc8857","article-title":"Laparostomy: Why and when?","volume":"14","year":"2010","journal-title":"Crit. Care"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1532","DOI":"10.52768\/2766-7820\/1532","article-title":"Spontaneous choledoco-enteric fistula formation after bile duct injury due to laparoscopic cholecystectomy: A case report","volume":"3","author":"Kakaei","year":"2022","journal-title":"J. Clin. Images Med. Case Rep."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"rjz141","DOI":"10.1093\/jscr\/rjz141","article-title":"Spontaneous choledochoduodenal fistula in a patient with a bile duct injury following laparoscopic cholecystectomy","volume":"2019","author":"Shea","year":"2019","journal-title":"J. Surg. Case Rep."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1016\/j.ijscr.2016.06.040","article-title":"Spontaneous postoperative choledochoduodenal fistula due to bile duct injury following laparoscopic cholecystectomy","volume":"25","author":"Yilmaz","year":"2016","journal-title":"Int. J. Surg. Case Rep."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/9\/1621\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T20:46:59Z","timestamp":1760129219000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/9\/1621"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,9,7]]},"references-count":29,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2023,9]]}},"alternative-id":["medicina59091621"],"URL":"https:\/\/doi.org\/10.3390\/medicina59091621","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,9,7]]}}}