Two possibly iatrogenic biliary-duodenal fistulas in a single patient after medical and surgical interventions.

Twice in January 2003 we treated a 66-year-old man for recurrent severe bleeding from a duodenal ulcer by endoscopic injection of polidocanol. After the second intervention, he suffered acute but mild pancreatitis. One year later, he presented with abdominal pain in the right upper quadrant and intermittent cholestasis. The cholangio-MRI showed cholecystolithiasis and stenosis of the CBD and was consistent with chronic pancreatitis. Endoscopic cholangiopancreatography (ERCP) was attempted, but the papilla of Vater could not be cannulated. A laparoscopic cholecystectomy was performed. Cholangiography done intraoperatively showed a choledochoduodenal fistula distal to the CBD stenosis (i.e., between the stenosis and the papilla). Postoperatively, a guidewire was placed endoscopically through the fistula opening, allowing definitive access to the CBD and successful stenting of the stenosis. Nine months later, the patient again suffered from cholestasis due to occlusion of the stent. The stent was replaced. Seven months after this, the patient was readmitted because of diarrhea, bloating and pain in the right upper abdominal quadrant after a high fat meal. The elevated liver function test results indicated cholestasis. Because of the recurrent episodes of cholestasis, indicating the failure of stenting, and because of the undefined nature of the CBD stenosis, the patient underwent bilioenteric diversion. The preoperative ERCP confirmed the choledochoduodenal fistula located about 3 cm proximal to the papilla of Vater (Fig. 1, Fig. 2). Proximal to this fistula, a 2–3-cm long filiforme stenosis was cannulated. During the operation, a 3-cm long cystic duct was prepared. Around this, a cavity extended to the caval vein, with connection to a duodenal diverticulum. The cavity was surrounded by granulomatous tissue indicating chronic inflamma-