[Spontaneous bilio-biliary fistulae. Experience in 18 cases].

Six cholecyst-hepatic, nine cholecyst-hepatic-choledochic, and three cholecyst-choledochic spontaneous fistulae were observed in subjects (89% females) aged 28-76 (average 52) yr, forming 0.9% of a series of bile duct operands. Lithiasis is seen as the origin of these forms. A large calculus wedged in the gallbladder basis leads, due to decubitus, to symphysis between the basis and the main bile duct. Later, infection results in necrosis of the walls and gives rise to the fistula. The symptoms are not pathognomonic. Clinical diagnosis is virtually impossible and the condition is usually an unexpected surgical discovery. The only sound management consists of elimination of the fistula and calculus and reestablishment of free bilio-enteric transit. Anterograde cholecystectomy (including section of the organ in nearly every case) may or may not be accompanied by papillotomy. The fistulae is sutured or a bilio-enteric diversion is provided. Personal experience suggests that Y-diversion to the jejunal loop according to Roux is preferable to choledocho- or hepatico-duodenostomy. Very good results are usually obtained and mortality is low at 5-9%.