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An unusual complication of acute calculous cholecystitis: subdiaphragmatic abscess through transhepatic biliary fistula

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A 73 year old man presented to hospital with an acute calculouscholecystitis and important associated comorbidities. Due to altered coagulation tests (INR value 3,2) the surgical treatment cholecystectomy was temporized, in order to allow the deployment of surgical procedures in better safer conditions. Before laparotomy, the clinical and paraclinical data prefigured a milder cholecystitis. After administration of fresh plasma the patient was operated, two days later. The intraoperative diagnosis was severest than before showing the occurrence of an unusual complication, namely a transhepatic fistula which penetrated towards supra-hepatic area. Surgical procedure consisted in viscerolisis, cholecystectomy, evacuation of suprahepatic collection and subhepatic suprahepatic drainages. The postoperative evolution was favorable, with a good recovery and discharge after seven days. This case not only presents an uncommon complication of acute calculous cholecystitis, but also further emphasizes the fact that the clinical and paraclinical data are insufficient in some cases (multiple comorbidities, immunocompromised elderly patients) for establishing of an accurate preoperative diagnosis. Intraoperative exploration and evaluation still remain the gold standard with respect to diagnosis for some surgical patients.

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