This case report presents a 56-year-old male patient diagnosed with obstructive jaundice, complicated by bile duct stones, bile duct dilation, and a possible biliary-enteric fistula. The patient’s medical history included previous abdominal surgeries, such as laparoscopic cholecystectomy and intestinal adhesion release, which likely predisposed him to these complications. Despite initial supportive treatment, his condition progressed, requiring invasive interventions like endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery to address the biliary obstruction (1).

This case is noteworthy due to the complex interplay of factors, including the rare complication—a biliary-enteric fistula—likely resulting from prior surgery (2). It highlights the challenges in diagnosing and treating obstructive jaundice in patients with a complex surgical history and underscores the importance of a multidisciplinary approach.

Our literature review examined diagnostic approaches and treatments for obstructive jaundice complicated by surgical history, using key terms including “biliary-enteric fistula” and “post-surgical biliary complications.” While biliary-enteric fistulas are rare (3), they occur in patients with prior biliary surgeries (Table 1). This case contributes to understanding biliary disease management in complex clinical histories, emphasizing early detection, monitoring, and tailored intervention.

The case presented offers a complex scenario involving a 56-year-old male patient who was diagnosed with obstructive jaundice, potentially caused by a combination of bile duct stones, bile duct dilation, and a biliary-enteric fistula. The case was further complicated by the patient’s medical history, which included prior cholecystectomy and intestinal adhesion release, as well as a mild enlargement of the spleen. The patient’s symptoms were initially alleviated with supportive treatment, but the condition worsened, requiring more invasive interventions such as ERCP and laparoscopic surgery (1). This report raises important points regarding both the strengths and limitations of this case, the relevant medical literature, and the scientific rationale for the conclusions drawn.

One of the key strengths of this case report is the thorough diagnostic approach employed. A combination of imaging modalities, including ultrasound, CT scans, and MRCP, was used to confirm the diagnosis of obstructive jaundice and identify the possible causes, including bile duct stones and a biliary-enteric fistula (2). The integration of these diagnostic tools is in line with current best practices, as the use of advanced imaging can provide accurate visualization of biliary tract abnormalities, as supported by the literature (3). Furthermore, the patient’s surgical management—combining endoscopic procedures and laparoscopic surgery—demonstrates a comprehensive approach to addressing the multifactorial nature of the condition. This aligns with established treatment protocols for complex biliary diseases (4).

However, this case also has limitations. For one, the lack of pre-surgical biopsies or tissue samples to definitively confirm the etiology of the biliary-enteric fistula poses a challenge in establishing a clear causal relationship between the patient’s symptoms and the fistula itself (5, 6). Although imaging findings suggest the presence of the fistula, direct pathological confirmation would have strengthened the case. The absence of histopathological verification warrants further elaboration. Intraoperative biopsy was not pursued due to the significant technical challenges posed by dense inflammatory adhesions at the fistula site and concerns regarding iatrogenic injury to adjacent structures during dissection. Furthermore, the fistula’s macroscopic features—including its well-defined communication between the common bile duct and duodenum, active bile leakage, and surrounding fibrotic changes—were deemed pathognomonic under direct visualization. This aligns with standard surgical practice in similar emergent settings, where definitive anatomical identification and repair supersede histological sampling, particularly when imaging and operative findings are concordant (7, 8). Unlike Gibreel et al. (7) report on gallbladder-colostomy fistula patients requiring emergency open surgery, this case demonstrated that while ERCP decompression failed in the same patient, a minimally invasive obstruction relief was achieved through laparoscopic partial gastrectomy combined with Roux-en-Y gastrostomy, avoiding the significant trauma of open surgery. Moreover, compared to Agathis et al. (8) staged robotic approach (first addressing intestinal obstruction, then repairing fistulas), this case successfully completed adhesion lysis, fistula-related obstruction relief, and gastrointestinal reconstruction in a single laparoscopic procedure. This provides a novel clinical strategy for concurrent minimally invasive treatment of complex postoperative biliary fistulas with obstruction. In addition to the lack of pre-surgical biopsies, the collected intraoperative tissue samples of the fistula margin were small and had limited representativeness. Although HE staining confirmed chronic inflammation and fibrosis at the fistula site, the absence of more extensive tissue sampling (e.g., from the deeper layers of the fistula wall or the interface between the bile duct and duodenum) prevented definitive verification of the fistula’s etiology (e.g., whether it was directly related to the 2022 laparoscopic cholecystectomy or secondary to other inflammatory processes). Additionally, the patient’s medical history, including previous surgeries, could be a confounding factor in interpreting the progression of his current symptoms. The possibility that previous procedures might have contributed to the development of the biliary fistula or other complications is not fully explored in the report. As such, a more detailed exploration of the patient’s surgical history, particularly focusing on the outcomes and complications of prior surgeries, would have added depth to the analysis.

In comparing this case with the literature, several key similarities and differences arise. Previous studies have shown that obstructive jaundice often results from conditions such as choledocholithiasis, cholangitis, or biliary strictures. The patient’s symptoms, including jaundice, fever, and abdominal pain, are consistent with those described in the literature for biliary obstruction (9). However, the presence of a biliary-enteric fistula as a possible complication of prior surgery is a less common finding (10). Literature on this specific complication highlights its association with previous cholecystectomy and other biliary surgeries. This case, therefore, contributes to a broader understanding of the complications that can arise following abdominal surgeries and the importance of considering such factors in the diagnosis and treatment of biliary diseases.

However, while acknowledging the documented occurrence of biliary-enteric fistulas following biliary surgery (Table 1), our case offers distinct insights into diagnosis and management. The unique challenge stemmed from the combination of factors: a large fistula causing significant biliary leakage and obstruction, dense inflammatory adhesions obscuring anatomy consequent to multiple prior abdominal surgeries, and the concomitant presence of choledocholithiasis. Crucially, initial ERCP was not only diagnostic but also highlighted severe inflammatory stenosis at the fistula site, rendering endoscopic therapy insufficient and necessitating definitive laparoscopic surgical repair involving gastrectomy and Roux-en-Y reconstruction. This contrasts with many reported cases where fistulas were smaller, endoscopic management was successful, or the surgical history was less complex. Therefore, this case significantly contributes by detailing the diagnostic hurdles in complex post-surgical anatomy, demonstrating the critical role of ERCP in both diagnosis and triaging management, and outlining the specific laparoscopic surgical approach required when inflammation and adhesions preclude minimally invasive endoscopic resolution or less extensive surgery. The successful outcome underscores the importance of this tailored, step-wise approach in similar complex scenarios.

The causal relationship between the patient’s symptoms and the identified complications is complex. The primary causal factor for the patient’s obstructive jaundice appears to be the combination of bile duct stones and the biliary-enteric fistula (11). Previous studies suggest that biliary-enteric fistulas can develop as a result of chronic inflammation or complications from surgical procedures (12). In this case, the fistula likely resulted from the patient’s prior cholecystectomy and the associated changes in biliary anatomy. The inflammation at the site of the fistula further complicated the patient’s condition, as evidenced by the difficulty encountered during the ERCP. This provides strong evidence for a causal relationship between the surgical history and the current biliary obstruction, although more data on the patient’s surgical recovery and post-operative complications would help solidify this connection.

In terms of scientific rationale, the treatment choices were based on the understanding that biliary obstruction can lead to severe complications if not addressed promptly (13). Endoscopic interventions, including ERCP, are commonly used to manage biliary obstructions, and they are supported by the literature as effective first-line treatments for such conditions (14). The laparoscopic approach, involving a gastrectomy and Roux-en-Y gastrojejunostomy, was an appropriate next step given the patient’s worsening condition and the potential for a long-term solution to the biliary obstruction. The use of laparoscopic techniques, while more invasive, is supported in cases of complex biliary pathology where non-surgical interventions may not suffice (15).

Initially, ERCP was attempted for both diagnostic and therapeutic purposes. However, severe inflammatory stenosis and a significant duodenal-biliary fistula were encountered, precluding successful endoscopic intervention. In light of the patient’s clinical presentation—including abdominal pain, biliary infection, and pneumobilia—a multidisciplinary consensus was reached to proceed with laparoscopic Roux-en-Y gastrojejunostomy. This approach was selected to effectively alleviate symptoms and improve long-term outcomes, particularly given the concern for ongoing biliary infection which rendered biliary-enteric anastomosis less favorable. The postoperative course confirmed the efficacy of this strategy, with resolution of symptoms and stable clinical follow-up.

The case also presents a unique set of circumstances, with the potential for a biliary-enteric fistula complicating the presentation of obstructive jaundice (16). The patient’s previous surgeries, including cholecystectomy, likely predisposed him to the formation of this fistula. While such complications are rare, they are documented in the literature, and this case serves as a reminder of the complexities involved in managing patients with a history of abdominal surgeries (17).

From a clinical perspective, this case highlights several important lessons. First, it underscores the need for careful post-surgical follow-up, especially in patients who have undergone complex biliary or abdominal surgeries. It is crucial to monitor for late complications such as biliary-enteric fistulas, which may present with non-specific symptoms like jaundice and abdominal pain. Additionally, it reinforces the importance of a multidisciplinary approach in managing complex cases, particularly those involving multiple interventions like endoscopy and surgery. Given the potential for recurrence of symptoms or complications, ongoing monitoring is essential, and patients should be educated about the signs of potential issues following biliary surgery.

The case of a 56-year-old male with obstructive jaundice, complicated by bile duct stones and a biliary-enteric fistula, underscores the importance of a comprehensive diagnostic approach and tailored therapeutic interventions. The patient’s condition was successfully managed through a combination of ERCP and laparoscopic surgery. The use of advanced imaging techniques (ultrasound, CT, MRCP) and limited intraoperative tissue sampling proved essential in confirming the diagnosis of biliary-enteric fistula. Although the small size of the fistula tissue samples prevented definitive verification of the etiology, the pathological findings of chronic inflammation and fibrosis supported the inflammatory nature of the fistula, guiding the selection of surgical treatment strategies. This case emphasizes the need for careful follow-up in patients with complex biliary conditions, particularly those with a history of abdominal surgeries. It highlights the importance of a multidisciplinary approach to ensure effective management of multifactorial diseases. For future research, further studies into the long-term outcomes of patients with biliary-enteric fistulas and the role of minimally invasive techniques in managing such cases are recommended. This case provides valuable insights for clinical practice, particularly in the management of post-surgical biliary complications, and reinforces the need for vigilance in the follow-up care of patients with complex biliary diseases.