Management of acquired bronchobiliary fistula: 3 case reports and a literature review

Broncho biliary fistula following interventional radiology for hepatic metastases

Bronchobiliary fistulas are defined as an abnormal communication between the biliary system and the bronchial tree. They are extremely rare complications of radiofrequency or microwave ablation. A 39-year-old woman with a history of neuroendocrine pancreatic carcinoma suffering from liver metastasis was treated with microwave ablation (MWA). In this case report, we present a case of intractable biliptysis from a bronchobiliary fistula secondary to an MWA. The patient was diagnosed by endoscopic retrograde cholangiopancreatograph and hepatobiliary scintigraphy. Treatment involved a right hemihepatectomy, a redo-hepaticojejunostomy, and the surgical placement of a transhepatic drain. After 6 weeks of drain placement, this could be removed. The fistula was thus successfully treated.

Acquired Bronchobiliary Fistula in a Young Adult Patient With Sepsis: A Case Report

Bronchobiliary fistula (BBF) is a rare, highly morbid condition that results from an abnormal connection between biliary channels and the bronchial tree. In the past, this condition has been known to be caused by untreated hydatid cysts or hepatic abscesses that can erode through the diaphragm into the pleural cavity and bronchial tree, creating fistulation. However, the condition's spectrum has changed in recent years, and BBFs have also become associated with neoplasm, iatrogenic causes, and trauma. Cases of BBF are treated differently, either with simple conservative management or invasive surgery. We present a case of a 46-year-old male initially presenting with sepsis, who was found to have a BBF. The diagnosis was made after a hepatobiliary iminodiacetic acid scan showed the flow of a tracer in the lung fields. The condition was likely due to acute cholecystitis and prior biliary instrumentation. The patient was treated successfully with percutaneous cholecystostomy tube insertion followed by elective laparoscopic cholecystectomy several weeks after hospital discharge.

Delayed diagnosis of bronchobiliary fistula complicating a pediatric living donor liver transplantation: a case report

Bronchobiliary fistula (BBF) is a very rare condition in children. Only a few pediatric BBF cases have been reported, in the context of a ruptured hydatid cyst or liver abscess. BBF after living donor liver transplantation (LDLT) has not been reported in the pediatric literature. We report a 7-year-old female child with Wilson disease, who developed BBF post-LDLT. She had a clinically uneventful course in the immediate post-transplant period. She was readmitted on postoperative day (POD) 75 with a productive cough and respiratory difficulty, which was diagnosed as bilioptysis secondary to BBF. Endoscopic retrograde cholangiopancreaticography was attempted but failed. Exploratory laparotomy showed a fistula from the strictured biliary anastomotic site to the right thoracic cavity; it was excised, and a Roux-en-Y hepaticojejunostomy was performed. She tolerated the procedure well and remained clinically well on follow-up through POD 185. BBF is extremely rare in children. This is the first case report of BBF in a child following LDLT. BBF requires a high index of suspicion for a timely intervention to prevent subsequent complications.

Bronchobiliary fistula caused after percutaneous transhepatic biliary drainage treatment: A case report

RATIONALE

Percutaneous transhepatic biliary drainage (PTBD) plays a significant role especially in the diagnosis and decompression of bile duct obstruction. However, it is associated with complications such as hemobilia, occlusion of drainage, bile leakage, and even bronchobiliary fistula (BBF).

PATIENT CONCERNS AND DIAGNOSES

We herein describe a patient with a complication of BBF caused by long-term indwelling PTBD catheters. She underwent multiple operations including bilioenteric anastomosis, hepatic left lateral lobectomy, and long-term PTBD treatment. Her symptoms were mainly cough, fever, and yellow sputum and her diagnosis was confirmed by sputum culture (bilirubin detection was positive).

INTERVENTIONS AND OUTCOMES

The patient recovered uneventfully by minimally invasive treatment, was discharged after 1 week of hospitalization, and the drainage tube was removed 2 weeks later. During 2 years of follow-up, no recurrence of BBF was observed.

LESSONS

Patients with long-term indwelling PTBD catheters for biliary tract obstruction may lead to BBF. The treatment plan of BBF is tailored to the patient's individualized characteristics. And minimally invasive treatments might be an effective alternate way for the treatment of BBF. The accurate diagnosis, precision treatment, and multidisciplinary team play important roles in the treatment of BBF.

Bronchobiliary fistula after stenting of biliary duct as the management of iatrogenic bile duct injury during elective cholecystectomy

BACKGROUND

Bronchobiliary fistula is a rare and complex entity defined by an abnormal communication between the biliary and bronchial systems. The etiopathogenesis is not completely understood, but the most common factors implicated are hepatobiliary tumors, biliary obstruction, iatrogenic damage or trauma.

METHODS

Here we present a case of a 69-year-old man that developed a bronchobiliary fistula and a pulmonary abscess after migration of a bile duct stent placed as part of the treatment of an iatrogenic bile duct injury that occurred during elective cholecystectomy.

RESULTS

A conservative approach, that included broad-spectrum antibiotic, removal of the stent, and sphincterotomy, was enough for the closure of the fistula and resolution of the symptoms.

CONCLUSION

We emphasize the importance of prompt recognition of this entity and a concerted therapeutic strategy to optimize the probability of success, avoiding the destructive consequences of the bile in the pulmonary parenchyma and septic complications.

Case Series of MRI and CT Assessment of Acquired Hepato-Biliary and Pancreatic Transdiaphragmatic Fistulae

Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of abnormal communication between the liver and/or the biliary system and the thorax; while the pancreaticopleural fistula consists of abnormal communication between the pancreas and the thorax, the pleuro-biliary fistula represents the more common type. Clinical symptoms and laboratory findings are generally non-specific (e.g., thoracic and abdominal pain, dyspnea, cough, neutrophilia, elevated CPR, and bilirubin values) and initially, first-level investigations, such as chest RX and abdominal ultrasound, are generally inconclusive for the diagnosis. Contrast-enhanced CT represents the first two-level radiological imaging technique, usually performed to identify and evaluate the underlying pathology sustained by transdiaphragmatic fistulae, their complications, and the evaluation of the fistulous tract. When the CT remains inconclusive, other techniques such as MRI and MRCP can be performed. A prompt and accurate diagnosis is crucial because the recognition of fistulae and the precise definition of the fistulous tract have a major impact on the management acquisition process.

The management of thoracobiliary fistulas in children: a systematic review

Thoracobiliary fistula (TBF) is a rare condition, in which an atypical communication between the bronchial tree and the biliary tree is present. A comprehensive literature search was conducted on Medline, Embase and Web of Science databases for studies reporting TBF in children. Data regarding patient demographics, site of fistula presentation, preoperative diagnostic procedures needed, and treatment modalities employed were extracted for further analysis. The study pool consisted of 43 studies incorporating 48 cases of TBF. The most frequent symptom was bilioptysis (67%), followed by dyspnea (62.5%), cough (37.5%) and respiratory failure (33%). Regarding the origin of fistula, the left hepatic duct was involved in 29 cases (60.4%), the right hepatic duct in 4 cases (8.3%), and the hepatic junction in 1 case (2%). Surgical management was employed in 46 patients (95.8%). Fistulectomy was performed in 40 patients (86.9%), lung lobectomy or pneumonectomy in 6 (13%), Roux en Y hepaticojejunostomy in 3 (6.5%), and decortication or drainage in 3 cases (6.5%). Three patients died (overall mortality 6.3%), while 17 patients suffered from postoperative complications (overall morbidity 35.4%). TBF in children is a rare but morbid entity which evolves as a result of congenital malformation in the majority of cases. Preoperative imaging of the biliothoracic communication and proper surgical treatment are the components of current management.

Diagnosis of Traumatic Bronchobiliary Fistula With Late 99m Tc-Mebrofenin SPECT/CT

ABSTRACT

Bronchobiliary fistula (BBF) represents a rare disorder; it consists of abnormal interconnection between the biliary tract and bronchial trees. A 22-year-old woman with persistent chest pain, jaundice, and biliptysis was referred for hepatobiliary scintigraphy under clinical suspicion of a BBF. Patient medical history was consistent with biliary tree reconstruction secondary to an iatrogenic injury during cholecystectomy 4 years ago. Previous complementary studies (CT and MR cholangiopancreatography) were equivocal for diagnosis. Planar dynamic images of hepatobiliary scintigraphy in the first hour were inconclusive. A 24-hour SPECT/CT was performed and confirmed the BBF in a minimally invasive way.

Special presentation of bronchobiliary fistula after transcatheter arterial chemoembolization: A case report

RATIONALE

Transcatheter arterial chemoembolization (TACE) is a widely adopted treatment for advanced stage hepatocellular carcinoma (HCC). Nevertheless, several complications may occur, such as hepatic artery injury, nontarget embolization, pulmonary embolism, hepatic abscess, biloma, biliary strictures, and hepatic failure. However, bronchobiliary fistula is rarely mentioned before.

PATIENT CONCERNS

A 65-year-old man with HCC underwent the TACE procedure, and then he encountered fever, dyspnea, abdominal pain, and abundant yellowish purulent bronchorrhea.

DIAGNOSIS

Bronchobiliary fistula was diagnosed based on the computed tomography (CT) scan of his chest, which revealed the right lower lobe of his lung was connected to a hepatic cystic lesion.

INTERVENTIONS

Percutaneous transhepatic cystic drainage was performed, and we obtained yellowish bile, showing the same characteristics as the patient's bronchorrhea.

OUTCOMES

We kept drainage of his biloma and provided supportive care as the patient wished. Unfortunately, the patient passed away due to progressive right lower lobe pneumonia 2 weeks later.

LESSONS

This case exhibits a typical CT scan image that was helpful for the diagnosis of post-TACE bronchobiliary fistula. Post-TACE bronchobiliary fistula formation hypothesis includes biliary tree injuries with subsequent biloma formation and diaphragmatic injuries. Moreover, the treatment of bronchobiliary fistula should be prompt to cease pneumonia progression. Therefore, we introduce this rare complication of post-TACE bronchobiliary fistula in hopes that future clinicians will keep earlier intervention in mind.

Biliary Stent Obstruction Leading to Bronchobiliary Fistula: A Rare Case Report

Bronchobiliary fistula (BBF) is a rare complication encountered by surgeons, most commonly during the follow-up of surgically managed patients with inflammatory, traumatic, or neoplastic pathologies involving the hepatobiliary tree. We present an operated case of liver hydatidosis with biliary stent obstruction with complaints of bitter green colored sputum and upper abdominal pain. The patient underwent an ERCP-guided stent extraction with reinsertion of a common bile duct stent with complete removal after six weeks. Post operatively, the patient is doing well on follow-up. This complication could be prevented by regular follow-up and timely removal of the placed stents, as a prolonged stay of stent insitu could lead to blockage, leading to complications such as bronchobiliary fistula. Thus, it is concluded that judicious follow-up plays a pivotal role, and timely removal of the stents could prevent such avoidable delayed complications.

Bronchobiliary fistula: a rare postoperative complication of spilled gallstones from laparoscopic cholecystectomy

Bronchobiliary fistula (BBF) is defined as the abnormal connection between the biliary system and the bronchial tree, which presents clinically as an irritant cough with bilioptysis. Many conditions can lead to its development. We present a case of an acquired BBF in a 61-year-old man with a significant history of spilled gallstones from a prior laparoscopic cholecystectomy and subsequent presentation of intermittent right upper quadrant pain and recurrent pneumonia. Imaging studies revealed a liver and subdiaphragmatic abscess with right middle lobe pneumonia and a BBF traversing the right hemidiaphragm. The patient was surgically managed by takedown of fistula with drainage of the abscess and removal of spilled gallstone, followed by a resection of the right middle lobe. While previous studies indicate spilled gallstones are benign, this case demonstrates its potential for serious complications. Therefore, early diagnosis and proper management is essential as BBF has a high morbidity and mortality rate.

Posttraumatic bronchobiliary fistulae due to foreign body remnants after a road traffic injury: a case report

Background

Bronchobiliary fistula is an extremely rare disease that involves abnormal communication between a hepatic segment and bronchial tree. It is mostly caused by untreated hydatid cyst, liver abscess, iatrogenic stenosis, and, rarely, trauma.

Case presentation

We experienced an extremely rare case of bronchobiliary fistula after motor vehicle accident. A 15-year-old Persian boy visited our clinic with chief complaints of persistent pleuritic chest pain, productive cough, weight loss, and fever for 2 months. Coronavirus disease 2019 reverse transcription polymerase chain reaction test was negative. Chest X-ray revealed hazy opacification of right lower lobe. Bronchoalveolar lavage for acid-fast bacillus came back negative. Thoracoabdominal computed tomography scan revealed a collection in segment VIII of the liver communicating with another 13 × 5 cm multiloculated collection in the lower lobe of the right lung, with air foci within the collection. Right posterolateral thoracotomy was performed with the impression of bronchobiliary fistula. Drainage of hepatic collection with debridement, diaphragmatic repair, and open decortication of lung followed by resection of the involved segment of the right lung was performed. Histopathologic evaluations revealed abscess formation in pulmonary tissue, and many multinucleated giant cells were seen that appear to be due to foreign body remnants after previous laparotomy surgery. The foreign body seemed to be the remnants of Surgicel absorbable hemostat.

Conclusions

Herein, we report an extremely rare case of a posttraumatic bronchobiliary fistula caused by remnants of Surgicel hemostatic agent. Bronchobiliary fistula is mainly caused by untreated hydatid cyst, liver abscess, iatrogenic stenosis, and, rarely, trauma. Migration and erosion of oxidized regenerated cellulose through the diaphragm seems to be the causative factor of bronchobiliary fistula in this patient.

Biliothoracic Fistula after Microwave Ablation of Liver Metastasis : Literature Review

Microwave ablation is a safe and effective interventional approach, widely used in the treatment of unresectable primary or metastatic hepatic lesions. Thoracobiliary fistula is a rare postablation complication that can be treated with a conservative or surgical approach. We reviewed aetiology, pathogenesis, clinical picture, diagnostic possibilities, and therapeutic options for biliothoracic fistula developed after microwave ablation of liver metastasis. Furthermore, we reported our experience of successful conservative management of a nonhealing thoracobiliary fistula occurred after percutaneous thermal ablation of colorectal cancer liver metastasis. Our case supports a conservative approach based on percutaneous biliary system decompression and synthetic glue embolization for the treatment of combined biliopleural and biliobronchial fistula.

The development of broncho-biliary fistula after treatment for hepatocellular carcinoma: a report of two cases

Broncho-biliary fistula (BBF) is a rare but severe disorder defined as abnormal communication between the biliary system and bronchial tree. Cases of BBF have occasionally been reported, but no standard treatment has been established. We report two cases of BBF that developed after the treatment of hepatocellular carcinoma (HCC) and reviewed the relevant literature. Case 1, a man in his early eighties was diagnosed with BBF 4 months after undergoing surgical resection for HCC (diameter, 7 cm; location, segments 4 and 5). Percutaneous drainage and endoscopic nasobiliary drainage (ENBD) improved BBF without recurrence for more than a year. Case 2, a woman in her late sixties was diagnosed with BBF after percutaneous radiofrequency ablation for HCC. Although the BBF was treated with ENBD, bronchial occlusion, and percutaneous transhepatic portal vein embolization, these treatments were unsuccessful and the patient died. Although non-invasive treatments have been developed, refractory BBF still exists. The prediction of BBF and the development of more effective treatments are necessary to improve outcomes.

Successful Treatment of Bronchobiliary Fistula After Living Donor Liver Transplantation: A Case Report

A bronchobiliary fistula (BBF), which is defined by abnormal communication between the biliary system and the bronchial tree, is usually regarded as a consequence of local infection, such as hydatid or amebic disease of the liver, hepatic abscess, trauma, neoplasm, and other causes of biliary obstruction. We present a 40-year-old female patient who received a living donor liver transplantation for autoimmune hepatitis and who suffered from biliary stricture at the anastomosis, bile leakage in the right subphrenic region, and development of a BBF 1 year later. Magnetic resonance cholangiography (MRC) and fistulography showed a fistula between the subphrenic biloma and right lower bronchus. The patient was treated successfully by the subphrenic drainage tube and percutaneous transhepatic cholangial drainage (PTCD) crossing the biliary stricture. In conclusion, the BBF is an extremely rare complication after liver transplantation; and minimal-invasive procedures, such as percutaneous drainage and PTCD, are useful for the closure of BBF. This case report is approved by the Institutional Review Board (IRB) of Kaohsiung Medical University Chung-Ho Memorial Hospital, certifying that no prisoners were used in the case and that participants were neither paid nor coerced.

Bile in bronchi: A case report

Background

The biliary bronchial fistula is rare and difficult to treat. Here we report a 49-year-old woman diagnosed with biliary bronchial fistula due to cough with yellow-green sputum.

Case presentation

this is a typical case of the biliary bronchial fistula with typical symptoms. The position of the abscess cavity below the diaphragm could not be catheter drainage. After anti-infection treatment, yellow-green sputum was reduced. Follow-up showed a good prognosis.

Conclusion

biliary bronchial fistula is rare in the clinic, combined with chest and abdomen infection.

Risk factors and management of different types of biliary injuries in blunt abdominal trauma: Single-center retrospective cohort study

Background

Biliary injuries after blunt abdominal traumas are uncommon and difficult to be predicted for early management. The aim of this study is to analyze the risk factors and management of biliary injuries with blunt abdominal trauma.

Method

Patients with blunt liver trauma in the period between 2009 to May 2019 were included in the study. Patients were divided into 2 groups for comparison; a group of liver parenchymal injury and group with traumatic biliary injuries (TBI).

Results

One hundred and eight patients had blunt liver trauma (46 patients with liver parenchymal injury and 62 patients with TBI). TBI were; 55 patients with bile leak, 3 patients with haemobilia, and 4 patients with late obstructive jaundice. Eight patients with major bile leak and 12 patients with minor bile leak had been resolved with a surgical drain or percutaneous pigtail drainage. Nineteen patients (34.5%) with major and minor bile leak underwent successful endoscopic retrograde cholangiopancreatography (ERCP). Sixteen patients (29.1%) underwent surgical repair for bile leak. In Multivariate analysis, the possible risk factors for prediction of biliary injuries were central liver injuries (P = 0.032), high grades liver trauma (P = 0.046), elevated serum level of bilirubin at time of admission (P = 0.019), and elevated gamma glutamyl transferase (GGT) at time of admission (P = 0.017).

Conclusion

High-grade liver trauma, central parenchymal laceration and elevated serum level of bilirubin and GGT are possible risk factors for the prediction of TBI. Bile leak after blunt trauma can be treated conservatively, while ERCP is indicated after failure of external drainage.

Risk factors and management of different types of biliary injuries in blunt abdominal trauma: Single-center retrospective cohort study

Background

Biliary injuries after blunt abdominal traumas are uncommon and difficult to be predicted for early management. The aim of this study is to analyze the risk factors and management of biliary injuries with blunt abdominal trauma.

Method

Patients with blunt liver trauma in the period between 2009 to May 2019 were included in the study. Patients were divided into 2 groups for comparison; a group of liver parenchymal injury and group with traumatic biliary injuries (TBI).

Results

One hundred and eight patients had blunt liver trauma (46 patients with liver parenchymal injury and 62 patients with TBI). TBI were; 55 patients with bile leak, 3 patients with haemobilia, and 4 patients with late obstructive jaundice. Eight patients with major bile leak and 12 patients with minor bile leak had been resolved with a surgical drain or percutaneous pigtail drainage. Nineteen patients (34.5%) with major and minor bile leak underwent successful endoscopic retrograde cholangiopancreatography (ERCP). Sixteen patients (29.1%) underwent surgical repair for bile leak. In Multivariate analysis, the possible risk factors for prediction of biliary injuries were central liver injuries (P = 0.032), high grades liver trauma (P = 0.046), elevated serum level of bilirubin at time of admission (P = 0.019), and elevated gamma glutamyl transferase (GGT) at time of admission (P = 0.017).

Conclusion

High-grade liver trauma, central parenchymal laceration and elevated serum level of bilirubin and GGT are possible risk factors for the prediction of TBI. Bile leak after blunt trauma can be treated conservatively, while ERCP is indicated after failure of external drainage.

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In most of the published series they discussed the iatrogenic biliary injuries or injuries after sharp trauma.

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To our knowledge it is the largest series to discuss the biliary injuries with blunt liver trauma.

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We can predict the possible risk factors for bile duct injury after blunt liver trauma.

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So we can diagnose and treat it properly and early before sepsis and biliary complications.

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We can approach to the ideal treatment modality for each type of biliary injuries with prober timing.

Bronchobiliary fistula after ablation of hepatocellular carcinoma adjacent to the diaphragm: Case report and literature review

Background

Bronchobiliary fistula is a rare, but life‐threatening complication after ablation of hepatocellular carcinoma. Few cases of bronchobiliary fistula have been reported and the treatment is controversial.

Methods

From 2006 to 2019, a total of 11 patients were diagnosed with bronchobiliary fistula after ablation and received nonsurgical treatment.

Results

All 11 patients presented with cough and bilioptysis. There were only two patients in which MRI revealed an obvious fistulous tract connecting the pleural effusion and biliary lesions. Pleural effusion, liver abscess and hepatic biloma were found in other patients. Three patients died of uncontrolled bronchobiliary fistula.

Conclusions

Bronchobiliary fistula is a rare post‐ablation complication but should be taken into consideration in clinical decisions. Minimally invasive interventional treatment is a relatively effective means of dealing with bronchobiliary fistula, but as for the more severe cases, greater clinical experience is required.

Surgical Treatment of Bronchobiliary Fistula with Pulmonary Resection and Omentopexy

Bronchobiliary fistula is a rare disease defined as an abnormal connection between the biliary tract and the bronchial tree. We report the successful surgical repair of bronchobiliary fistula. A 78-year-old man underwent surgery and several rounds of transcatheter arterial chemoembolization and radiofrequency ablation as treatment for hepatocellular carcinoma. He presented with greenish sputum and chronic cough for several months, and his symptoms did not resolve after endoscopic treatment. We performed lobectomy of the right lower lobe and omentopexy for bronchobiliary fistula under laparotomy and thoracotomy. The bronchobiliary fistula was successfully closed, and the bilious sputum disappeared after surgery.

Post-traumatic bronchobiliary fistula

Post-traumatic bronchobiliary fistula (BBF) is a rare entity, with only a few cases reported worldwide. Bilioptysis is pathognomonic of the condition, however, bronchoscopy and bronchoalveolar lavage along with CT are used for confirmation. We describe this condition in a young woman who presented to us with bilioptysis following a laparotomy for blunt torso trauma. Diagnosis was made of BBF, followed by surgical management and complete recovery. We emphasise the signs of early diagnosis, confirmatory tests, individualised treatment and advocate surgical management as the gold standard of treatment.

Percutaneous Bronchial Embolization to Treat Intractable Bronchobiliary Fistula

Sixty-four-year-old female who underwent hemi-hepatectomy for intrahepatic cholangiocarcinoma a year ago presented with biliary sputum, cough and fever. Cross-sectional imaging showed a recurred tumor involving right diaphragmatic area and an abscess formation in liver dome with adjacent right lower lobe of lung. Percutaneous transhepatic biliary drainage and percutaneous drainage of lung abscess were performed. Tubogram showed connections between the lung abscess cavity and multiple distal bronchi, suggesting bronchobiliary fistulas. Two weeks of drainage treatment did not relieve symptoms. We successfully treated intractable bronchobiliary fistula via image-guided percutaneous access to closest distal bronchi near abscess with subsequent tandem placement of vascular plugs.

Bronchobiliary fistula after radiofrequency ablation for hepatocellular carcinoma successfully treated by double drainage

For hepatocellular carcinomas, radiofrequency ablation is extensively used to alleviate primary and metastatic hepatic tumours. Common complications of this procedure include bleeding, infection, and hollow organ perforation. We present the case of a patient with hepatoma who underwent radiofrequency ablation. He had intractable cough with yellowish sputum, particularly while lying down, three weeks after treatment. Chest computed tomography demonstrated a right middle lobe consolidation with pleural effusion and right subphrenic fluid collection. Thoracoscopic decortication was performed under the diagnosis of empyema. The attending anaesthesiologist noted bile-like fluid aspirated from the endotracheal tube. Therefore, we suspected bronchobiliary fistula. Percutaneous transhepatic drainage of the subphrenic fluid and simultaneous cholangiography confirmed bronchobiliary fistula. The patient was successfully treated using percutaneous drainage combined with endoscopic retrograde biliary drainage. An imaging finding of subphrenic fluid collection with right lower lung consolidation after radiofrequency ablation for hepatic tumours should raise the suspicion of bronchobiliary fistula.

Successful endoscopic management of a persistent bronchobiliary fistula with Histoacryl®/Lipiodol® mixture

Introduction A bronchobiliary fistula (BBF) following liver directed therapy (resection/ablation) is a rare complication in which an abnormal communication between the biliary tract and bronchial tree is formed. This case report describes the successful management of a persistent BBF following multiple liver wedge resections and microwave ablation in a patient with a metastatic neuroendocrine tumour of the terminal ileum. Case history A 69-year-old man presented with unexplained weight loss and was subsequently diagnosed with a neuroendocrine tumour of the terminal ileum and liver metastasis. Following elective right hemicolectomy and multiple bilobar liver wedge resections combined with liver microwave ablation, he developed an early bile leak. A month later, a right subphrenic collection was identified and four months following surgery, biloptysis was noted. Numerous attempts with endoscopic retrograde biliary drainage (ERBD) failed to achieve sufficient drainage. The patient was treated successfully with endoscopic injection of a mixture of Histoacryl® glue (B Braun, Sheffield, UK) and Lipiodol® (Guerbet, Solihull, UK). There was no evidence of the BBF one year following intervention. Conclusions This novel approach for persistent BBF management using endoscopic Histoacryl® glue embolisation of the fistula tract should be considered either as an adjunct to ERBD or when biliary tract decompression by drainage and/or sphincterotomy fails, prior to proceeding with surgical interventions.

Combined thoracic and hepatobiliary surgery for iatrogenic bronchobiliary fistula

Bronchobiliary fistula is a rare pathology mainly caused by hepatic tumors, bile duct obstruction, or hepatic hydatid disease. A 70-year-old man developed a bronchobiliary fistula after biliary stenting. After failure of conservative treatment including endoscopic retrograde biliary drainage, he underwent a combined operation with a two-level approach. Both a thoracotomy and laparotomy were performed, allowing pulmonary resection, diaphragmatic repair, and bile duct reconstruction during the same operation. Postoperative follow-up at one year showed optimal healing of the fistula.

Demonstration of a bronchobiliary fistula using magnetic resonance image with hepatospecific contrast agent

Bronchobiliary fistulas are a rare entity of difficult diagnosis. The utility of magnetic resonance image (MRI) with hepatospecific contrast agents to demonstrate such condition is seldom described in the literature. This case reports a patient with pulmonary infection with a past history of hepatic surgery for hydatid disease in whom the presence of bile in the sputum rose the suspicious of a bronchobiliary fistula. MRI with hepatospecific contrast agents showed the communication between the biliary and bronchial tree and provided anatomic data to allow a therapeutic approach.

Brocho-biliary fistula: A rare complication after ruptured liver abscess in a 3½ year old child

Bronchobiliary fistula (BBF) is a rare condition, defined by the presence of abnormal communication between biliary tract and bronchial tree. We describe a 3½-year-old child who developed BBF after rupture of liver abscess. She underwent exploratory laparotomy and peritoneal wash for ruptured liver abscess. Seven months later she presented with fever and cough with yellow-colored expectoration (bilioptysis). An abnormal communication between right branch of the hepatic duct and a branch of right main bronchus was identified. Child underwent right lateral thoracotomy and right lower lobectomy with surgical excision of sinus tract. On follow-up child was asymptomatic and doing well.

Intraductal papillary mucinous neoplasm of the liver: GI image

Intraductal papillary mucinous neoplasms (IPMNs) are rare, mucin-producing, predominantly noninvasive tumors arising from epithelial cells. Most IPMNs arise from the pancreas. There exists a subset of IPMN of the biliary tract (BT-IPMN). IPMNs regardless of origin produce large amounts of mucin relative to scant amounts of epithelial cells, leading to mass effect disturbances in bile flow. Affected bile ducts exhibit marked dilatation. The majority of IPMN patients present with a non-malignant neoplasm. Because of potential for transformation, surgery is the treatment of choice. Bronchobiliary fistulas can present as congenital defects, following thoracoabodominal trauma, or as rare complications of diseases of the biliary tract such as BT-IPMN. There are no reported cases in the literature of bronchobiliary fistula associated with BT-IPMN, but there is a clear theoretical risk.

Bronchobiliary fistula localized by cholescintigraphy with single-photon emission computed tomography

Biliptysis is an important clinical feature to recognize as it is associated with bronchobiliary fistula, a rare entity. Bronchobiliary fistulas have been diagnosed with planar cholescintigraphy. However, cholescintigraphy with single-photon emission computed tomography (SPECT) can better spatially localize a bronchobiliary fistula as compared to planar cholescintigraphy alone, and is useful for preoperative planning if surgical treatment is required. Here, we present the case of a 23-year-old male who developed a bronchobiliary fistula in the setting of posttraumatic and postsurgical infection, which was diagnosed and localized by cholescintigraphy with SPECT.

Bronchopleural fistula following laparoscopic liver resection

A rare case is presented of a 58-year-old woman who developed a bronchopleural fistula following a laparoscopic liver resection for a colorectal metastasis. The bronchopleural fistula was finally diagnosed when after repeated admissions for chest infections, the patient coughed up surgical clips. We propose a management plan based on our experience and hope this case report will add to the scarce reports of postoperative bronchopleural fistula cases in the literature.

The challenging management of hepatopulmonary fistulas

Hepatopulmonary fistula although benign in nature carries an unacceptable mortality risk up to 10.3% in some case series mainly due to surgical complications. From the first description by Ferguson and Burford in 1967 till present different approaches have been applied and with the introduction of less invasive techniques the results have significantly improved. Interestingly the prevalence of the different etiological factors has changed over the years especially with the advance of liver ablating techniques and surgery. A step by step approach to this entity, from diagnosis to treatment has to be reestablished in order to identify the role of interventional modalities and to develop a management algorithm.

Thoracoscopic surgery for bronchobiliary fistula: a case report

The bronchobiliary fistula is an abnormal interconnection between the biliary tract and bronchial trees. It is rare but troublesome. The management of such fistula is a challenge. Surgical intervention is considered after failure of conservative treatment. Here we presented the successful video-assisted thoracoscopic surgery for secondary bronchobiliary fistula in 68-year-old hepatocellular carcinoma patient.

Bilorrhea secondary to bronchobiliary fistula

Bronchobiliary fistula (BBF) is a rare condition which occurs most commonly as a complication of hydatid cyst liver disease. The following report describes a patient who presented with biliptysis 6 months following decortication of an empyema that had occurred following partial hepatectomy of a colon cancer metastasis. This is the only case to our knowledge that describes the presentation of a BBF in this context. The patient was diagnosed with BBF and successfully underwent open thoracotomy for fistulectomy and repair.

Thoracobiliary fistulas: literature review and a case report of fistula closure with omentum majus

Background

Thoracobiliary fistulas are pathological communications between the biliary tract and the bronchial tree (bronchobiliary fistulas) or the biliary tract and the pleural space (pleurobiliary fistulas).

Review of the literature

We have reviewed aetiology, pathogenesis, predilection formation points, the clinical picture, diagnostic possibilities, and therapeutic options for thoracobiliary fistulas.

Case report

A patient with an iatrogenic bronchobiliary fistula which developed after radiofrequency ablation of a colorectal carcinoma metastasis of the liver is present. We also describe the closure of the bronchobiliary fistula with the greater omentum as a possible manner of fistula closure, which was not reported previously according to the knowledge of the authors.

Conclusions

Newer papers report of successful non-surgical therapy, although the bulk of the literature advocates surgical therapy. Fistula closure with the greater omentum is a possible method of the thoracobiliary fistula treatment.

Transhepatic embolisation of a traumatic broncho-biliary fistula: a novel approach

Bronchobiliary fistula is a rare and challenging condition that most commonly presents worldwide following infection with hydatid cystic disease of the liver but is increasingly seen in cases of trauma involving the right upper quadrant. The most common presenting complaint is biliptysis. Treatment is initially aimed at decompressing the biliary tree which allows a considered approach for closure of the fistulous tract. Options range from conservative management to endoscopic and percutaneous approaches. Traditionally definitive treatment would have been surgical and may ultimately have resulted in hepatic and/or pulmonary segmentectomy. Current management strategies of this potentially serious condition are variable. We describe a particularly challenging case in which interventional embolisation with microcoils was used in an attempt to treat persistent post-traumatic bronchobiliary fistula in a tertiary centre. We describe this technique and hope that it is may be of useful reference for those contemplating a similar approach.

Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years

AIM: To outline the appropriate diagnostic methods and therapeutic options for acquired bronchobiliary fistula (BBF).

METHODS: Literature searches were performed in Medline, EMBASE, PHMC and LWW (January 1980-August 2010) using the following keywords: biliobronchial fistula, bronchobiliary fistula, broncho-biliary fistula, biliary-bronchial fistula, tracheobiliary fistula, hepatobronchial fistula, bronchopleural fistula, and biliptysis. Further articles were identified through cross-referencing.

RESULTS: Sixty-eight cases were collected and reviewed. BBF secondary to tumors (32.3%, 22/68), including primary tumors (19.1%, 13/68) and hepatic metastases (13.2%, 9/68), shared the largest proportion of all cases. Biliptysis was found in all patients, and other symptoms were respiratory symptoms, such as irritating cough, fever (36/68) and jaundice (20/68). Half of the patients were treated by less-invasive methods such as endoscopic retrograde biliary drainage. Invasive approaches like surgery were used less frequently (41.7%, 28/67). The outcome was good at the end of the follow-up period in 28 cases (range, 2 wk to 72 mo), and the recovery rate was 87.7% (57/65).

CONCLUSION: The clinical diagnosis of BBF can be established by sputum analysis. Careful assessment of this condition is needed before therapeutic procedure. Invasive approaches should be considered only when non-invasive methods failed.

Uncommon acquired fistulae involving the digestive system: summary of data

PURPOSE

Most gastrointestinal fistulae commonly occur following surgery. A minority is caused by a myriad of other etiologies and is termed by some as "uncommon fistulae". The aim of this study was to review these fistulae and their treatment.

METHODS

A literature review was carried out. Searches were conducted in Pubmed and related references reviewed.

RESULTS

Except for Crohn's disease and diverticulitis, "uncommon fistulae" are described in case reports or very small case series. Most of the patients were treated by surgery.

CONCLUSIONS

The anatomic features of the fistula and the etiology usually dictate the approach. Most patients will eventually need surgery to resolve this pathology.

Confident diagnosis of bronchobiliary fistula using contrast-enhanced magnetic resonance cholangiography

We report the utility of contrast-enhanced magnetic resonance cholangiography (MRC) using gadoxetic acid (Gd-EOB-DTPA) in the diagnosis of bronchobiliary fistula associated with liver hydatid cyst. Contrast-enhanced MRC clearly delineated the leakage of contrast agent from the biliary duct and its communication with the bronchial tree. Providing functional information about physiologic or pathologic biliary flow in addition to the display of biliary anatomy, contrast-enhanced MRC stands as a robust technique in confidently detecting bronchobiliary fistula and bile leaks.

Surgical management of complicated hydatid cysts of the liver

AIM: To review the clinical presentation and surgical management of complicated hydatid cysts of the liver and to assess whether conservative surgery is adequate in the management of complicated hydatid cysts of liver.

METHODS: The study was carried out at Sher-i-Kashmir Institute of Medical Science, Srinagar, Kashmir, India. Sixty nine patients with hydatid disease of the liver were surgically managed from April 2004 to October 2005 with a follow up period of three years. It included 27 men and 42 women with a median age of 35 years. An abdominal ultrasound, computed tomography and serology established diagnosis. Patients with jaundice and high suspicion of intrabiliary rupture were subjected to preoperative endoscopic retrograde cholangiography. Cysts with infection, rupture into the biliary tract and peritoneal cavity were categorized as complicated cysts. Eighteen patients (26%) had complicated cysts and formed the basis for this study.

RESULTS: Common complications were infection (14%), intrabiliary rupture (9%) and intraperitoneal rupture (3%). All the patients with infected cysts presented with pain and fever. All the patients with intrabiliary rupture had jaundice, while only four with intrabiliary rupture had pain and only two had fever. Surgical procedures performed in complicated cysts were: infection-omentoplasty in three and external drainage in seven; intrabiliary rupture-omentoplasty in two and internal drainage in four patients. Two patients with intraperitoneal rupture underwent external drainage. There was no mortality. The postoperative morbidity was 50% in complicated cysts and 16% in uncomplicated cysts.

CONCLUSION: Complicated hydatid cyst of the liver can be successfully managed surgically with good long term results.