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

Approach to Acute Traumatic and Nontraumatic Diaphragmatic Abnormalities

Acute diaphragmatic abnormalities encompass a broad variety of relatively uncommon and underdiagnosed pathologic conditions, which can be subdivided into nontraumatic and traumatic entities. Nontraumatic abnormalities range from congenital hernia to spontaneous rupture, endometriosis-related disease, infection, paralysis, eventration, and thoracoabdominal fistula. Traumatic abnormalities comprise both blunt and penetrating injuries. Given the role of the diaphragm as the primary inspiratory muscle and the boundary dividing the thoracic and abdominal cavities, compromise to its integrity can yield devastating consequences. Yet, diagnosis can prove challenging, as symptoms may be vague and findings subtle. Imaging plays an essential role in investigation. Radiography is commonly used in emergency evaluation of a patient with a suspected thoracoabdominal process and may reveal evidence of diaphragmatic compromise, such as abdominal contents herniated into the thoracic cavity. CT is often superior, in particular when evaluating a trauma patient, as it allows rapid and more detailed evaluation and localization of pathologic conditions. Additional modalities including US, MRI, and scintigraphy may be required, depending on the clinical context. Developing a strong understanding of the acute pathologic conditions affecting the diaphragm and their characteristic imaging findings aids in efficient and accurate diagnosis. Additionally, understanding the appearance of diaphragmatic anatomy at imaging helps in differentiating acute pathologic conditions from normal variations. Ultimately, this knowledge guides management, which depends on the underlying cause, location, and severity of the abnormality, as well as patient factors. ©RSNA, 2024 Supplemental material is available for this article.

Congenital bilio-bronchial fistula in an adult: a review of literature and video demonstration of laparoscopic fistula tract excision

This article presents a review of the literature on congenital bilio-bronchial fistula (BBF), a rare anomaly characterized by abnormal communication between the bile duct and respiratory tract. Congenital BBF often presents with bilioptysis in early neonates and infants; however, patients with no overt symptoms may occasionally present in adulthood. Our literature search in Medline from 1850 to 2023 revealed 42 reported cases of congenital BBF, primarily managed with thoracotomy and excision of the fistula tract. About one-third of these cases required multiple surgeries due to associated biliary anomalies. The review underscores the importance of diagnostic imaging, including bronchoscopy, in identifying and delineating the extent of the fistula. It also highlights the evolving surgical management, with recent cases showing the efficacy of minimally invasive approaches such as laparoscopy and thoracoscopy. In addition to the literature review, we report a young female patient with a history of recurrent respiratory infections presenting with bilioptysis and extensive left lung damage. Initial management included bronchoscopy-guided glue instillation, left thoracotomy, and pneumonectomy. Following the recurrence of symptoms, the patient was successfully treated with laparoscopic excision of the fistula tract. In recent times, minimally invasive approaches such as laparoscopy and thoracoscopy, with excision of the fistula tract are gaining popularity and have shown good results. We suggest biliary communication being the high-pressure end, tackling it transabdominal may prevent recurrent problems.

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.

Endobronchial closure of broncho-biliary fistula using Amplatzer device: Case report

Broncho-biliary fistula (BBF) is an extremely rare but serious medical condition resulting from pathological communication between the biliary system and the bronchial tree. Treatment options include both surgical and non-surgical approaches. Several endobronchial techniques, such as the spigot and glue, can be used for this purpose. This report discusses a patient who developed a broncho-biliary fistula following a liver biopsy. The BBF was diagnosed during bronchoscopy and successfully treated with an endobronchial Amplatzer device. To the best of our knowledge, this is the first report of the use of the Amplatzer device to manage 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.

Complications of Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Case Report of Bronchobiliary Fistula Development in a 68-Year-Old Man

BACKGROUND Bronchobiliary fistulas (BBFs) are abnormal communications between the biliary tract and bronchial tree. Transcatheter arterial chemoembolization (TACE) is a widely employed treatment for advanced hepatocellular carcinoma (HCC). While TACE is generally considered safe, there have been reports of severe complications. This case report is about a 68-year-old man who developed a BBF 6 months after undergoing TACE for HCC. CASE REPORT A 68-year-old man was diagnosed with HCC and underwent TACE at a local medical department. Two months after TACE, he presented with a liver abscess, which was drained and catheterized. Subsequently, the patient was transferred to our hospital. Initial MRI revealed abscesses in the right hepatic lobe extending into the lung cavity. Intrahepatic catheter replacement was performed. Six months after TACE, the patient developed cough and yellow sputum. Subsequent MRI confirmed smaller lung and liver abscesses, along with a BBF. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous catheter replacement were conducted, closing the BBF with a covered stent. Despite drainage, antibiotics, and nutritional support, the patient's condition deteriorated. Transition to hospice care was initiated, and the patient died due to sepsis and multiple organ failure. CONCLUSIONS This case highlights the importance of obtaining a comprehensive patient history when a patient has bile in the sputum, and discusses the rare but previously reported BBF as a complication of TACE for HCC. The presence of bile collections in the lungs and liver can result in tissue necrosis, potentially leading to chronic infection, emphasizing the need for early diagnosis and management.

Biliptysis Revealing a Bilio-Bronchial Fistula

The presence of a bilio-bronchial fistula (BBF) of hydatid origin is considered a serious complication as it can lead to significant injuries at the abdominal, diaphragmatic, and thoracic levels. Here, we report the case of a 70-year-old patient presenting with biliptysis as a symptom and whose thoracic and abdominal CT scan confirmed the presence of a right BBF. The management consisted of an initial endoscopic sphincterotomy, followed by an exclusive left thoracotomy surgery to treat lung, liver, and diaphragmatic injuries. Fortunately, the evolution was favorable with the disappearance of the biliptysis. To diagnose a BBF, it is crucial to conduct a precise assessment, focusing mainly on imaging to accurately locate the injury before any surgical intervention.

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.

Bronchobiliary fistulae as a complication of untreated pulmonary hydatid cyst presenting with bilioptysis: A report of two cases

We reported two patients, a 45-year-old lady and a 48-year-old man, known cases of untreated liver and lung hydatid cysts complicated with bronchobiliary fistulae. Surgery was performed, and bronchobiliary fistulae were diagnosed intraoperatively. Lobectomy was done on the lobe, which was chronically infected. Symptoms resolved after surgery in both cases. Green-colored sputum in a patient with a history of echinococcosis should raise the physician's attention to the probability of a connection between the bronchial tree and the biliary tract. Surgery in advanced cases is a suitable therapeutic option.

Endobronchial Watanabe Spigot Placement for Hepatic Abscess and Bronchobiliary Fistula Following Radiofrequency Ablation for Hepatocellular Carcinoma

A bronchobiliary fistula (BBF) is an uncommon but severe complication after radiofrequency ablation (RFA). However, the definitive salvage methods are controversial. We herein report a patient with hepatocellular carcinoma with hepatic abscess and BBF following RFA. We also review previous reports of BBF after RFA. The patient was a man in his 70s who underwent RFA for recurrent hepatocellular carcinoma in the subphrenic area. Despite percutaneous transhepatic abscess drainage, bilioptysis persisted. Finally, the BBF was occluded with an endobronchial Watanabe spigot under fiber-optic bronchoscopy. Placing an endobronchial Watanabe spigot should be considered as a salvage therapy for refractory BBF following RFA.

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.

Case report: Biliobronchial fistula after biliary tract stenosis

Biliobronchial fistula (BBF) is a rare abnormality resulting from congenital or acquired communication between the bile ducts and the bronchial tree. Patients often suffer from chronic cough, dyspnea, and bilioptysis, a pathognomonic symptom of this condition. Conservative methods such as less-invasive procedures are gradually consolidating. Nonetheless, surgery remains the primary treatment, especially in more complex cases. We present the case of a 44-year-old woman with a chronic cough, no verified periods of fever, cyclic jaundice, and episodes of yellowish sputum. She had undergone cholecystectomy in 2018 and had been hospitalized several times since for pneumonia treatment. All consequent investigations for mycobacteriosis were negative. When referred to our hospital, she had cyclic jaundice and parenchymal consolidation in the right lower lobe. Suspected bilioptysis motivated the search for a biliobronchial fistula. Magnetic resonance cholangiography (MRC) confirmed stenosis of the biliary tract and fistulous path, and sputum analysis indicated high bilirubin levels. External biliary bypass was performed as an initial conservative and definitive therapy due to the presence of liver cirrhosis. Although BBF is a rare condition when bilioptysis is suspected, a diagnostic investigation should be initiated. Our case study proposes two criteria for diagnosis: an imaging exam demonstrating the fistulous path and confirmation of bilirubin in the sputum or bronchoalveolar lavage (BAL). When diagnosed, surgical correction should be performed.

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.

Bronchial-biliary fistula secondary to cholangiocarcinoma: long-term efficacy of biliary self-expandable metal stent

A 77-year-old female with previous medical history of non-cirrhotic chronic hepatitis B and hepatocellular carcinoma treated with sequential partial hepatectomy followed by transarterial chemoembolization complained of pruritus and jaundice. Magnetic resonance cholangiopancreatography revealed a peri-hilar ill-defined stenosing lesion suggestive of malignancy. Endoscopic retrograde cholangiopancreatography with cholangioscopy confirmed a circumferential peri-hilar stenosis with fragile mucosa and tortuous dilated vessels and biopsies of this area were consistent cholangiocarcinoma. After 3 months, she presented with new-onset dyspnea and bilioptysis and abdominal computed tomography revealed a bronchial-biliary fistula. ERCP was performed to place a self-expandable metal stent in the biliary tract, which resulted in rapid clinical improvement. The patient has been followed for 2 years and remains globally stable with two episodes of worsening of bilioptysis secondary to stent obstruction by lithiasis that were easily resolved with Fogarty balloon-assisted extraction, with rapid improvement. This case demonstrates the long-term efficacy of endoscopic biliary drainage with self-expandable metallic stent for bronchial-biliary fistula in the setting of cholangiocarcinoma. .

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.

Rapidly progressive interstitial pneumonia associated with anti-NXP2 antibody secondary to malignancy

The diagnosis of a diffuse lung disease is challenging for physicians and it requires a multidisciplinary team approach to solve this problem. Herein, we present a case of common bile duct obstruction from pancreatic ductal adenocarcinoma after biliary stent placement, which developed a rapidly progressive bilateral lung infiltration after oesophagogastroduodenoscopy. After a diagnostic evaluation based on clinical, radiographic, and pathological findings, a diagnosis of rapidly progressive interstitial pneumonia associated with anti-nuclear matrix protein (NXP) 2 antibody secondary to malignancy was made. In patients with interstitial lung disease with unclear aetiologies, autoantibodies, including antinuclear antibody and myositis-specific antibodies should be evaluated, even if there are no clinical signs of autoimmune disease. Although this is the first case report of an acute interstitial pneumonitis-associated anti-NXP2 antibody, physicians should recognise this condition as it can rapidly cause acute fulminant respiratory failure.

First case report of spontaneous biliary pleural fistula diagnosed using near infrared region I/II fluorescence of indocyanine green

We report a rare case of spontaneous biliary pleural fistula in a patient whose diagnosis was aided by the use of near-infrared I/II fluorescence imaging. When both 99mTc-mebrofenin hepatobiliary scintigraphy and CT examination were diagnostically difficult, we found strong fluorescent signals in the patient’s pleural drainage fluid and sputum using NIR I/II fluorescence imaging, and therefore diagnosed the patient with a biliary pleural fistula. This provides a safe and effective test for diagnosing biliary pleural fistulas.

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.

Intrapulmonary Gallstones and Pleuro-Biliary Fistula Formation Due to Complication From Prior Cholecystectomy: A Case Report and Literature Review

Intrapulmonary gallstones and the formation of pleuro-biliary fistula is a rare complication of laparoscopic cholecystectomy. The stones are most commonly found in the right lower lobe of the lungs. The symptoms tend to be insidious in nature and can manifest as hemoptysis, irritating cough, and cholelithoptysis years after the procedure. The stones can be removed through lobectomy or may also be treated non-invasively with antibiotics only. Here, we describe a case of a patient who developed hemoptysis and was found to have intrapulmonary gallstones from laparoscopic cholecystectomy and subsequent fistula formation.

Multimodal Approach to Acquired Bronchobiliary Fistula Secondary to Hepaticojejunostomy Stricture Following Yttruim-90 Therapy

Bronchobiliary fistula (BBF) is an abnormal connection between the bronchial system and the biliary tree. It pathognomonically presents with bilioptysis (production of bilious-tinged sputum) and is associated with mortality rates up to 12.7%. Here we present a 56-year-old male with stage IV neuroendocrine pancreatic cancer status post pylorus-preserving pancreaticoduodenectomy. The patient developed an acquired BBF secondary to repeated Yttrium-90 radioembolization therapy that resulted in complete stenosis of the hepaticojejunostomy (HJ) anastomosis. The diagnosis was confirmed using cholescintigraphy and bronchoscopy. Biliary decompression with percutaneous transhepatic cholangiogram was unsuccessful, necessitating resection of the HJ anastomosis with salvage bilioenteric reconstruction using Kasai-type anastomosis between the pancreaticobiliary limb and hepatic duct. Complete resolution was noted following surgery. Although a minimally invasive approach to treatment of BBF may be favorable, patients with previous biliary reconstruction may warrant multimodal treatments including percutaneous procedures and complex surgical reconstructions.

Successful Radiograph-guided Bronchial Occlusion with Silicon Spigots for Bronchobiliary Fistula

Bronchobiliary fistulas (BBF), defined as abnormal connections between a bronchus and the bile duct, are rare. Bronchial occlusion with silicon spigots under radiographic guidance is a good alternative means of treating a BBF when surgical intervention is considered too risky. A 60-year-old man was diagnosed with intrahepatic cholangiocarcinoma and underwent chemotherapy. He developed obstructive jaundice, which was treated with percutaneous transhepatic cholangiography drainage (PTCD). Subsequent bronchoscopy with contrast medium via the PTCD tube enabled identification of a BBF and the responsible bronchus, which was occluded with silicon spigots. There were no complications after this procedure.

A case report of a lung abscess as a rare complication of a pyogenic liver abscess

RATIONALE

A hepatobronchial fistula and lung abscess following a pyogenic liver abscess is a rare entity and it is not easy to diagnose this condition based on the symptoms and chest radiography.

PATIENT CONCERNS

An 81-year-old man presented with productive cough and dyspnea.

DIAGNOSIS

Chest radiography indicated increased opacities in the right lower lung field with an air-fluid level suggestive of pneumonia complicated by a lung abscess. Chest and abdominal computed tomography revealed an abscess in the right lower lung field that bordered an abscess at segment 7 of the liver. Tubography confirmed a fistula between the liver and lung abscesses.

INTERVENTIONS

Due to communication between 2 abscesses, transhepatic approach was done instead of transpleural approach to avoid complications.

OUTCOMES

A liver abscess complicated by a lung abscess was resolved following percutaneous transhepatic drainage of the liver abscess and antibiotic administration.

LESSONS

Though uncommon, the lack of suspicion of sub-diaphragmatic liver abscess often lead to a delay in diagnosis and proper treatment. Our case implies the importance of computed tomography in early diagnosis of liver abscess in case of lung abscess in the right lower lung field.

Hepatic cyst infection complicated by a hepatobronchial fistula diagnosed with unique features

A hepatobronchial fistula (HBF) is a rare condition, defined as an abnormal connection of the respiratory system with the liver parenchyma. Although imaging may be helpful for diagnosis, fistulae are often difficult to identify. An 81-year-old woman presented with mild fever and right upper quadrant abdominal pain. Computed tomography (CT) showed bilateral pneumonia and hepatic cyst infection with air-fluid levels. After mechanical ventilation, abdominal CT showed increased air in the hepatic cyst. The drainage bag for the hepatic cyst infection was also inflated by positive pressure ventilation, suggesting a possible HBF. The ventilator was adjusted to minimize pressure on the fistula and prevent retrograde infection. The fistula eventually closed spontaneously. Appropriate antibiotic treatment and continuous drainage resulted in improvement of the hepatic cyst infection; however, the patient died due to respiratory complications. HBF should be suspected when positive pressure ventilation results in increased air at the hepatic infection site.

Non-Operative Management of Bronchobiliary Fistula Due to Proximal Migration of Biliary Stent in a Patient With Unresectable Klatskin Tumor

Introduction:

One of the methods for the biliary tree decompression in the case of Klatskin tumor is transpapillary stenting, which could be completed by stent migration in 4% to 10% of cases. Approximately half of the stent migrations are in the proximal direction. In this study, we reported a rare case of proximal trans-diaphragmatic stent migration to the lower lobe of the right lung with the formation of a biliary-bronchial fistula (BBF).

Case presentation:

A 60-year-old woman was diagnosed with hilar cholangiocarcinoma (type 3B by Bismuth-Corlette) complicated by posthepatic jaundice. To relieve jaundice there were performed endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, endobiliary stent placement (10 Fr, 150 mm). A restenting (11.5 Fr, 130 mm) was performed in 2.5 months due to endobiliary tube occlusion. In the next 2 months, coughing attacks and biliptysis have appeared in the patient. A CT scan showed penetration of the liver, diaphragm, and lower lobe of the right lung with the proximal part of the stent and caused BBF formation. Anti-inflammatory and antibacterial therapy was administrated for 14 days and BBF was closed. Stent retrieval from the right hemithorax and endobiliary restenting was performed in 9 months after primary stenting. During follow-up, appropriate positioning and functioning of the stent were observed.

Conclusion:

BBF formation is a rare complication of endobiliary stenting, which can be successfully treated by anti-inflammatory and antibiotic therapy, followed by transpapillary stent retrieval.

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.

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.

Percutaneous Treatment of Bronchobiliary Fistula: Report of a Successful Transhepatic Embolization and a Decision-Making Strategy Driven by Systematic Literature Review

Bronchobiliary fistula is a rare condition characterized by bile leaking into the bronchial tree causing biliptysis. It may arise from liver infection or as a consequence of resection and thermal ablation of cancer. Currently, there is no consensus about the treatment strategy. Surgery is considered the main therapy by most authors. However, this systematic literature review shows that the success rate of percutaneous treatments may reach 75%. Adding to such evidence, we also report the case of a woman affected by iatrogenic bronchobiliary fistula secondary to liver thermal ablation, successfully treated with percutaneous drainage plus embolization. Summarizing these results, we encourage the percutaneous management of bronchobiliary fistula by providing a 3-step decision-making algorithm, aimed at reducing the need for major surgery.

Congenital bronchobiliary fistula: a case report and literature review

Congenital bronchobiliary fistula (CBBF) is a very rare malformation associated with clinical symptoms of dyspnoea, vomiting, cyanosis, persistent pneumonia, and poor response to antibiotics. Typical imaging techniques used to diagnose this malformation include bronchography, computed tomography (CT), cholangiography, hepatobiliary nuclear imaging, and magnetic resonance imaging (MRI). We diagnosed a case of CBBF that was initially diagnosed as non-resolving pneumonia. CT and fistulography were used to obtain the correct diagnosis. The fistula was confirmed by fistulography under the guidance of bronchoscopy. Surgical excision of the fistulous tract was performed, with complete recovery. The aim of this report was to emphasize the epidemiology and clinical features of CBBF patients.

Large Diaphragm Defect Reconstruction Using Reverse Latissimus Dorsi Muscle Flap

Surgical treatment of bronchobiliary fistula (BBF) is difficult. A 47-year-old woman presented with a cough with yellow yielding sputum due to BBF. The patient had the adhesion of the liver, diaphragm, and lung. We performed liver, diaphragm, and lung resections. Patient had a large defect of diaphragm. Diaphragm reconstruction was performed using a pedicled reverse latissimus dorsi muscle flap. No flap necrosis was observed. Seven months after surgery, the patient did not present yellow yielding sputum and the BBF was not observed in the computed tomography. This surgical procedure was useful for treating the diaphragm defect both safely and easily. We believe that the reverse pedicled latissimus dorsi muscle flap is a reliable alternative for large diaphragm reconstruction after severe BBF.

Bronchopleurobiliary fistula following right lower lobectomy in a patient with prior hepatic abscess: a case report

In a 68-year-old male patient with cholangitis microabscess in the liver, cavitary lung cancer of the right lower lobe was incidentally diagnosed. The patient’s medical history comprised totally laparoscopic distal gastrectomy (TLDG) and cholecystectomy 9 years ago. Before TLDG, endoscopic retrograde cholangiopancreatography (ERCP) was performed because of a common bile duct stone and cholangitis. Three months ago, he was readmitted with cholangitic microabscess, and a cavitary lesion of right lower lobe was detected incidentally. Hepatobiliary microabscess was improved with ERCP and antibiotic treatment. Video-assisted thoracoscopic surgery (VATS) right lower lobectomy and mediastinal lymph node dissection were undergone uneventfully. Pneumonic infiltration in the right lower lung field and hydropneumothorax on the right side were developed on postoperative day 10. Chest computed tomography showed pneumobilia and micro-bronchopleural fistula (BPF) was suspected with bronchoscopic examination. Despite antibiotics usage and thoracic suction, air leakage could not be improved. VATS Talc pleurodesis was performed on postoperative day 38. Contralateral pneumonia developed 1 week following talc pleurodesis. Furthermore, bilirubin was detected in the repeated bronchial washing and pleural fluid and they showed the same color and nature. Though ERCP and endoscopic nasobiliary drainage, the patient’s condition deteriorated and the patient passed away on postoperative day 60. Bronchopleurobiliary fistula is an extremely rare complication after thoracic surgery for which surgical treatment is challenging, early recognition of a developing fistula and the aggressive treatment at an early stage can reduce the associated morbidity and mortality from the sequelae of this rare disease entity.

Spontaneous bronchobiliary fistula: Case report

Bronchobiliary fistula (BBF) is a rare condition that results from the communication between the bile ducts and the bronchial tree. It is characterized by the presence of bile in the sputum as pathognomonic symptom, and it is often associated with suspicious pneumonia. The most common causes include infections (e.g. echinococcosis), hepatobiliary surgery, blunt torso traumas, tumors and percutaneous transhepatic procedures. Opinions about BBF treatment are still controversial as it can be treated by both conservative and surgical procedures, while pharmacological treatments are only rarely used. This case report presents a patient who had been diagnosed with chronic BBF of unknown cause, underwent several ineffective conservative procedures and was at last surgically treated.

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.

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.