Biliopleural fistula: A rare complication of percutaneous transhepatic gallbladder drainage

Biliothorax in a patient with unresectable cholangiocarcinoma

Biliothorax is a rare but serious condition, as the presence of bile is damaging and can lead to empyema. Here, we report a case of a 51-year-old man recently diagnosed with unresectable cholangiocarcinoma, admitted to the hospital for malignant obstructive jaundice. After interventional management of biliary obstruction, the patient developed a significant right pleural effusion compatible with biliothorax, successfully managed with pleural drainage and antibiotic therapy. Resolution was possible with a conservative approach: biliary decompression, chest tube drainage and antibiotics.

Nonoperative management of biliopleural fistula following living-donor liver transplantation: A case report

Key Clinical Message

Biliopleural fistula is a rare but serious complication after liver transplantation that should be managed nonoperatively with antibiotics, pleural drainage, decompression of high-pressure biliary tract, or ultimately surgery in unresponsive cases.

Abstract

Bilious pleural effusion is a rare entity often iatrogenic, following hepatobiliary surgeries and biliary interventions, and has been reported only in a limited number of patients after liver transplantation. A 5-year-old girl underwent living donor liver transplantation due to progressive familial intrahepatic cholestasis. At the 7th day of the postoperative course, due to increased liver enzymes and bilirubin levels and intrahepatic bile duct dilatation on sonography, Magnetic Resonance Cholangiopancreaticography followed by a liver biopsy were performed; the findings demonstrated moderate intrahepatic bile duct dilatation and moderate cellular rejection associated with mild cholestasis, respectively. The patient was therefore administered a pulse of methylprednisolone; however, due to fever, peritonitis and also sonographic evidence of infected biloma collection adjacent to the transplanted liver, the patient underwent surgery. Laparotomy and peritoneal washout were performed and a Jackson-Pratt drain was inserted adjacent to the liver cut surface. Succeeding tachypnea on 28th post day, led to detection of right side massive pleural effusion on chest Xray and hence thoracostomy tube was inserted. A diagnosis of biliopleural fistula was established and broad-spectrum intravenous antibiotic therapy was started, followed by cholangiography, fistula closure, and bile duct stricture ballooning and internal-external biliary catheter insertion. The patient was discharged in generally good condition on the 50th posttransplant day. The diagnosis of biliopleural fistula is facilitated with the utilization of chest imaging and pleural fluid analysis, however, a high index of suspicion is required.

Gallbladder perforation with fistulous communication

BACKGROUND

The management of gallbladder perforation (GBP) with fistulous communication (Neimeier type I) is controversial.

AIM

To recommend management options for GBP with fistulous communication.

METHODS

A systematic review of studies describing the management of Neimeier type I GBP was performed according to the PRISMA guidelines. The search strategy was conducted in Scopus, Web of Science, MEDLINE, and EMBASE (May 2022). Data extraction was obtained for patient characteristics, type of intervention, days of hospitalization (DoH), complications, and site of fistulous communication.

RESULTS

A total of 54 patients (61% female) from case reports, series, and cohorts were included. The most frequent fistulous communication occurred in the abdominal wall. Patients from case reports/series had a similar proportion of complications between open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) (28.6 vs 12.5; P = 0.569). Mortality was higher in OC (14.3 vs 0.0; P = 0.467) but this proportion was given by only one patient. DoH were higher in OC (mean 26.3 d vs 6.6 d). There was no clear association between higher rates of complications of a given intervention in cohorts, and no mortality was observed.

CONCLUSION

Surgeons must evaluate the advantages and disadvantages of the therapeutic options. OC and LC are adequate options for the surgical management of GBP, with no significant differences.

Imaging of benign biliary pathologies

Pathologies of the biliary tree include a wide-spectrum of benign and malignant processes. The differential for benign disease includes congenital and acquired disease with variable prognosis and management pathways. Given the ability to mimic malignancy, benign processes are difficult to diagnose by imaging. Direct cholangiography techniques with tissue sampling are the gold standards for the diagnosis of benign and malignant biliary pathologies. Non-invasive imaging with ultrasound offers a first-line diagnostic tool while MRI/MRCP offers higher specificity for identifying underlying pathology and distinguishing from malignant disease. In this review, we focus on the imaging appearance of dilatation, cystic anomalies obstruction, inflammation, ischemia, strictures, pneumobilia, and hemobilia to help construct a differential for benign processes.

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.

Gallbladder: Role of Interventional Radiology

Percutaneous cholecystostomy is an established procedure for the management of patients with acute cholecystitis and with significant medical comorbidities that would make laparoscopic cholecystectomy excessively risky. In this review, we will explore the role of percutaneous cholecystostomy in the management of acute cholecystitis as well as other applications in the management of biliary pathology. The indications, grading, technical considerations, and postprocedure management in the setting of acute cholecystitis are discussed. In addition, we will discuss the potential role of percutaneous cholecystostomy in the management of gallstones and biliary strictures, in establishing internal biliary drainage, and in a joint setting with other clinicians such as gastroenterologists in the management of complex biliary pathology.

Late onset of biliopleural fistula following percutaneous transhepatic biliary drainage: a case report

Biliopleural fistula (BF) and formation of biliopleural effusion is a rare complication following percutaneous transhepatic biliary drainage (PTBD). It occurs when the pleura is traversed by the catheter before entering the bile duct. Biliopleural fistula should be suspected when right side pleural effusion develops following the PTBD procedure. The diagnosis of biliopleural fistula is made when greenish pleural fluid with high concentration of bilirubin is aspirated. Here we present a case where a patient develops a biliopleural fistula following PTBD due to obstructive jaundice caused by neuroendocrine tumor of pancreas. Biliopleural fistula was disclosed after a scheduled catheter replacement procedure. Treatments of biliopleural fistula include thoracentesis with drainage tube installation into pleural space. In addition, a drainage tube was installed through percutaneous transhepatic gallbladder drainage (PTGBD) to reduce the bile induced pressure. Surgical repair of fistula was performed after the conservative treatment was unsuccessful. The patient expired 5 days after surgery due to respiratory failure.

Biliary-Pleural Fistula following Portal Vein Embolization for Perihilar Cholangiocarcinoma

Biliary-pleural fistula (BPF), an abnormal communication between the biliary tract and pleural space, is a rare but potentially life-threatening complication following percutaneous biliary intervention. We report a case of BPF following portal vein embolization (PVE) in a 79-year-old woman with obstructive jaundice secondary to perihilar cholangiocarcinoma. The patient successfully underwent right-sided PVE; however, the patient developed a symptomatic right-sided bilious pleural effusion the following day. Despite aggressive drainage of the pleural effusion with a large-bore chest tube and maximal medical management, the patient died from respiratory failure and pneumonia. Although rare, knowledge of this complication is important when performing PVE in patients with biliary obstruction because it can be life-threatening. Early recognition and management of this complication are crucial to avoid a poor outcome.

Endoscopic Gallbladder Drainage for Acute Cholecystitis

Background/Aims

Surgery is the mainstay of treatment for cholecystitis. However, gallbladder stenting (GBS) has shown promise in debilitated or high-risk patients. Endoscopic transpapillary GBS and endoscopic ultrasound-guided GBS (EUS-GBS) have been proposed as safe and effective modalities for gallbladder drainage.

Methods

Data from patients with cholecystitis were prospectively collected from August 2004 to May 2013 from two United States academic university hospitals and analyzed retrospectively. The following treatment algorithm was adopted. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and cystic duct stenting was initially attempted. If deemed feasible by the endoscopist, EUS-GBS was then pursued.

Results

During the study period, 139 patients underwent endoscopic gallbladder drainage. Among these, drainage was performed in 94 and 45 cases for benign and malignant indications, respectively. Successful endoscopic gallbladder drainage was defined as decompression of the gallbladder without incidence of cholecystitis, and was achieved with ERCP and cystic duct stenting in 117 of 128 cases (91%). Successful endoscopic gallbladder drainage was also achieved with EUS-guided gallbladder drainage using transmural stent placement in 11 of 11 cases (100%). Complications occurred in 11 cases (8%).

Conclusions

Endoscopic gallbladder drainage techniques are safe and efficacious methods for gallbladder decompression in non-surgical patients with comorbidities.

A rare pleural effusion in a young male

A 28-year-old male presented with fever with right-sided chest pain for 2 weeks. Clinicoradiological picture was suggestive of right-sided pleural effusion. He had history of polytrauma following a road traffic accident and had to undergo emergency laparotomy a month ago. Microscopic and culture examination of the pleural fluid showed neutrophilia, high bilirubin content and presence of gram-negative bacilli. Ultrasound of the abdomen showed the presence of biloma in the liver and right subdiaphragmatic space with fistulous communication into the right thoracic cavity. The patient was managed successfully with complete recovery.

Biliopleural fistula following gun shot injury in right axilla

A biliopleural fistula (BPF) is a rare and atypical manifestation of thoracoabdominal trauma. A stepwise approach for the management is recommended for a successful outcome. We report a case of a 22-year-old man who was referred to our hospital with respiratory discomfort after sustaining a gunshot injury in the right axilla. On investigations he had haemopneumothorax, central liver contusion with perihepatic fluid and a bullet lodged at the level of right renal hilum. He was at first managed by placing a right intercostal tube drain, which initially drained blood and subsequently started draining bile. He was managed successfully with endoscopic biliary stenting, pigtail drainage of subphrenic collection and antibiotics.

Thoracic Empyema Caused by Percutaneous Transhepatic Gallbladder Drainage

Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative to emergency laparoscopic cholecystectomy in high-risk patients with acute cholecystitis. Severe complications of this procedure are rare, except for drainage tube-related complications. A case of thoracic empyema, which is a rare complication of PTGBD, is reported; penetration of the pleural cavity seemed to be the cause of the thoracic empyema.

Defying gravity: subdiaphragmatic causes of pleural effusions

Intra-abdominal fluid may migrate readily into the pleural space through naturally occurring holes in the diaphragm or intradiaphragmatic lymphatics. Although any type of fluid in the abdomen may migrate, additional pathologic mechanisms are involved in the development of chylous ascites/chylothorax, yellow nail syndrome, urinothorax, pancreaticopleural fistulas, or other connections. In the differential diagnosis of the large list of potential pleural fluid causes, intra-abdominal sources should be entertained by the practicing physician in the right clinical context.

Bronchobiliary fistula: a rare complication of hepatic endometriosis

OBJECTIVE

To report the case and surgical therapy of a patient with bilioptysis after vaginal delivery, caused by bronchobiliary fistula. Histologic analysis revealed endometrial glands embedded in the decidual stroma neighboring the liver and the lung.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 39-year-old patient, 7 days after vaginal delivery, without endometrial history.

INTERVENTION(S)

Synchronous liver and lung resection of a bronchobiliary fistula by laparotomy and a transdiaphragmatic approach.

MAIN OUTCOME MEASURE(S)

For complicated brochobiliary fistula caused by endometriosis, radical surgical treatment is mandatory.

RESULT(S)

Histopathologic analyses confirmed the presence of clusters of endometrial glands embedded in the decidual stroma that were neighboring the liver, and perifistulous lung tissue was shown to contain biliary pigment absorbed by macrophages and their derivatives.

CONCLUSION(S)

Hepatic and perihepatic endometriosis can cause a bronchobiliary fistula. Exacerbation of the symptoms can be triggered by high estrogen levels, physiologically dominating the last trimester. For such a rare case, surgery is mandatory.

Changing approaches to cholecystectomy in elderly patients: a 10-year retrospective study in Taiwan

BACKGROUND

The prevalence of symptomatic gallbladder diseases increases with age. The present study evaluated cholecystectomy risk factors and hospital resource utilization in an elderly (aged 60 years and older) population of patients who had undergone open cholecystectomy (OC) or laparoscopic cholecystectomy (LC).

METHODS

The study analyzed 20,538 OC and 29,318 LC procedures performed in Taiwan from 1996 to 2007. Odds ratio (OR) and 95% confidence interval were calculated to assess the relative change rate. Regression models were employed to predict length of stay (LOS) and total surgical cost.

RESULTS

Patient characteristics associated with increased likelihood of undergoing LC were age 60-69 years, female gender, and lack of current co-morbidities. Length of stay associated with both OC and LC decreased during the study period. Total surgical cost for elderly OC patients increased during the study period, whereas that for elderly LC patients declined. Compared to OC patients, LC patients had significantly larger changes in LOS (-2.27 days) and total surgical cost ($ -368.64 U.S. dollars) (p < 0.001). The following factors were associated with considerable increases in both LOS and total surgical cost: advanced age, female gender, presence of one or more co-morbidities, treatment in a regional or a district hospital, and long LOS.

CONCLUSIONS

Decreases in hospital resource utilization were larger in elderly LC patients than in elderly OC patients. Health care providers and patients should observe that hospital resource utilization may depend on hospital attributes as well as patient attributes. These analytical results should be applicable to similar elderly populations in other countries.

Chronic percutaneous gallstone discharge following videothoracoscopic decortication

Computed tomographic imaging is not recommended as an essential prerequisite in surgery for pleuro-pulmonary sepsis in the current guidelines. We highlight one consequent pitfall and its sequelae. We report the discharge of gallstones through a healed intercostal drain site four months following video-assisted thoracic surgery for early pleural empyema secondary to missed calculous gallstone disease. The importance of awareness and a high index of suspicion to diagnose the underlying extra-thoracic cause of a right-sided pleural collection in a patient with a previous history of gallstone disease cannot be overemphasised.