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

Biliptysis

Background

Biliptysis means coughing of bile which is a presenting symptom of a rare condition called bronchobiliary fistula (BBF). BBF is a connection between the biliary tract and bronchial tree. BBF mostly occurs secondary to malignancy, liver abscess, and trauma. Surgical approach in BBF management was the main management strategy, then endoscopic approach.

Case presentation

We managed our first encountered case of biliptysis endoscopically by endoscopic retrograde cholangiopancreatography (ERCP).

Conclusion

ERCP management seems to be effective in management of biliptysis.

Biliptysis

Background

Biliptysis means coughing of bile which is a presenting symptom of a rare condition called bronchobiliary fistula (BBF). BBF is a connection between the biliary tract and bronchial tree. BBF mostly occurs secondary to malignancy, liver abscess, and trauma. Surgical approach in BBF management was the main management strategy, then endoscopic approach.

Case presentation

We managed our first encountered case of biliptysis endoscopically by endoscopic retrograde cholangiopancreatography (ERCP).

Conclusion

ERCP management seems to be effective in management of biliptysis.

Bronchobiliary fistula after hepatectomy: A case report and review of the literature

Bronchobiliary fistula (BBF) is a rare complication following hepatectomy, and consists of an abnormal intercommunication between the biliary tract and bronchial tree. The management of this rare entity is challenging with limited current evidence to date on how to treat this condition. Herein, a case of BBF following a central hepatectomy and the successive steps of the management was presented. Fourteen months postoperatively, the patient presented to the Oncology Department complaining of new onset fever and expectoration. A computerized tomography scan revealed a BBF and the patient was subsequently referred to our department for further treatment. The surgical team decided that a further operation was required. Using the transabdominal approach, a communication between the initial intrahepatic collection and one inferior lobular bronchus was revealed. Transhiatal removal of fistula was performed with closure of the defect through the abdomen. There was no bile leak through the remaining liver parenchyma. Multidisciplinary management should be considered, taking into consideration the underlying pathology leading to this rare complication. Conservative treatment should be considered first, while surgical resection of the BBF remains an option when other therapies have failed. Surgeons should be aware of this rare complication bile duct injuries during hepatic operations can cause.

Bronchobiliary fistula after ramucirumab treatment for advanced gastric cancer: A case report

BACKGROUND

Bronchobiliary fistula (BBF) is a rare disease characterized by an abnormal connection between the biliary system and bronchi. Traditional causes of BBF include trauma and infections, and more recent causes include malignancies and certain cancer treatments. Ramucirumab is an antivascular endothelial growth factor receptor 2 monoclonal antibody, currently used as a second-line treatment for gastric cancer.

CASE SUMMARY

A 43-year-old man visited our hospital with the complaint of jaundice. He was diagnosed with inoperable advanced gastric cancer owing to invasion of the hepatic hilum by the tumor. After percutaneous transhepatic biliary drainage (PTBD) and stent placement, capecitabine and oxaliplatin were administered as first-line palliative chemotherapy. The tumor progressed, and paclitaxel and ramucirumab were administered as second-line chemotherapy. However, on the first day of the second cycle, the patient suddenly developed dyspnea and pneumonia. BBF was diagnosed on the basis of the presence of bilious sputum and the results of computed tomography, and PTBD was repeated.

CONCLUSION

This is the first report of BBF after administration of the new antiangiogenic agent ramucirumab.

Anesthetic management for a patient with bronchobiliary fistula after pancreaticoduodenectomy: A case report

RATIONALE

Perioperative management of patients with bronchobiliary fistula (BBF) is an anesthetic challenge because they typically exhibit poor lung function preoperatively, require meticulous lung isolation intraoperatively and need postoperative respiratory support.

PATIENT CONCERNS

A 44-year-old man with a past surgical history of pancreaticoduodenectomy presented fluctuating fever, jaundice, dyspnea and yellowish sputum. Despite intravenous antibiotic treatment and repeated percutaneous drainage, patient showed gradual deterioration with hypoxemia, and uncontrolled pneumonia.

DIAGNOSES

The patient was diagnosed with BBF based on the clinical manifestation such as biloptysis with pneumonia, and imaging studies.

INTERVENTIONS

Resection of the fistula and bilobectomy was performed under general anesthesia. Avoidance of positive pressure ventilation before lung isolation and precise lung isolation are essential for patients with BBF to protect the unaffected lung. Therefore, rapid sequence induction was performed. Left-sided double-lumen tube was inserted for lung isolation and position of the tube was confirmed by visualization with fiberoptic bronchoscopy. Bile-stained secretion was repeatedly suctioned in trachea and both bronchi during surgery.

OUTCOMES

In spite of decrease in SpO2 with institution of one-lung ventilation, the patient's oxygenation was gradually improved as surgery progressed without hemodynamic instability. At the end of surgery, the double-lumen tube was replaced with a single-lumen endotracheal tube for postoperative mechanical ventilation.

LESSONS

Absolute lung isolation using double-lumen tube for one-lung ventilation and bronchial toilet during surgery and replacement of single-lumen tube for postoperative respiratory support at the end of surgery are effective to improve oxygenation in patients with BBF.

Hepatopulmonary Fistula in a Colorectal Cancer Patient

Cancer patients with liver metastasis may be candidates for liver surgery and local interventional techniques as part of their treatment. Although rare in this setting, hepatopulmonary fistula has been described as a possible complication. The clinical picture may be atypical, and, without specific treatment, it usually has a dismal prognosis. As locoregional treatments (whether interventional or surgical techniques) in liver neoplasms are being more frequently used we need to include this entity as a possible differential diagnosis of local liver treatment complications.

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.

Hepatic artery pseudoaneurysm, bronchobiliary fistula in a patient with liver trauma

BACKGROUND

Bronchobiliary fistula and hepatic artery pseudoaneurysm are rare complications of hepatic trauma. There are isolated case reports for both pseudoaneurysm and bronchobiliary fistula following hepatic trauma but there aren't reports of both conditions developing in a single patient.

CASE PRESENTATION

This case describes an 18 year old hindu male who developed right hepatic artery pseudoaneurysm and bronchobiliary fistula following blunt abdominal trauma. Patient was managed with exploratory laparotomy followed by coil embolization and Endoscopic retrograde cholangiopancreatography stenting respectively.

CONCLUSION

Rare complications of liver trauma include pseudoaneurysm and bronchobiliary fistula. These complications can rarely co- exist in a single patient.

Bronchobiliary fistula following radiofrequency ablation for liver metastases from breast cancer: A case report and literature review

RATIONALE

Bronchobiliary fistula (BBF) is a rare clinical condition which is characterized by a channel between biliary tract and bronchial tree. BBF can present with fever, dyspnea, and cough. However, it can be easily misdiagnosed as biliary vomiting, dyspnea, or even severe pneumonia.

PATIENT CONCERNS

A 53-year-old woman was diagnosed with breast cancer in April 2011 and underwent radical mastectomy and lymph node dissection, chemotherapy, and radiotherapy. Unfortunately, the patient suffered from bone metastasis during the 1st year and liver metastasis during the 2nd year after radical mastectomy. In 2013, the patient underwent transcatheter arterial chemoembolization therapy twice for liver metastasis. The patient was then treated with radiofrequency ablation (RFA) in 2016. Unfortunately, the patient developed a cough with bitter-tasting yellow sputum and chest tightness 2 weeks after the RFA treatment. Approximately 6 months later, the patient still complained of a cough with yellow sputum and persistent chest tightness. The patient was then admitted to our department.

DIAGNOSES

The presence of bile in the sputum supported a diagnosis of BBF. Bronchoscopy was performed, and the presence of bile in the lavage fluid confirmed the diagnosis of BBF.

INTERVENTIONS

The patient was treated with antibiotics including sulbactam, cefoperazone, levofloxacin and meropenem, was well as hepatoprotectants, nutritional support and other supportive treatments in our department.

OUTCOMES

The patient died because of liver failure.

LESSONS

This case demonstrates that we should consider the possibility of BBF when patients experience a recurrent cough with discolored sputum after RFA. In particular, a diagnosis of BBF should be considered in patients who do not respond to antibiotic treatment.

Bronchobiliary fistula: a rare complication after pancreaticoduodenectomy

Biliary anatomic pathologies are rare disease occurrences that can result from a number of causes, most commonly iatrogenic, infectious and malignant aetiologies. Communications between the biliary and bronchial systems are even rarer and few cases have been documented in the literature. The present study describes a case of a 70-year-old man who underwent a pancreaticoduodenectomy (Whipple Procedure) as a curative procedure for an early stage neuroendocrine tumour. He presented nearly a decade after surgery with a communication between the biliary and bronchial tree initially manifesting as bilioptysis. His underlying medical conditions and poor clinical picture made treatment options limited. Therefore, he was treated conservatively with percutaneous biliary balloon dilation of the anastomotic stricture followed by temporary percutaneous internal/external drain and made a full recovery.

Bronchobiliary fistula caused by diaphragmatic invasion of a hepatic tumour

A 71-year-old man presented with a productive cough consisting of yellow fluid. He had previously been treated for pneumonia without resolution in his symptoms. Sputum was tested for bilirubin using a urine dipstick given its similar appearance to bile, which was positive. Hepatobiliary scintigraphy scan revealed uptake of radiotracer in the right lower lobe of the lung. Endoscopic retrogade cholangiopancreatography confirmed diagnosis of a bronchobiliary fistula. The patient had a stent placed in the common bile duct promoting anterograde bile flow with complete resolution of symptoms.

Two cases of bronchobiliary fistula: Case report

A bronchobiliary fistula, or a biliobronchial fistula (BBF), is a rare condition. It results from an abnormal connection between the biliary and bronchial trees, and is characterized by pathognomonic bilious sputum with suspicious pneumonia. Traditionally, an infectious disease, such as a hydatid infection, has been known to cause a BBF, but BBFs have recently become associated with tumors. In every case, procedures and treatments differ between centers, from simple conservative management to invasive surgical procedures. This case report presents two patients who had BBF after liver resection. Symptoms of each patients were treated and controlled successfully by percutaneous transhepatic biliary drainage tube insertion. We hope that this report helps in the management of BBF in other cases.

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.

Role of Cholescintigraphy with Single-Photon Emission Computerized Tomography-Computed Tomography in Detecting Bronchobiliary Fistula: Unusual Complication of a Common Disease

Bronchobiliary fistula (BFF) is an abnormal communication between the biliary tree and airway. A patient usually presents with cough and bilioptysis, and at times, it poses diagnostic and therapeutic challenge. This case demonstrates the usefulness of cholescintigraphy with single-photon emission computerized tomography in diagnosing BFF in case of hydatid cyst of the liver.

Hepatopleural Fistula with Empyema Thoracis: A Rare Complication of Autosomal Dominant Polycystic Kidney Disease

We report a 70-year-old man with autosomal dominant polycystic kidney disease (ADPKD) who presented with right-sided extended-spectrum beta-lactamases Escherichia coli empyema thoracis. Chest and abdominal computed tomography showed hepatopleural fistula. The patient refused a surgical operation and was treated with tube thoracotomy, percutaneous drainage of dominant liver cyst, and intravenous antibiotics. His symptoms improved after 2 months of nonsurgical treatment.

A Biliobronchial Fistula in a Patient With Hepatocellcular Carcinoma Treated With Chemoembolization Diagnosed by Hepatobiliary Iminodiacetic Acid Scan and Managed by Endoscopic Retrograde Cholangiopancreatography

A biliobronchial fistula is an abnormal communication between the biliary tract and the bronchial tree. It may be a rare complication after treatment of hepatocellular carcinoma with transcatheter arterial chemoembolization (TACE). We present a case of a 71-year-old man that developed a biliobronchial fistula as a complication of hepatocellular carcinoma treated with TACE. It was successfully diagnosed by hepatobiliary iminodiacetic acid (HIDA) scan and treated with endoscopic retrograde pancreatography.

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.

[Hepatobronchial Fistula and Lung Abscess after Transarterial Chemoembolization]

Transarterial chemoembolization (TACE) is a common treatment modality to locally manage hepatocellular carcinoma. Liver abscess and bile duct injury are common complications of TACE. However, hepatobronchial fistula is a rare complication. Herein, we report a case of lung abscess due to hepatobronchial fistula after TACE. A 67-year-old man, who had underwent TACE 6 months ago, presented cough and bile-colored sputum. He was diagnosed with lung abscess and hepatobronchial fistula. We performed endoscopic retrograde cholangiopancreatography; however, there was no improvement in his symptoms. Thereafter, partial hepatectomy and repair of fistula were successively conducted.

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.

A Case Report of the Anesthetic Management for Liver Retransplantation in a Patient With a Bronchobiliary Fistula

A 64-year-old woman with a previous liver transplant developed graft failure with biliary complications including a bronchobiliary fistula, which did not respond to preoperative conservative therapy. Liver retransplantation provided definitive therapy for the liver failure and bronchobiliary fistula. We present anesthestic considerations for the intraoperative management of a liver retransplant with one-lung ventilation.

Bronchobiliary fistula caused after hepatectomy for hepatocellular carcinoma: a case report

Background

A bronchobiliary fistula, an intercommunication between the biliary tract and bronchial trees, is an extremely rare complication after hepatectomy.

Case presentation

A 70-year-old male underwent partial resection of the liver for recurrent hepatocellular carcinoma under a thoracoabdominal approach. The immediate postoperative clinical course was uneventful, but the patient was febrile and laboratory examinations revealed leukocytosis on the 15th postoperative day. An intraabdominal abscess was suspected based on the computed tomography findings, and percutaneous drainage was performed. Bile was drained, and fluoroscopy using a contrast medium from the drainage tube revealed a communication between the cavity and the common hepatic duct. Two weeks after drainage, bilioptysis was seen. Fistulography demonstrated the presence of the bronchus in the right lower lobe of the lung via the subphrenic space. Therefore, the patient was diagnosed to have a bronchobiliary fistula. Fistulography revealed closure of the communication with the bronchus about a month after drainage. However, the bile leakage and bilioptysis did not stop even after endoscopic nasogastric biliary drainage, and ethanol injection therapy were performed. Eventually, residual right bisectionectomy without resection of the fistulous tract and involved lung was performed to remedy the intractable bile leakage. The clinical course after the reoperation was good without bile leakage, bilioptysis, or pulmonary disorders, and the patient was discharged 40 days after reoperation.

Conclusions

We experienced a rare case of bronchobiliary fistula that occurred after hepatectomy for hepatocellular carcinoma. Careful attention should be paid to prevent bile leakage during hepatectomy, since bile leakage has the potential to cause a bronchobiliary fistula.

Delayed bronchobiliary fistula following radiofrequency ablation in a patient with hepatocellular carcinoma: A case report and lesson regarding treatment

Bronchobiliary fistula (BBF) is a rare complication of radiofrequency ablation (RFA) of hepatocellular carcinoma. The rupture of a biloma following RFA may result in the development of BBF, with their early detection and timely management important in the prevention of BBF. The current study presents a case of BBF, which developed at 17 months after radiofrequency ablation (RFA), due to biloma rupture in a patient with hepatocellular carcinoma. Despite the percutaneous drainage of the biloma following BBF, the persistent fever did not resolve due to biliary infection. Finally, an extensive surgical intervention was performed. The magnetic resonance imaging (MRI) scans that had been performed following RFA were reviewed, and it was found that the biloma and increased bile leakage had presented prior to biloma rupture. For that reason, it is advised that patients who present with biloma following RFA should receive regular follow-up MRI scans. Biloma enlargement could be a predictor for the development of BBF; therefore, timely drainage of an enlarging biloma may be able to prevent this complication.

Broncho-biliary fistula secondary to biliary obstruction and lung abscess in a patient with pancreatic neuro-endocrine tumor

We present a case report of broncho-biliary fistula that developed due to the blockage of biliary stent placed during the management of pancreatic neuroendocrine tumor (pNET); diagnosed on high clinical suspicion, percutaneous cholangiogram and contrast enhanced computed tomography (CECT); and successfully treated with percutaneous transhepatic biliary drainage (PTBD).

The rising incidence of pediatric empyema with fistula

PURPOSE

The incidence and etiology of empyema with fistula (EWF) in children is unknown. We analyzed a national database to define the epidemiology and diagnoses associated with this condition.

METHODS

Discharge data from the Kids' Inpatient Database were reviewed for EWF (ICD-9 diagnosis code 510.0) in children ≤18 years from 2000 to 2012. Patient characteristics, institutional data, and accompanying conditions were evaluated. Weighted national estimates were calculated and incidence compared across years (2000, 2003, 2006, 2009) using the Rao-Scott Chi Square.

RESULTS

From 2000 to 2012, 908 children were hospitalized with EWF. Age distribution was bimodal. Common primary diagnoses related to the hospitalization were pneumonia/pulmonary abscess (31.2 %) and EWF (19.3 %). Manipulation of the pleural space (e.g. decortication, drainage) comprised 45.0 % of procedures. Incidence rates of EWF increased (Rao Scott Adjusted Chi Square: 16.13, p < 0.01) over the study period. Although not statistically significant, median length of stay and age of diagnosis decreased and increased, respectively.

CONCLUSION

This first, national pediatric EWF study reveals rising incidence during the years 2000-2009. Despite limitations in ICD-9 coding, concomitant primary diagnoses and procedures suggest bronchopleural fistulae likely represent the vast majority of cases in this cohort. Multi-institutional studies are needed to confirm etiology and characterize outcome of EWF.

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.

A lethal complication after transarterial chemoembolization with drug-eluting beads for hepatocellular carcinoma

Background. The current standard of care for patients with large or multinodular noninvasive hepatocellular carcinoma is conventional transarterial chemoembolization (TACE). TACE may also be performed with drug-eluting beads, but serious complications of this procedure have been reported. Methods. Aim of this report is to present a patient affected by multifocal HCC who underwent TACE with drug-eluting bead (DEB-TACE). Results. Following the procedure the patient developed a hepatic abscess and biliobronchial fistula resulting in adult respiratory distress syndrome and death. Conclusion. We speculate that DEB-TACE has a prolonged effect on the tumor and the surrounding liver, resulting in progressive enlargement of the necrotic area. This activity that can extend to the surrounding healthy hepatic tissues may continue indefinitely.

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.

Broncho-hepatico-cutaneous fistula in a case of amoebic liver abscess

Pulmonary complications occur in 7-20% of patients with amoebic liver abscess(ALA) and may present as pleural effusion, empyema, lung abscess or a bronchohepatic fistula. Rupture into a bronchus presents as sudden coughing with expectoration of chocolate-coloured sputum and is usually managed by postural drainage, bronchodilators and anti-amoebic drugs. A young boy presented with a large amoebic liver abscess of about 1 L volume which ruptured into the lung. He required surgical drainage of the liver abscess as even after intubation he was not able to maintain adequate ventilation. Following this he developed a broncho-hepatico-cutaneous fistula with drainage of 400-500 mL bile per day and bubbling of air in the abdominal drain. He underwent selective right hepatic duct cannulation with endo-papillotomy, following which the fistula closed gradually.

Surgical treatment of bronchobiliary fistula due to radiofrequency ablation for recurrent hepatocellular carcinoma

Bronchobiliary fistula (BBF) is a rare complication of radiofrequency ablation (RFA), in which there is abnormal communications between the biliary tract and the bronchial trees. Surgery should only be considered for BBF when non-invasive interventions have failed. In this report, we describe the surgical management for BBF when complicated by an abscess that was encountered after RFA in a 52-year-old woman with recurrent hepatocellular carcinoma (HCC). She had previously undergone central bisectionectomy of HCC 7 years ago, and had been treated with a sixth transarterial chemoembolization and first RFA for recurrent HCC after the operation. After the liver abscess and BBF occurred in the posterior section of the liver, she received posterior sectionectomy and hepaticojejunostomy, drainage of the lung abscess, diaphragmatic resection and repair because it was impossible to drain the abscess radiologically. Symptomatic improvements were being achieved through operative treatments where pleural effusion and pneumonic consolidation was obliterated on a 2-months follow-up image.

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.

Successful percutaneous management of bronchobiliary fistula after radiofrequency ablation of metastatic cholangiocarcinoma in a patient who has a postoperative stricture of hepaticojejunostomy site

Bronchobiliary fistula (BBF) is a rare condition that is defined as an abnormal communication between the biliary system and bronchial tree. Furthermore, a BBF is an extremely rare complication of radiofrequency ablation (RFA). A 54 year-old man with a history of extrahepatic biliary cancer had been suffering with a benign stricture of hepaticojejunostomy site and was treated with RFA for metastatic cholangicarcinoma. In this report, we describe a patient with BBF complicated by an abscess which occurred after RFA. He was treated by placement of external drainage catheter into the liver abscess and percutaneous transhepatic biliary drainage (PTBD) into the right intrahepatic duct. After 6 weeks, a complete obliteration of the BBF was confirmed by a repeated follow-up of computed tomography scan and cholangiography through PTBD.