Use of histoacryl and a covered nitinol stent to treat a bronchobiliary fistula

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.

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.

[Gastro-bronchial fistula major complication of sleeve gastrectomy]

BACKGROUND

Gastrobronchial fistula is a rare complication in gastroesophageal surgical procedures. It is difficult to diagnose and handling is complex. Therefore, there have been developments for non-surgical alternatives to obliterate minor fistula mortality. Endoscopic treatment is an option for patients with small fistulas or in serious condition.

CLINICAL CASE

A 38 year old woman with evidence of gastrobronchial fistula postoperated of gastric sleeve, diagnosed during the postoperative period due to clinical variegated was initially handled as infectious respiratory symptoms; once the fistulous path was established, the intention was to close the path using endoclips. However, adding hemopneumothorax, drainage tube placement and thoracotomy were required. It was decided to chose a prosthetic esophageal endoscopic management of polytetraflouroethylene and fibrin as last therapy, because the patient had systemic inflammatory response syndrome, with favorable response to endoscopic management.

DISCUSSION

Bariatric surgery has shown satisfactory results, however, the complexity of the procedure favors severe complications such as the present case. Gastrobronchial fistulas represent a diagnostic and therapeutic challenge, this is considering from a conservative management to endoscopic procedures, as in our patient.

CONCLUSION

Although gastrobronchial fistulas are a rare complication, the use of endoscopy in resolution should be a first class weapon in its management, since it offers a lower morbidity in a patient with habitual respiratory symptoms that are difficult to control, with satisfactory results in the medium and long term.

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.

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

Background

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

Review of the literature

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

Case report

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

Conclusions

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

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

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

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

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

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

Bronchobiliary fistula in a cirrhotic patient: a case report and review of the literature

Bronchobiliary fistula is defined as the passage of bile in the bronchi. The presence of bronchobiliary fistula in patient with cirrhosis is extremely rare. Management of these fistulas is often very difficult and can be associated with high morbidity and mortality. We are presenting a patient with ethanol related cirrhosis and biliptysis in whom a diagnosis of bronchobiliary fistula was made. A review of the literature including diagnosis and management is performed.

Successful treatment of intractable bronchobiliary fistula using long-term biliary stenting

A bronchobiliary fistula (BBF) is an uncommon entity with bilioptysis being a pathognomonic sign. We describe the case of a 41-year-old man who had recurrent BBF, 6 months after resection of the anterior segment of the right lower pulmonary lobe and repair of a BBF due to hepatic hydatid disease. Magnetic resonance cholangiography revealed a communication between the biliary tree and the lower lobe of the right lung. Endoscopic biliary sphincterotomy and repeated insertion of large size biliary plastic stents led to a successful resolution of the symptoms and closure of the fistula.

Bronchobiliary fistula successfully treated with n-butyl cyanoacrylate via a bronchial approach

A bronchobiliary fistula is an abnormal communication between the biliary tree and the airway that can result in debilitating amounts of bilioptysis, or bile-stained sputum. The authors present an approach for the conservative management of a bronchobiliary fistula in a patient who failed traditional conservative therapy and refused surgical intervention.

[Is endoscopic treatment of bronchopleural fistula useful?]

OBJECTIVE

New endoscopic techniques have been developed as an alternative to surgical treatment of bronchopleural fistula. The objective of this study was to analyze our experience with endoscopic treatment of such fistulas.

MATERIAL AND METHODS

We conducted a retrospective study of patients with bronchopleural fistula diagnosed by fiberoptic bronchoscopy. Patient characteristics, underlying disease, fistula size, and outcome of endoscopic treatment were analyzed. The endoscopic technique consisted of injection of fibrin sealants (Histoacryl and/or Tissucol) through the catheter of the fiberoptic bronchoscope.

RESULTS

Between 1997 and 2004, 18 patients were diagnosed with bronchopleural fistula by fiberoptic bronchoscopy. All were men with a mean (SD) age of 62 (12) years. Bronchopleural fistula was diagnosed after neoplastic surgery in 16 patients, in the bronchial suture after lung transplantation in 1 patient, and concurrently with pleural effusion due to hydatidosis in the remaining patient. The size of the fistula ranged from 1 mm to 10 mm (mean 3.6 [2.7] mm). Fibrin sealants were applied in 14 patients, 2 underwent direct surgery after diagnosis, and the bronchopleural fistula closed spontaneously in the remaining 2. The fibrin sealant used was Histoacryl in 12 patients and Tissucol in 2. Pleural drainage was employed simultaneously and antibiotic therapy was administered at the discretion of the surgeon. The 4 patients whose bronchopleural fistula was associated with empyema also underwent pleural lavage. In 12 patients the fistulas closed as a result of the endoscopic technique (85.7%), and no complications were observed. For 85.7%, fewer than 3 applications of fibrin sealant were necessary.

CONCLUSIONS

The success rate of closure of bronchopleural fistula with fibrin sealants injected under guidance with fiberoptic bronchoscopy is high and there are no complications. This technique can render surgery unnecessary.

Percutaneous interventional therapy of persistent biliary fistulas

BACKGROUND

Persistent biliary leakage is a challenging problem when conservative treatment methods fail. We present our experience with alternative percutaneous radiologic interventions to seal refractory biliary leaks.

METHODS

From April 1998 to December 2005, a retrospective analysis of 23 patients with biliary leakage revealed six patients who were unresponsive to drainage were treated with use of Histoacryl (n = 5), microcoils (n = 2), or covered stent (n = 2) alone or in various combinations.

RESULTS

In all patients, the biliary leakage ceased following a single procedure. Distally migration of microcoils into the abscess cavity was observed in a one coiling procedure, which was clinically insignificant. In one patient treated with covered stent, in-stent restenosis was seen in the postprocedural second year, which required another intervention. No recurrence of fistula was noted in the follow-up period (ranging from 6 to 47 months).

CONCLUSIONS

Persistent biliary fistulas can be treated successfully by means of various percutaneous radiological interventions that can decrease the morbidity associated with prolonged external drainage and avert the need for surgery. We recommend superselective embolization, preferably with Histoacryl, for a safe and effective control of leakage. Although restenosis after stenting remains problematic, covered stents should be reserved as a feasible alternative for selected cases.

Bronchobiliary fistula treated by self-expanding ePTFE-covered nitinol stent-graft

A 71-year-old man, who had undergone right hepatectomy extended to the caudate lobe with terminolateral Roux-en-Y left hepatojejunostomy for a Klatskin tumor, developed bilioptysis 3 weeks postoperatively due to bronchobiliary fistula. Percutaneous transhepatic cholangiography revealed a non-dilated biliary system with contrast medium extravasation to the right subphrenic space through a resected anomalous right posterior segmental duct. After initial unsuccessful internal-external biliary drainage, the fistula was sealed with a VIATORR covered self-expanding nitinol stent-graft placed with its distal uncovered region in the hepatojejunal anastomosis and the proximal ePTFE-lined region in the left hepatic duct. A 10-month follow-up revealed no recurrence of bilioptysis and confirmed the complete exclusion of the bronchobiliary fistula.

Recurrent bronchobiliary fistula: unsuccessful management with repeated insertion of metallic biliary stent

This case of a recurrent bronchobiliary fistula was first managed temporarily with repeated metallic biliary stent placement, and finally required surgery. A 65-year-old man, who had undergone a hepatic resection for metastatic colon carcinoma, with a bronchobiliary fistula was treated with metallic biliary stent placement for a stenosis in the common bile duct. During 16 months of follow-up, the biliptysis recurred twice by a recurrent stricture of the common bile duct, which was managed by placement of a second and third stent in a coaxial manner. Three months after placement of the third stent, jaundice developed and the patient finally underwent a Roux-en-Y choledochojejunostomy.

Endobronchial closure of postoperative bronchopleural fistula using vascular occluding coils and n-butyl-2-cyanoacrylate

We report herein 2 patients with intractable postoperative bronchopleural fistula with empyema after lobectomy or subsegmentectomy. The patients underwent several treatments including thoracotomy, but the fistula closure was not successful. Finally, the bronchopleural fistula was successfully treated by endobronchial closure using vascular occluding coils and n-butyl-2-cyanoacrylate (Histoacryl).