Bronchobiliary fistula in a cirrhotic patient: a case report and review of the literature. Am J Med Sci. 2008;335:315-319. [PMID: 18414073 DOI: 10.1097/maj.0b013e31812e9633]

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 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.

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.