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

Anesthetic Management of Bronchobiliary Fistula as a Complication of Liver Hydatid Cyst: A Case Report

Bronchobiliary fistula (BBF) in adults is a quite infrequent complication characterized by the abnormal interconnection between the right bronchial system and the biliary tract. BBF may occur due to various causes, including trauma, infections, malignancies, and complications of certain surgical procedures involving the liver or the hepatobiliary system. In this paper, we report a case of BBF following liver hydatid cyst resection that developed in a 58-year-old Iranian male. The patient had acute dyspnea with yellowish sputum. After diagnostic measures such as bronchoscopy, computed tomography (CT) scan, endoscopic retrograde cholangiopancreatography (ERCP), and confirmation of the diagnosis of BBF, the patient underwent Intravenous (IV) antibiotic therapy, placement of pleural drain, sphincterotomy and CBD stents insertion but unfortunately, these measures were not effective and the patient was a candidate for thoracotomy and resection of fistula and the involved lung. During surgery, absolute lung isolation was done by insertion of a left-sided double-lumen endobronchial tube and uneventful anesthesia was maintained for about 5 hours. Patients with BBF present unique challenges in terms of anesthetic management. Sepsis, pulmonary impairment, electrolyte imbalances and malnutrition will make anesthesiologists face many perioperative challenges. During surgery, absolute lung isolation is typically necessary and achieving effective lung isolation can be quite challenging due to the presence of the fistula. Postoperatively, intensive respiratory support, chest tube drainage, and appropriate antibiotic therapy may be required .In addition, a multidisciplinary approach involving anesthesiologists, thoracic surgeons, and other specialists is crucial.

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.

[Efficacy of local infiltration of ropivacaine combined with multimodal analgesia with parecoxib for perioperative analgesia in patients undergoing pancreaticoduodenectomy]

OBJECTIVE

To explore the effect of local infiltration of ropivacaine combined with multimodal analgesia with parecoxib for perioperative pain management in patients undergoing pancreaticoduodenectomy.

METHODS

This randomized controlled trial was conducted among 98 patients undergoing pancreaticoduodenectomy in the Department of Biliary Surgery of West China Hospital between March, 2017 and August, 2018. The patients were randomized to receive perioperative analgesia with local infiltration anesthesia with ropivacaine combined with multimodal analgesia with parecoxib (experimental group, n=50) or postoperative analgesia with dizosin (control group, n=48). The regimens for intraoperative anesthesia and postoperative pain relief were identical in the two groups. The differences in NRS pain score, use of pain relief agents, the incidences of adverse reactions to analgesia and wound infection, and the time to first ambulation and first flatus passage after the operation were compared between the two groups.

RESULTS

At 12, 24 h, 48 h, 72 h and 7 days after the operation, the patients in the experimental group had significantly lower NRS scores (P < 0.05) than those in the control group. The rate of use of rescue analgesics was significantly lower in the experimental group than in the control group (32% vs 66.67%, P < 0.05); the rate of tramadol hydrochloride use was also significantly lower in the experimental group (P < 0.05). Compared with those in the control group, the patients in the experimental group showed a significantly lower total incidence of adverse reactions (22% vs 54.17%, P < 0.05) as well as a lower incidence of nausea and vomiting (P < 0.05), an earlier time of first ambulation and first flatus passage after the operation (P < 0.05), and a shorter postoperative hospital stay (P < 0.05).

CONCLUSIONS

In patients undergoing pancreaticoduodenectomy, local infiltration of ropivacaine combined with multimodal analgesia with ropivacaine can effectively relieve perioperative pain, reduce the use of relief analgesics, lower the incidence of adverse reactions, and promote the recovery after the surgery.