Surgical Management of Thoraco-Biliary Fistula

Abstract

ABSTRACT
Background: A thoracobiliary (pleurobiliary and bronchobiliary) fistula is a rare and
challenging condition and is due to an abnormal communication between the thoracic
cavity and the biliary tree.
Objectives: Is to outline the appropriate therapeutic options for acquired bronchobiliary
fistula following trauma and infection with hydatid cystic disease.
Methods: Fourteen patients were referred to our department from 2004 to 2010 due to a
complication of surgery for either liver or right pulmonary hydatid cyst (four patients) or
penetrating abdominal and right lower thoracic injuries (ten patients). They categorized as
bronchobiliary and pleurobiliary fistula according to presenting symptoms and history of
their surgery. All patients were investigated with CXR, US and CT scan for abdomen and
chest. Only nine patients were subjected to ERCP with sphincterotomy. Thoracostomy
tube was the initial treatment to drain the pleural cavity. Right thoracotomy was performed
for all patients, excising the fistula with damaged lung parenchyma and diaphragmatic
repair.
Results: All fourteen patients were males and mean age was 29.8 years. Ten patients
had penetrating abdominal and right lower thoracic injuries and (4) patients presented as
a complication of surgical removal of hydatid cyst of liver and right lung. Biliptysis,
jaundice, biliary effusion, irritative cough with suspicion of pneumonia and bile empyema
were the main presenting symptoms. Preoperative radiological studies showed a variable
degree of obliteration of right costophrenic angle and pulmonary haziness. ERCP and
sphencterotomy failed to close the fistula in (9) patients and all fourteen patients
underwent right thoracotomy to excise the fistula with mortality and morbidity of 7.1% for
each.
Conclusion: Traumatic thoracobiliary fistulas are complex lesions and can be associated
with high morbidity and mortality rates. Therefore, a multidisciplinary approach is required
for a timely and successful outcome with well-planned management strategy.
Thoracotomy, however, is indicated in chronic and complicated fistulas, it should not be
delayed beyond 3 weeks. This approach, although invasive but provided a rapid resolution
of the patients' problem.