MANAGEMENT OF BRONCHOBILIARY FISTULA AS A LATE COMPLICATION OF HEPATIC RESECTION

Bronchobiliary fistula is an uncommon but remarkable complication afte r hepatic resection. The case reported illustrates the clinical presen tation and preferred initial management of these fistulae. A 61-year-o ld white male underwent two wedge resections for colorectal metastases to the liver with removal of a portion of the right diaphragm. Four y ears later, he developed obstructive jaundice secondary to tumor recur rence in the porta hepatis, which required endoscopic stent placement, radiation, and chemotherapy. Almost 2 years later, he developed frank biliptysis. Percutaneous transhepatic cholangiography (PTC) revealed occlusion of the common hepatic duct stent and a bronchobiliary fistul a. With adequate reestablishment of common duct drainage, the patient rapidly improved and was discharged free of symptoms. Bronchobiliary f istulae are rare complications of hepatic resection that fan present f rom days to years after operation. Endoscopic retrograde cholangiopanc reatography and PTC are the diagnostic studies of choice and offer the possibility of therapeutic intervention. Although large series in the literature emphasize the surgical management of bronchobiliary fistul ae, the reoperative procedures tend to be complicated, with a signific ant morbidity and mortality. Nonsurgical interventions via endoscopic retrograde cholangiopancreatography or PTC are more recently notably s uccessful when resolution of a distal biliary obstruction is accomplis hed. Only after aggressive attempts at nonoperative, interventional te chniques have failed should operative approaches be entertained.