Multimodal approach to acquired bronchobiliary fistula secondary to hepaticojejunostomy stricture following yttrium-90 therapy

Abstract

Presenter: Asmita Chopra MD | The University of Toledo Background: Acquired bronchobiliary fistula (BBF) is a rare and challenging complication resulting in an abnormal connection between the bronchial system and biliary tree. It most commonly presents with a pathognomonic productive cough featuring bilious-tinged sputum or “biloptysis”. BBFs can be associated with hepatic abscesses, malignancy and liver directed interventions. They are known to have high mortality rates, in some series up to 12.7%. A patient with development of biliary obstruction and BBF secondary to Y-90 (yttrium-90) radioembolization therapy is presented. Methods: A 56-year-old male presented with stage IV neuroendocrine pancreatic cancer and underwent initial sequential treatments included pancreaticoduodenectomy with partial hepatectomy, Y-90, and liver microwave ablation. Patient did well for 2.5 years at which time he was noted to have an interval increase of hepatic lesions on surveillance imaging. Additional Y-90 was given for the right sided lesions. This was poorly tolerated resulting in significant abdominal pain and failure to thrive and further Y-90 therapy was not pursued. Patient gradually improved and was referred for potential peptide receptor radionuclide therapy. Ten months later patient returned to the HPB Surgery clinic with complaints of persistent abdominal pain, cough with copious amounts of yellow-tinged sputum and history of multiple bouts of pneumonia. Imaging demonstrated intrahepatic biliary dilation, a right-sided peri-hepatic abscess and right-sided pleural effusion. Right hepatic lobe involution with significant left lobe hypertrophy was also noted. Results: Patient subsequently underwent percutaneous drainage of abscess and chest tube placement for effusion. However, his cough and sputum production persisted, prompting evaluation of an acquired BBF. The diagnosis was confirmed on HIDA (hepatobiliary iminodiacetic acid) and bronchoscopy. Cholescintigraphy with single-photon emission computed tomography (NM spect CT scan) localized the fistula tract to the right upper lobe of the liver near the abscess (Figure 1). Initial treatment focused on biliary decompression with PTC (percutaneous transhepatic cholangiogram) and abscess drain placement. During the procedure, attempts at cannulating the hepaticojejunostomy were unsuccessful, indicating complete stenosis at the anastomosis. Finally, the patient underwent elective surgery to restore biliary enteric continuity. This involved resection of the hepaticojejunostomy with mobilization of the pancreaticobiliary (PB) limb and Kasai-type porto-enteric anastomosis between the PB and hepatic duct at the previously placed PTC drain entrance site. Complete resolution of the bronchopulmonary fistula was demonstrated during subsequent biliary drain exchange following surgery and patient doing well greater than 4 years after initial cancer diagnosis. Conclusion: BBFs are rare, misdiagnosed, and difficult to treat. Although treatment has shifted toward less invasive approaches with favorable results, in the setting of previous biliary reconstruction these fistulas pose unique challenges. Multimodal treatments including advanced percutaneous and complex surgical intervention may be required to rescue these patients.