Bronchobiliary and Bronchopleural Fistulas

doi:10.1016/S0003-4975(10)63443-1

The Annals of Thoracic Surgery

Volume 24, Issue 5, November 1977, Pages 481-487

https://doi.org/10.1016/S0003-4975(10)63443-1 Get rights and content

Abstract

In the course of treating approximately 2,000 patients with postoperative stricture of the bile duct, 16 bronchopleural and bronchobiliary fistulas were encountered. Three patients have been seen in the past year. This has prompted a review of our experience since it was previously recorded in 1955.

Fistulous complications of obstructive biliary tract disease take three forms: (1) massive fulminating biliary empyema; (2) acute necrotizing bile bronchiolitis and pneumonia when pleural symphysis exists; and (3) a more indolent, chronic, recurring form of bronchobiliary communication.

We have learned that transdiaphragmatic perforation occurs at a certain characteristic location in the diaphragm. An understanding of the pathological anatomy and pathogenesis has provided a specific and sequential mode of surgical treatment. When this has been adhered to strictly, cure has resulted.

References (7)

HD Adams
Pleurobiliary and bronchobiliary fistulas
J Thorac Surg
(1955)
DP Boyd
Anatomy and pathology of the subphrenic spaces
Surg Clin North Am
(1958)
DP Boyd
The intrathoracic complications of subphrenic abscess
J Thorac Cardiovasc Surg
(1959)

There are more references available in the full text version of this article.

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As described in Fig. 1, with regard to other possible pathophysiologies, the collection of bile acid in the abdominal cavity, with or without biliary tract obstruction, can cause secondary infection or peritonitis. This can lead to a communicating pathway to the pleural cavity [22], especially in the recesses of the posterior subphrenic space [23]. Physicians should be aware of the fact that bile acid is an intense chemo-irritant [3], that can cause extensive pleural inflammation and provide a favorable medium for bacterial growth [8].
Bilious pleural effusion is an extremely rare condition associated with liver diseases, subphrenic or subhepatic abscess formation, biliary peritonitis, and invasive procedures (i.e., percutaneous biliary drainage or liver biopsy). The current diagnostic test is based on the measurement of the ratio of pleural total bilirubin to serum total bilirubin, which is greater than 1 in patients with bilious pleural effusion. Given the low incidence of bilious pleural effusion, the precise diagnostic yield of this ratio based test has not been evaluated.
We retrospectively reviewed the medical records of our institution and searched the PubMed database for reports of bilious pleural effusion.
We identified a total of 12 cases of bilious pleural effusion (9 from 8 Pubmed reports and 3 from our institutional records). The factors causing this condition were broadly classified into three categories based on the pathophysiology: 1) liver diseases (echinococcosis, tuberculosis and amebiasis); 2) subhepatic/subphrenic abscess or biliary peritonitis, with or without biliary tract obstruction; and 3) iatrogenic disease after percutaneous biliary drainage and/or liver biopsy. The sensitivity of detection was 76.9% when the ratio of pleural total bilirubin to serum total bilirubin was greater than 1. The sensitivity increased to 100% when a combination test including pleural glycoholic acid was adopted.
This study demonstrates the high diagnostic yield for bilious pleural effusion using a combination of two test criteria; a ratio of pleural total bilirubin to serum total bilirubin greater than 1 and the presence of pleural glycoholic acid.
Black pleural effusion
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Bilious pleural effusion is a rare complication of biliary tract disorders. Causes of a biliopleural fistula include thoracoabdominal trauma,22,23 parasitic liver disease,24,25 suppurative complications of biliary tract obstruction, postoperative strictures of bile ducts,26 liver biopsy,27 internal stent,28 and percutaneous biliary drainage for an obstructed biliary system.29,30 Nichols et al31 reported that pleural and diaphragmatic penetration is usually unavoidable during intercostal puncture because of the great depth of the pleural sinus beneath the lung margin.
Black pleural effusions are extremely rare and have been reported in patients with infection, malignancy, and hemorrhage. However, no review articles appear to have focused on this rare clinical presentation.
To classify and characterize diseases causing “black pleural effusion” based on the pathophysiological mechanisms involved.
We searched the medical literature to find reports of “black pleural effusion” using the PubMed database.
We identified 8 cases and classified the underlying diseases into the following 4 entities based on pathophysiological conditions: 1) infection (Aspergillus niger and Rhizopus oryzae); 2) malignant melanoma, in which cells contain melanin pigment; 3) hemorrhage and hemolysis associated with non-small cell lung cancer or rupture of a pancreatic pseudocyst; and 4) other causes (charcoal-containing empyema). Discrimination between biliopleural fistula and pancreatico-pleural fistula, which also mimicking in color, was easily achieved by focusing on pleural amylase levels, elevation of pleural indirect bilirubin, presence of pleural glycoholic acid, and the predominant site of pleural effusion.
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It should be moreover noted that all cases of symptomatic bilomas or fistulas developed in patients with central hepatic lesions6 or large tumors7 because of damage to large intrahepatic bile ducts.8 The surgical approach required thoracicoabdominal exploration9,10 to perform debridement, ductal repair, and controlled drainage of the biliary system. The percutaneous approach has obvious advantages, obviating general anesthesia and the morbidity associated with major surgery.11
Bronchobiliary fistula as a persistent respiratory-tract infection and abdominal pain of several years of evolution [6]
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: Presented at the Thirteenth Annual Meeting of The Society of Thoracic Surgeons, Jan 24-26, 1977, San Francisco, CA.

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Bronchobiliary and Bronchopleural Fistulas

Abstract

J Thorac Surg

Surg Clin North Am

J Thorac Cardiovasc Surg