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Ann Thorac Surg 2002;73:1088-1091
© 2002 The Society of Thoracic Surgeons

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Original article: general thoracic

Conservative management of thoracobiliary fistula

^a department of General Surgery, Faculty of Health Sciences, Nelson R. Mandela School of Medicine, University of Natal, Congella, South Africa
^b department of Cardiothoracic Surgery, Faculty of Health Sciences, Nelson R. Mandela School of Medicine, University of Natal, Congella, South Africa

Accepted for publication December 18, 2001.

* Address reprint requests to Dr Singh, Department of Surgery, Faculty of Health Sciences, Nelson R. Mandela School of Medicine, University of Natal, Private Bag 7, Congella 4013, South Africa
e-mail: moodleyj6{at}nu.ac.za

Background. Thoracobiliary fistulas are rare manifestations of biliary disruption. Given their rarity it is not surprising that there is little consensus on the optimal management of thoracobiliary fistulas.

Methods. Patients presenting with thoracobiliary fistulas over a 5-year period (1996 to 2001) were evaluated. Initial management was conservative with tube thoracostomy or drainage of sepsis when appropriate, or both; antibiotics and somatostatin were routinely administered. Endoscopic retrograde cholangiography was performed when symptoms persisted to delineate the thoracobiliary communication and undertake sphincteroplasty.

Results. Eight patients with a mean age of 31.9 years (range 15 to 42) were evaluated. Biliary effusion occurred in 3 patients after hepatic injury (n = 2) and percutaneous transhepatic cholangiography (n = 1). Bilioptysis occurred in 5 patients after hepatic abscess (n = 4) and hepatic injury (n = 1) The biliary effusion (n = 3) was successfully managed by endoscopic sphincterotomy in 2 patients; the third patient underwent urgent surgical biliary drainage. Bilioptysis (n = 5) was successfully managed in 3 patients; persistence of symptoms in 2 patients prompted surgical intervention.

Conclusions. Thoracobiliary fistulas may be successfully managed using a conservative approach. Surgery should be reserved for persistence of symptoms after exhaustion of this approach.

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