Ann Thorac Surg 2002;73:1645-1647
© 2002 The Society of Thoracic Surgeons
Case report
Bullets and biliptysis
John J. Nigro, MD, MS*a,
Hector Arroyo, Jr, MDb,
Demitri Theodorou, MDb,
George C. Velmahos, MD, PhDb,
Ross M. Bremner, MD, PhDa
a Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles County University of Southern California Medical Center, Los Angeles, California, USA
b Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles County University of Southern California Medical Center, Los Angeles, California, USA
Accepted for publication October 10, 2001.
* Address reprint requests to Dr Nigro, Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, USC Health Science Consultation Center, 1510 San Pablo St, Suite 415, Los Angeles, CA 90033, USA
e-mail: jnigro{at}hsc.usc.edu
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Abstract
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Biliptysis is a dramatic physical finding which suggests the presence of a direct communication (fistula) between the biliary and bronchial tree. We report a bronchial biliary fistula resulting from penetrating thoracoabdominal trauma and the use of positive-pressure ventilation to obtain initial fistula control prior to definitive surgical repair.
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Introduction
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Bronchobiliary fistula is a rare complication of penetrating thoracoabdominal trauma [1]. The most recent review of this lesion was published almost 20 years ago [1] and identified only 7 prior reports. This report describes the management of a patient who sustained a thoracoabdominal gunshot wound complicated by a bronchobiliary fistula and the use of positive pressure ventilation to obtain initial fistula control before definitive repair.
A 20-year-old man presented to our emergency department with fever and cough. The cough was progressive, productive of yellow sputum, and associated with shortness of breath. Three weeks prior he was admitted to another hospital with a gunshot wound to his right back that had exited his periumbilical region. Review of the operative record (from the other hospital) revealed that a right chest tube was placed for a hemopneumothorax, a right hemicolectomy was performed, and a Penrose drain (Sherwood, Davis & Geck, St. Louis, MO) was placed into a large but hemostatic liver defect. No diaphragmatic injury was identified and the thorax was not explored. The chest tube was removed on postoperative day 3, and subsequently the patient was discharged home on postoperative day 10.
He did well until the day of presentation to our hospital, when he was febrile (101.8°F), tachycardic (126/min), and had tachypnea (32 breaths/min). Bile was draining through the Penrose drain. A right lower lobe infiltrate was present on chest roentgenogram. Despite antibiotic therapy, the patient continued to be septic and required intubation for progressive respiratory distress. The copious secretions immediately ceased after initiation of positive pressure ventilation. Computed tomographic scan revealed consolidation of the lower lobe of the right lung and a large liver defect containing the Penrose drain (Fig 1).
Bilirubin was strongly positive on dipstick of the sputum. Bronchoscopy revealed bilious secretions in the basal segments of the right lung (Fig 2).
A hepato-imino-diacetic acid scan demonstrated bile flow from the liver and through the Penrose drain, but there was no evidence of bile flow into the chest. A closed suction drain was positioned through the existing Penrose tract into the liver defect and somatostatin was administered. Over the following 4 days the patient’s sepsis resolved and both his chest roentgenogram and follow-up computed tomographic chest scan demonstrated improvement (Fig 3).
However, during a T-piece trial, copious bilious secretions immediately returned. He was then taken to surgery where a right posterior-lateral thoracotomy was performed and multiple pleural adhesions were taken down. The liver was found to be extruded upward through the diaphragm and was adhered to the inferior aspect of the right lower lobe at the site of the transpulmonic bullet tract. The lung was mobilized and dissected off the liver, revealing direct communication between the bronchial and biliary trees. The diaphragm was freed from the liver and closed with interrupted nonabsorbable monofilament sutures. A wedge resection of the affected portion of the right lower lobe was performed. The patient was extubated the next day and ultimately discharged home in good condition.
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Fig 1. Thoracoabdominal computed tomographic scan demonstrates lobar infiltrate and atelectasis of the (A) right lower lobe and the (B) large hepatic defect (arrow).
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Fig 3. Follow-up chest computed tomographic scan revealing marked resolution of the right lower lobe infiltrate after the institution of positive pressure ventilation.
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Comment
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Despite the proximity of the bronchial and biliary trees, fistulous communication resulting from penetrating thoracoabdominal trauma is rare. Nearly 20 years ago Coselli and Mattox [1] reviewed these injuries, and in spite of the current abundance of penetrating trauma there have been no subsequent reports. Because this complication is the result of persistent transdiaphragmatic contact, it may become more common with the increasing use of nonoperative management for penetrating thoracoabdominal trauma [2, 3]. However, the existing experience with nonoperative management of penetrating trauma does not reveal an increase in the number of bronchobiliary fistulas [2–4].
Cough productive of bile, biliptysis, is a dramatic physical finding and is indicative of a bronchobiliary fistula [1]. These fistulas are potentiated by the transdiaphragmatic pressure gradient with bile flowing from the biliary system (positive intraabdominal pressure) into the bronchial system (negative intrathoracic pressure). Bile is both caustic to the bronchial mucosa and a potential source of bacterial contamination. The resulting respiratory distress sumps (more) bile into the airway and exacerbates the respiratory insult. Positive pressure ventilation reverses the pressure gradient and acts to attenuate biliary contamination of the bronchus.
Radioisotope imaging (hepato-imino-diacetic acid scan) has been previously used to document the flow of bile into the chest [1, 5]. We believe that the hepato-imino-diacetic acid scan did not demonstrate thoracic penetration in this case because of the reversal of the trans-diaphragmatic pressure gradient provided by positive pressure ventilation. Computer assisted tomography is obtained to define the involved anatomy and identify any adjacent potentially infected fluid collections. All previous traumatic thoracobiliary fistulas have had an associated empyema or subphrenic abscess [1].
Initial treatment for these fistulas includes stabilization of the patient’s respiratory status and control of sepsis. Because some reports suggest that small fistulas can close with nonoperative management [5, 6], an initial trial of conservative therapy is justified. However, most of these fistulas require transthoracic repair. This patient was intubated for control of his airway and respiratory distress. Distal drainage was optimized by placement of a closed suction drain within the liver defect to encourage drainage away from the bronchus, and somatostatin was used to decrease the quantity of hepatobiliary secretion. The bilious bronchial secretions returned once positive intrathoracic pressure was removed, suggesting that positive pressure ventilation attenuated fistula flow. We believe that this initial fistula control allowed for resolution of the patient’s sepsis and subsequent surgical repair.
Repair is transthoracic with decortication, lung mobilization, resection of involved tissue, and closure of the diaphragmatic defect. Pulmonary wedge resection is preferred to lobectomy because it leaves less residual space within a contaminated thorax.
Finally, the most effective management of these lesions is prevention. We believe that this patient’s fistula was a consequence of persistent transdiaphragmatic contact and incomplete biliary drainage. This complication may have been averted with closed suction biliary drainage coupled with a thorough diaphragmatic exploration and defect closure.
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References
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Coselli J.S., Mattox K.L. Traumatic bronchobiliary fistula. J Trauma 1983;23:161-162.[Medline]
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Demetriades D., Velmahos G., Cornwell E., 3rd, et al. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg 1997;132:178-183.[Abstract]
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Renz B.M., Feliciano D.V. Gunshot wounds to the right thoracoabdomen: a prospective study of nonoperative management. J Trauma 1994;37:737-744.[Medline]
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Velmahos G.C., Demetriades D., Foianini E., et al. A selective approach to the management of gunshot wounds to the back. Am J Surg 1997;174:342-346.[Medline]
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Poullis M., Poullis A. Biliptysis caused by a bronchobiliary fistula. J Thorac Cardiovasc Surg 1999;118:971-972.[Free Full Text]
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Khandelwal M., Inverso N., Conter R., Campbell D. Endoscopic management of a bronchobiliary fistula. J Clin Gastroenterol 1996;23:125-127.[Medline]
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Abstract
Introduction
