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Ann Thorac Surg 2004;78:1512-1513
© 2004 The Society of Thoracic Surgeons
Division of Gastroenterology, Sunnybrook and Women's College Health Sciences Centre, Room HG 63, 2075 Bayview Ave, Toronto, ON, Canada M4N 3M5
lawrence.cohen{at}sw.ca
To the Editor:
Singh and colleagues [1] described the management of bronchobiliary fistula (BBF) by endoscopic retrograde cholangiography and medical therapy. Their use of octreotide for BBF was not previously documented according to our MEDLINE search. We report 2 cases of patients demonstrating the therapeutic utility of octreotide in BBF management.
A 56-year-old woman was seen with chest pain, fever, and bilioptysis. History included percutaneous liver abscess drainage and thoracotomy for iatrogenic hemothorax 4 years earlier. There was no jaundice or pallor. Crackles were heard at the base of the right lung. The level of alkaline phosphatase was slightly elevated (154 IU/L). A biliary scan showed activity above the diaphragm, and endoscopic cholangiography revealed a filling defect in the intrahepatic ductal system with contrast material extravasating into the right lung. Multiple bile duct stones were extracted, and a stent was inserted into the common bile duct for biliary decompression, but bilioptysis persisted 4 days later. A repeat cholangiogram confirmed a persistent BBF. A 28-day trial of octreotide, 100 µg subcutaneously three times a day, was initiated, during which progressive reduction in bilioptysis was seen until resolution on day 17, and repeat biliary scanning confirmed closure of the fistula. The patient remained asymptomatic after discontinuance of octreotide and removal of the endobiliary stent.
A 71-year-old woman was seen with painless bilioptysis 4 months after undergoing a right hepatectomy for colon metastases. Decreased air entry and dullness to percussion were noted at the base of the right lung. The alkaline phosphatase level was elevated (431 IU/L). The presence of a BBF was suggested by a right subphrenic accumulation of fluid on a computed tomographic scan and by isotope concentration above the right hemidiaphragm on a biliary scan. An endoscopic cholangiogram confirmed the diagnosis of BBF, and a common bile duct stent was inserted, but bilioptysis continued for 4 days. Octreotide was then initiated at 100 µg subcutaneously three times a day, with marked reduction in frequency and production of bilioptysis; however, follow-up biliary scanning showed a persistent BBF. Octreotide was continued until the patient underwent operation to repair the BBF 6 weeks later. A laceration of the inferior vena cava resulted in uncontrollable hemorrhage and cardiac arrest. Postmortem examination revealed a patent malignant BBF.
Reports of BBF secondary to choledocholithiasis or right hepatectomy are rare, but morbidity and mortality are high as a result of pulmonary sequelae and therapeutic complications [2]. We think our experience with the use of octreotide to lower morbidity in BBF is encouraging. Patients benefit from amelioration of bilioptysis [3], and accelerated fistula closure may occur in response to octreotide [4]. However, octreotide can precipitate rebound biliary output when discontinued and is ineffective if infection, obstruction, or malignancy maintain fistula patency [4].
References
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