Bronchobiliary fistula in fibrolamellar hepatocellular carcinoma with anesthetic challenges during living donor liver transplantation: A case report

Table 1 Timeline of the patient’s clinical course

Time	Clinical event	Intervention	Outcome/note
2020 (5 years prior)	Diagnosis of FL-HCC	Two cycles of nivolumab	Discontinued due to immune-related type 1 DM and thyroiditis
Within first year	Extensive hepatic tumor burden	Ex vivo hepatic tumor resection with Roux-en-Y hepaticojejunostomy	Major alteration of biliary anatomy
Following years	Tumor recurrence	Microwave ablation and radioembolization	Progressive hepatic injury
4 years after diagnosis	Pulmonary metastasis	Left lung wedge resection and stereotactic radiation to both lungs	Radiation exposure to lung parenchyma
Subsequent course	Development of hepatic bilomas, intrahepatic abscesses, polymicrobial cholangitis	Internal–external biliary drainage	Recurrent sepsis and chronic biliary complications
Later period	Development of BBF	Surgical repair with diaphragmatic reconstruction	Recurrent fistulae and persistent bilioptysis
Preoperative period	Drain malfunction and persistent BBF	IR exchange and repositioning of chest tube, biloma drain, biliary drain	Multiple drains present in right hemithorax and RUQ
Preoperative status (2025)	Dyspnea on exertion, bilioptysis, poor nutritional status (BMI: 16)	Evaluation for surgery	Compromised pulmonary and systemic condition
Final stage	Persistent BBF with metastatic FL-HCC	Referral for living donor liver transplantation	Considered as potential curative option

FL-HCC: Fibrolamellar hepatocellular carcinoma; BMI: Body mass index; DM: Diabetes mellitus; BBF: Brochobiliary fistula; RUQ: Right upper quadrant.