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Kim NY, Sadowsky MG, Woodyard De Brito KC, Williams C, Janowak CF. Thoracobiliary Fistula Complications Following Concomitant Diaphragm and Liver Injury. J Surg Res 2025; 305:163-170. [PMID: 39700892 DOI: 10.1016/j.jss.2024.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 10/28/2024] [Accepted: 11/16/2024] [Indexed: 12/21/2024]
Abstract
INTRODUCTION Thoracobiliary fistula (TBF) is a rare and highly morbid complication of hepatic trauma. There is a paucity of literature regarding incidence, disease course, and treatment. This study identifies etiologic factors and outcome patterns in patients at risk for TBF. METHODS A retrospective review of patients presenting with concern for trans-diaphragmatic bile leak over an 8-y period was performed at an urban level 1 trauma center. Early postinjury deaths were excluded. Records were reviewed for presence of a delayed bile leak. Patient characteristics with concern for (No-TBF) and confirmed fistula (TBF) were compared using Fisher's exact and Mann-Whitney U-tests. The disease courses of patients with TBF were further examined. RESULTS Over the study period, 118 patients with concomitant right diaphragm and liver injury were reviewed, of these 114 patients (96.6%) survived longer than 72 h. Four patients developed TBF (3.5%). Patients with TBF were younger (P = 0.01) and had trends toward less frequent liver repair (P = 0.061) or concomitant liver and diaphragm repair (P = 0.061). Video-assisted thoracoscopic surgery for retained hemothorax was associated with increased risk of TBF (P = 0.005). Patients with TBF were significantly more likely to develop infectious complications such as sepsis, pneumonia, or complicated parapneumonic effusion (P < 0.001). Treatment of TBF included endoscopic retrograde cholangiopancreatography, sphincterotomy, and stent placement. CONCLUSIONS Although TBF incidence is low, patients with concomitant right hemidiaphragm and liver trauma may be at higher risk for developing TBF without prompt and definitive operative intervention. This injury is characterized by infectious complications requiring further interventional treatment and monitoring.
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Affiliation(s)
- Nathan Y Kim
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mordechai G Sadowsky
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Christina Williams
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Christopher F Janowak
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
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Acharya R, Kafle S, Sedhai YR, Shrestha DB, Walsh K, Shamsi WE, Gyawali S, Acharya N, Loschner AL, Rubio ER. Bilothorax: A Case Report and Systematic Literature Review of the Rare Entity. Pulm Med 2024; 2024:3973056. [PMID: 38947176 PMCID: PMC11213635 DOI: 10.1155/2024/3973056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/14/2024] [Accepted: 06/07/2024] [Indexed: 07/02/2024] Open
Abstract
Background Bilothorax is defined as the presence of bile in the pleural space. It is a rare condition, and diagnosis is confirmed with a pleural fluid-to-serum bilirubin ratio of >1. Methods The PubMed, Embase, Google Scholar, and CINAHL databases were searched using predetermined Boolean parameters. The systematic literature review was done per PRISMA guidelines. Retrospective studies, case series, case reports, and conference abstracts were included. The patients with reported pleural fluid analyses were pooled for fluid parameter data analysis. Results Of 838 articles identified through the inclusion criteria and removing 105 duplicates, 732 articles were screened with abstracts, and 285 were screened for full article review. After this, 123 studies qualified for further detailed review, and of these, 115 were pooled for data analysis. The mean pleural fluid and serum bilirubin levels were 72 mg/dL and 61 mg/dL, respectively, with a mean pleural fluid-to-serum bilirubin ratio of 3.47. In most cases, the bilothorax was reported as a subacute or remote complication of hepatobiliary surgery or procedure, and traumatic injury to the chest or abdomen was the second most common cause. Tube thoracostomy was the main treatment modality (73.83%), followed by serial thoracentesis. Fifty-two patients (51.30%) had associated bronchopleural fistulas. The mortality was considerable, with 18/115 (15.65%) reported death. Most of the patients with mortality had advanced hepatobiliary cancer and were noted to die of complications not related to bilothorax. Conclusion Bilothorax should be suspected in patients presenting with pleural effusion following surgical manipulation of hepatobiliary structures or a traumatic injury to the chest. This review is registered with CRD42023438426.
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Affiliation(s)
- Roshan Acharya
- Division of Pulmonary and Critical Care MedicineVirginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Smita Kafle
- Department of Family Nurse PractitionerFrontier Nursing University, Versailles, KY, USA
| | - Yub Raj Sedhai
- Division of Pulmonary and Critical Care MedicineUniversity of Kentucky, Bowling Green, KY, USA
| | | | - Kevin Walsh
- Division of Pulmonary and Critical Care MedicineVirginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Wasif Elahi Shamsi
- Division of Pulmonary and Critical Care MedicineVirginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Suraj Gyawali
- Department of Emergency MedicineGrande International Hospital, Kathmandu, Nepal
| | - Nikita Acharya
- Department of Internal MedicineUniversal College of Medical Sciences, Siddharthanagar, Nepal
| | - Anthony Lukas Loschner
- Division of Pulmonary and Critical Care MedicineVirginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Edmundo Raul Rubio
- Division of Pulmonary and Critical Care MedicineVirginia Tech Carilion School of Medicine, Roanoke, VA, USA
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3
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Kazemi K, Rasekhi A, Nazari SS, Lashkarizadeh MM, Shamsaeefar A, Alikhani M, Akbari A, Shahriarirad R. Nonoperative management of biliopleural fistula following living-donor liver transplantation: A case report. Clin Case Rep 2023; 11:e8210. [PMID: 38028040 PMCID: PMC10654471 DOI: 10.1002/ccr3.8210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/19/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Key Clinical Message Biliopleural fistula is a rare but serious complication after liver transplantation that should be managed nonoperatively with antibiotics, pleural drainage, decompression of high-pressure biliary tract, or ultimately surgery in unresponsive cases. Abstract Bilious pleural effusion is a rare entity often iatrogenic, following hepatobiliary surgeries and biliary interventions, and has been reported only in a limited number of patients after liver transplantation. A 5-year-old girl underwent living donor liver transplantation due to progressive familial intrahepatic cholestasis. At the 7th day of the postoperative course, due to increased liver enzymes and bilirubin levels and intrahepatic bile duct dilatation on sonography, Magnetic Resonance Cholangiopancreaticography followed by a liver biopsy were performed; the findings demonstrated moderate intrahepatic bile duct dilatation and moderate cellular rejection associated with mild cholestasis, respectively. The patient was therefore administered a pulse of methylprednisolone; however, due to fever, peritonitis and also sonographic evidence of infected biloma collection adjacent to the transplanted liver, the patient underwent surgery. Laparotomy and peritoneal washout were performed and a Jackson-Pratt drain was inserted adjacent to the liver cut surface. Succeeding tachypnea on 28th post day, led to detection of right side massive pleural effusion on chest Xray and hence thoracostomy tube was inserted. A diagnosis of biliopleural fistula was established and broad-spectrum intravenous antibiotic therapy was started, followed by cholangiography, fistula closure, and bile duct stricture ballooning and internal-external biliary catheter insertion. The patient was discharged in generally good condition on the 50th posttransplant day. The diagnosis of biliopleural fistula is facilitated with the utilization of chest imaging and pleural fluid analysis, however, a high index of suspicion is required.
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Affiliation(s)
- Kourosh Kazemi
- Shiraz Transplant CenterAbu Ali Sina Hospital, Shiraz University of Medical SciencesShirazIran
| | - Alireza Rasekhi
- Shiraz Transplant CenterAbu Ali Sina Hospital, Shiraz University of Medical SciencesShirazIran
- School of MedicineShiraz University of Medical SciencesShirazIran
| | - Sahar Sohrabi Nazari
- Shiraz Transplant CenterAbu Ali Sina Hospital, Shiraz University of Medical SciencesShirazIran
| | | | - Alireza Shamsaeefar
- Shiraz Transplant CenterAbu Ali Sina Hospital, Shiraz University of Medical SciencesShirazIran
| | - Mohammad Alikhani
- Shiraz Transplant CenterAbu Ali Sina Hospital, Shiraz University of Medical SciencesShirazIran
| | - Ali Akbari
- Shiraz Transplant CenterAbu Ali Sina Hospital, Shiraz University of Medical SciencesShirazIran
| | - Reza Shahriarirad
- School of MedicineShiraz University of Medical SciencesShirazIran
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical ScienceShirazIran
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Park C, Lee J. Massive hemothorax due to intercostal arterial bleeding after percutaneous catheter removal in a multiple-trauma patient: A case report. World J Clin Cases 2021; 9:9942-9947. [PMID: 34877334 PMCID: PMC8610904 DOI: 10.12998/wjcc.v9.i32.9942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 06/30/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intercostal arterial bleeding is unusual complication of percutaneous chest procedures. However, intercostal arterial bleeding is likely to result in critical complications such as abnormalities in vital signs, hypovolemic shock, and death due to massive bleeding. Therefore, it is very important to establish the diagnosis of intercostal arterial bleeding and to initiate treatment.
CASE SUMMARY We report a case in which a 59-year-old woman who was hospitalized at intensive care unit with multiple trauma had a massive hemothorax after the removal of a percutaneous catheter. She sustained a refractory right pleural effusion due to biloma caused by a traumatic injury to the liver, despite persistent intraperitoneal drainage. As a result, atelectasis persisted in the dependent portion of the right lung. Therefore, we performed right percutaneous catheter drainage (8.5-F pigtail catheter) for pleural effusion drainage at the 7th intercostal space. After percutaneous catheter removal, portable chest radiography and vital signs of the patient assisted in establishing a diagnosis of intercostal arterial bleeding. Intercostal arterial bleeding was also confirmed using transarterial angiography; and embolization was performed. The patient’s condition progressively improved, and no further intervention was required.
CONCLUSION Massive hemothorax is a rare complication of percutaneous catheter removal. Clinicians should carefully examine and diagnose patients to improve prognosis. And interventional selective angiography may be a feasible and minimally invasive treatment for intercostal arterial bleeding control.
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Affiliation(s)
- Chanhee Park
- Department of Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu 42601, South Korea
| | - Jeongwoo Lee
- Division of Trauma Surgery, Department of Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu 42601, South Korea
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Angelou VN, Patsikas MN, Kazakos GM, Tragoulia I, Paraskevas GK, Theodoridis TD, Ilia GM, Koutsouflianiotis K, Ilia TSM, Tselepidis S, Papazoglou LG. Bilothorax Associated with Bile Peritonitis in a Dog with No Diaphragmatic Disruption: A Case Report. Top Companion Anim Med 2020; 40:100453. [PMID: 32690288 DOI: 10.1016/j.tcam.2020.100453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 05/28/2020] [Accepted: 05/31/2020] [Indexed: 10/24/2022]
Abstract
A 4-year-old intact male mixed-breed dog was presented with vomiting and severe depression of 6-day duration after being struck by a car 2 weeks before presentation. Clinical examination revealed hypothermia, respiratory difficulty, jaundice, and a bicavitary (pleural and peritoneal) effusion. Hematological and biochemical abnormalities included neutrophilic leukocytosis, increased total bilirubin concentration, and increased serum lipase activity. Biochemical and cytological evaluation of both abdominal and thoracic fluids were suggestive of bilious effusions. During celiotomy, a rupture of the cystic duct was observed, which necessitated cholecystectomy. A diaphragmatic rupture was not found. A thoracostomy tube was inserted in the right pleural space, and continuous suction was maintained for 48 hours. The dog was discharged 20 days after surgery and no abnormalities were detected on either blood tests or ultrasonographic examinations of the thorax and abdomen on follow-up examination 7 months after surgery. The presence of a bilothorax should be considered in animals with bile peritonitis, grossly intact diaphragm and pleural effusion. The exact mechanisms of the development of bilothorax are unclear, but the transport of bile through microscopic congenital or acquired weaknesses or defects of the diaphragm, via abdominal lymphatics penetrating the diaphragm and draining into the thoracic lymphatics represent the most probable route.
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Affiliation(s)
- Vasileia N Angelou
- Department of Clinical Studies, School of Veterinary Medicine, AUT, Greece
| | - Michail N Patsikas
- Department of Clinical Studies, School of Veterinary Medicine, AUT, Greece.
| | - George M Kazakos
- Department of Clinical Studies, School of Veterinary Medicine, AUT, Greece
| | - Ioanna Tragoulia
- Department of Clinical Studies, School of Veterinary Medicine, AUT, Greece
| | | | | | - Georgia M Ilia
- Department of Surgery, Agios Dimitrios General Hospital, Thessaloniki, Greece
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Iatrogenic Bilothorax: A Rare Complication of Orthotopic Liver Transplant. ACG Case Rep J 2019; 6:e00137. [PMID: 31620534 PMCID: PMC6722382 DOI: 10.14309/crj.0000000000000137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/10/2019] [Indexed: 11/24/2022] Open
Abstract
Bilothorax is a rare condition involving drainage of bile from the biliary system into the lung's pleural space. Several cases have been reported in the literature, where the most commonly reported cause is iatrogenic injury. To date, no cases of bilothorax as a complication of liver transplantation have been reported. Given its rarity and concurrent morbidity, early recognition is paramount as this condition can quickly deteriorate into adult respiratory distress syndrome.
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Sano A, Yotsumoto T. Bilothorax as a complication of percutaneous transhepatic biliary drainage. Asian Cardiovasc Thorac Ann 2015; 24:101-3. [PMID: 26294694 DOI: 10.1177/0218492315603214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report two cases of bilothorax that occurred as a complication of percutaneous transhepatic biliary drainage. In an 86-year-old woman who had undergone percutaneous transhepatic biliary drainage for obstructive jaundice, bilothorax occurred after accidental removal of the tube. She recovered with chest drainage only. An 83-year-old man who had undergone percutaneous transhepatic biliary drainage for cholecystitis developed bilothorax with infection. He recovered with thoracoscopic curettage. Although bilothorax is a rare complication of percutaneous transhepatic biliary drainage, appropriate diagnosis and prompt treatment is important, especially when bilothorax is accompanied by infection.
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Affiliation(s)
- Atsushi Sano
- Department of Thoracic Surgery, Chigasaki Municipal Hospital, Japan
| | - Takuma Yotsumoto
- Department of Thoracic Surgery, Chigasaki Municipal Hospital, Japan
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Abstract
A 28-year-old male presented with fever with right-sided chest pain for 2 weeks. Clinicoradiological picture was suggestive of right-sided pleural effusion. He had history of polytrauma following a road traffic accident and had to undergo emergency laparotomy a month ago. Microscopic and culture examination of the pleural fluid showed neutrophilia, high bilirubin content and presence of gram-negative bacilli. Ultrasound of the abdomen showed the presence of biloma in the liver and right subdiaphragmatic space with fistulous communication into the right thoracic cavity. The patient was managed successfully with complete recovery.
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Affiliation(s)
- Shabana Begum
- Department of Anatomy, North Bengal Medical College and Hospital, Sushrutanagar, Siliguri, Darjeeling, West Bengal, India
| | - Subhasis Mukherjee
- Department of Pulmonary Medicine, College of Medicine, and Sagar Dutta Medical Hospital, Kolkata, West Bengal, India
| | - Debabani Biswas
- Department of Pulmonary Medicine, College of Medicine, and Sagar Dutta Medical Hospital, Kolkata, West Bengal, India
| | - Amartya Kumar Misra
- Department of Pulmonary Medicine, College of Medicine, and Sagar Dutta Medical Hospital, Kolkata, West Bengal, India
| | - Priyanka Ghosh
- Department of Pulmonary Medicine, College of Medicine, and Sagar Dutta Medical Hospital, Kolkata, West Bengal, India
| | - Pulakesh Bhanja
- Department of Pulmonary Medicine, College of Medicine, and Sagar Dutta Medical Hospital, Kolkata, West Bengal, India
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Dahiya D, Kaman L, Behera A. Biliopleural fistula following gun shot injury in right axilla. BMJ Case Rep 2015; 2015:bcr-2014-207454. [PMID: 25666247 DOI: 10.1136/bcr-2014-207454] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A biliopleural fistula (BPF) is a rare and atypical manifestation of thoracoabdominal trauma. A stepwise approach for the management is recommended for a successful outcome. We report a case of a 22-year-old man who was referred to our hospital with respiratory discomfort after sustaining a gunshot injury in the right axilla. On investigations he had haemopneumothorax, central liver contusion with perihepatic fluid and a bullet lodged at the level of right renal hilum. He was at first managed by placing a right intercostal tube drain, which initially drained blood and subsequently started draining bile. He was managed successfully with endoscopic biliary stenting, pigtail drainage of subphrenic collection and antibiotics.
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Affiliation(s)
- Divya Dahiya
- Department of General Surgery, PGIMER, Chandigarh, India
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Bilothorax: a bitter complication of liver surgery. Case Rep Surg 2013; 2013:372827. [PMID: 23533911 PMCID: PMC3603614 DOI: 10.1155/2013/372827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 01/29/2013] [Indexed: 01/01/2023] Open
Abstract
Bilothorax is a rare condition, mostly associated with surgery involving the biliary system or trauma. In this article a case of bilothorax secondary to liver surgery is reported, which recovered by pleural and abdominal drainage. Bilothorax should be considered as a cause of respiratory detoriation in patients with recent biliary or hepatic surgery.
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