Multimodal approach to acquired bronchobiliary fistula secondary to hepaticojejunostomy stricture following yttrium-90 therapy

Presenter: Asmita Chopra MD | The University of Toledo Background: Acquired bronchobiliary fistula (BBF) is a rare and challenging complication resulting in an abnormal connection between the bronchial system biliary tree. It most commonly presents with pathognomonic productive cough featuring bilious-tinged sputum or “biloptysis”. BBFs can be associated hepatic abscesses, malignancy liver directed interventions. They are known to have high mortality rates, some series up 12.7%. A patient development obstruction BBF secondary Y-90 (yttrium-90) radioembolization therapy presented. Methods: 56-year-old male presented stage IV neuroendocrine pancreatic cancer underwent initial sequential treatments included pancreaticoduodenectomy partial hepatectomy, Y-90, microwave ablation. Patient did well for 2.5 years at which time he was noted interval increase lesions on surveillance imaging. Additional given right sided lesions. This poorly tolerated significant abdominal pain failure thrive further not pursued. gradually improved referred potential peptide receptor radionuclide therapy. Ten months later returned HPB Surgery clinic complaints persistent pain, copious amounts yellow-tinged history multiple bouts pneumonia. Imaging demonstrated intrahepatic dilation, right-sided peri-hepatic abscess pleural effusion. Right lobe involution left hypertrophy also noted. Results: subsequently percutaneous drainage chest tube placement However, his production persisted, prompting evaluation acquired BBF. diagnosis confirmed HIDA (hepatobiliary iminodiacetic acid) bronchoscopy. Cholescintigraphy single-photon emission computed tomography (NM spect CT scan) localized tract upper near (Figure 1). Initial treatment focused decompression PTC (percutaneous transhepatic cholangiogram) drain placement. During procedure, attempts cannulating hepaticojejunostomy were unsuccessful, indicating complete stenosis anastomosis. Finally, elective surgery restore enteric continuity. involved resection mobilization pancreaticobiliary (PB) limb Kasai-type porto-enteric anastomosis PB duct previously placed entrance site. Complete resolution bronchopulmonary during subsequent exchange following doing greater than 4 after diagnosis. Conclusion: rare, misdiagnosed, difficult treat. Although has shifted toward less invasive approaches favorable results, setting previous reconstruction these fistulas pose unique challenges. Multimodal including advanced complex surgical intervention may required rescue patients.