Importance of liver drainage in biliary-bronchopleural fistula resulting from thoracoabdominal gunshot injury.

A 27-year-old man presented to our centre with a right-sided thoracoabdominal gunshot wound. He was hypotensive and tachycardic. His extended focussed assessment by sonography for trauma confirmed a right hemothorax and intraperitoneal hemorrhage. After inserting a chest drain, we did an emergency celiotomy. His injuries included a diaphragmatic laceration, a bleeding grade 2 renal laceration, minimally hemorrhaging grade 3 liver injury and 2 colotomies. We performed a medial-visceral rotation, then did a partial nephrectomy and right hemicolectomy, packed the liver defect, carried out a double-layered suture repair of the diaphragm (after irrigating the thorax) and did a temporary silo closure. On postoperative day 3, the patient underwent primary closure of the abdomen. All repairs were intact, and the liver injury appeared hemostatic with no evidence of a bile leak. We did not insert abdominal drains. On postoperative day 6, the patient had an increased leukocyte count (22 × 109/L). Computed tomography (CT) identified a right-sided abdominal fluid collection with a persistent pneumothorax. We inserted an additional chest tube in the thorax. A CT-guided drain inserted into the peritoneal collection initially gave purulent fluid. The patient’s leukocyte count normalized. On postoperative day 10, the patient became febrile with an increased leukocyte count (26 × 109/L). Blood cultures confirmed a gram-negative bacteremia, and he was noted to have biloptysis (ventilator circuit). The abdominal drain was dry. Repeat CT imaging identified large, complex right abdominal (Fig. 1) and thoracic (Fig. 2) fluid collections with separate air–fluid levels. Bronchoscopy confirmed a continuous bile leak from the right lower hepatic lobe. A contrast enema showed an intact ileocolonic anastomosis. The following day, through a right thoracoabdominal incision, we drained 1 L of purulent bile from a cavity posterior and lateral to the kidney. We divided the fistula by separating the diaphragm from the right lower lung lobe and excised a 2-cm fistulous tract by means of a stapled pulmonary wedge resection. We also carried out lung decortication. After repairing the diaphragmatic dehiscence, we inserted 2 chest tubes and 3 peritoneal drains. Using endoscopic retrograde cholangiopancreatography (ERCP), we inserted a biliary stent. The drainage stopped within 8 days, and the patient was discharged in good condition. Correspondence to: Dr. J.M. Nicholas Department of Surgery Grady Memorial Hospital Campus Glenn Memorial Bldg., Rm. 302 69 Jesse Hill Jr. Dr. SE Atlanta, GA 30303 fax 404 616-7333 [email protected] CASE NOTE