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Conservative management of thoracobiliary fistula
Bhugwan Singh1, Jaynathan Moodley, Mohamed H Sheik-Gafoor
1Department of General Surgery, Faculty of Health Sciences, Nelson R. Mandela School of Medicine, University of Natal, Congella, South Africa. moodleyj6@nu.ac.za
Background:
Thoracobiliary fistulas are rare manifestations of biliary disruption. Given their rarity it is not surprising that there is little consensus on the optimal management of thoracobiliary fistulas.
Methods:
Patients presenting with thoracobiliary fistulas over a 5-year period (1996 to 2001) were evaluated. Initial management was conservative with tube thoracostomy or drainage of sepsis when appropriate, or both; antibiotics and somatostatin were routinely administered. Endoscopic retrograde cholangiography was performed when symptoms persisted to delineate the thoracobiliary communication and undertake sphincteroplasty.
Results:
Eight patients with a mean age of 31.9 years (range 15 to 42) were evaluated. Biliary effusion occurred in 3 patients after hepatic injury (n = 2) and percutaneous transhepatic cholangiography (n = 1). Bilioptysis occurred in 5 patients after hepatic abscess (n = 4) and hepatic injury (n = 1) The biliary effusion (n = 3) was successfully managed by endoscopic sphincterotomy in 2 patients; the third patient underwent urgent surgical biliary drainage. Bilioptysis (n = 5) was successfully managed in 3 patients; persistence of symptoms in 2 patients prompted surgical intervention.
Conclusions:
Thoracobiliary fistulas may be successfully managed using a conservative approach. Surgery should be reserved for persistence of symptoms after exhaustion of this approach.