ABSTRACT
INTRODUCTION: Thoracobiliary fistula is a rare presentation of biliary obstruction which is secondary to anastomotic Roux-en-Y cholangiojejunostomy stricture. CASE PRESENTATION: A 52-year-old man presented with fever, fatigue, and anorexia. He was jaundiced. He had a history of a laparoscopic cholecystectomy complicated by iatrogenic bile duct injury which was corrected by Roux-en-Y cholangiojejunostomy. The CT revealed a subphrenic abscess. Therefore, we established CT-directed percutaneous drainage and antibiotics treatment. Four months later, he presented again with fever, fatigue, and jaundice. He also complained of bilioptysis. Pleurocentesis revealed a deep yellow pleural fluid. Thoracobiliary fistula was suspected. Our patient underwent a right thoracotomy where we drained bile, performed pleural decortication, and excised the damaged portion of the right lower pulmonary lobe. We also inserted a subphrenic drain. The fistula was remained to close spontaneously and the patient had a good postoperative recovery. DISCUSSION: The obstruction of the bile ducts leads to the retention of bile proximal to the obstruction site, the formation of a liver biloma, and subsequently the abscess formation. By increasing, the abscess gradually erodes the diaphragm. A presence of adhesions between the lower lung lobe and the diaphragm will lead the abscess to erode directly into the lung parenchyma until it reaches the nearest bronchus and a BBF is formed. CONCLUSION: The presence of bile in the pleural space due to pleurobiliary fistula, or bilioptysis due to bronchobiliary fistula are rare presentations. However, they are serious conditions that may follow bile duct operations. They require early recognition and intervention.
