Bronchobiliary fistula (BBF), which often presents with bilioptysis, is an abnormal communication between the bronchial system and biliary tree. It is a complication associated with a high mortality rate and requires a well-planned management strategy. Although hydatid disease is still the leading cause, extensive surgical interventions and invasive procedures of the liver have altered the profile of patients in recent decades. This paper presents 3 cases of BBF and reviews the literature regarding the treatment options generally mandated by clinical presentation and the underlying disease.

The presence of microscopic deposits of tumour cells at the bronchial resection margin (BRM) may adversely affect the prognosis of patients. Residual tumour cells were identified at the BRM in 40 (5.4%) of 735 patients who had been operated on for non-small cell lung carcinoma (NSCLC). The extent of disease was stage I in 7 (17.5%), stage II in 21 (52.5%), stage IIIa in 10 (25%) and stage IIIb in 2 (5%) patients. Malignant cells were found to have infiltrated the submucosal lymphatics in 5 (12.5%) cases and the peribronchial tissue in the remaining 35 (87.5%). Fifteen (37.5%) patients received adjuvant radiotherapy (RT). Recurrence of the disease was diagnosed in 29 (72.5%) patients after a median of 17 months (range 3-111). The recurrence was local in 17 (59%) and distant in 12 (41%). The 5-year overall actuarial survival rate was 21.6% and was not affected by RT (P = NS). Only patients with stage IIIa disease and a positive bronchial stump had a significantly reduced 5-year survival rate compared to those with a negative stump, 0% vs 17% (P < 0.001). Tumour cells at the resection margin did not affect the survival in this cohort except those with stage IIIa disease, and the addition of adjuvant RT did not significantly affect its recurrence in patients with NSCLC.

It seems that the outcome is unpredictable in terms of lung expansion after decortication, which is a relatively simple procedure compared with other surgical options. We think that the risk of rethoracotomy is acceptable, considering the devastating complications and high mortality rates of resectional surgery in the treatment of such patients.

Lobar torsion is reported as very rare but sometimes catastrophic complication if overlooked during the early postoperative period following a lobectomy, though it is totally preventable. In this novel technique, a piece of parietal pleural flap is harvested from the posterior wall of the chest using a hook diathermy while keeping its upper border as close to the apex as possible. Finally, distal end of the flap is secured to the upper edge of the lobe using a fine monofilament absorbable suture. This procedure not only protects the lobe from rotation but also maintains continuous expansion of the lung in the early postoperative period and may, therefore, be a good option to prevent such a serious complication in selected patients following a lobectomy.

Regardless of the daily drainage, chest tubes can safely be removed earlier than anticipated in most patients after lobectomy if the protein content of the draining fluid is low.