Non-Operative Management of Bronchobiliary Fistula Due to Proximal Migration of Biliary Stent in a Patient With Unresectable Klatskin Tumor

Abstract

Introduction: One of the methods for the biliary tree decompression in the case of Klatskin tumor is transpapillary stenting, which could be completed by stent migration in 4% to 10% of cases. Approximately half of the stent migrations are in the proximal direction. In this study, we reported a rare case of proximal trans-diaphragmatic stent migration to the lower lobe of the right lung with the formation of a biliary-bronchial fistula (BBF). Case presentation: A 60-year-old woman was diagnosed with hilar cholangiocarcinoma (type 3B by Bismuth-Corlette) complicated by posthepatic jaundice. To relieve jaundice there were performed endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, endobiliary stent placement (10 Fr, 150 mm). A restenting (11.5 Fr, 130 mm) was performed in 2.5 months due to endobiliary tube occlusion. In the next 2 months, coughing attacks and biliptysis have appeared in the patient. A CT scan showed penetration of the liver, diaphragm, and lower lobe of the right lung with the proximal part of the stent and caused BBF formation. Anti-inflammatory and antibacterial therapy was administrated for 14 days and BBF was closed. Stent retrieval from the right hemithorax and endobiliary restenting was performed in 9 months after primary stenting. During follow-up, appropriate positioning and functioning of the stent were observed. Conclusion: BBF formation is a rare complication of endobiliary stenting, which can be successfully treated by anti-inflammatory and antibiotic therapy, followed by transpapillary stent retrieval.

Influencing factors of biliary fistula after radical resection of hilar cholangiocarcinoma: a prospect cohort

“…Previous studies [ 11 , 23 , 24 ] have found that the incidence of biliary fistula after such surgery is high, and biliary fistula has adverse effects on the short-term and long-term prognosis of patients. In this study, the incidence of biliary fistula after radical resection of hilar cholangiocarcinoma was 20.63%, which was lower than that reported in the previous literatures [ 12 , 25 , 26 ]. The reason may be that they have reported biliary fistulas with grades A, B, and C at the same time, and we only reported grade B, C cases of biliary fistula.…”

“…In this study, preoperative cholangitis and positive Klebsiella pneumoniae in preoperative bile culture may be associated with the occurrence of postoperative clinically relevant biliary fistulas. Inflammation caused by biliary tract infection can lead to bile duct wall edema and the formation of small abscesses, hinder the healing of postoperative bile duct stumps and lead to the occurrence of hepatic section or anastomotic biliary leakage [ 25 , 34 ]. Previous studies [ 35 , 36 ] have shown that the clinical isolation rate and drug resistance rate of Klebsiella pneumonia e are increasing year by year, and it has become one of the main pathogens of biliary tract infection.…”

Proximal Biliary Stent Migration Causing Cardiac Tamponade

“…Extrahepatic stent migration is very rare, but bronchobiliary fistula, biliary pneumonitis, hepaticogastric fistula, pleural effusion, and abdominal wall abscess have been reported after stent migration through the liver capsule. [7][8][9][10][11] To the best of our knowledge, there are only 3 reported cases of stent migration involving the pericardium. [4][5][6] The first 2 published cases described patients with IgG-4associated cholangitis who presented with chest pain and echocardiogram changes after $10F stent placement.…”

“…Extrahepatic stent migration is very rare, but bronchobiliary fistula, biliary pneumonitis, hepaticogastric fistula, pleural effusion, and abdominal wall abscess have been reported after stent migration through the liver capsule. 7–11 To the best of our knowledge, there are only 3 reported cases of stent migration involving the pericardium. 4–6…”

“…However, a handful of cases of transdiaphragmatic stent migration leading to abdominal wall, pulmonary, or pericardial injury have been described. [4][5][6][7][8]…”