A CASE OF BILIPTYSIS CAUSED BY A CHOLECYSTECTOMY

biliobronchial fistula biliary ductal 3x3 lower bile duct hepatic fistula reparation duct hepaticojejunostomy the hepatic

At our hospital, the patient's abdomen was soft and flat. She no longer showed abdominal pain and tenderness. The results of laboratory evaluations were as follows: PAL: 477 IU/L; GGT: 448 IU/L. MRI scans showed intrahepatic parietal formation appearing to have a wall and fluid content measuring 19x17mm: subphrenic collection and biliobronchial fistula and intrahepatic biliary ductal dilatation especially at the level of the left lobe. Laparotomy revealed a 3x3 cm abscess collection in the right lobe of the liver communicating with the right lower lobe of the lung and bile duct injury type E4 according to Strasberg classification of biliary injury: Stricture of the hilus with involvement of confluence and loss of communication between right and left hepatic ducts. The patient underwent a decortication of the abscess cavity with closure of the diaphragmatic fistula and reparation of the bile duct injury by the Roux-en-Y hepaticojejunostomy elongated to the left hepatic duct. The postoperative course was uneventful. After 06 months of follow up, patient had excellent outcome.

Discussion:-
BBF is a rare complication caused by several mechanisms whose l'obstruction biliary after surgery haptobiliary, which produces an inflammatory reaction in the subdiaphragmatic space, with subsequent rupture into the bronchial system, this one favorised by the differential pressure gradient between the abdominal and thoracic cavity (1).
The diagnosis is usually clinical, but the presence of bilibtysia is the sine qua non of a BBF. Imaging studies used to confirm the diagnosis (CT scan, MRI and endoscopic retrograde cholangiopancreatography) must demontrate the fistulous tract (2).
There is no general agreement on how to deal with BBFs. Management is often multimodal and directed at the underlying etiology. Ong et al used subcutaneous octreotideand succeding in reducing bilous sputum in a patient and allows closure of the fistula, but its use is limited and is not practical in case of infection, neoplasia or obstruction (4).
Indeed, other conservative interventions can be used for reducing the pressure in the biliary tract, such as endoscopic retrograde cholangiography to treat BBF as a complication of gallstone, hepatic trauma and bil duct injury. Although there is little doubt that other factors may be implicated in the continuance of a BBF, the most notable of which appears to be sepsis, the importance of these factors cannot be conclusively established (5).
Our patient did not have an endoscopic retrograde cholangiography given the type of bile duct injury evoked on the MRI.
The deffinitive treatment is surgical and should have the repair of lesions of bile duct with biliary diversion or stents to relieve the obstruction and fistulectomywith soft tissue reconstruction (6). Adams reported two BBFs associated with common bile duct stricture, he also emphasized the importance of early and adequate drainage to prevent the occurrence of acute necrotizing bronchitis and pneumonitis caused by infected bile. In the discussion of this presentation it was recommended that the primary method of treatment should be laparotomy to correct the basic biliary disease rather than any type of thoracotomy. Subsequent pulmonary resection may become necessary if there are severe structural changes in the lungs (7).
Biliptysis is a rare complication of biliary tract surgery remains of easy diagnosis but specific management.