From January 2000 to March 2010, our department treated 3625 patients with hepatobiliary stones and 35 patients (0.97%) with bronchobiliary fistulas, all of whom were treated surgically and achieved better results. The results are reported below.
Data and methods
1. General data: Among the 35 cases in this group, 14 were male and 21 were female, aged 32-65 years old, with an average of 55 years old. The duration of hepatic bile duct stones ranged from 10 to 45 years, with an average of 33 years. There were 3 cases with no previous history of biliary surgery, 12 cases with a history of 1 biliary surgery, 15 cases with 2, and 5 cases with 3 or more. Bronchobiliary fistula occurred in the right lower lung in 28 cases and in the left lower lung in 7 cases. The clinical manifestations of the patients were recurrent abdominal pain, chills and fever and jaundice, combined with cough and yellow, extremely bitter sputum, with yellow sputum up to 300 ml/d. The symptoms could be relieved after more yellow sputum was produced. The lung auscultation can mostly be heard in the lower lung and the wet woven Mü tremor framedЪ frighteningly private supper Uf receipts MU planted the muscle to be careful about the I am afraid of the bruises.
2. Surgical management: 35 patients were treated with general anesthesia, and after entering the abdomen, the adhesions between the liver and diaphragm were carefully separated, the subdiaphragmatic abscess was removed, and the diaphragmatic fistula was repaired. The focal liver was resected in 22 cases, including 8 cases of right hemicolectomy, 3 cases of partial resection of the right anterior lobe of the liver, 4 cases of resection of the right posterior lobe of the liver, 4 cases of resection of the left hemicolectomy, and 3 cases of resection of the left outer lobe of the liver. Bile duct obstruction stenosis incision and plastic surgery was performed in 13 cases. Hepatobiliary pelvic Roux-en-Y internal drainage was performed in 13 cases, common bile duct T-tube supported drainage in 19 cases, and hepatic cross-sectional bile duct jejunal internal drainage in 3 cases. A multi-hole rubber tube or double cannula was left between the liver and diaphragm for drainage.
3. Postoperative management: Postoperative treatment was given to strengthen anti-inflammation, nutritional support, and maintain water-electrolyte balance, and nebulized inhalation was given to encourage patients to cough and excrete sputum to prevent pulmonary infection and promote the recovery of respiratory function. Keep the bile duct and abdominal drainage tube unobstructed, closely observe the color, quantity and nature of drainage, and prevent complications such as bile duct bleeding and bile leakage.
Results
The cough and sputum of this group of patients were significantly reduced after surgery, and the sputum did not contain bile. The bile drainage was 300-600 ml/day, and three patients were found to have a small amount of banded blood clots in the bile at 7-10 days after surgery, and the bleeding stopped after treatment with thrombin bile duct flushing and other treatments. There were no recent complications such as bile leakage, intra-abdominal bleeding, or subdiaphragmatic abscess in the whole group. Four patients were lost after surgery, and the remaining 31 patients were followed up for 1-10 years without recurrence of bronchobiliary fistula. Four patients still had abdominal pain and chills and fever, and were found to have residual stones in the intrahepatic bile ducts by imaging, while the rest had no special discomfort and satisfactory results.
Discussion
Patients with hepatobiliary stones combined with bronchobiliary fistula have a long course and complex condition, which requires close cooperation among related departments such as hepatobiliary surgery, respiratory medicine, anesthesiology and surgical ICU in the process of diagnosis and treatment.
1. Etiology and pathogenesis
In the course of patients with hepatobiliary stones, bile duct stones, stenosis and inflammation are mutually causal. When the infection is more serious, the pressure in the bile duct increases and the bile duct breaks down to the surface of the liver to form a subdiaphragmatic abscess, which may penetrate the diaphragm and spread to the lower lung after further development, and eventually penetrate the bronchus to form a bronchobiliary fistula. The more bitter yellow pus sputum is a typical clinical feature of the patient. All the patients in this group had the above-mentioned manifestations.
2.Preoperative preparation
The preoperative imaging examination focused on understanding the distribution of hepatobiliary stones, bile duct strictures, variants and complications, and whether there was abscess formation under the diaphragm. In 22 patients, bronchial manifestations were found by PTC or T-tube angiography and other examinations. Patients with hepatobiliary stones combined with bronchobiliary fistulas have a long course of disease. 32 of the 35 cases in this group had a history of biliary surgery, recurrent biliary tract infections, and more serious pulmonary infections after the formation of bronchobiliary fistulas.
Therefore, preoperative nebulizer inhalation was given to help patients cough up sputum, and bile and sputum were collected for bacterial culture and drug sensitivity test to select sensitive antibiotics to control infection. 14 patients had T-tube or PTCD tube for more than 1 month, and hyperbaric oxygen therapy was given for about 10 days to control anaerobic bacterial infection. 8 patients were found to have subdiaphragmatic abscess formation in preoperative examination, and abscess puncture and drainage were performed successfully under ultrasound guidance, and patients’ fever and other symptoms were relieved and infection was controlled. The patient’s fever and other symptoms were relieved and the infection was controlled. Preoperative consultation with the departments of respiratory medicine and anesthesiology was requested, and pulmonary function tests and arterial blood gas analysis were performed to assess the impact of pulmonary infection on anesthesia and surgery. Most patients had poor nutritional status and were given parenteral or enteral nutritional support. Considering that most of the patients had a history of biliary tract surgery and more serious intra-abdominal adhesions, intestinal preparation and blood preparation were given before surgery.
3. Surgical points
3. 1 All patients in this group were under general anesthesia, and the trachea was intubated with a double-lumen tracheal tube to avoid asphyxia caused by obstruction of the airway by bile and pus in the bronchus of the affected side. Bronchial lavage was performed on the affected lung before extubation of the tracheal tube to reduce postoperative bronchial inflammation. If the bronchial inflammation on the affected side is more severe, intraoperative one-lung ventilation on the healthy side can be used. Arterial oxygen saturation was closely monitored intraoperatively, and blood gas analysis was performed if necessary. The intraoperative respiratory condition of this group of patients was stable after the above treatment.
3. 2 In this group of patients, a reverse L-shaped or inverted T-shaped incision was made in the upper abdomen with a total abdominal automatic retractor to fully reveal the liver. The adhesions between the hepatic and diaphragmatic surfaces are carefully separated. If more blood is lost during the separation process, the hepatoduodenal ligament can be freed first and the first hepatic hilar can be temporarily blocked, which can reduce blood loss. The abscess between the liver and diaphragm should be completely removed and repeatedly flushed with dilute complex iodine. After finding the fistula in the diaphragm, it is repaired properly with non-absorbable sutures. Because bronchial inflammation will gradually improve after treatment of the abdominal lesion, it is not necessary to open the chest for bronchial repair, and no drainage tubes need to be placed in the chest cavity [3].
3. 3 Since the root cause of the formation of bronchobiliary leakage is bile duct obstruction and infection, the key to surgical treatment is to release bile duct obstruction and establish unobstructed drainage. According to the principles of treatment of hepatobiliary stones [4], resection of the focal liver can achieve the purpose of removing stones, relieving bile duct obstruction and stricture, and reducing stone recurrence, which is a more ideal procedure; therefore, 22 patients in our group underwent different types of lobectomy with good results.
It should be pointed out that the bile duct severance plane should be far from the narrow obstruction in order to achieve the effect of releasing the obstruction. During liver resection, techniques such as first hepatic portal block and hemihepatic entry blood flow block can be flexibly applied, and liver tissues can be separated by clamping method or bipolar electrocoagulation, ultrasonic suction knife (CUSA), etc. The liver section is thoroughly hemostatic, and the bile duct severed end is carefully ligated or sutured, and the section can be covered with hemostatic gauze or wound closure gel to reduce the occurrence of postoperative bleeding and bile leakage.
In the other 3 patients, due to multiple biliary surgeries and infections, dense adhesions were formed in the hepatoportal area, and the extrahepatic bile duct could not be separated, so the bile duct of the liver section was drained with the jejunum for intra-biliary drainage. The obstructed bile ducts were located in the hypertrophic liver lobe, and resection of the hypertrophic liver lobe could lead to postoperative liver insufficiency and endanger the life of the patients, so the hepatectomy could only be abandoned and the obstructed bile ducts were removed through the hepatic hilum for plastic surgery to remove the stones and release the obstruction, and then the hepatobiliary ducts were drained by pelvic Roux-en-Y drainage. The rest of the patients had satisfactory results. After the operation, four patients had residual intrahepatic bile duct stones, and the rest had satisfactory results.
4.Postoperative management points
Postoperative stay in the surgical ICU, close observation of respiratory rate and amplitude, oxygen saturation, blood gas analysis and other indicators, turning and patting the back, helping patients to drain sputum and keeping the airway unobstructed. Observe the color, quantity and properties of the biliary tract and subdiaphragmatic drainage fluid, and promptly detect and manage complications such as postoperative bleeding and bile leakage.