Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years

AIM:To outline the appropriate diagnostic methods and therapeutic options for acquired bronchobiliary fistula(BBF).METHODS:Literature searches were performed in Medline,EMBASE,PHMC and LWW(January 1980August 2010)using the following keywords:biliobronchial fistula,bronchobiliary fistula,bronchobiliary fistula,biliarybronchial fistula,tracheobiliary fistula,hepatobronchial fistula,bronchopleural fistula,and biliptysis.Further articles were identified through crossreferencing.RESULTS:Sixtyeight cases were col...     

Bronchobiliary fistula in a cirrhotic patient: a case report and review of the literature

Bronchobiliary fistula is defined as the passage of bile in the bronchi. The presence of bronchobiliary fistula in patient with cirrhosis is extremely rare. Management of these fistulas is often very difficult and can be associated with high morbidity and mortality. We are presenting a patient with ethanol related cirrhosis and biliptysis in whom a diagnosis of bronchobiliary fistula was made. A review of the literature including diagnosis and management is performed.     

The use of endoscopy to treat bronchobiliary fistula caused by choledocholithiasis

Bronchobiliary fistula is a rare disorder consisting of the formation of a passageway between the biliary ducts and the bronchial tree. We describe an 87-yr-old woman who had a bronchobiliary fistula secondary to obstruction caused by multiple common bile duct stones. The diagnosis was confirmed by the presence of bile in the sputum and transhepatic cholangiography. Successful stone extraction with balloon and basket techniques and endoscopic sphincterotomy decompressed the biliary tract and was followed by healing of the bronchobiliary fistula without surgical intervention, which has heretofore been considered the only successful means of treatment.     

Bronchobiliary fistula due to alveolar hydatid disease

Bronchobiliary fistula is a serious complication of echinococcosis of the liver. Surgical and endoscopic treatments have been used successfully in the management of bronchobiliary fistula due to hepatic hydatid cysts. However, very little information exists on the management of bronchobiliary fistula due to alveolar hydatid disease. We report here the efficacy of various potential therapies in three cases.     

Bronchobiliary fistula complicating oriental cholangiohepatitis

Bronchio biliary fistula in adults is a rare event defined by the passage of bile into the bronchus and the sputum (biloptysis).Typically these lesions occur in the congenital form, as a result of thoracoabdominal trauma, or in rare instances as a result of iatrogenic injury or long-standing biliary tract disease and obstruction. In this paper, we report a novel case of a fatal bronchobiliary fistula that developed in a 67-year-old Chinese male with Oriental cholangiohepatitis. To our knowledge, this is the first case report of a bronchobiliary fistula complicating the clinical management of a patient with this disease.     

Chronic cough due to bronchobiliary fistula.

Bronchobiliary fistula is a rare cause of chronic cough. Here we describe a 70-year-old woman complaining of chronic cough and copious dark-yellow watery sputum. The presence of air in the biliary tract in the lower cuts of a computerized tomography scan of the chest and positive bile in the sputum led to the suspicion of bronchobiliary fistula. The diagnosis was confirmed by percutaneous transhepatic cholangiography. Drainage of the intrahepatic biliary tract resulted in complete resolution of her symptoms.     

Hepatopulmonary Fistula: Treatment with Biliary Metallic Endoprosthesis

Hepatopulmonary communication, most commonly in the form of bronchobiliary fistula, is an unusual lesion that can occasionally close spontaneously, but usually requires surgical therapy. The usual treatment has been a combined thoracoabdominal approach with correction of the fistulous tract or an abdominal approach to correct the causative bile duct obstruction. Both endoscopic and percutaneous therapy of the biliary ductal system have been described as forms of treatment. We present a case of hepatopulmonary fistula in a patient with bilioptysis, treated with percutaneous biliary metallic endoprosthesis. To our knowledge, this is the first reported case in which metallic stents were used to treat a hepatopulmonary fistula.     

Left hepatic duct injury and thoracobiliary fistula after abdominal blunt trauma

Thoracobiliary fistula after blunt hepatic trauma is rare. We report a case of pleurobiliary fistula after a blunt hepatic trauma leading to a left hepatic lobe laceration together with a left hepatic duct injury. The management of this traumatic lesion is discussed and related to the existing literature data. The diagnosis of traumatic thoracobiliary fistula rests upon clinical suspicion in the setting of a persistent right pleural effusion. Demonstration of the presence of bile in the pleural cavity by thoracocentesis is considered a proof of pleural biliary fistula. We think that laparotomy is an appropriate route for the treatment of pleurobiliary fistulas. However, when a bronchobiliary fistula is suspected, the patient should be treated with thoracotomy and may require pulmonary resection to remove the fistulous tracts.     

Congenital bronchobiliary fistula in a 65-year-old woman

Congenital bronchobiliary fistula (CBBF) is quite a rare malformation and the diagnosis is usually made within a few hours or years from birth because of lower respiratory diseases beginning from early infancy. Surgical repair is necessary. Of the 29 cases reported, 4 occurred in adults aged 22-32 years. We detected CBBF incidentally in a 65-year-old woman. During bronchoscopy and thoracic computed tomographic study of the pulmonary nodules, we found an accessory bronchus descending from the carina and composed of a dark green secretion that contained 10% bilirubin. Drip infusion cholangiography revealed air in the left bile duct. Cholescintigraphy showed dilatation of the left bile duct and radiotracer pooling at the top edge of the left hepatic lobe. These findings indicated a narrow fistula between the airway and biliary duct. We attributed the patient's long survival without major complications to the narrowness of the communication. To our best knowledge, this is the fifth and oldest reported adult diagnosed with CBBF.     

Repair of injuries to the bile ducts—The hepaticojejunal anastomosis

Summary 1. When the common duct has been damaged during a cholecystectomy, the chief purpose of the surgeon must be to restore the flow of bile to the gastrointestinal tract and not merely to restore a duct.2. In our experience, duct-to-duct anastomosis is not the procedure of choice, except in a few cases. The best procedure is hepaticojejunal anastomosis (Roux Y) realized by side-to-side technic, and encroaching upon the left hepatic duct, which is uncovered by a special trick. Since we began using this type of operation our results are noticeably better.3. When such a procedure cannot be used, a transhepatic anastomosis must be done either by transcissural, or by transparenchymatous approach.4. Special circumstances, such as angiocholitis with intrahepatic abscess, bronchobiliary fistula, or portal hypertension may compel the surgeon to find different solutions peculiar to the individual case.5. Liver biopsy and operative cholangiograms must be taken to establish exactly the type of lesions one is dealing with, and to keep an accurate record for statistical analyses.     

Management of adult choledochal cysts--a 15-year experience

Background. Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology. Methods. The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed. Results. The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months. Conclusions. Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary–enteric communication by hepaticojejunostomy form the basis of ideal treatment.     

Endoscopic treatment of persistent thoracobiliary fistulae after penetrating liver trauma

Background:

This study evaluated the outcomes of patients with complex or persistent thoracobiliary fistulae following penetrating liver trauma, who underwent endoscopic biliary intervention at a tertiary referral centre.

Methods:

All patients who underwent endoscopic retrograde cholangiography (ERC) and endoscopic biliary intervention for traumatic thoracobiliary fistulae between 1992 and 2008 were evaluated. Bile duct injuries were classified according to their biliary anatomic location on cholangiography and type of pulmonary communication.

Results:

Twenty-two patients had thoracobiliary (pleurobiliary, n = 19; bronchobiliary, n = 3) fistulae. The site of the bile duct injury was identified in 20 patients on cholangiography. These 20 patients underwent either sphincterotomy and biliary stenting (n = 18) or sphincterotomy alone (n = 2). In 17 patients the fistulae resolved after the initial endoscopic intervention. Three patients required secondary stenting with replacement of the initial stent. Three patients developed mild pancreatitis after stenting and one stent migrated and was replaced. All fistulae healed after endoscopic treatment. In 18 patients the stents were removed 4 weeks after bile drainage ceased. Three of the 22 patients required a thoracotomy for infected loculated pleural collections after initial catheter drainage.

Conclusions:

Endoscopic retrograde cholangiography is an accurate and reliable method of demonstrating post-traumatic thoracobiliary fistulae and endoscopic biliary intervention with sphincterotomy and stenting in this situation is safe and effective. Surgery in patients with thoracobiliary fistulae should be reserved for fistulae which do not heal after endoscopic biliary stenting or for patients who have unresolved pulmonary or intra-abdominal sepsis as a result of bile leak.     

Orthotopic liver transplantation and the cytosolic estrogen-androgen receptor status of the liver: the influence of the sex of the donor

Mammalian liver is known to contain cytosolic receptors for both estrogens and androgens. Furthermore, certain mammalian hepatic functions are known to display a sexual dimorphism. However, in clinical liver transplantation, the sex of the donor is not taken into consideration in selection of the donor. In this study, the effect of liver transplantation on the estrogen and androgen receptor content of the liver was determined. Adult male and female rats were subjected to orthotopic liver transplantation, using donors from both the same and the opposite sex as the recipient. The animals were killed on the tenth postoperative day, and the livers were assayed to determine their cytosolic estrogen and androgen receptor content. Transplantation of a liver from a male donor into a male recipient, from a male donor into female recipient and from a female donor into a male recipient produced similar changes in the number of cytosolic estrogen and androgen receptors in hepatic cytosol. In all three situations, the estrogen receptor content in the cytosol of the transplanted liver was the same as that found in an unoperated male liver, and the cytosolic content of the androgen receptor was the same as that of an unoperated female liver. After transplantation of the liver from a female donor into a female recipient, the estrogen and androgen receptor content in the cytosol of the transplanted liver was the same as that of an unoperated female.(ABSTRACT TRUNCATED AT 250 WORDS)     

Closing the loop: the adicol experience

The objective of the project Advanced Insulin Infusion using a Control Loop (ADICOL) was to develop a treatment system that continuously measures and controls the glucose concentration in subjects with type 1 diabetes. The modular concept of the ADICOL's extracorporeal artificial pancreas consisted of a minimally invasive subcutaneous glucose system, a handheld PocketPC computer, and an insulin pump (D-Tron, Disetronic, Burgdorf, Switzerland) delivering subcutaneously insulin lispro. The present paper describes a subset of ADICOL activities focusing on the development of a glucose controller for semi-closed-loop control, an in silico testing environment, clinical testing, and system integration. An incremental approach was adopted to evaluate experimentally a model predictive glucose controller. A feasibility study was followed by efficacy studies of increasing complexity. The ADICOL project demonstrated feasibility of a semi-closed-loop glucose control during fasting and fed conditions with a wearable, modular extracorporeal artificial pancreas.     

The relation of the intrapleural pressure to the mechanics of the circulation

Experiments have been carried out on the dog showing the effects of increased and decreased intrapleural pressure upon the heart, blood pressure, and pulmonic and peripheral circulation.It has been demonstrated that rendering the intrapleural pressure more negative produces dilatation of the heart, a diminished rate of flow through the pulmonary circuit with a relative anoxemia, a slow pulse, an increased blood pressure, fall of venous pressure, and rise in body temperature.Rendering the intrapleural pressure less negative, i.e., more nearly atmospheric, results in a fall of blood pressure, rise of venous pressure, increased pulse rate, relatively small heart, a lowered body temperature, and an increased rate of flow through the pulmonary circuit with increased oxygenation.An instrument has been devised for recording graphically changes in venous pressure.     

Myelodysplasia: the good, the fair and the ugly

The myelodysplastic syndromes (MDS) are a heterogeneous group of hematopoietic disorders. The molecular pathogenesis of the disease is poorly understood and a large number of fundamental biologic questions remain. This heterogeneity presents challenges in selecting therapy for individual patients as well as for evaluating response to treatment. Only a small number of randomized clinical trials have been conducted, although three new drugs (azacitidine, lenalidomide, and decitabine) have been approved for use in the last few years. Response to most therapies occurs slowly, and sometimes months elapse before response can be evaluated. The response rates for most drugs used or studied for MDS range from <10%-20%. Some therapies seem more promising than others: immunosuppression with antithymocyte globulin results in extended durations of benefit in responders; lenalidomide induces a very high erythroid response rate in patients with del 5q- karyotype. The DNA hypomethylating agents, azacitidine and decitabine, can be of significant benefit for a fraction of patients and further investigation is needed to determine whether higher response rates occur in particular subgroups of MDS patients. Further refinements of dose and schedule of administration are also under investigation.     

The value and the limitations of the coagulation time in the study of the hemorrhagic diseases

The coagulation time is a measurement of the intrinsic power of the blood toconvert fibrinogen to fibrin. It is an empirical test no matter how performed, andtherefore in order to be reliable requires that the test be done on venous blood understrictly controlled conditions. A recommended procedure is outlined in detail.

The coagulation time is prolonged in hemophilia, hypoprothrombinemia,afibrinogenemia and heparinemia. In hemophilia, the coagulation time theoretically is a measure of the severity of the disease but practically is of limited valuesince the coagulation time may be within normal limits in some patients; the prothrombin consumed in the coagulation of hemophilic blood is therefore a betterguide for diagnosis. The coagulation time in hypoprothrombinemia is relativelylittle prolonged until a drastic reduction occurs. The test is therefore of no value forestablishing a hemorrhagic condition in hypoprothrombinemia. In afibrinogenemiathe blood is incoagulable. A small amount of fibrinogen restores the coagulationtime to normal.

The presence of heparin increases the coagulation time. The test is therefore useful in controlling the therapeutic action of this drug.

The senior author, in making a survey of the literature on hemorrhagic diseasesin preparation of his monograph, was impressed by the significant and diverse contributions which Dr. George R. Minot made to this field of medicine. We feelhonored to contribute this study to the collection of papers offered as a fittingtribute to Dr. Minot, who has so successfully and productively combined scienceand clinical medicine.

     

Assessment of the Soft-Tissue Seal at the Interface between the Base of the Fixed Denture Pontic and the Oral Mucosa

Fixed dentures (bridges) are often selected as a treatment option for a defective prosthesis. In this study, we assess the contact condition between the base of the pontic and oral mucosa, and examine the effect of prosthetic preparation and material biocompatibility. The molars were removed and replaced with experimental implants with a free-end type bridge superstructure after one week. In Experiment 1, we assessed different types of prosthetic pre-treatment: (1) the untreated control group (Con: mucosa recovering from the tooth extraction); (2) the laser irradiation group (Las: mucosa recovering after the damage caused by a CO₂ laser); and (3) the tooth extraction group (Ext: mucosa recovering immediately after the teeth extraction). In Experiment 2, five materials (titanium, zirconia, porcelain, gold-platinum alloy, and self-curing resin) were placed at the base of the bridge pontic. Four weeks after the placement of the bridge, the mucosa adjacent to the pontic base was histologically analyzed. In Experiment 1, the Con and Las groups exhibited no formation of an epithelial sealing structure on the pontic base. In the Ext group, adherent epithelium was observed. In Experiment 2, the sealing properties at the pontic interface were superior for titanium and the zirconia compared with those made of porcelain or gold-platinum alloy. In the resin group, a clear delay in epithelial healing was observed.     

On the sequencing of the human genome

Two recent papers using different approaches reported draft sequences of the human genome. The international Human Genome Project (HGP) used the hierarchical shotgun approach, whereas Celera Genomics adopted the whole-genome shotgun (WGS) approach. Here, we analyze whether the latter paper provides a meaningful test of the WGS approach on a mammalian genome. In the Celera paper, the authors did not analyze their own WGS data. Instead, they decomposed the HGP's assembled sequence into a "perfect tiling path", combined it with their WGS data, and assembled the merged data set. To study the implications of this approach, we perform computational analysis and find that a perfect tiling path with 2-fold coverage is sufficient to recover virtually the entirety of a genome assembly. We also examine the manner in which the assembly was anchored to the human genome and conclude that the process primarily depended on the HGP's sequence-tagged site maps, BAC maps, and clone-based sequences. Our analysis indicates that the Celera paper provides neither a meaningful test of the WGS approach nor an independent sequence of the human genome. Our analysis does not imply that a WGS approach could not be successfully applied to assemble a draft sequence of a large mammalian genome, but merely that the Celera paper does not provide such evidence.     

Coronary calcium: the good, the bad, and the uncertain

BACKGROUND: Coronary calcium deposits have been widely regarded to result from a passive process of encrustation or adsorption of mineral onto advanced, complex atherosclerotic lesions. Increasing interest has focused on noninvasive radiologic detection of these calcium deposits as a diagnostic and prognostic adjunct to clinical evaluation of coronary artery disease, particularly with the use of newer, high-resolution imaging techniques such as electron beam computed tomography. METHODS AND RESULTS: We reviewed the literature on coronary calcium and its relation to pathologic atherosclerosis, angiographic stenoses,and clinical events. Clinical calcium detection studies have demonstrated an association between coronary calcium and both extent of coronary artery disease and risk of adverse events. These studies have in the past tended to reinforce the perception that calcific deposits result from a passive mineralization process, signify advanced coronary artery disease, and foreshadow future coronary events. CONCLUSIONS: Recent pathologic, genetic, clinical, and biochemical evidence reviewed in this article suggests that coronary calcium deposits are a manifestation of a complex, organized, and regulated process similar in many respects to new bone formation and may not be a reliable indicator of either the extent of coronary disease or the risk of a future event. These studies also suggest that atherosclerosis and calcific deposits may be distinct pathologic entities that frequently occur together and are related to each other in ways that are poorly understood.