Bilio-thoracic fistula (communication between bile ducts and thorax) is a rare but severe disease, still having a high mortality. The paper analyses our 18 years experience with the aim to establish the best surgical management. The tactical principles of surgical treatment aim for the next 4 objectives: removal of the suppurated hydatid cyst from the liver and treatment of the remnant cavity; resection of the pulmonary parenchyma with or without lung decortication; repair of the diaphragmatic defect; desobstruction of the common bile duct through abdominal approach.
During 18 years we operated 8 patients: 7 cases of hydatid origin (2 bilio-pleural, 3 bilio-pulmonary and 2 bilio-bronchial fistulae) and one of lithiasic origin (stone impacted in the Vaterian ampulla). In all cases we started with a transthoracic approach with resolution of the intra-thoracic lesions, large phrenotomy, treatment of the hepatic cavity and repair of the diaphragmatic defect. In order to reduce the haemorrhage we changed the classical order, by performing the parietal pleurectomy just before closure of the thoracotomy.
In 4 cases we didn′t perform the abdominal part of the operation due to intraoperative failure of blood pressure: one patient had a favourable evolution with spontaneous resolution of jaundice; one developed a biliary fistula which closed after 4 months, the patient having been operated before in another unit with sphinctero-papillotomy; in 2 patients the bilio-pleural fistulae relapsed and needed drainage of the common bile duct after 14 days. One postoperative death by uncontrolable sepsis.CONCLUSIONS: We believe that a one-stage bipolar thoracic and abdominal approach, beginning with the thoracic part of the operation is the best treatment for bilio-thoracic fistulae if the general condition of the patient allows a major procedure.
The technical and tactical changes presented will improve the results by allowing to perform a complex surgical procedure in extremely fragile patients.
A.M. Botianu, None.