Management of biliopleural fistula after transarterial chemoembolization of a liver lesion

The Brooklyn Hospital Center, Brooklyn, New York, USA Correspondence: Dr Amir Shahzad Butt, The Brooklyn Hospital Center, 121 Dekalb Avenue – Maynard Building 4th Floor, Brooklyn, New York 11201, USA. Telephone 347-756-8485, fax 718-250-6489, e-mail amir.s.butt@gmail.com Received for publication July 17, 2009. Accepted July 19, 2009 CASE PRESENTATION A 64-year-old Caucasian woman with a carcinoid tumour with multiple liver metastases underwent superselective hepatic transarterial chemoembolization (TACE) with adriamycin (Bedford Laboratories, USA) and low compressible beads over several months. Seven days after TACE of her third lesion in segment VII (Figure 1), the patient presented to the emergency room with nausea, vomiting and a productive brief coMMunication

A case of a biliopleural fistula with a biloma occurring after superselective hepatic transarterial chemoembolization ablation of a metastatic hepatic carcinoid is described.The presentation was complicated by choledocholithiasis.The biloma was successfully treated with endoscopic drainage.
After informed consent was obtained, endoscopic retrograde cholangiopancreatography (ERCP) was performed and revealed a BPF, with contrast collecting into the pleural cavity in the region of the chest tube (Figure 3) and three concomitant filling defects noted on the cholangiogram, consistent with choledocholithiasis.The intrahepatic ducts and common bile duct were not dilated.Biliary sphincterotomy was performed to facilitate stone extraction, which was performed with two balloon sweeps.A 15 cm, 7 Fr plastic endoprosthesis (Boston Scientific, USA) was positioned downstream of the fistula (Figure 4), with good bile flow noted in the duodenum.Two days after ERCP, a repeat hepatobiliary scan confirmed resolution of the biloma (Figure 5), with no output noted in the chest tube drainage, which was removed that evening.The patient felt better the following morning and was discharged on day 5 after ERCP without complications.

DISCuSSION
Primary or metastatic liver lesions deemed to be unresectable or in patients who are poor surgical candidates may undergo    TACE to improve mortality (1)(2)(3).A BPF is a well-described complication of radiofrequency ablation of hepatic lesions (4,5).A review of the literature revealed that a BPF had not been previously described after TACE ablation of a metastatic hepatic lesion.After TACE, tumour cells and the adjacent normal tissue undergo necrosis secondary to ischemia and the cytotoxic properties of time-released chemotherapeutic agents (6).After tumour necrosis, a cavity is created, with bile spillage resulting in biloma formation (7).In the present case, the liver lesion was juxtaposed with the diaphragm and it was likely that the necrotic effects extended to the diaphragm, leading to bile collecting in the pleural cavity.We do not believe that the choledocholithiasis, although present, aided in the upstream flow of bile because our patient had neither obstructive symptoms nor dilated ducts on ERCP.We believe that the negative intrathoracic pressure created a favourable gradient aiding in bile collection in the pleural cavity from a lesion that was adjacent to the diaphragm.In the present case, the placement of a biliary stent likely reversed this gradient by maintaining constant patency of the common bile duct at the ampulla, and allowed drainage of the biloma and pleural collection.A further review of other cases is needed to ascertain whether a smaller dose of TACE may prevent this complication from occurring in liver lesions that juxtapose the diaphragm.

Figure 3 )
Figure 3) Endoscopic retrograde cholangiopancreatography revealing a biliopleural fistula, with contrast collecting into the pleural cavity in the region of the chest tube

Figure 5 )
Figure 5) Hepatobiliary scan confirming resolution of the biloma