Thoracobiliary Fistula Complications Following Concomitant Diaphragm and Liver Injury

Introduction: Thoracobiliary fistula (TBF) is a rare and highly morbid complication of hepatic trauma. There is a paucity of literature regarding incidence, disease course, and treatment. This study identifies etiologic factors and outcome patterns in patients at risk for TBF.

Methods: A retrospective review of patients presenting with concern for trans-diaphragmatic bile leak over an 8-y period was performed at an urban level 1 trauma center. Early postinjury deaths were excluded. Records were reviewed for presence of a delayed bile leak. Patient characteristics with concern for (No-TBF) and confirmed fistula (TBF) were compared using Fisher's exact and Mann-Whitney U-tests. The disease courses of patients with TBF were further examined.

Results: Over the study period, 118 patients with concomitant right diaphragm and liver injury were reviewed, of these 114 patients (96.6%) survived longer than 72 h. Four patients developed TBF (3.5%). Patients with TBF were younger (P = 0.01) and had trends toward less frequent liver repair (P = 0.061) or concomitant liver and diaphragm repair (P = 0.061). Video-assisted thoracoscopic surgery for retained hemothorax was associated with increased risk of TBF (P = 0.005). Patients with TBF were significantly more likely to develop infectious complications such as sepsis, pneumonia, or complicated parapneumonic effusion (P < 0.001). Treatment of TBF included endoscopic retrograde cholangiopancreatography, sphincterotomy, and stent placement.

Conclusions: Although TBF incidence is low, patients with concomitant right hemidiaphragm and liver trauma may be at higher risk for developing TBF without prompt and definitive operative intervention. This injury is characterized by infectious complications requiring further interventional treatment and monitoring.