Multimodal Approach to Acquired Bronchobiliary Fistula Secondary to Hepaticojejunostomy Stricture Following Yttruim-90 Therapy

Bronchobiliary fistula (BBF) is an abnormal connection between the bronchial system and the biliary tree. It pathognomonically presents with bilioptysis (production of bilious-tinged sputum) and is associated with mortality rates up to 12.7%. Here we present a 56-year-old male with stage IV neuroendocrine pancreatic cancer status post pylorus-preserving pancreaticoduodenectomy. The patient developed an acquired BBF secondary to repeated Yttrium-90 radioembolization therapy that resulted in complete stenosis of the hepaticojejunostomy (HJ) anastomosis. The diagnosis was confirmed using cholescintigraphy and bronchoscopy. Biliary decompression with percutaneous transhepatic cholangiogram was unsuccessful, necessitating resection of the HJ anastomosis with salvage bilioenteric reconstruction using Kasai-type anastomosis between the pancreaticobiliary limb and hepatic duct. Complete resolution was noted following surgery. Although a minimally invasive approach to treatment of BBF may be favorable, patients with previous biliary reconstruction may warrant multimodal treatments including percutaneous procedures and complex surgical reconstructions.