Thoracobiliary Fistulae: Diagnostic Challenges and Surgical Solutions in Two Cases

Thoracobiliary fistulae (TBF) are rare and highly morbid conditions characterized by communication between the biliary tract and the pleural cavity or bronchial tree. The vague nature of symptoms results in delays in diagnosis, and there are no standardized treatment guidelines. Here, we share the experiences of two patients treated at the Hepatobiliary Unit, Shaikh Zayed Hospital, Lahore. The first case developed a bronchobiliary fistula after a right hemihepatectomy for a hydatid cyst, while the second developed a biliopleural fistula following hepaticojejunostomy stenosis, performed for a common bile duct injury. Both patients were evaluated with advanced imaging (CT, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP)) and ultimately received surgery through an abdominal approach. In both cases, removing the fistulous tract and repairing the liver and diaphragmatic fistulous openings provided full relief of symptoms. The first patient recovered smoothly, while the second experienced transient hepatic decompensation (due to longstanding cholestasis), which improved with supportive care. Early detection of TBF, using bilirubin levels in sputum or pleural fluid and targeted imaging to delineate anatomy, is critical to reducing the risk of complications. For patients who can undergo surgery, excision of the fistulous tract through the transabdominal route is a safe and effective option. Our experience adds to the limited global knowledge on TBF and highlights the need for clear treatment guidelines for this rare but morbid condition.