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Bronchobiliary fistula due to bevacizumab: a method of palliation.
Kendal Hervert, Jacob Mahaffey, Daniel Nader, Peter Baik.
Southwestern Regional Medical Center, Cancer Treatment Centers of America, Tulsa, OK, USA.

OBJECTIVE: Acquired bronchobiliary fistula is an uncommon but highly morbid complication of hepatocellular carcinoma treatment. We report a case of a bronchobiliary fistula in a patient being treated for hepatocellular carcinoma with bevacizumab, its sequelae and treatment.
METHODS: A 57 year-old female initially diagnosed with stage I (cT1N0M0) hepatocellular carcinoma in 2011, underwent a right hepatic lobectomy. She was diagnosed with recurrence to her left lobe of liver and was started on multiple cycles of chemotherapy. Bevacizumab was added in April 2013. She experienced recurrent pneumonias beginning in October 2013, and hemoptysis followed by bilioptysis in November 2013. A HIDA scan revealed an acquired bronchobiliary fistula. She continued to have worsening bilioptysis, even after discontinuing bevacizumab and undergoing multiple intrahepatic drainage procedures. To treat this highly morbid complication, the patient underwent a robotic assisted resection of bronchobiliary fistula.
RESULTS: The patient underwent right robotic assisted resection of bronchobiliary fistula along with intercostal muscle flap closure of diaphragm tract. Bilioptysis resolved. However, she began having bilious drainage from her 24 French Blake drain on post-operative day 6 and continued to have biliocutaneous fistula drainage with a drain after discharge. She continued to report no episodes of bilioptysis at 2 month follow-up.
CONCLUSIONS: The majority of bronchobiliary cases are described due to trauma, hepatic abscess, hydatid disease, liver surgery, hepatocellular malignancy, or radiofrequency ablation of hepatic mass. Patients may present with a number of conditions including bilioptysis, respiratory distress and aspiration1. In instances where bronchobiliary fistula persists after hepatic drainage procedures, surgical intervention should be considered to palliate bilioptysis. Minimally invasive technique utilizing robotic assistance decreases the morbidity associated with thoracotomy and allows excellent palliation.

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