Thoracoabdominal war wounds complicated by thoracobiliary fistulae: A report of cases managed over the past eighteen years and a review of the literature

Purpose: To describe the management of combat-related thoracobiliary fistulae (TBF) and to review the existing literature on this complication of thoracoabdominal trauma. Results: Three patients with TBF were managed during Operation Restore Hope and Operation Iraqi Freedom. Two of the fistulae developed after initial operative treatment of major thoracoabdominal injuries while the third developed after non-operative management of a penetrating right upper quadrant injury. One patient expired following bile aspiration. The others survived their injuries and the fistulae resolved after multiple interventions including operative exploration, percutaneous drainage, and therapeutic endoscopic biliary decompression. Discussion: Due to the challenges presented by TBF, avoidance is paramount. To that end, we emphasize meticulous surgical technique for operative management of thoracoabdominal trauma and judicious patient selection for non-operative management. Should a TBF develop, traditional fistula management principles should be followed in order to eliminate the ongoing bile excretion into the chest cavity including drainage of associated collections, positive pressure ventilation, and biliary decompression. The literature on this complication consists of 43 case reports and one recent case series of 22 patients. These reports indicate that many of these patients require multiple interventions to resolve the fistulous communication although endoscopic management has recently proven highly successful in facilitating the management of these very challenging cases.