An innovative surgical approach using the hepatic falciform ligament to repair bronchobiliary fistula after radiofrequency ablation: a case report

Introduction

Bronchobiliary fistula (BBF) is an abnormal intercommunication between the biliary ducts and bronchus, allowing bile to be expectorated through the respiratory tract (1). The hallmark symptom of BBF is biliptysis, which was reported in all BBF cases in a retrospective review (2). Other clinical manifestations of BBF include fever, jaundice, and chest pain (3). Although rare, BBF is a life-threatening complication of hepatobiliary diseases, with reported mortality rates ranging from 12.2% to 50% (4,5). Acquired BBF frequently occur secondary to liver tumor infiltration, accounting for 32.3% of cases (2,6). In recent years, the widespread use of radiofrequency ablation (RFA) and transarterial chemoembolization (TACE) for liver cancer (7) has contributed to a gradual increase in the incidence of postoperative BBF (8,9).

We present the case of a 66-year-old male with intrahepatic cholangiocarcinoma (ICC) who developed a BBF following multiple sessions of RFA. The patient underwent minimally invasive surgery, during which we utilized the falciform and round ligaments to cover the hepatic resection surface and create an anatomical barrier between the liver and repaired diaphragm. The uneventful postoperative recovery suggests that this technique may provide a viable option for managing complex BBF cases. We present this article in accordance with the CARE reporting checklist (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-959/rc).

Case presentation

A 66-year-old male was admitted with a cough producing yellow-green, bile-like sputum for 6 days and a fever of 39 ℃ for 4 days. Six months prior, he had been diagnosed with ICC at the junction of Couinaud segments IVa and VIII (S4/8), measuring 8 cm × 5 cm in diameter. He subsequently underwent two rounds of computed tomography (CT)-guided RFA, TACE, and targeted immunotherapy with lenvatinib and camrelizumab. Half a month ago, follow-up enhanced magnetic resonance imaging (MRI) revealed a suspected liver abscess at the RFA site, measuring approximately 10.7 cm × 8.2 cm. Tumor assessment showed no evidence of disease (NED), and the patient reported no discomfort. Subsequently, a percutaneous transhepatic liver abscess puncture and drainage procedure were performed, initially draining approximately 650 mL of yellow purulent fluid, but the drainage then became obstructed. Four days post-percutaneous catheter drainage (PCD), the patient developed a cough with bile-like sputum and a fever. After treatment with meropenem, his temperature normalized, but the productive cough persisted.

Physical examination demonstrated diminished breath sounds over the right hemithorax without abdominal tenderness. Past medical history included two decades of controlled hypertension and type 2 diabetes mellitus. Laboratory investigations revealed marked inflammatory markers: C-reactive protein (CRP) 109 mg/L (reference <10 mg/L) and erythrocyte sedimentation rate (ESR) 50 mm/h (reference, 0–15 mm/h). Contrast-enhanced CT imaging identified a multiloculated hepatic cystic lesion containing gas-fluid levels, accompanied by a wedge-shaped consolidative lesion with cavitation in the right middle lobe adjacent to the diaphragmatic surface (Figure 1).

Figure 1 CT transverse plane images pre-operation demonstrate infection with abscess formation in the right middle lobe and an abnormal density measuring 73 mm × 45 mm in the right lobe of the liver, accompanied by gas and fluid accumulation. CT, computed tomography.

Although there is no direct imaging evidence to confirm the presence of a BBF, the high risk of diaphragmatic injury during RFA on the liver surface, along with the current co-occurrence of liver abscesses, lung abscesses, and bile-like sputum, indirectly suggests its existence. Owing to the failure of percutaneous transhepatic drainage in treating liver abscesses, surgical intervention was deemed necessary. A laparoscopic approach was adopted, with ports placed at the supraumbilical, subxiphoid, epigastric, right upper abdominal, and right subcostal regions to allow adequate access and visualization. Upon entering the abdominal cavity, the RFA site in the liver was found to be tightly adherent to the adjacent diaphragm. After separating the RFA site from the diaphragm, a large amount of clumped necrotic and purulent material was discovered in the liver abscess cavity, likely explaining the poor drainage (Figure 2). The previously placed drainage tube was removed, pus was aspirated, and the necrotic tissue was debrided. After debridement, bile leakage was visible in multiple areas of the abscess. Two adjacent fistulas, each approximately 1 cm in size, were identified on the diaphragm. The right lower lung tissue could be seen from the fistulas, but no thoracic cavity was observed, suggesting the formation of an encapsulating adhesion around this area. Therefore, no intervention was performed on the thoracic side. Significant edema and erosion were observed around the fistulas.

Figure 2 Laparoscopic view of surgical field. (A) Laparoscopic view of the liver abscess demonstrating extensive necrotic tissue and purulent material within the hepatic cavity. (B) Surgical field post-drainage of the middle liver abscess, showing the repaired diaphragm and released adhesions. The liver wound is covered using the falciform and round ligaments.

Thoracic surgery was consulted and recommended thorough debridement for better healing of the diaphragmatic defect and BBF, including removal of the liver and lung abscesses, tension-free repair of the diaphragmatic defect, and drainage of both the pleural and abdominal cavities. Given the patient’s poor condition, extensive surgery may not be tolerated. An alternative approach, which isolated the liver abscess from the diaphragmatic defect, potentially promoted healing of the diaphragmatic defect and BBF, thereby avoiding the need for extensive surgical resection. However, the efficacy of this treatment requires further evaluation. After written surgery informed consent was obtained, we closed the diaphragmatic fistula using continuous 2-0 V-Loc sutures without applying any mesh. The liver abscess cavity was closed, and a 28-Fr latex drain was placed within the hepatic abscess cavity for redirect drainage. Moreover, to achieve complete isolation of the liver wound from the diaphragm, the falciform and round ligaments were detached from the abdominal wall, while preserving the portions attached to the liver. The ligaments were then spread to cover the liver wound and sutured along the edges for secure fixation (Figure 2). Finally, another 28-Fr latex drain was placed in the right subdiaphragmatic space to drain exudate and necrotic material. The necrotic liver tissue and pus were sent for pathological examination and culture.

Postoperatively, the liver wound drainage consistently ranged from 10 to 20 mL/day, with a bile-like appearance. The subdiaphragmatic drainage initially measured 200 mL and gradually decreased to less than 10 mL, resembling ascites. Meropenem was continued as an antimicrobial treatment until the pathogen cultures identified Enterobacter cloacae and Shewanella algae. Based on the antibiotic sensitivity testing, the antibiotic regimen was adjusted to ceftazidime. The patient’s body temperature remained afebrile after surgery. A CT scan on day 8 after surgery showed reduced consolidation in the right middle lobe, decreased size of the liver abscess cavity, and a small amount of fluid accumulation beneath the diaphragm (Figure 3). Laboratory results showed improvement in the patient’s condition, with ESR reduced to 28 mm/h and CRP to 15.10 mg/L. Consequently, the subdiaphragmatic drainage tube was removed on postoperative day 9. The patient was discharged on day 10 with a liver-wound drainage tube still in place.

Figure 3 CT transverse plane images 8 days post-operation demonstrate reduced consolidation in the right middle lobe, decreased size of the liver abscess cavity, and a small amount of fluid accumulation beneath the diaphragm. CT, computed tomography.

After discharge, the patient’s anti-infection regimen was adjusted to oral cefuroxime, which was gradually reduced and discontinued over 4 weeks. The patient still reported no fever, the symptoms of phlegm cough gradually resolved, the daily drainage volume from the liver wound remained below 10 mL, and no bile-like fluid was observed. One month after discharge, a CT scan indicated a small amount of fluid around the liver wound drainage tube and disappearance of both the liver and lung abscesses (Figure 4). On day 42 after surgery, the wound drainage tube was removed, and the patient experienced no further fever or abdominal pain. In addition, the postoperative paraffin pathology report revealed no viable adenocarcinoma in the excised liver abscess mass. Three months later, follow-up MRI showed that the previously observed mixed-signal lesion at the junction of S4/8 of the liver had disappeared, leaving only localized liver tissue defects and residual mixed signals (Figure 5). Clinical follow-up was continued for 5 months, with no reported symptoms. All procedures in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Verbal informed consent was obtained from the patient for publication of the case details and accompanying images. All identifying information has been removed to ensure confidentiality.

Figure 4 CT transverse plane images obtained 35 days post-operation show resolution of subcapsular fluid accumulation adjacent to the liver, and absence of previously noted gas accumulation. The subphrenic drainage tube was removed. CT, computed tomography.

Figure 5 Enhanced MRI coronal plane images obtained three months post-operation showed the disappearance of the mixed-signal lesion at the junction of segments IV and VIII (S4/8) of the liver, with only localized liver tissue defects and residual mixed signals remaining. MRI, magnetic resonance imaging.

Discussion

RFA is a common cause of BBF, with a possible mechanism involving thermal damage to the bile ducts and diaphragm. This can lead to cholestasis, infection, and liver abscess formation, which may erode through the diaphragm into the thoracic cavity, damaging the bronchi and resulting in BBF (10). Ablation of larger tumors located on the diaphragmatic surface of the liver is particularly prone to BBF formation (11). In this case, the ablated tumor was located on the liver surface at the junction of S4/8, with a size of approximately 8 cm × 5 cm and close to the diagram. After two RFA treatments, liver abscess and BBF developed at this site. Therefore, for large hepatic tumors near the diaphragmatic dome, extensive thermal ablation should be performed with caution to prevent injury to the diaphragm and bile ducts, which may lead to a BBF. In addition, artificial ascites may help reduce thermal injury during ablation (12).

The diagnosis of BBF primarily relies on clinical symptoms and imaging studies. The main clinical manifestations of BBF include recurrent biliptysis, sometimes accompanied by fever, jaundice, abdominal pain, and chest pain (13). Imaging studies such as hepatobiliary iminodiacetic acid (HIDA) scan, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP), CT scan, or magnetic resonance cholangiopancreatography (MRCP) can further confirm the diagnosis by revealing a connection between the bile ducts and respiratory tract (14). However, in most cases, the fistulous tract is not readily visible on imaging. Diagnosis typically relies on a combination of clinical symptoms and indirect imaging findings such as pleural effusion, atelectasis, liver abscess, and intrahepatic bile duct dilation. A retrospective single-center case series reviewed 11 cases of BBF following liver tumor ablation and found that all patients presented with cough and bile-stained sputum, with four cases also experiencing fever. CT/MRI revealed varying degrees of pleural effusion; however, a clear fistula tract between the pleural effusion and bile duct lesions was identified on MRI in only two patients (15). In our case, the patient exhibited persistent biliptysis and fever. Although CT/MRI did not reveal a distinct fistula tract, the presence of both liver and lung abscesses strongly suggested BBF. Furthermore, the intraoperative findings of a diaphragmatic defect and its close relationship with the right lung provided further confirmation of the BBF diagnosis.

Management of BBF typically involves either nonsurgical or surgical intervention. Based on the limited literature, the general treatment principles for BBF focuses on relieving bile duct obstruction and eliminating local abscesses and fistulas (11,16). Reported non-surgical options include PCD, ERCP drainage, and novel histoacryl embolization techniques (12,17-21), while surgical approaches range from abscess drainage alone to extensive thoracoabdominal procedures involving lobectomy, partial hepatectomy, and fistula repair (5). Nonsurgical treatment is less invasive and is generally the first choice for managing BBF. However, these minimally invasive interventions typically require prolonged drainage accompanied by antibiotic therapy and often necessitate multiple radiological procedures (14,22). Surgery is considered the definitive curative treatment for BBF, especially in patients who either do not respond to nonsurgical methods or are unsuitable for them. In this case, the patient showed no bilirubin elevation or bile duct dilation, indicating no biliary obstruction and rendering bile duct drainage unnecessary. The primary issue contributing to BBF was a liver abscess, and due to inadequate drainage and progression of symptoms with abscess cavity expansion, surgical intervention was deemed necessary.

The conventional operative plan for this case should include abdominal and thoracic approaches for the removal and drainage of the liver abscess, resection of the infected lobe of the right lung, and repair of the diaphragmatic fistula. Although these methods may be effective, they can be associated with major complications such as bleeding, bile leaks, pneumothorax, respiratory failure, and prolonged recovery times (23). Due to the patient’s compromised health status, extensive surgery was difficult for him to tolerate. Therefore, to avoid extensive resection, minimize surgical trauma, and promote postoperative recovery, we propose an innovative surgical approach that involves altering the drainage direction of the hepatic abscess and using falciform and round ligaments as flaps to isolate the hepatic abscess from the repaired diaphragmatic defect.

Given the risk of exacerbating the infection with a biological patch and the inadequate thickness and excessive distance of the greater omentum, we opted for the falciform and round ligaments as flaps. These flaps were chosen because of their proximity to the liver wound and potential to retain some blood supply, which can aid in healing and prevent infection (24,25). Furthermore, the central part of the flap is broad and thick enough to bridge large gaps or wounds, and its pliability facilitates easy placement and fixation (26). A systematic review reported over 200 retrospective studies or cases utilizing falciform and round ligaments in abdominal surgeries, including diaphragmatic hernias, biliary reconstructions, liver transplantation, cardiopexy, peptic perforations, venous reconstructions, and postoperative pancreatic fistula or hemorrhage (24). In addition, in previously reported cases of hepatobiliary surgery, falciform and round ligaments have been used to obliterate hydatid cysts or simple hepatic cysts following laparoscopic or open cyst deroofing (27,28).

The limitations and risks of this surgical strategy lie in the fact that suturing the liver abscess wound contradicts the principle of keeping the wound open for full drainage of the liver abscess (29). Additionally, the use of hepatic ligaments to reinforce fistula closure deviates from the established principle of complete resection of the fistula tract (30), which may result in the risk of abscess and fistula healing, potentially worsening post-surgery. Therefore, placing a drainage tube inside the wound for full drainage of exudate and necrosis is crucial. Fortunately, the patient recovered smoothly following surgery. All drainage tubes were eventually removed 42 days after surgery, the liver and lung abscesses and BBF resolved, and no severe complications occurred throughout the process.

Conclusions

In conclusion, managing BBF continues to pose significant challenges, and treatment decisions should be made with careful consideration, in which case we propose a method that utilizes the falciform ligament and round ligament to isolate the liver abscess from the repaired diaphragmatic defect, thereby promoting healing of the BBF. This method not only minimizes the trauma of surgery, but also accelerates the recovery time of patients, making it an innovative surgical approach for BBF treatment.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-959/rc

Peer Review File: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-959/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-959/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Verbal informed consent was obtained from the patient for publication of the case details and accompanying images. All identifying information has been removed to ensure confidentiality.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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