Gomez-Sanchez A, Hilmi IA, Hughes CB, Park D. Bronchobiliary fistula in fibrolamellar hepatocellular carcinoma with anesthetic challenges during living donor liver transplantation: A case report. World J Transplant 2026; 16(2): 117975 [DOI: 10.5500/wjt.v16.i2.117975]
Corresponding Author of This Article
Dahye Park, MD, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, 200 Lothrop Steet, Pittsburgh, PA 15213, United States. dahye.md@gmail.com
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Anesthesiology
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case-report
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Gomez-Sanchez A, Hilmi IA, Hughes CB, Park D. Bronchobiliary fistula in fibrolamellar hepatocellular carcinoma with anesthetic challenges during living donor liver transplantation: A case report. World J Transplant 2026; 16(2): 117975 [DOI: 10.5500/wjt.v16.i2.117975]
World J Transplant. Jun 18, 2026; 16(2): 117975 Published online Jun 18, 2026. doi: 10.5500/wjt.v16.i2.117975
Bronchobiliary fistula in fibrolamellar hepatocellular carcinoma with anesthetic challenges during living donor liver transplantation: A case report
Andrea Gomez-Sanchez, Ibtesam A Hilmi, Christopher B Hughes, Dahye Park
Andrea Gomez-Sanchez, Ibtesam A Hilmi, Dahye Park, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
Christopher B Hughes, Department of Surgery, Abdominal transplantation Division, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
Author contributions: Gomez-Sanchez A, Hilmi IA, Park D conceptualized the study; Sanchez AG, Park D collected and analyzed the data, literature review, and wrote the manuscript; Hughes CB provided detailed input on the surgical procedure; All authors have read and approved the final manuscript.
AI contribution statement: This manuscript was not generated by AI. The author wrote the main body. Only ChatGPT was used to assist in condensing the introduction and conclusion sections to meet the word count requirements. The AI tool was employed for language polishing and grammar review.
Informed consent statement: Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Dahye Park, MD, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, 200 Lothrop Steet, Pittsburgh, PA 15213, United States. dahye.md@gmail.com
Received: December 22, 2025 Revised: February 3, 2026 Accepted: February 25, 2026 Published online: June 18, 2026 Processing time: 159 Days and 17.6 Hours
Abstract
BACKGROUND
Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare malignancy that may lead to complex postoperative complications, including brochobiliary fistula (BBF).
CASE SUMMARY
We report a 21-year-old patient with pulmonary metastatic FL-HCC, previously treated with multiple liver ablations, left lung wedge resections, and thoracic radiation, who subsequently developed a right-sided BBF. The patient presented for living donor liver transplantation after persistent bilioptysis and recurrent infections despite biliary drainage and prior surgical repair. Intraoperative management was challenging. A left-sided double-lumen tube was used to isolate the left lung and avoid positive-pressure ventilation of the fistulized right lung. However, one-lung ventilation resulted in hypoxia requiring return to two-lung ventilation with continuous suctioning. Surgical dissection was prolonged due to dense adhesions between the liver, right hemidiaphragm, and lung, causing major blood loss and necessitating rapid, high-volume transfusion of blood products.
CONCLUSION
This case underscores the significant airway, ventilation, and hemorrhage challenges encountered during liver transplantation in patients with persistent BBF and extensive thoracoabdominal adhesions.
Core Tip: Bronchobiliary fistula in a patient with fibrolamellar hepatocellular carcinoma creates major anesthetic challenges during liver transplantation, particularly when one-lung ventilation is not tolerated. In this case, despite successful lung isolation with a double-lumen tube, one-lung ventilation resulted in hypoxemia, likely due to impaired pulmonary physiology related to chronic liver disease, prior lung surgery, and thoracic radiation. Ventilation therefore had to be transitioned to two-lung ventilation with continuous airway suctioning to control persistent biliary contamination. The operation was further complicated by extensive thoracoabdominal adhesions and significant blood loss, requiring early vascular access planning and rapid, high-volume transfusion. This case highlights the importance of understanding altered hypoxic pulmonary vasoconstriction and ventilation-perfusion mismatch in liver disease, anticipating potential failure of one-lung ventilation, and preparing flexible airway, ventilation, and transfusion strategies to maintain oxygenation and hemodynamic stability during complex liver transplantation.
