Background <p>Bronchobiliary Fistula (BBF), a rare abnormal connection between the biliary tract and bronchial tree, typically arises from hepatobiliary surgery, infection, or trauma. Perioperative anesthetic management presents substantial challenges due to risks of pulmonary aspiration, cross-contamination, and respiratory compromise.</p> Case presentation <p>A 61-year-old female with a history of intrahepatic cholangiocarcinoma resection developed cough, fever, and bilious sputum. Imaging confirmed BBF with bilateral pneumonia. She underwent re-exploration and fistula repair. Anesthetic management included: left-sided Double-Lumen Tube placed under bronchoscopic guidance for lung isolation; lung-protective ventilation (low tidal volume, Positive End-Expiratory Pressure, intermittent recruitment maneuvers); anti-inflammatory therapy; goal-directed fluid management; temperature preservation; invasive hemodynamic monitoring; and multidisciplinary coordination.</p> Conclusions <p>Successful anesthetic management of BBF requires meticulous lung isolation to prevent contralateral lung contamination, individualized ventilation strategies to minimize lung injury, and comprehensive perioperative planning involving surgeons, intensivists, and anesthesiologists. This case highlights the importance of a structured, physiology-based approach in rare, high-risk clinical scenarios.</p>