Endoscopic therapy of hepatic hydatid cyst disease in preoperative and postoperative settings

Cholangiohydatidosis. Clinical features, postoperative complications and hospital mortality. A systematic review

BACKGROUND

Cholangiohydatidosis (CH) is an evolutionary complication of hepatic cystic echinococcosis, associated with increased morbidity and mortality. The aim of this study was to describe the available evidence regarding clinical characteristics of CH, postoperative complications and hospital mortality.

METHODOLOGY/PRINCIPAL FINDINGS

Systematic review. Studies related to CH with no language or publication restriction were included. Sensitive searches were performed in Trip Database, SciELO, BIREME-BVS, WoS, PubMed, EMBASE and SCOPUS. MeSH and free terms were used, including articles up to April 2023. The main outcome variables were postoperative complications and hospital mortality; the secondary ones were publication year, origin and design of primary studies, main clinical manifestation, anatomical location and type of cysts, hospital stay, surgical procedure performed, reinterventions; and methodological quality of primary studies, which was assessed using MInCir-T and MInCir-P scales. Descriptive statistics, calculation of weighted averages and their comparison by least squares logistic regression were applied. 446 studies were retrieved from the searches performed, 102 of which met the inclusion and exclusion criteria. The studies analyzed represent 1241 patients. The highest proportion of articles was published in the last decade (39.2%). Reports are mainly from Turkey (28.4%), Greece (9.8%), Morocco and Spain (8.8% each). With a weighted mean of 14.3 days of hospital stance; it was verified that 26.2% of patients developed postoperative complications (74,3% Clavien y Dindo III y IV), 6.7% needed re-interventions, and 3.7% died. When comparing the variables age, postoperative complications, hospital mortality, and reinterventions in two periods of time (1982-2006 vs. 2007-2023), no statistically significant differences were found. When applying the MInCir-T and MInCir-P scales, the methodological quality of the primary studies was 9.6±1.1 and 14.5±4.3 points, respectively.

CONCLUSION/SIGNIFICANCE

CH is associated with severe postoperative complications and significant hospital mortality, independent of the development of therapeutic support associated with the passage of time.

Complication of Hepatic Hydatid Cyst Surgery Presenting as Obstructive Jaundice

The liver is the commonest organ affected by hydatid disease. We report a rare case of a 25-year-old female patient who was treated surgically for hepatic echinococcosis two weeks ago with laparoscopic excision of hepatic hydatid cyst with marsupialization and omentoplasty. She then presented with features of obstructive jaundice, which is a known complication following hydatid endocystectomy. Cholangiogram revealed a communication of the residual hydatid cyst with right segmental intrahepatic biliary radicals. She was treated with endoscopic retrograde cholangiopancreatography (ERCP)-guided stenting. ERCP is regarded as an important therapeutic strategy for hydatid cysts occurring in the extra biliary tree either as primary or as complications of liver cysts. It facilitates the clearing of hydatid debris from the biliary tree, and the closure of fistulas and bile leaks followed by laparoscopic cholecystectomy when the hydatid cysts are also located in the gallbladder.

[Angiocholitis on hepatic hydatid cyst fistulised in the main bile duct: two case reports]

Hydatid cyst is a zoonosis that frequently affects the liver, which is endemic in several countries such as Morocco. The hepatic hydatidosis can be complicated by angiocholitis, currently, the treatment of choice is endoscopic retrograde cholangio-pancreatography with sphincterotomy. We report two clinical cases of angiocholitis on hepatic hydatid cyst fistulised in the main bile duct which were treated endoscopically with a favourable outcome. Early diagnosis and adequate management can improve the prognosis of these patients.

Surgical treatment of liver hydatic cyst and evaluation of cystobiliary fistula: experience of two centers

Objective: Intrabiliary rupture or cystobiliary fistula is the most common complication of hepatic hydatid cyst. In this article, our objective is to evaluate the clinical, laboratory, imaging, surgical treatment and results of cystobiliary fistulas, which is the most common complication of hydatid cysts. Material and Method: In our study, patients who underwent open surgery and were followed up and treated for hydatid cyst in the gastroenterology and general surgery outpatient clinic and service between years 2015-2021 were included. The clinical, laboratory, radiological and surgical results of 171 patients with hydatid cysts were retrospectively analyzed. Results: The mean age of 171 patients who underwent surgery for hydatid cyst was 44.8 (18-71), 68 of whom were men and 103 were women. Bile leakage was present in 50 patients (50 (29.23%)). There were 24 (48%) men and 26 (52%) women with bile leakage. The cyst diameter was 74.2 (36-170) mm and the number of cysts was 1.2 (1-2). The cysts were located in the right lobe of the liver in 116 (79%) patients, in the left lobe in 30 (15%) patients, and in both lobes in 25 (6%) patients. Cystobiliary fistula developed more frequently, especially in cysts located in the right lobe(36 (72%)). Cystobiliary fistula was most common in CE3 (Gharbi type 2) type (30 (60%)). Cystectomy+drainage was performed in 137 (80%) patients in all groups. Cystectomy and drainage were the most common surgical procedures. The cyst diameter was 10 cm in the group with cystobiliary fistula and was significant compared to the group without fistula (p<0.001). Aminotransferase (AST and ALT) levels were high in patients with cystobiliary fistula (p=0.012, p=0.054). However, there was no significant difference between the two groups in alkaline phosphatase, total bilirubin, and gamma glutamyl transferase (p=0.231, p=0.097, p=0.544). Conclusion: Liver hydatid cyst is endemic in our country as well as in many other countries in the world. Complicated hepatic hydatid cysts require timely and appropriate treatment because of their life-threatening complications. Cytobiliary fistula is the most common complication. In the surgical treatment of hydatid cyst disease, the earlier the diagnosis of occult cystobiliary fistulas is made (especially in the preoperative or peroperative period), the easier the treatment is, and the risk of bile leakage and consequently the morbidity and mortality decreases. Our results and experience showed that treatment and complications are related to the location and size of the cyst, occult/large cystobiliary fistula, detectability of occult fistulas, experienced center and surgeon.

Endoscopic Management of Obstructive Jaundice in Pregnancy Due to Hepatic Hydatid Disease

Liver is one of the most common site of hydatid infection. Intra-biliary rupture of the hydatid cyst is a common and serious complication that can occur during course of pregnancy. Early diagnosis and treatment as mortality is high due to cholangitis. Surgical treatment is the definitive option, however but in the presence of cholangitis and pregnancy, ERCP with biliary drainage is the preferred management option.

Current approaches in the surgical treatment of liver hydatid disease: single center experience

Background

Liver hydatid disease is a common benign condition in many countries. Compared to open surgery, laparoscopic treatment can play an important role in improving the post-operative recovery, reducing the morbidity and recurrence rate of these patients.The purpose of this study is to show that the laparoscopic method is effective and safe in the treatment of liver hydatid cysts compared to open surgery, even in large cysts.

Methods

All consecutive cases surgically managed for liver hydatid cyst from 7 January 2008 and 15 January 2010 in our institution were included in this study.The surgical approach (laparoscopic or open) and operative strategy, as well as operative and prognostic outcomes, were analyzed. Cyst size, type, location, presence of biliary tract communication, radiological findings, duration of hospitalization, recurrence and postoperative morbidity were analysed and compared retrospectively.

Results

A total of 60 patients were included in the study.A total of 23 patients underwent open surgery, and 37 patients underwent laparoscopic surgery.Operation types of laparoscopic surgery were as follows: partial pericystectomy (12patients), total cystectomy(2 patients), partial pericystectomy+total cystectomy(7patients) and cystectomy(16patients).The surgical procedures chosen for open treatment of the residual cavity were partial pericystectomy and omentoplasty(17cases), total pericystectomy(3cases) and partial and total pericystectomy(3cases).Cysto-biliary communication was found in 9 patients. A total of 10 patients underwent preoperative endoscopic retrograde cholangiography, and one patient underwent postoperative endoscopic retrograde cholangiography.There was a progression of hypernatremia in 1 patient, wound infections in 3 patients, and perioperative hemorrhage in 3 patients. There were no statistically significant differences concerning age(p = 0.344), gender(p = 0.318), ASA classification(p = 0.963), Gharbi classification(p = 0.649) whereas there were significant differences related to cyst location(p = 0.040) and size(p = 0.022) in patients undergoing laparoscopic and open surgery.

Postoperative temporary biliary fistulas were observed in 2 patients undergoing open surgery. Patients undergoing laparoscopic surgery had the advantages of shorter hospital stays and operation times, less blood loss, faster recovery, and lower wound infection rates. Recurrences were detected in 2.7% of patients undergoing laparoscopic surgery and 4.7% of those undergoing open procedures.

Conclusion

Compared to open surgery in the treatment of liver hydatid cysts, we have shown that laparoscopic method can be safely performed even in large cysts and/or cysto-biliary communication.

A retrospective analysis of endoscopic treatment outcomes in patients with postoperative bile leakage

OBJECTIVE:

Bile leakage, while rare, can be a complication seen after cholecystectomy. It may also occur after hepatic or biliary surgical procedures. Etiology may be underlying pathology or surgical complication. Endoscopic retrograde cholangiopancreatography (ERCP) can play major role in diagnosis and treatment of bile leakage. Present study was a retrospective analysis of outcomes of ERCP procedure in patients with bile leakage.

METHODS:

Patients who underwent ERCP for bile leakage after surgery between 2008 and 2012 were included in the study. Etiology, clinical and radiological characteristics, and endoscopic treatment outcomes were recorded and analyzed.

RESULTS:

Total of 31 patients (10 male, 21 female) were included in the study. ERCP was performed for bile leakage after cholecystectomy in 20 patients, after hydatid cyst operation in 10 patients, and after hepatic resection in 1 patient. Clinical signs and symptoms of bile leakage included abdominal pain, bile drainage from percutaneous drain, peritonitis, jaundice, and bilioma. Twelve (60%) patients were treated with endoscopic sphincterotomy (ES) and nasobiliary drainage (NBD) catheter, 7 patients (35%) were treated with ES and biliary stent (BS), and 1 patient (5%) was treated with ES alone. Treatment efficiency was 100% in bile leakage cases after cholecystectomy. Ten (32%) cases of hydatid cyst surgery had subsequent cystobiliary fistula. Of these patients, 7 were treated with ES and NBD, 2 were treated with ES and BS, and 1 patient (8%) with ES alone. Treatment was successful in 90% of these cases.

CONCLUSION:

ERCP is an effective method to diagnose and treat bile leakage. Endoscopic treatment of postoperative bile leakage should be individualized based on etiological and other factors, such as accompanying fistula.

Role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease

Most cases of hepatic hydatid disease exhibit uncomplicated clinical course and management. However, the diagnosis and management of complicated hepatic hydatid disease is a special issue. One of the most common and serious complications of hepatic hydatid disease is the rupture of the cyst into intrahepatic bile ducts. The clinical appearance of intrabiliary rupture can range from asymptomatic to jaundice, cholecystitis, cholangitis, liver abscess, pancreatitis and septicemia. Current treatments for major ruptures can result in high morbidity and mortality rates. Furthermore, ruptures that cannot be diagnosed preoperatively can induce complications such as biliary fistulae, biloma, cavitary infection and obstructive jaundice. In the past, these complications were diagnosed and treated by surgical methods. Currently, complications in both the pre- and postoperative periods are diagnosed and treated by non-invasive or minimally invasive methods. In clinical practice, endoscopic retrograde cholangiopancreatography (ERCP) is indicated for patients with preoperative frank intrabiliary rupture in which hydatid elements are clearly seen in the bile ducts, or for biliary adverse events after surgery, including persistent biliary fistulae and jaundice. However, controversy concerning routine preoperative ERCP and prophylactic endoscopic sphincterotomy in patients suspected of having minor cystobiliary communications still remains. In this article, the role of ERCP in the diagnosis and management of hepatic hydatid disease during the pre- and postoperative periods is reviewed.

Cysto-biliary communication in liver hydatidosis

BACKGROUND

Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree.

AIM

The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree.

RESULTS

Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm.

CONCLUSIONS

The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

Endoscopic management of hepatic hydatid cyst with biliary communication

BACKGROUND AND AIM

A serious complication of hepatic hydatid cyst disease is communication between the cyst and the biliary tree. Surgical management of biliary fistulas is associated with high morbidity and mortality. We carried out a prospective study of endoscopic management of hydatid cysts communicating with bile ducts in 28 patients.

METHODS

Presence of biliary fistula was suspected by jaundice and/or persistent external biliary fistula after surgical excision and was confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Patients underwent endoscopic sphincterotomy, and either biliary stenting or nasobiliary drainage. Nasobiliary drains were removed when bile leakage stopped and closure of the fistula was confirmed by cholangiography; stents were removed after 4-6 weeks.

RESULTS

Of 120 patients with hepatic hydatid cyst seen over a 10-year period, 28 patients developed fistula between the hepatic hydatid cyst and intrahepatic bile ducts (right intrahepatic bile ducts in 20 patients, left intrahepatic bile ducts in eight patients). Nine of 28 patients had persistent external biliary fistula after surgery. Ten patients showed membranes in bile ducts on cholangiography. We carried out either sphincterotomy with insertion of a nasobiliary drain (n=6) or sphincterotomy with biliary stenting (n=22). In 10 patients, the membranes were removed from bile ducts during ERCP. Fistulas healed in all patients after a median time of 11 days (range 5-45 days) after endoscopic treatment. We were able to remove nasobiliary drainage catheters and stents 8-45 days after placement.

CONCLUSIONS

Endoscopic therapy is an effective mode of treatment for biliary fistulas complicating hepatic hydatid cyst.

Comparison of endoscopic therapeutic modalities for postoperative biliary fistula of liver hydatid cyst: a retrospective multicentric study

BACKGROUND

Hydatid disease most commonly affects the liver, and rupture into the bile ducts is a frequent complication occurring in 5% to 25% of patients. Biliary endoscopic procedures have become the treatment of choice for the management of biliary fistulae. Objective parameters for the endoscopic management of biliary fistulas are still necessary.

METHODS

In this multicentric retrospective study, a total of 109 patients who underwent surgery for a hydatid cyst localized to the liver and presented with persistent drainage of bile from a lodge drain after surgical intervention were included in this study. All patients were treated by an endoscopic retrograde cholangiopancreatography. Patients were divided into 3 groups according to the therapeutic endoscopic procedure: group 1 (n: 70) included patients who underwent only endoscopic sphincterotomy; group 2 (n: 22) included patients who had a 10 F biliary stent inserted; and group 3 (n: 17) included patients who had a 7 F biliary stent inserted. Recorded data were reviewed and the groups were compared.

RESULTS

The mean daily fistula output was 247 mL (range: 100 to 600 mL) in group 1, 534 mL (range: 200 to 1000 mL) in group 2, and 372 mL (range: 120 to 780 mL) in group 3, respectively. There were significant differences between the sphincterotomy group and the stenting groups (P<0.001). The closure time of the external biliary fistula was 23.7 days (range: 6 to 60 d) in group 1, 12.6 days (range: 7 to 23 d) in group 2, and 20 days (range: 6 to 33 d) in group 3, respectively. When compared with the sphincterotomy group, the fistula closure time was shorter in group 2 than in group 1 (P<0.001). There were no differences in this respect between the groups 1 and 3 (P=0.214). Group 2 also had a shorter fistula closure time than group 3 (P<0.001). There was no mortality in any of the study groups. Mild bleeding was observed in 3 cases in group 1 and in 1 in group 3. CONCULUSIONS: Endoscopic retrograde cholangiopancreatography and related therapeutic procedures are safe and valuable in the postoperative management of external biliary fistulae in the hepatic hydatid disease. In high-output fistulae (>300 mL/d), indicating a major cystobiliary communication, stent placement may be preferred. The diameter of the stent should preferably be 10 F. This 10 F stent is superior to other endoscopic approaches in the treatment of biliary fistulas.

Indications and results for transduodenal sphincteroplasty in the era of endoscopic sphincterotomy

BACKGROUND

Transduodenal sphincterotomy (TS) has fallen into disuse since endoscopists developed techniques to treat sphincter problems nonsurgically. However, some patients experience recurrent sphincter strictures after endoscopic sphincterotomy (ES), with the ampulla endoscopically inaccessible, and pancreas divisum (PD); these patients are referred to a surgeon because they are unsuitable for ES.

METHODS

The medical records of patients who underwent TS at the First Department of Surgery of the Medical School, University of Rome "La Sapienza," between January 1997 and December 2005 were reviewed. A total of 82 patients, including 47 women and 35 men with a mean age of 47 years (range, 26-67 y), underwent TS in our unit in the aforementioned period. Previous unsuccessful endoscopic retrograde cholangiography and ES were the indications for TS in 44 patients, and previous gastric surgery with duodenal bypass was the indication for TS in 21 patients. Five patients underwent TS because of a PD and 10 because of the intraoperative findings of daughter hydatid cysts in the common bile duct and of a wide communication between the cyst cavity and the intrahepatic biliary tree. Two patients were referred to our institution after a surgical papillotomy performed elsewhere. Symptoms included abdominal pain in 100% of patients, nausea and/or vomiting in 78% of patients, and referred back pain in 56% of patients. Acute pancreatitis was present in the history of 26 patients, including 23 with previous ES. All patients underwent TS. Sphincteroplasty of the accessory papilla was performed in all patients with PD. Cornerstones of a successful TS are depicted.

RESULTS

Asymptomatic hyperamylasemia was observed in 37 patients, and cholangitis and pancreatitis, which was resolved with conservative management, occurred in 2 patients. One patient developed an intra-abdominal abscess that was treated with image-guided percutaneous drainage. No perioperative deaths occurred in this series. The mean length of follow-up evaluation was 84.4 months (range, 16-115 mo). Good results were achieved in 53 patients (73.6%), fair results in 17 patients (23.6%), and poor results in 2 patients (2.7%). Both patients with poor results required reoperation because of recurrent pancreatitis and pancreatic pseudocyst.

CONCLUSIONS

TS still represents, although undoubtedly with updated indications compared with the past, a surgical procedure that must be up to date, ensuring absolutely satisfactory results.