Resolution of hydatid liver cyst by spontaneous rupture into the biliary tract

Intra-biliary hydatid cyst rupture: A rare case report with superinfection

Key Clinical Message

Hydatid cysts, primarily found in the liver (70%), are caused by parasitic infections and can lead to severe complications such as cyst rupture. This case report describes a unique instance of a hydatid liver cyst occupying the right lobe with a communicating part with the biliary tree that ruptured showing a concurrent superinfection.

Abstract

Hydatid cysts are a clinical pathology resulting from parasitic infections. They may occur in different organs of the body. However, these are mostly found in the liver (70%). This can cause significant complications including cyst rupture. Several case reports have described various hydatid cyst ruptures; however, only a few have reported an intra-biliary hydatid cyst rupture. A 24-year-old male patient presented with right upper quadrant pain, jaundice, dark urine, and pale stool. Imaging studies, including Magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT), revealed a beavertail liver, cystobiliary communication and intrahepatic biliary tree-ruptured hydatid cysts. The cyst was in the right liver lobe, which is the most common site for hydatid cysts. Surgical intervention involving laparoscopic de-roofing and cyst removal resulted in a smooth recovery without complications. Several case reports have described various hydatid cyst ruptures; however, only a few have reported originally placed intra-biliary hydatid cyst ruptures. This case report describes a unique instance of a hydatid liver cyst occupying the right lobe with a communicating part with the biliary tree that ruptured showing a concurrent superinfection.

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.

ERCP management of acute cholangitis caused by rupture of Echinococcus hepaticus into the biliary tract

Background

Hepatic cystic echinococcosis (HCE) rupture into the biliary tract, one of the most common and refractory complications, is treated by laparotomy to remove hydatid lesions. The aim of this article was to investigate the role of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of this particular disease.

Patients and Methods

This was is a retrospective analysis of 40 patients with HCE ruptured into the biliary tract in our hospital from September 2014 to October 2019. They were divided into two groups, ERCP group (group A, n = 14) and conventional surgery group (group B, n = 26). Group A was treated with ERCP first to control infection and improve the general condition before undergoing laparotomy at an optional stage while group B was treated with laparotomy directly. First, the infection parameters and liver, kidney and coagulation functions of group A patients before and after ERCP were compared to evaluate treatment effectiveness. Second, the intraoperative and post-operative parameters during the laparotomy of group A were compared with group B to evaluate the impact of ERCP treatment on laparotomy.

Results and Conclusions

White blood cell, NE%, platelet, procalcitonin, C-reactive protein, interleukin-6, Total bilirubin (TBIL), alkaline phosphatase, gamma-glutamyl transpeptidase, aspartate transaminase, alanine transaminase (ALT), ALT and Cr in group A significantly improved by ERCP (P < 0.05); during laparotomy, the bleeding amount and hospital stay in group A were better (P < 0.05); moreover, concerning the post-operative complications, the incidence of acute renal failure and coagulation dysfunction in group A was significantly less (P < 0.05). ERCP, which not only quickly and effectively controls infection and improves the patient's systemic condition but also provides good support for subsequent radical surgery, enjoys good prospects for clinical application.

Central nervous system hydatidosis around the world: a systematic review

INTRODUCTION

Echinococcosis is a chronic disease caused by Echinococcus species. The central nervous system (CNS) hydatidosis is still a major concern, especially in endemic countries, due to non-specific features and late diagnosis and treatment. This study aimed to provide a systematic review to elucidate the epidemiology and clinical characteristics of CNS hydatidosis worldwide over the past decades.

EVIDENCE ACQUISITION

PubMed, Scopus, EMBASE, Web of Science, Ovid, and Google Scholar were systematically searched. The gray literature and the references of included studies were searched as well.

EVIDENCE SYNTHESIS

Our results showed that the CNS hydatid cyst was more prevalent in the male gender, and it is known as a recurrent disease with a rate of 26.5%. CNS hydatidosis was more common in the supratentorial region and was also significantly common in developing countries, including Türkiye and Iran.

CONCLUSIONS

It was demonstrated that the disease would be more prevalent in developing countries. Also, there would be a trend toward a male predominance of CNS hydatid cyst, younger age involvement, and the recurrence rate of 25% in general. There is no consensus about chemotherapy unless in recurrent disease and the patients who experienced cyst rupture intraoperatively, recommended for a wide range of 3 to 12 months.

Management of Incidental Rupture of Abdominal Hydatid Cyst

Abdominal hydatid cyst rupture is one of the critical situations which challenged the surgeon incidentally during explorative lobotomy for acute abdominal conditions. It is considered an endemic area for hydatid disease. To study and evaluate different modalities of surgical treatments used to deal with the incidental rupture of abdominal hydatid cyst. Patient and methodology: Patients (n=200) underwent surgical treatment for abdominal hydatid cysts in Al -Kindy teaching Hospital and Diala private hospital. A review was carried out from January 1996 to January 2006. About 18 patients (6%) had a rupture of abdominal hydatid cyst; in 15 patients (83.3%), the rupture was discovered incidentally during surgery for urgent acute abdomen, and 3 patients (16.7%) were detected clinically and using ultrasound. The median age was 32 years, and the female to male ratio was 2:1. 17 patients presented with signs & symptoms of acute abdomen. 11 patients presented with hypovolaemic shock after trauma to the liver (RTA in 9 patients, anaphylactic shock in 1 patient, allergic reaction in 1 patient). 4 patients presented with spontaneous rupture, 2 presented with secondary hydatidosis, and 1 presented with haematuria. Results: Twelve females and six males were affected. Rupture of abdominal hydatid cyst was diagnosed in only three patients by history, clinical examination, and ultrasound. At the same time, the other 15 patients were diagnosed during surgery. The mean hospital stay was 14 days. About 5 patients developed post-operative complications, i.e., wound infection (n=1), stress ulceration in the duodenum (n=1), subphrenic abscess (n=1), an infected remnant of hepatic hydatid cyst cavity (n=1), and recurrence of the hydatid cyst (n=1). Unfortunately, intra-operative mortality was recorded in 1 patient. The clinical diagnosis is usually tricky, but ultrasonography is an excellent initial diagnosis in suspected cases. Keywords: Surgical treatment, Incidental Ruptured Abdominal hydatid cyst, Traumatic rupture.

Bile leakage test in emergency hydatid liver cyst surgery

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It is not always possible to reveal the existing occult CBC during the operation.

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Bile leakage test has been shown to reduce postoperative biliary complications.

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Bile leakage test has been performed by cannulated the common bile duct via 22G catheter.

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Normal saline and parenteral lipid solution has been given to demonstrate the CBCs.

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This test can be applied even in emergency conditions.

Introduction and importance

In liver cyst hydatid surgery, presence of cysto-biliary communication (CBC) is important for the prevention of postoperative morbidity. If cysto-biliary connections are not obvious, diagnosis is not easy. Intraoperative bile leakage test has been shown to reduce postoperative biliary complications by revealing occult CBCs. However, bile leakage testing in emergency conditions such as hydatid cyst perforation has not been experienced so far.

Case presentation

Here, a bile leakage test performed in a 23-year-old male patient undergoing emergency surgery due to the perforation of the hydatid liver cyst was presented. Following the treatment of perforated hydatid liver cyst and biliary peritonitis, a bile leakage test was performed. The common bile duct was cannulated with a 22G catheter, normal saline and parenteral lipid solution were given to demonstrate the CBCs, and leakage areas were suture ligated. The patient was discharged postoperatively without any problem.

Conclusion

We recommend detection and treatment of the CBCs even in emergency hydatid liver cyst surgery for prevention of postoperative biliary complications.

Risk factors and biomarkers of non-alcoholic fatty liver disease: an observational cross-sectional population survey

OBJECTIVE

Non-alcoholic fatty liver disease (NAFLD) is a major public health burden in China, and its prevalence is increasing. This study aimed to determine the risk factors and biomarkers of NAFLD.

DESIGN

An observational cross-sectional primary survey.

SETTING

Central China.

PARTICIPANTS

The study included 1479 participants aged over 18 and below 80 years, not currently being treated for cancer or infectious disease or no surgery in the previous year, and no history of cancer or an infectious disease. Participants underwent clinical examination, metabolomic assay and anthropometric assessment. Univariate and logistic regression analyses were used to evaluate associations between covariates and NAFLD.

MAIN OUTCOME MEASURES

Risk factors and metabolic biomarkers including sex, body mass index, hypertension, body fat ratio, blood triglycerides, blood fasting glucose, liver enzyme elevation, uric acid and oleic acid-hydroxy oleic acid (OAHOA).

RESULTS

Data from the 447 participants (mean age 44.3±11.9 years) were analysed, and the prevalence of NAFLD was 24.7%. Male sex (OR 3.484, 95% CI 2.028 to 5.988), body mass index ≥24 kg/m² (OR 8.494, 95% CI 5.581 to 12.928), body fat ratio (≥25 for women, ≥20 for men) (OR 1.833, 95% CI 1.286 to 2.756), triglycerides ≥1.7 mmol/L (OR 1.340, 95% CI 1.006 to 1.785), fasting glucose ≥6.1 mmol/L (OR 3.324, 95% CI 1.888 to 5.850), blood pressure ≥140/90 mm Hg or antihypertensive drug treatment (OR 1.451, 95% CI 1.069 to 1.970), uric acid (≥357 μmol/L for women, ≥416 μmol/L for men) (OR 2.755, 95% CI 2.009 to 3.778) and OAHOA (<5 nmol/L) (OR 1.340, 95% CI 1.006 to 1.785) were independent predictors of NAFLD (all P<0.05). These results were verified by all 1479 participants.

CONCLUSIONS

NAFLD was common among the study participants. In particular, NAFLD was correlated with uric acid. We identified OAHOA as a novel marker of NAFLD prevalence. It provides a reference on the prevention of NAFLD and related metabolic diseases with the rapid urbanisation, technological advancement and population ageing in China over the recent decades.

The Role of Prophylactic Endoscopic Sphincterotomy for Prevention of Postoperative Bile Leak in Hydatid Liver Disease: A Randomized Controlled Study

BACKGROUND

Bile leak is the main cause of morbidity and mortality after surgery for hydatid liver cysts. Aim was to assess the role of prophylactic endoscopic sphincterotomy (ES) in reducing postoperative bile leak in patients undergoing partial cystectomy.

METHODS

Fifty-four patients with hepatic hydatid cyst met inclusion criteria, 27 were excluded or declined to participate. Twenty-six women and 28 men (mean age 44.6 ± 10.1, range: 22-61 years) were randomly assigned to either group I with ES (n = 27) or group II without ES (n = 27).

RESULTS

Demographics and clinical, laboratory, and radiological characteristics of cysts were not statistically different between two groups. Group I had a significant decrease in bile leak rate compared with group II (11.1% versus 40.7%, P = .013), with significantly shorter duration of hospital stay (P < .0001). Biliary fistula in group I had significantly lower daily output (100 mL/day versus 350 mL/day) with gradual reduction till stoppage of leak in 3-4 days without intervention. Biliary fistula in group II had a significantly higher need for biliary intervention through postoperative endoscopic retrograde cholangiopancreatography with ES compared with biliary fistula in group I (^FEP = .002), with significantly longer mean time of fistula closure (P = .011) and longer time to drain removal (P < .0001). Nonbiliary complications were comparable between two groups.

CONCLUSION

Prophylactic ES provides significant reduction in postoperative bile leak rate with shorter hospital stay after partial cystectomy of hydatid cyst. Biliary fistula in patients with ES has significantly lower daily output with shorter time of drain removal and shorter time to closure than patients without ES.

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.

Assessment of the effect of Allium sativum on serum nitric oxide level and hepatic histopathology in experimental cystic echinococcosis in mice

The current study was carried out to evaluate the prophylactic and therapeutic effects of Allium sativum on experimental cystic echinococcosis by measuring the serum nitric oxide level and studying hepatic histopathological changes. The experimental animals were divided into five groups, ten mice in each, group (I): prophylactic; group (II): therapeutic; group (III): prophylactic and therapeutic; group (IV): infected nontreated; group (V): non infected non treated. The results showed that serum nitric oxide was significantly increased as a result of infection in all infected groups compared to group V. Statistical significant difference was noted in serum nitrate level in group I at 1st and 8th week post infection compared to the same time interval in group IV. In group II, statistical significance was noticed only at the 1st week post infection. Statistical significant difference was noted in serum nitrate level in group III at 1st, 4th, 6th and 8th week post infection compared to same time interval in group IV. Hydatid cysts developed in livers of mice of group IV as early as 4 weeks of infection while no cysts were found in groups I,II and III. Histopathologically there were moderate pathological changes in group I and group II as hepatocytes showed moderate steatosis, moderate venous congestion and inflammatory cellular infiltrate with foci of degeneration and necrosis. While livers of mice of group III showed mild steatosis, mild venous congestion, mild inflammatory cellular infiltrate, no necrosis and no biliary hyperplasia. Accordingly, that garlic (Allium sativum) may be a promising phototherapeutic agent for cystic echinococcosis.

A new and simple score for predicting cystobiliary fistula in patients with hepatic hydatid cysts

BACKGROUND

Hepatic hydatid cysts are common disorders in Turkey. Although most patients are treated by percutaneous drainage, some cases require operative intervention. Biliary fistula is a major complication of hydatid cyst operations. The purpose of this study is to identify preoperative predictors of cystobiliary fistula (CBF) and to develop a scoring system for this disorder.

METHODS

Overall, 135 patients with hepatic hydatid cysts were included in this study. The following variables were analyzed as potential predictors of CBF: Age, gender, findings on physical examination, complete blood cell count, liver function tests, and ultrasonographic features of the cysts (type, diameter, number, and localization).

RESULTS

CBF was detected in 33 of 135 patients. Univariate analyses showed significant differences in cyst diameter, levels of alkaline phosphatase (ALP) and direct bilirubin, platelet count, and white blood cell (WBC) count between patients with and without CBF. On multivariate analyses, WBC count > 9,000/mm(3) (odds ratio [OR], 4.5), direct bilirubin level > 0.7 mg/dL (OR, 2.76), cyst diameter > 8.2 cm (OR, 5.48), and ALP level > 120 U/L (OR, 3.82) were significant and independent predictors of CBG. One point was given for the presence of each of these factors to develop a new score. The resulting area under the receiver operator characteristic curve was 0.803 (95% confidence interval, 0.726-0.866).

CONCLUSION

Preoperative detection and management of CBF are important issues in the treatment of hydatid cysts of the liver. Developing a scoring system based on routinely measured laboratory and radiologic factors will help the clinician to manage patients with hepatic hydatid cysts. External studies are needed to validate this new scoring system in routine clinical practice.

Complications of Hydatid Cysts of the Liver: Spiral Computed Tomography Findings

Background

The purpose of this retrospective study is to evaluate the role of Spiral Computed Tomography (CT) in the detection of the complications of hepatic hydatid cysts.

Methods

During a period of 8 years and after establishing the diagnosis of numerous hydatid cysts, 7 patients with complications of hydatid cysts were found. These 7 patients (5 females, 2 males, mean age 74.2 years, range 63 - 92 years) were studied. Four of them had a known medical history of hydatid disease, while all of them presented to our department as emergency cases.

Results

They underwent Spiral CT which revealed the following complications of hydatid cysts: intrabiliary rupture in 2 patients, rupture into the peritoneal cavity resulting to peritonitis in 1 patient, contained rupture and secondary transdiaphragmatic thoracic rupture in 1 patient, rupture into both biliary tract and hepatic subcapsular space in 1 patient, rupture into the subcapsular hepatic space in 1 patient and secondary bacterial infection of the cyst resulting to abscess formation in 1 patient. All of these CT findings were surgically confirmed.

Conclusions

CT provided a rapid and accurate diagnosis in all of these cases and proved to be a very useful preoperative imaging method.

Can occult cystobiliary fistulas in hepatic hydatid disease be predicted before surgery?

BACKGROUND

Biliary fistulas because of the cystobiliary communication is the most frequent and undesirable postoperative complication of hepatic hydatid surgery. We aimed to identify the predicting factors of the occult cystobiliary communication in this study.

METHODS

The patients who underwent surgical treatment for hepatic hydatid disease between 2003 and 2008 were reviewed retrospectively. The patients who had jaundice history, preoperative high total bilirubin and direct bilirubin levels, dilated bile duct in preoperative radiologic imagings were not included the study. Patients were divided into two groups: group A; without postoperative biliary fistula, group B; with biliary fistula. The two groups were compared according to preoperative descriptive findings, cystic specialties, and laboratory findings.

RESULTS

There were 53 patients and 15 patients in groupA and groupB, respectively. The 20 (37.7%) of 53 patients were male in group A and the 10 (66.7%) patients were male in group B (p<0.05). The age, number of cysts, Garbi scores of cysts, the rate of recurrent cysts, the level of preoperative bilirubin, alkalene phosphatase, and transaminases were similar in both groups (p>0.05). GGT was significantly different between two groups (p<0.05). The cystotomy + drainage, cystotomy + omentopexy, and intracystic biliary suture rates were similar in both groups. Postoperative non biliary complications were determined in 4 (7.5%) patients in group A and 7 patients (46.7%) in group B (p<0.05). Hospital stay was longer in group B significantly (p<0.05).

CONCLUSIONS

In conclusion, GGT as a laboratory [corrected] test for predicting occult CBC preoperatively have been shown to be useful in the clinical practice. However, larger prospective studies are needed on this subject. Occult cysto-biliary fistulas can only be exposed during surgery when suspected by a surgeon. If occult CBC is found, the opening in the biliary system should be sutured with absorbable material, with or without cystic duct drainage. If no biliary opening is found, cystic duct drainage may be performed if preoperative factors predict the presence of CBC. As the development of external biliary fistulas increases the morbidity and the hospitalization period, novel surgical methods to prevent the development of bile fistulas are required in such patients.

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.

Asymptomatic occult cysto-biliary communication without bile into cavity of the liver hydatid cyst: a pitfall in conservative surgery

BACKGROUND

An occult cysto-biliary communication in liver hydatid disease is still a major problem in surgical practice. Radiologic and intraoperative findings may not be helpful to detect cysto-biliary communications in some asymptomatic patients with liver hydatid disease. Biliary leakage is a troubling complication that arises after conservative surgery in patients who have occult "insidious" cysto-biliary communications. We aimed to identify the factors which are associated with the risk of occult insidious cysto-biliary communications in patients preoperatively who developed biliary leakage after surgery.

PATIENTS AND METHODS

We investigated the records of 183 asymptomatic patients treated for liver hydatid cyst and analyzed potential predictors of occult insidious cysto-biliary communication, retrospectively.

RESULTS

There were 115 female and 68 male patients; the mean age was 42.3 years. Occult insidious cysto-biliary communications which presented as postoperative biliary leakage found in 24 (13.1%). Independent clinical predictors were alkaline phosphatase >133 U/L, total bilirubin levels >1.2 mg/dL, white blood cell count >10,000/mm(3) and cyst diameter >10 cm on multivariate analysis. Seventeen of 24 were low output biliary fistula which resolved spontaneously within 9.2 days. The remaining 7 were high output biliary fistula for which endoscopic sphincterotomy was performed in all patients, fistulas resolved within 22.6 days. Average interval between endoscopic sphincterotomy and fistula closure was 10.3 days. Mean hospital stay was longer in patients with biliary leakage than in those without (9.8 vs. 4.2 day p<0.001). There was no hospital mortality.

CONCLUSION

The predictors demonstrated in this study should allow the likelihood of occult insidious cysto-biliary communication to be determined and, thus, indicate the need for additional procedures during operations to prevent the complications of biliary leakage.

Clinical and sonographic management of viable hydatid liver cysts

AIM

The aim of this study was to review our 18-year experience in the treatment of viable hydatid liver cysts (HLCs) with double percutaneous aspiration and ethanol injection (D-PAI) and to provide indications for the clinical management of HLCs.

MATERIALS AND METHODS

From January 1989 to December 2007, 127 patients (100 males; 13-80 years) with 184 viable HLCs (137 univesicular, 47 multivesicular; 2.8-20 cm) underwent D-PAI.

RESULTS

Ultrasonography (US) showed complete disappearance of 125/184 (68%) cysts; in the remaining 59 cases, an inactive solid (37 cases, 20%) or liquid pattern (22 cases, 12%) was observed with volume decreases of 50-80%. The final US pattern was unmodified during the follow-up in 96.8%. Local recurrences were observed in 5 patients (3.9%): 4 patients with 8 multivesicular cysts and 1 patient with a bilocular cyst (with a solid pattern on US) that ruptured into the biliary tree 2 years after the procedure and disappeared after endoscopic sphincterectomy. The mortality rate was 0.8%, and the overall morbidity was 8.6%. The mean hospital stay was 2.9 days. The time of healing for smaller cysts (<5 cm) was shorter than that of large cysts (≥5 cm) (P < 0.001).

CONCLUSION

Our long-term results confirm the high effectiveness of D-PAI in the treatment of HLCs. These results suggest that multilocular cysts require closer follow-up than unilocular cysts.

Sonographic management of complicated cystic echinococcosis

INTRODUCTION

In this survey we evaluated the usefulness of ultrasonography (US) in the diagnosis, and in the treatment of complicated hydatid cysts.

MATERIALS AND METHODS

From June 1985 to June 2004, 221 patients with 294 hydatid cysts were examined. Twenty patients (9.0%) presented 22 complicated cysts (7.4%): 9 with infection, 5 ruptured into the bile ducts, 2 bilomas, 2 cysto-pleural fistulas, 2 allergic reactions, 1 rupture into the peritoneum and 1 intrasplenic hematoma. In all cases, US yielded a specific or suspected diagnosis, also in complications affecting non-hepatic sites, confirmed by computed tomography (CT), endoscopic papillotomy or percutaneous US-guided sampling. All patients with complicated cystic echinococcosis were treated with Albendazole 800 mg/day for at least 3 months. In addition to this therapy, 12 underwent US-guided drainage (9 infected cysts, 2 bilomas, 2 cysto-pleural fistulas, 1 intrasplenic hematoma); of these patients 3 subsequently underwent surgery because US-guided treatment was ineffective. Five patients were treated with perendoscopic sphincterotomy for obstruction of the bile passages, while 3 patients received only medical therapy.

RESULTS

Medical, echoguided and surgical treatments led to resolution of the complications and complete remission of the parasitic pathology in 19/20 patients (95%) and in 21/22 cysts (95.4%). There was partial remission in 1 case only. The therapy did not cause major complications and the results were confirmed during follow-up lasting from 5 months to 15 years (mean time 3 years).

DISCUSSION AND CONCLUSION

This study shows that the incidence of complications of hydatid cysts is low and that correct echographic management allows a rapid diagnosis and optimization of treatment in most cases.

Satellite cysts and biliary fistulas in hydatid liver disease. A retrospective study of 17 liver resections

In Switzerland, the preferred mode of treatment for hydatid liver disease caused by Echinococcus granulosus is surgery, giving us the opportunity for a retrospective histopathologic study of 17 consecutive liver resections. We focused on the occurrence of satellite cysts and of biliary fistulas and their effects on bile ducts. Of 17 patients, 6 (35%) had one or more satellite cysts, to be distinguished from internal daughter cysts. Small areas of fibrinoid necrosis within the fibrous pericyst, a surprisingly constant histologic finding, offer a simple explanation for the occurrence of such satellite cysts as well as for the development of biliary fistulas. Large fistulas with gross drainage of cyst contents into bile ducts were present in 5 patients (30%). The accompanying cholangitis was distinctly granulomatous in 2 of them, an observation rarely mentioned in the literature. All 5 patients with large fistulas also had chronic sclerosing cholangitis and dilatation of smaller bile ducts, in all probability the result of chronic cyst fluid leakage through preexisting, clinically silent smaller fistulas. Dilatation of small bile ducts is rightly considered a precursor sign for large fistulas. Awareness of the histopathology of these complications facilitates the interpretation of ultrasound and radiologic imaging, sheds light on their pathogenesis, and may influence the choice of treatment.

Role of endoscopic intervention in biliary complications of hepatic hydatid cyst disease

OBJECTIVE

Biliary complications of hepatic hydatidosis are often difficult to detect and manage. The aim of this study was to present our experience on the effectiveness of endoscopic treatment modalities in cases of biliary complications of hepatic hydatid cysts.

MATERIAL AND METHODS

Over the past 10 years, 15 patients diagnosed with hepatic hydatidosis and manifesting symptoms and signs indicative of biliary involvement were examined by means of endoscopic retrograde cholangiopancreatography (ERCP) in our Gastroenterology Endoscopic Unit; 7 patients had already been operated on for hepatic hydatid cysts; one of them had a concomitant hydatid cyst in the lung. Diagnosis of the disease was based on a combination of ultrasonography (US), computed tomography (CT) and specific immunologic and/or microbiologic studies.

RESULTS

Biliary complications of hydatid cysts were detected by ERCP in 9 patients (60%). Eight (88.9%) patients displayed a communication between the hydatid cyst or its residual cavity and the biliary tree; 5 patients had daughter cysts or residual hydatid material within the biliary tree, 1 patient had a biliocutaneous fistula, 1 patient a postoperative biliary leakage and 1 patient had only an opacification of the hydatid cyst during ERCP. In one patient, ERCP showed stenoses of both of the main hepatic ducts due to their compression by the cyst. Jaundice (88.9%), fever (33.3%) and right upper quadrant abdominal pain (88.9%) were the most frequent manifestations. These complications were demonstrated by US and CT imaging in only 25% of the cases. Four patients underwent ERCP before surgery and 5 after surgery. Endoscopic management was successful in all patients, resulting in clearance of the biliary tree, closure of fistulas, stopping of biliary leakage and jaundice remission. No serious endoscopy-related complications were recorded, with the exception of a pulmonary hydatid cyst rupture during ERCP.

CONCLUSIONS

This study suggests that endoscopic treatment modalities are helpful and safe methods in the treatment of biliary complications of hepatic hydatidosis before and after definitive surgical management of the hydatid cysts.

Endoscopic management of a relapsing hepatic hydatid cyst with intrabiliary rupture: a case report and review of the literature

Hydatid disease, although endemic mostly in sheep-farming countries, remains a public health issue worldwide, involving mainly the liver. Intrabiliary rupture is the most frequent complication of the hepatic hydatid cyst. Endoscopy is advocated, preoperatively, to alleviate obstructive jaundice caused by intracystic materials after a frank rupture and is also a useful and well-established adjunct in locating postoperative biliary fistulas. Endoscopic retrograde cholangiography with sphincterotomy has been successful as the sole and definitive means of treatment of intrabiliary ruptured hydatid cysts. A case of an elderly woman with frank rupture is presented, where the rupture was definitively managed endoscopically in conjunction with sphincterotomy to remove the intrabiliary obstructive daughter cysts and to achieve decontamination of the biliary tree. Endoscopic retrograde cholangiography provided an excellent diagnostic and therapeutic modality in the present case and, thus, it should be considered as definitive treatment in similar cases especially if surgical risk is anticipated to be high.

The usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae

Hydatid disease is an important health problem in areas where it is endemic. There are several therapeutic modalities, the most important being surgery, antibiotherapy, and percutaneous treatment. In recent years percutaneous treatment has become popular, and for this method or surgery it is sometimes lifesaving to know the relation between the biliary ducts and the cyst cavity. The aim of this study was to examine the usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae before percutaneous or surgical treatment. A total of 72 patients diagnosed with hepatic hydatid disease via ultrasound and serologic tests were enrolled in the study. Endoscopic retrograde cholangiopancreatography was successfully performed in all patients. (99m)Tc-labeled albumin macroaggregates also were injected into cysts at a dose of 1.5-2 mCi just before the treatment. All but three patients were treated percutaneously. Scintigraphy of abdominal and thoracic areas was performed with a GE Starcam 3200 XC/T gamma camera at 30 and 120 min after Tc-labeled albumin macroaggregate injections. Endoscopic retrograde cholangiopancreatography revealed communications between biliary ducts and cyst cavities in nine patients (12.5%). However, (99m)Tc-labeled albumin macroaggregates showed not only leakage into the systemic circulation in nine patients but also into the biliary ducts in two (15.4%). In one patient, mild acute pancreatitis occurred as a complication of endoscopic retrograde cholangiopancreatography. No complications of (99m)Tc-labeled albumin macroaggregates injection were seen. Three patients were surgically treated because of clinically manifested cystobiliary fistulae. We conclude that endoscopic retrograde cholangiopancreatography is a gold standard technique for the diagnosis of communication between the biliary duct and the cyst cavity, and (99m)Tc-labeled albumin macroaggregate injection is useful for revealing leakage into the systemic circulation. The diagnosis of biliary fistulae before percutaneous treatment of hydatid disease may enable planning of the optimal therapy.

Endoscopic retrograde cholangiography for intrabiliary rupture of hydatid cyst

BACKGROUND

Hydatid disease affects most commonly the liver, and rupture into the bile ducts is a frequent complication, occurring in 5% to 25% of cases. These complications can cause major clinical problems either preoperatively or postoperatively with post-resectional abscess or prolonged biliary fistula. We reviewed our experience with preoperative endoscopic retrograde cholangiography (ERC) and the diagnosis of major cyst-biliary fistula.

METHODS

During a 7-year period, 78 patients underwent surgery for hepatic hydatid disease. Ten patients, in whom a major intrabiliary rupture of the cyst was suspected on the basis of clinical and radiological criteria, underwent preoperative ERC, with clearing of the biliary tree. Endoscopic sphincterotomy was performed in 7 cases when the fluid contained daughter cysts or pus. Three patients, in whom the biliary content was fluid only, did not undergo sphincterotomy. One patient in whom a preoperative ERC was not feasible underwent operative transduodenal sphincterotomy. In all 11 patients the cyst was resected. Two patients underwent preoperative ERC, but no fistula was detected . They were compared with the remaining group of 67 patients who underwent resectional surgery during the same period, for apparently uncomplicated echinococcal cysts, and with an historical group of 569 patients operated on from January 1966 to January 1995.

RESULTS

According to the clinical and radiological preoperative criteria, there were 2 false positives. Preoperative ERC allowed visualization of the fistula, clearing of the biliary tree, and sphincterotomy in selected cases. The incidence of postoperative fistula was significantly decreased after the introduction of selective preoperative ERC, on the basis of preoperative clinical and radiological criteria.

CONCLUSIONS

Preoperative ERC is very helpful in patients with cyst-biliary fistula, allowing visualization of the fistula and drainage of the biliary tree, and reducing the incidence of postoperative complications from 11.1% to 7.6%. In selected cases it can solve the problem, without further surgical therapy.

Occult intrabiliary rupture of hydatid cysts in the liver

The aim of this study was to investigate the effects of various surgical modalities directed at the cavity of hydatid cysts in patients with occult intrabiliary rupture. In this respect, 324 patients with hydatid cyst of the liver operated on during 1983-2003 were analyzed; among them, 39 patients with occult intrabiliary rupture were included in the study. Clinical symptomatology, physical examination, laboratory findings, results of imaging studies, the localization and size of the cyst, and operative findings were reviewed. Twelve patients had complications, and there was no mortality. The most common complication was bile fistula. The average postoperative hospital stay was 7.0 +/- 3.8 days for patients with omentoplasty and 6.0 +/- 2.5 days for those who underwent cavitary drainage. For patients who do not have bile-stained cystic fluid, the utilization of scolicidal agents is appropriate. Although the opening of the duct is sutured when it is identified, the risk of biliary fistula is not clearly correlated with this approach. In such cases, omentoplasty provides a good alternative to cavitary drainage.

Classification of hydatid liver cysts

A number of investigations advocate various classification systems for liver hydatid cysts. However, none permits predicting the treatment outcome or making clinical decisions regarding medical treatment; open surgery; punction, aspiration, injection, reaspiration (PAIR); or laparoscopy. An international hydatid disease registry employing an uniform nomenclature and consistent reporting methods would allow more rational comparison of different management strategies. TN(R)C (topography, nature, recurrent, complication) classification is a comprehensive system based on four criteria: location (T), natural history (N), recurrence (R) and complications (C) of the cyst. This pictorial review illustrates the classification and puts accent of its clinical usefulness. The TN(R)C classification provides a standardized description formula of every liver hydatid cyst, permitting multiple comparisons and analyses.

Acute pancreatitis complicating intrabiliary rupture of liver hydatid cyst

Acute pancreatitis is a rare complication of hydatidosis, and the successful use of endoscopic sphincterotomy in the treatment of pancreatitis complicating ruptured hydatid cyst has been very rarely reported.We report here a case of a 50-year-old man, known to have hydatid cyst of the liver, who presented with upper abdominal pain. Amylase and lipase were elevated and echinococcus serology was positive. Abdominal CT scan showed a cystic lesion in the right lobe of the liver and a diffusely swollen pancreas with indurations around it. At endoscopic retrograde cholangiopancreatography (ERCP) the common bile duct was dilated. A sphincterotomy was performed and a mucoid structure was extracted, after which the patient made an uneventful recovery.

Spontaneous and traumatic intra-peritoneal perforations of hepatic hydatid cysts: a case series

Little is known about the presentation, management, outcome, and recurrence of hydatid cyst perforations. We reviewed the charts of all patients admitted to our emergency service for 7 years to identify patients who were surgically treated for intra-peritoneal hydatid cyst perforations. Twelve hydatid cysts were identified in 7 patients (5 males; median age 22 yr; range 8-67). The perforations occurred spontaneously in 5 patients, and were the result of mild trauma in 2 patients. Diagnostic tools included ultrasound (US, n = 4), computed tomography (CT, n = 3), and diagnostic peritoneal lavage (DPL, n = 1). The cysts were treated with radical (n = 3) or conservative (n = 9) operative techniques. Intra-cavitary and intra-abdominal spaces were washed in 6 and 5 patients, respectively. The median follow-up time was 41 months (range 3-58). Indirect hemagglutination test was positive in 3 patients, but CT confirmed cyst recurrence in only 2 of these patients. Both had had large cysts and had undergone conservative therapy (endocystectomy and external drainage). An intra-abdominal recurrence was observed in a patient whose abdomen had not been washed during surgery. In conclusion, patients with hydatid cyst perforations in our study generally presented with severe abdominal findings. US, CT, and DPL may be helpful for the diagnosis. Recurrence may be related to operative technique, location of the cyst, and abdominal wash during the surgery.

Endoscopic therapy in the management of hepatobiliary hydatid disease

Hydatid disease constitutes a serious public health problem throughout the world, especially in endemic areas, despite the use of various kinds of preventive measures. Currently, there are three treatment options for hepatic hydatid disease including surgery, PAIR (puncture, aspiration, injection, and re-aspiration), and chemotherapy with benzimidazole compounds. Each of these therapeutic modalities has limitations depending on the individual case. The authors review the use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary hydatid disease (HHD) to clarify its place in the treatment algorithm among surgical, medical, and percutaneous measures. ERCP in the preoperative period: (1) defines the cystobiliary relationship to help in surgery planning, (2) permits evaluation for acute conditions like cholangitis and obstruction so that subsequent surgery can be performed on an elective basis, (3) may give permanent cure specifically in cases of frank intrabiliary rupture if evacuation of biliary tract and cystic cavity is manageable, and (4) when combined with preoperative endoscopic sphincterotomy may decrease the incidence of the development of postoperative external fistula. ERCP in the postoperative period: (1) can help to clarify the causes of ongoing or recurrent symptoms or laboratory abnormalities, (2) may help to resolve the obstruction or cholangitis due to residual material in biliary ducts, (3) may provide the chance to manage postoperative external biliary fistulae, and (4) may be a realistic solution for secondary biliary strictures. Considering the current literature and adding this experience, the authors propose a new treatment algorithm in HHD including medical, surgical, PAIR, and ERCP-related therapies. To illustrate the algorithm, a case is presented of a patient who had a persistent external biliary fistula in the postoperative period and was managed successfully by endoscopic approach.

Intrabiliary rupture of hydatid cyst: diagnosis with MRI and hepatobiliary isotope study

Intrabiliary rupture is the most common complication of hepatic hydatid cyst yet it is unusual, occurring in only 3-17% of cases. The diagnosis is rarely difficult on ultrasound and CT when typical radiological features are present. In rare cases of complete evacuation, when characteristic findings of hydatid cyst are absent or when there is no evidence of the previous existence of liver hydatid cyst, the diagnosis may be difficult. In difficult cases, MRI, MRCP, ERCP and (99)Tc(m)-mebrofenin hepatobiliary scintigraphy are employed. We present a rare case of surgical obstructive jaundice due to rupture of a liver hydatid cyst into the biliary tract and gall bladder, with complete evacuation of its contents leading to misdiagnosis on CT and ultrasound. MRCP and (99)Tc(m)-mebrofenin hepatobiliary scintigraphy were able to establish a firm pre-operative diagnosis.

GB virus C (GBV-C/HGV) and E2 antibodies in children preliver and postliver transplant

The association of GB virus type C (GBV-C) virus and clinical disease is uncertain. The role of GBV-C and (Envelope) E2 antibody in children with liver transplants has not been determined. This study's aim is to examine the prevalence of GBV-C in children with liver transplants, to assess the relationship of GBV-C to posttransplant hepatitis, and to determine the role of E2 antibodies. Sera from 34 children, preliver and postliver transplant, between 1989-1996 were tested for GBV-C (Ribonucleic acid) RNA by the automated Abbott LCx PCR assay. Anti-E2 antibodies were detected by an Abbott immunoassay. Recent posttransplant liver biopsies were examined for hepatitis. The results of the study determined that pretransplant, four children (12%) were GBV-C RNA positive. Posttransplant, 14 (42%) children were GBV-C RNA positive. The GBV-C RNA positive conversion rate was 33% (CI 17.2-55.7%). Patients received blood products from a mean of 68 +/- 34 donors, which correlated with GBV-C acquisition. There was no difference in the incidence (32%versus 36%; p = 0.726) or severity (grade 2.00 versus 0.68; p = 0.126) of posttransplant hepatitis in the liver biopsies of GBV-C RNA negative and/or positive children, respectively. Pretransplant, nine of 32 children were anti-E2 positive. Posttransplant, eight of 32 children were anti-E2 positive, including five children who were anti-E2 positive pretransplant. Of nine children who were anti-E2 positive and GBV-C RNA negative pretransplant, three became GBV-C RNA positive posttransplant. The results of this study conclude that the prevalence of GBV-C infection in children postliver transplantation is high and that blood product transfusions correlate with GBV-C acquisition. Also, no correlation was found between GBV-C RNA and the incidence or severity of posttransplant hepatitis. Finally, E2 antibody presence before transplantation failed to provide complete protection from GBV-C acquisition.

Long-term outcome of asymptomatic liver hydatidosis

BACKGROUND/AIMS

The aim of this study was to determine the outcome of asymptomatic liver hydatid cysts in a cohort of 33 out of 59 carriers by evaluating clinical and ultrasonographic (US) changes 10-12 years after initial diagnosis.

METHODS

We compared US features and cyst size with the original descriptions from 1984-1986. Patients were questioned about hydatid-related symptoms and signs.

RESULTS

Thirty-three of the 59 carriers could be reevaluated, five (15.2%) of whom had undergone surgery without presenting symptoms, while of 28 unoperated cases, 21 (75%) remained asymptomatic. Of the unoperated cases evaluated by US, in 8/14 (57.1%) there were no modifications in cyst size during the 10-12-year period, in five (35.7%) growth was slight (<3 cm) and in one (7.1%) the cyst grew 4 cm. Mean cyst growth in all 14 cases was 0.7 cm.

CONCLUSIONS

Despite the limited number of cases, our results show that most asymptomatic liver hydatid cases (75%) remain symptom-free for more than 10 years, regardless of cyst size or type. We believe that such carriers are at low risk of developing complications, so that it is difficult to establish specific rules for their therapy, if any. Longitudinal follow-up of larger series of asymptomatic hepatic hydatidosis cases is essential to gain a deeper insight into the natural history of such patients, and to draw up comprehensive guidelines for treatment.