Endoscopic management of intrabiliary-ruptured hepatic hydatid cyst

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.

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.

Cystic echinococcosis of the liver: A primer for hepatologists

Cystic echinococcosis (CE) is a complex, chronic and neglected disease with a worldwide distribution. The liver is the most frequent location of parasitic cysts. In humans, its clinical spectrum ranges from asymptomatic infection to severe, potentially fatal disease. Four approaches exist in the clinical management of CE: surgery, percutaneous techniques and drug treatment for active cysts, and the ”watch and wait” approach for inactive cysts. Allocation of patients to these treatments should be based on cyst stage, size and location, available clinical expertise, and comorbidities. However, clinical decision algorithms, efficacy, relapse rates, and costs have never been properly evaluated. This paper reviews recent advances in classification and diagnosis and the currently available evidence for clinical decision-making in cystic echinococcosis of the liver.

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.

Long-term results utilizing the unroofing technique in treating hydatid cysts of the liver

PURPOSE

The aim of this study was to present the long-term follow-up results of liver hydatid cysts treated with unroofing, together with a review of the related literature data.

METHODS

Of 700 liver hydatid cyst patients examined and treated at Selcuk University Meram Medical Faculty, General Surgery Department, between 1985 and 2007, 650 had accessible data and the unroofing method had been applied in 189 of them. The clinical and laboratory findings, stages, operations, and complications of patients treated with unroofing were reviewed. In particular, the resolution of residual cyst cavities over time after the application of this method was evaluated using computed tomography.

RESULTS

Four hundred and thirty-six (67.07%) of the cases were female [mean age: 35 (range: 10-73) years] and 214 (32.9%) were male [mean age: 46 (range: 12-76) years]. Of the 189 cases treated with unroofing and followed by tomography, the data of 144 were documented. Cavities were classified into five groups (A-E) according to their postoperative appearance.

CONCLUSIONS

Unroofing is an easy approach and it does not require extensive experience. This technique is recommended for peripherally localized cysts but may also be applied to those more deeply situated. Unroofing should be applied as deeply as possible and the residual cavity should also be as shallow as possible.

Intrabiliary rupture of hydatid cysts of the liver

BACKGROUND

Intrabiliary rupture is a common and serious complication of hepatic hydatidosis, and its treatment remains controversial.

METHODS

Sixty-seven patients who underwent surgery for rupture of a hydatid cyst in the biliary tree were studied retrospectively. The following data were analyzed: age, sex, clinical presentation, and so on.

RESULTS

In 55 patients, intrabiliary rupture was diagnosed preoperatively and in 12 patients intraoperatively. In 51 patients, partial pericystectomy and closed-tube drainage followed. Pericystorraphy was performed in 9 patients. Omentoplasty was performed in 5 cases. After the meticulous cleansing of the common bile duct, T-tube drainage (60 patients), choledochoduodenostomy (4 patients), or sphincteroplasty (1 patient) was added. In 4 patients, there was a persisting external biliary fistula. The mean length of hospital stay was 18 days. Follow up (1-35 years) elicited 4 recurrences and 1 postoperative death.

CONCLUSIONS

Our results in intrabiliary rupture of echinococcal cysts are considered to be satisfactory. Surgical treatment can be improved with the modern methods of investigation, wider use of newer chemotherapeutics, and appropriate modification of surgical procedures.