Roux En Y drainage of a large hepatic hydatid cyst as treatment for recalcitrant bile leak: a case report

Saswati Behera,Ashwani Sood,Ram Samujh,Monika Bawa,Ravi P Kanojia

doi:10.1186/s43159-020-00053-9

Saswati Behera, Ashwani Sood + Show 3 more

Open Access

https://doi.org/10.1186/s43159-020-00053-9

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Abstract

BackgroundHydatid disease is relatively uncommon in children and thus rarely reported in literature. Pediatric patients with large hydatid cysts can have grave complications due to mass effect. Postoperative bile leak is the most common morbidity and continues to be a challenge for the treating surgeon.Case presentationA 7-year-old boy diagnosed with a giant hydatid cyst of the liver, almost replacing the right lobe, and underwent a laparotomy and excision of cyst with tube drainage. He developed postoperative major bile leak which did not subside even after a redo laparotomy and closure of the suspected bile leak areas. The child underwent a third laparotomy after a hepatobiliary scintigraphy (HIDA scan) which confirmed a persisting major leak. A Roux En Y cystojejunostomy was done this time which drained the bile adequately postoperatively with no evidence of bile in the subhepatic drain. Oral feeds were resumed on the fifth postoperative day. He was discharged in a satisfactory condition and is doing well in the follow-up. Repeat HIDA scan showed no evidence of spillage, with adequate bilio-enteric drainage.ConclusionPersistent major bile leak requiring ERCP with sphincterotomy can be managed successfully in children by internal drainage as Roux En Y cystojejunostomy.

Highlights

Hydatid disease is relatively uncommon in children and rarely reported in literature
Postoperative biliary fistula is the most common morbidity accounting from 13 to 30% incidence in children which poses a challenge to the treating surgeon [2]
Conservative measures like partial cystectomy with external drainage, omentoplasty, and capitonnage carry a high incidence of postoperative biliary leakage and recurrence [4], which are lesser with procedures like hepatectomy and pericystectomy at a cost of radical resection

Summary

Background

Pediatric giant hydatid cysts are rare and can have grave complications due to mass effect. Sudden decompression of giant cyst during drainage causes reversal of pressure dynamics and bile flow into the residual cavity rather than into the bilio-enteric path through ampulla of Vater [1]. Hereby, report a major postoperative bile leak in a 7-year-old child with a large liver hydatid cyst, managed successfully with a cysto-jejunostomy. Case presentation A 7-year-old boy presented with sudden onset severe pain in the right hypochondrium, associated with multiple episodes of non-bilious copious vomiting. He was referred from a primary health care center as a suspected case of hepatic malignancy. Repeat HIDA (Fig. 2c, d) scan suggested evidence of bile leak into the surgical cavity (cystojejunal cavity) with minimal drainage through the subdiaphragmatic drain. The child is doing well under regular follow-up since last 2 years

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Competing interests None