Abstract
Conservative surgery (partial peri-cystectomy and cyst contents evacuation with cavity management by external drainage, omentoplasty or capitonnaige) for uncomplicated hydatid cysts of the liver is known to be safe but is often associated with bile leak in rate of 18.81% and its sequela. The cause of bile leak is almost always due to cysto-biliary communication, this is usually occult and difficult to be diagnosed pre-operatively, if remain undiagnosed intra-operatively it will be presented as post-operative bile leak. In this study, several laboratory and radiological predictors used to evaluate those patients having high risk of bile leak after conservative hepatic hydatid cyst surgery. Also it aimed to study the fate of bile leak, it’s complications, how to avoid it and the way of management. This study is a combined prospective (from 2004-2010) & retrospective cases study performed in basrah hospitals, Iraq; (Al-Mawani Hospital, Basrah General Hospital, Al-Sader Teaching Hospital, and some of Private Hospitals); we analyzed records of 183 cases of hepatic hydatid cyst undergoing conservative surgery, of them 15 patient had bile leak intra-operatively and 20 patients had bile leak post-operatively. Patients with intra-biliary rupture of hydatid cyst or obstructive jaundice are excluded from this study. Bile leak occur in 35 patients (18.81%) from total 183 patients of which intra-operative bile leak seen in 15 patients (43%) and 20 patients (57%) as post-operative bile leak represented as external biliary fistula. L aboratory predictors of biliary leakage were alkaline phosphatase >250 U/L, total serum bilirubin >17 umol/l, cyst diameter >8 cm, multilocular or degenerative cyst also increase risk of bile leak. Post-operative complications are more in patients with bile leak (57%) than those without bile leak (12%). Hospital stay is longer in patients with bile leak 4.9 weeks while it is 1.06 week in those without bile leak. In conclusion, bile leak is not uncommon after hepatic hydatid cyst surgery, it can be predicted by certain laboratory and radiological factors thus indicate the need for additional procedures during operation to detect the cysto-biliary communication and manage the biliary leakage and its complications.
Highlights
Liver hydatid disease is a common health problem in the middle east including Iraq, it is caused by larval stage of a tape worm, Echinococcus granulosus, and in 70-80% of cases occur in the liver[1-6].Surgery is the mainstay of treatment and it is the only curative approach, medical treatment is of limited use[1-3,6,7].The objectives of surgical approach are: inactivate scolices, prevent spillage of cyst contents, eliminate viable daughter cysts and manage the residual cavity by external drainage, omentoplasty or capitonnage[1,6]
Most Patients with bile leak occur between the age of 25-54 years; the main age groups of patients without bile leak were 24-54 years; no significance difference was found between the two groups in risk of bile leak regarding age p value >0.05
Of the 35 patients with bile leak 24 patients (70%) came from rural areas and 11 patients (30%) were came from urban region; while patients without bile leak that came from rural areas were 83 patients (56%) and those came from urban region were 65 patients (44%)
Summary
The objectives of surgical approach are: inactivate scolices, prevent spillage of cyst contents, eliminate viable daughter cysts and manage the residual cavity by external drainage, omentoplasty or capitonnage[1,6]. This surgery is safe, simple, faster, easier, less blood loss, used in very large cyst and used in management of deep cysts of liver hydatidosis, but it has variaties of complications[1,2,8,9]. The most common complication is being bile leak from a cysto-biliary communication and its sequels like prolong biliary-cutaneous fistula through the drain placed during surgery[2,7,8]. Pathophysiology of bile leak: intra-cystic pressure is 30-80mm H2O, while normal biliary pressure is 15-20 mmH2O so the flow is toward biliary system into duodenum through ampulla of Vater; the pericyst acts as a mechanical barrier, after surgery this pressure gradient will be reversed &bile leak occur if there is cysto-biliary communication[1,4]
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