Cystobiliary Communication Research Articles

Biliary cystadenoma: An unusual cause of recurrent cholangitis

Biliary cystic neoplasm is a rare variety of liver cyst. Cystobiliary communication is even more uncommon. Biliary complications from cystobiliary communication can mimic liver hydatid disease, particularly in endemic areas. A middle‐aged female presented with recurrent cholangitis and a cystic lesion in the liver, which ultimately turned to be a biliary cystadenoma. We report on this case for its rarity.

Pre operative predictors for cysto biliary communication in patients with hepatic hydatid disease

Pre operative predictors for cysto biliary communication in patients with hepatic hydatid disease

Effect of cyst volume and other risk factors on biliary leak following liver hydatid cyst surgery

Aim: This study aimed to determine the effect of prognostic factors indicating the presence of cystobiliary communication in the preoperative period and volume values obtained using the magnetic resonance imaging technique on the rate of biliary leak. Material and Methods: Twenty-six patients surgically treated for hydatid disease were included in the study. Age, sex, number, localization, volume and size of cysts, and liver function test results were statistically compared between the patients with and without biliary leak. Results: There were no significant differences between the groups with respect to age, gender, and number, volume and localization of cysts (p>0.05). However, a significant difference was found concerning the increase in liver function test results and cystobiliary relationship (p

Clinical profile and surgical outcome of abdominal hydatid cyst at a university hospital in Nepal

Introductions: Hydatid cyst is caused by the tapeworm. It is common in sheep and cattle rearing communities. Liver is the most common affected organ. There are various methods of surgical approaches for hydatid cyst.
 Methods: This was a retrospective descriptive study of patients operated for intra-abdominal hydatid cysts from July 2012 to June 2018 at Patan Hospital, Patan Academy of Health Sciences, Nepal. Ethical approval from institutional review committee was obtained. Patient files with incomplete data were excluded. Variables analyzed were, age, gender, site and numbers of cyst, methods of surgery, complications and mortality. Data were descriptively analyzed.
 Results: There were 19 patients of abdominal hydatid cysts who underwent surgery during the study period. Five records files could not be accessed and were excluded. In remaining 14, male were 6 (42.85%), female 8 (57.15%), mean age 39.57±17.35 years (14-70), cyst size 11±4.22 cm (5-21), complain of abdominal pain in 10 (71%). Open surgery for liver cyst was done in 11 and laparoscopic in one, and open splenectomy for two splenic cysts. One patient developed superficial wound infection. Four had cystobiliary communication of which one underwent ERCP. Post ERCP patient developed acute severe pancreatitis and expired.Mean hospital was 8.57±2.24 days (6-14).
 Conclusions: Liver was the main organ involved, abdominal pain and lump were main presenting complaints. Surgery had successful outcome. Open surgery was the mainstay of treatment.

Cysto-biliary communication (CBC) in hepatic hydatidosis: predictors, management and outcome

Background: Liver hydatidosis is a common health problem in endemic areas. Cystobiliary communication is the most common complication of liver hydatid.Methods: Cases of liver hydatid operated during the period June 2012 to July 2018 were retrospectively assessed. Patients diagnosed with cystobiliary communication (preoperatively, intraoperatively or postoperatively) were analysed. Demographics, laboratory tests were noted. Computed tomographic (CT) findings including size, location, Gharbi’s type, presence of intrahepatic biliary radical dilatation, CHD and CBD dilatation were noted. Intraoperative findings were noted. Postoperative outcomes and any intervention if done were noted. Results were analysed.Results: Around 108 patients with liver hydatid underwent surgical intervention. Of which 20 (18.5%) patients were found to have cystobiliary communication. Mean cyst size was 8cms. Location of cyst in segment IV and V commonly. 8 patients were diagnosed preoperatively by elevated bilirubin and alkaline phosphatase and on contrast enhanced computerized tomography. Out of 8, 4 patients underwent preop ERCP and stenting, followed by surgery and the other 4 underwent direct surgery with CBD exploration. 4 were diagnosed intraoperatively and the fistula site sutured. But 2 patients had postop biliary fistula which required postop ERC and stenting. Remaining 8 presented postoperatively with biliary fistula. Of 8 patients, 2 had major and 6 had minor fistulas. Postoperative mortality was 0%.Conclusions: Cystobiliary communication is more common in males with large cyst size, located in the central segments of liver close to biliary confluence, Gharbi type IV cysts. Timely diagnosis and appropriate management decrease the morbidity and mortality.

Surgical treatment of Abdominal Echinococcosis

Background: Cystic Echinococcosis is a zoonosis with worldwide geographical distribution caused by dog tapeworm. Cystic echinococcosis most frequently involves only one organ by forming a solitary cyst. Hydatid disease commonly involves the liver (75%) and lungs (15%), followed by other regions of the body (10-15%). Multi-organ abdominal HD is the most serious form and is potentially fatal.Methods: It is a retrospective study for a duration of 3 years. The recorded data of all the patients undergoing treatment has been collected and analyzed.Results: A total of 30 patients were identified. Most common organ involved was liver followed by spleen, pancreas and kidney. Cysts are more commonly seen in right lobe. All the patients underwent surgical treatment. 17 patients underwent open surgery, while 13 patients were treated by laparoscopy. Cysto biliary communication was identified in 3 patients, all in laparoscopy and a primary closure was done. All the patients were started on albendazole 400 mg twice daily per oral at least 15 days prior to surgery and this treatment was continued for 3 months post-operatively.Conclusions: Hydatid disease is endemic in sheep farming and cattle farming areas of Asia. Most patients remain asymptomatic for years. Diagnosis is by imaging techniques. Echinococcal infection usually requires multimodality treatment and the best treatment is always individualized. Surgery along with anti-helminthic treatment holds the best curative measure at present.

Laparoscopic management of hydatid cysts with biliary communication: Clips may rescue when suture fails-report of 3 cases.

Hydatid disease is a parasitic zoonosis caused by the larval form of the Echinococcus worm. Hepatic hydatidosis is the most common form of disease in humans. Centrally located, large hydatid cysts have the tendency to rupture into the adjoining bile duct and form a fistulous communication. Suture closure of the cystobiliary communication detected during surgery is recommended to avoid postoperative complications related to bile leak. In the era of minimally invasive surgery, laparoscopic management of the cystobiliary communication can be challenging, and laparoscopic suturing may not always be feasible. Postoperative endoscopic biliary decompression is necessary in such situations, but it has its own set of potential risk and complications. In this case report, we present a simple and easy technique for laparoscopic closure of the cystobiliary communication when suture ligation is technically not possible.

Management of liver hydatid cyst with cystobiliary communication and acute cholangitis: a 27-year experience.

The rupture of the hydatid cyst into the bile ducts is a common and serious complication. The rupture can be latent or revealed after a complication such as acute cholangitis. The objective of this study was to discuss the clinical features, radiographic findings, and surgical treatment of this rare complication. A retrospective analysis of patients operated for acute cholangitis caused by hydatid cyst between January 1990 and May 2016 was conducted. Our study included 55 cases of acute cholangitis caused by ruptured hydatid cyst: 35 were men and 20 were women. Five patients had medical history of hydatid cyst. On imaging, all patients had a dilated bile duct. In 51 cases, there was a single hydatid cyst. Hydatid cysts with fistula were located in the right lobe of the liver in 49 cases and in the left lobe in 6 cases. Seven patients underwent an emergency surgery after admission, while others were operated after 3-8days. A conservative procedure associated with drainage was applied in 49 cases. Endoscopic treatment was performed in four cases which failed in two cases. Twenty-eight cases developed postoperative complications, among which the most common complication was biliary fistula (n - 17). There were eight cases of postoperative deaths (14.5%). Liver hydatid cyst with cystobiliary communication and superadded acute cholangitis is a serious clinical problem requiring the early diagnosis and surgery in the absence of endoscopic therapy.

Management of cystobiliary communication in hepatic hydatidosis

Aim: Communication to the bile duct is the most common complication of hepatic echinococcosis.As non surgical treatment options have no primary role in the management of hepatic hydatidosis with cysto biliary communication, optimization of the surgical approach is imperative. Materials and methods: Medical records of 22 patients who underwent surgical management of Hydatid cyst of liver with cystobiliarycommunication analysed retrospectively.Study Period - between January 2013 and October 2016.All patients were followed up for a period of atleast 2 months to 36 months. Readmission and recurrences were evaluated Results: Cystobiliary communication could be identified pre operatively in 9 out of the 22 patients whereas in the rest it was made intraoperatively.Cyst evacuation with omentoplasty and partial pericystectomy were considered as conservative surgeries whereas total cystopericystectomy and right or left hemi hepatectomies were considered as radical procedures. 2 patients who were offered conservative surgical treatment underwent post op ERCP.CBD exploration and T tube placement was necessitated in 7 patients. Conclusion: Treatment options are multiple. While conservative approaches carried a small but significantly high incidence of recurrence, radical surgery has its own disadvantages in terms of prolonged operating time, higher blood loss and in its need for a HPB surgeon. The need for CBD exploration and T tube drainage was comparable in both approaches. Larger studies are needed to formulate a protocol.

Surgical treatment of cystobiliary communications in hepatic hydatidosis

Surgical treatment of cystobiliary communications in hepatic hydatidosis

Liver hydatid cyst with cystobiliary communication: Laparoscopic surgery remains an effective option.

Introduction:Most centres offer laparoscopic treatment for liver hydatid cyst (LHC). There have been concerns about the management of intra-peritoneal spillage, bleeding, and cystobiliary communication (CBC) during laparoscopic surgery for LHC. CBC can exist in 13%–37% of cases of LHC. No randomised studies have compared open versus laparoscopic approach for the treatment of LHC. We specifically analysed the outcomes of laparoscopic treatment of LHC with special reference to associated biliary complications.Patients and Methods:We analysed our prospectively collected data of patients undergoing laparoscopic treatment of LHC from 2009 to 2016. Patients undergoing open surgery or interventional radiology procedures were not included. Data analysed included demographic profile, investigational parameters, intra-operative findings and postoperative results with special reference to biliary complications and presence/management of CBC.Results:A total of 41 patients underwent laparoscopic treatment of LHC. History of jaundice was present in 5 (12.2%) patients. CBC was documented in 16 (39.02%) patients. In 11 patients, CBC was detected intra-operatively as visible communication, which was suture ligated or clipped. Five patients had occult CBC, detected as bile leak in the post-operative period. The leak resolved spontaneously in 7 patients and with biliary stenting in 2 patients. Only one patient had a persistent biliary leak. Postoperative bile leak was more common in patients with raised alkaline phosphatase. No statistically significant association was seen with size or location of the cyst, number of cysts and World Health Organisation classification.Conclusion:Laparoscopic treatment of LHC with associated CBC provides acceptable results.

Management of cysto-biliary communication in hydatid cyst of liver

Introduction: Biliary communication of hepatic hydatosis is one of the important complications. It may be minor or major communication. Minor communication is usually diagnosed during operation by the presence of bile stained hydatid fluid on aspiration or bile leak during surgery. However, in major communication, patients present with obstructive jaundice, abdominal pain and cholangitis. Surgical management of major communication is difficult and is associated with high morbidity and mortality.Methods: This is a retrospective study at Tribhuvan University Teaching Hospital, Kathmandu, Nepal over a period of two year (April 15th 2012 to April 15th 2014) and analyzed the medical records of 30 patients admitted and treated for hydatid cyst of liver in surgical ward during that period. Demography, clinical features, management and outcome were analyzed.Results: Of 30 patients with hepatic hydatid cyst operated over a period of two years, thirteen patients had cystobiliary communication. Amongst them, five minor communications were diagnosed during operation and managed with suture plication and omentopexy. Out of the eight major communications, seven were diagnosed preoperatively and all had cholangitis, and one had hydatid cyst of gallbladder and was diagnosed intraoperatively. Among six cases of major communication, five cases required CBD exploration and bile duct reconstruction while partial cholecystectomy was done for hydatid cyst of gall bladder and one case was managed by ERCP sphincterotomy, evacuation of cyst content and stenting. one case was managed with pigtail drain as the patient had infected hydatid cyst and not fit for surgery.Conclusion: Cystobiliary communication is a common complication of hydatid cyst of liver. Therapeutic options are related to size and location of the cyst and size of communication.Journal of Society of Surgeons of Nepal Vol.17(1) 2014: 31-34

Value of cyst localization to predict cystobiliary communication in patients undergoing conservative surgery with hydatid cyst.

ObjectiveThe objectives of this study were to investigate the relationship between the segmental localization of liver hydatid cyst by computed tomography (CT) and the presence of cystobiliary communication (CBC) and to identify the risk factors for CBC.Patients and methodsOne hundred and eleven of 163 patients who underwent liver hydatid surgery between January 2011 and September 2014 were included in this study and analyzed retrospectively. The size, number, stage, and segmental and lobar localization of the cysts were investigated by CT. The presence of CBC and preoperative laboratory findings were recorded from operation notes.ResultsCBC was more frequent in single large cysts. CBC was most commonly detected in segment 1 (50%), 8 (48.3%), 7 (41.2%), and 4 (40%). CBC was more frequent in the right lobe (40.4%) and Gharbi stage 3 (41.8%) and 4 (55.6%) lesions. There were no differences in CBC according to distance from the hilus. In addition, preoperative total bilirubin, direct bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT) elevations were associated with higher CBC frequency (P<0.05). Cyst diameter, number of cysts, and ALP and GGT elevations were independent predictors of CBC presence.ConclusionThe evaluation of hydatid cyst diameter, morphological stage, and segmental and lobar localization by abdominal CT and measurement of preoperative cyst diameter, number of cysts, and ALP and GGT values may predict the presence of CBC.

Predictive factors for cystobiliary communication in hepatic hydatidosis: A 15 yr experience at a tertiary care institute in South India

Predictive factors for cystobiliary communication in hepatic hydatidosis: A 15 yr experience at a tertiary care institute in South India

Myriad Imaging Appearances of Biliary Hydatidosis

A 35 years old lady, farmer by occupation, presented to the outpatient department with intermittent pain in right upper quadrant for the last 3 months which was mild to moderate intensity, dull ache, non-radiating with occasional nausea and nonbilious vomiting, no relation of pain to meals. She had experienced similar episodes of pain 3 years back for 1 year and was managed conservatively. Pain was not associated with fever, jaundice, abdominal distension, lump in abdomen or altered sensorium. On examination she was conscious, afebrile and her vitals were normal. On per abdominal examination she had hepatomegaly. There was no evidence of splenomegaly, ascites or lump in abdomen. Investigations revealed normal haemogram and renal function tests. Liver function tests revealed normal bilirubin with elevated aspartate aminotransferase [180 U/L (40U/L)], alanine aminotransferase [97U/L (40U/L)] and alkaline phosphatase [564U/L (91U/L)]. Contrast enhanced computed tomography (CECT) showed well defined cystic lesion of size 5 × 4 cm in segment 4 of liver with peripheral calcification, showing communication with one of the peripheral branches of left hepatic duct with intrahepatic biliary radicle dilatation (IHBRD) and common bile duct dilatation up to 12 mm (Image A-C). In view of dilated common bile duct up to 12 mm and normal bilirubin, endoscopic ultrasonography examination (EUS) was planned. It showed normal gall bladder with common bile duct diameter of 11 mm with presence of longitudinal floating membranes within CBD (Image D). She underwentendoscopic retrograde cholangiography (ERCP) which revealed CBD of 15 mm with longitudinal filling defects with cystobiliary communication (Image E). On flushing and suctioning, green membranes were seen oozing from papilla (Image F). A 10 Fr x 10 cms plastic biliary stent was placed. Post biliary stenting, she was given Tablet albendazole 400 mg once a day for 3 months and repeat ERCP with cholangiogram was performed. It showed normal CBD with no filling defects. Her CBD stent was removed and discharged in clinically stable condition after stent removal.

Clinical study of hydatid disease

Background: Hydatid cyst is zoonosis caused due to Echinococcus species Echinococcus granulosus. In developing countries like India, Iran, China and Mediterranean countries it is still remains a major problem. It can involve any organ and can mimic almost any pathological condition. Complication associated rather than disease itself, are difficult to treat. Aims was to study about; (1) The major organs involved by hydatid disease. (2) The best treatment modality depending upon the site, size and organ involving the cyst. (3) The preoperative and postoperative complications of hydatid disease. Methods: Prospective clinical study was conducted on 58 patients. All patients diagnosed as hydatid disease mainly by ultrasound or CT scan and then treated either operatively or non-operatively were included in this study. The choice of surgical procedure was guided by site, size, organ involving the cyst and associated complications. The patients were followed up for a period of 6 months. Results: The highest incidence was found in 3rd decade (27.59%). It is more common in females (70.69%). Liver is most common organ involved (86.2%). Ultrasonography was the imaging modality of choice for diagnosis. Partial cystectomy with omentoplasty with external drainage was most commonly performed surgery after through irrigation with scolicidal solution. Presence of cystobiliary communications was most common intra-operative complication (22%). The mean duration of stay after surgery was about 9.34 days. Conclusions: Hydatid disease is still a major problem in rural agricultural population. Surgery is most widely acclaimed procedure for treatment of hydatid.

Occult cysto-biliary communication: A forgotten complication of hepatic hydatidosis.

Occult cysto-biliary communication: A forgotten complication of hepatic hydatidosis.

Changing paradigms in the surgical management of cystic liver hydatidosis improve the postoperative outcomes

Our aim was to propose and examine the outcomes of a comprehensive strategy for the management of cystic liver hydatidosis (CLH) based on extensive intraoperative assessments and optimal management of cystobiliary communications. Although operative intervention remains the preferred treatment for CLH, and the presence of a cystobiliary communication remains a well-established predictive factor for postoperative complications, no internationally accepted management strategy integrates the specific management of cystobiliary communication into the choice of surgical approach. Early postoperative outcomes were compared before (1990-2004; P1 group; n = 664) and after (2005-2013; P2 group; n = 156) the implementation of a CLH surgical management strategy for CLH in our overall group of patients in subgroups selected by risk factors (as determined by multivariate analysis), and in 2 propensity score-matched groups. Specific complications related to the hepatic procedure (intraabdominal complications) were independently associated with the presence of ≥ 3 cysts (P = .013), a fibrotic pericyst (P = .005), a cystobiliary communication (P < .001), and the P1 treatment period (P = .002). Between P1 and P2 groups, the rate of specific complications decreased in the overall group of patients with CLH (18.3% vs 4.5%; P < .001). The rate also decreased in risk factor-based subgroups: patients with ≥ 3 cysts (31.0% vs 4.0%; P = .005), a fibrotic pericyst (23.1% vs 9.2%; P = .011), and a cystobiliary communication (33.0% vs 13.2%; P = .006). After propensity score matching among 123 well-balanced matched pairs of patients, the overall complication rate, specific hepatic surgery-related complication rate, and median duration of hospital stay decreased between the P1 and P2 groups: 23.6% vs 12.2% (P = .02), 21.1% vs 4.9% (P < .001), and 7 vs 5 days (P < .001), respectively. Implementation of a CLH surgical management strategy based on specific intraoperative assessment and optimal management of cystobiliary communications improved early postoperative outcomes.

Role of endoscopic retrograde cholangiography in ruptured hepatic hydatid cyst.

To report endoscopic retrograde cholangiopancreatography (ERCP) findings of intrabiliary hydatid cyst rupture. A retrospective study of cases with intrabiliary rupture of hydatid cyst was conducted. A total of 4 cases (all female with a mean age of 32 years) were included. ERCP and ultrasound data were evaluated. Assessment involved number, location, size, internal and wall characteristics of cyst; intrahepatic biliary radicle dilatation (IHBRD); common bile duct (CBD) dilatation and evidence of extrabiliary rupture on ultrasound. ERCP evaluation included IHBRD, CBD dilatation, communication between cysts and intrahepatic biliary radicles (IHBR) and filling defects within the IHBR and CBD. Treatment details were also obtained. A total of 5 cysts were evaluated in 4 patients. Left lobe cysts were most common (n=4). Segment II/III were the most commonly affected segments (n=3). Cyst outline was smooth and cystobiliary communication noted in all cases. Deformation of cyst wall was noted in 2 cases. Isolated (left or right) IHBRD lateralised to the side of the cyst was most common (n=4). CBD dilatation was seen in all cases with a mean calibre of 1.4 cm. Concomitant extrabiliary rupture was seen in 3 cases. Endoscopic management was done in all cases without complications. Three patients underwent surgical excision after a mean period of 8 weeks following ERCP. Isolated IHBRD lateralized to the side of hydatid cyst with CBD dilatation is the commonest ERCP finding of intrabiliary rupture of hydatid cyst.

Abdominal echinococcosis: outcomes of conservative surgery

Hydatid disease, infection with the larval stage of the cestode Echinococcus spp., represents a substantial disease burden worldwide. We report here the outcomes of conservative surgery in patients with abdominal echinococcosis. We carried out a retrospective review of patients who underwent conservative surgery for abdominal hydatid disease during the period January 2008 to December 2011. Perioperative outcomes were analysed after a mean follow-up of 24 months (range 6-36 months). Thirty patients (mean age 40.4 years; male:female=7:3) underwent surgery. Most (29 patients) had a hepatic hydatid cyst and underwent partial cystectomy with omentoplasty; surgery was open in 22 cases (73%), laparoscopic in six cases (20%) and laparoscopic converted to open in one case (3%); one patient with a splenic cyst underwent open splenectomy. Cystobiliary communication was present in 10 cases (3%). Postoperative complications included transient biliary leak in two cases (7%), grade 1 surgical site infection in five cases (17%) and respiratory tract infection in three cases (10%), with no mortality. Mean hospital stay was 17 ± 9.2 days. None of the patients had recurrence of disease on follow-up imaging. Conservative surgery offers an effective approach for abdominal echinococcosis, with minimal morbidity or recurrence, and is an alternative to radical procedures.