Cystobiliary Communication Research Articles

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.

Non-invasive detection of biliary leaks using Gd-EOB-DTPA-enhanced MR cholangiography: comparison with T2-weighted MR cholangiography

ObjectiveTo evaluate the added role of T1-weighted (T1w) gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance cholangiography (MRC) compared with T2-weighted MRC (T2w-MRC) in the detection of biliary leaks.MethodsNinety-nine patients with suspected biliary complications underwent routine T2w-MRC and T1w contrast-enhanced (CE) MRC using Gd-EOB-DTPA to identify biliary leaks. Two observers reviewed the image sets separately and together. MRC findings were compared with those of surgery and percutaneous transhepatic cholangiopancreatography. The sensitivity, specificity and accuracy of the techniques in identifying biliary leaks were calculated.ResultsAccuracy of locating biliary leaks was superior with the combination of Gd-EOB-DTPA-enhanced MRC and T2w-MRC (P < 0.05).The mean sensitivities were 79 % vs 59 %, and the mean accuracy rates were 84 % vs 58 % for combined CE-MRC and T2w-MRC vs sole T2w-MRC. Nineteen out of 21 patients with biliary-cyst communication, 90.4 %, and 12/15 patients with post-traumatic biliary extravasations, 80 %, were detected by the combination of Gd-EOB-DTPA-enhanced MRC and T2w-MRC images, P < 0.05.ConclusionsGd-EOB-DTPA-enhanced MRC yields information that complements T2w-MRC findings and improves the identification and localisation of the bile extravasations (84 % accuracy, 100 % specificity, P < 0.05). We recommend Gd-EOB-DTPA-enhanced MRC in addition to T2w-MRC to increase the preoperative accuracy of identifying and locating extravasations of bile.Key Points• Magnetic resonance cholangiography (MRC) does not always detect bile leakage and cysto-biliary communications.• Gd-EOB-DTPA-enhanced MRC helps by demonstrating extravasation of contrast material into fluid collections.• Gd-EOB-DTPA-enhanced MRC also demonstrates the leakage site and bile duct injury type.• Combined Gd-EOB-DTPA-enhanced and T2w-MRC can provide comprehensive information about biliary system.• Gd-EOB-DTPA-enhanced MRC is non-invasive and does not use ionising radiation.

External Tube Drainage Versus no Drainage in Hepatic Hydatid Cysts with Cystobiliary Communications

Echinococcosis (hydatid disease) is a zoonosis caused by the larval stage of Echinococcus granulosus. About seventy-five per cent of all hydatid cysts are found in the liver. Surgical management of hepatic hydatid cyst includes neutralization of the parasite, evacuation of cyst, removal of germinal lining and management of the residual cavity. Our study focussed on the management of the residual cavity in patients with cystobiliary communications. We divided the patients into two groups of 40 patients each. In both the groups the cystobiliary communications were ligated using sutures. After closing the cystobiliary communications, the residual cavity was left to drain externally using a polyvinyl chloride tube in group 1 whereas either capitonnage or omentoplasty was done in group 2. The results were studied in terms of the postoperative complications, mortality and hospital stay. In the patients managed by external tube drainage, average hospital stay was 6.95 ± 0.93 days while as patients in group 2 had an average post operative stay of 4.54 ± 0.76 days (p value = 0.0001). Bile leak was seen in 6 (15%) patients in group 1, while as only 1(2.5%) patient from group 2 developed an intra-abdominal bile collection. Wound infection and deep vein thrombosis was seen in one patient each in group 1, whereas no such complication was seen in group 2. One (2.5%) patient from each group had a recurrence of the disease during follow-up.

Surgical Emergencies in Liver Hydatidosis: Not too Much, but Severe

Surgical Emergencies in Liver Hydatidosis: Not too Much, but Severe Liver hydatidosis is a zoonosis caused by Echinococcus that has worldwide distribution. There are three types of therapeutical options: surgery, medical treatment and PAIR. But surgery is the treatment that offers better long-term results. Usually surgery for liver hydatidosis is made as a scheduled procedure, but sometimes, severe symptoms provoked by liver cysts must be treated in emergency setting. We have made a review of every complication that could provoke liver hydatidosis: complications related to cysto-biliary communication, intraperitoneal rupture, vascular complications and rupture in surrounding organs. We have made a review of epidemiology, diagnosis and treatment of each complication, focusing when an emergency treatment is needed. We could conclude that only few patients require an emergency treatment due to liver hydatidosis, but morbidity and even mortality is high because diagnosis is difficult and sometimes delayed, and we have to face to severe medical situations.

STUDY OF BILE LEAK AFTER HEPATIC HYDATID CYST SURGERY IN BASRAH

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.

Intraoperative diagnosis of cystobiliary communications of hydatid liver cysts

The liver is the most frequent location for hydatid disease, and the most common complication of hydatid liver cysts is cystobiliary communications. Prevention methods for this frequent complication can decrease postoperative interventions and the duration of hospital stay. Technical details of the surgical methods are very useful for clinicians who treat hydatid cysts. We would like to thank Irkorucu et al. (1) for their interest in our study (2). We agree with the authors that a colored agent injected into the biliary tree can make the orifices more visible. We have previously experienced that methylene blue can cover the cyst cavity, particularly if there is more than one orifice in the same cavity. However, methylene blue is not an easy-clean dye, and it is difficult to find the other orifices when methylene blue covers the cyst. We do not routinely evaluate the whole biliary tree by intraoperative cholangiography, and none of our cases had remnant hydatid cyst material in the biliary tract. In some cases, a deep or multilocular cyst must be checked for cystobiliary communications. In these cases, we prefer a large unroofing of the pericyst to examine the bottom of the cyst cavity to determine whether there is any accumulation of normal saline during saline injection.

Cysto-biliary communication in liver hydatidosis

Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree. The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree. Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm. The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

The detection of cysto-biliary communications during surgery for liver hydatid cysts: let's speak the unspoken

We read with great interest the article by Kayaalp et al. (1), whose work identified biliary orifices using a bile test and described the use of suturing cysto-biliary communications to reduce postoperative biliary complications significantly following hydatid liver surgery. We would like to express our opinion that testing using the injection of normal saline into the biliary system has several disadvantages based on three important concerns. First, normal saline is colorless, and in some cases, small or hidden cysto-biliary communications may not be detected. Why did the authors not use a colored agent, such as methylene blue? Second, small daughter cysts and minor fragments of cysts in the biliary tree may not be detected by injecting normal saline. How did the authors evaluate the whole biliary tree in patients with cysto-biliary communications? Third, in some cases, especially for deep cysts with multiple connections, the whole cavity may not be observable by the naked eye using a colorless agent. How did the authors evaluate the cyst cavities in these patients? During routine surgical practice, we prefer injecting water-soluble contrast media and using cholangiography in patients with suspected cysto-biliary communications (Figure 1). If we detect leaks using cholangiography, we can inject methylene blue into the biliary system to find hidden orifices (2). There are certain advantages to using this technique. First, the surgeon can see the location and the diameter of the cysto-biliary communications and understand the severity of the problem. Second, using cholangiography, small daughter cysts or minor fragments of endocysts in the biliary tree can be detected. Third, hidden biliary-thoracic communications can be visualized. Fourth, the use of cholangiography may prevent the complete suture capture and occlusion of biliary branches when suturing cysto-biliary communications.

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

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. 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. 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). 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.

Leakage tests reduce the frequency of biliary fistulas following hydatid liver cyst surgery

BACKGROUND AND AIM:Biliary fistulas are the most common morbidity (8.2-26%) following hydatid liver surgery. The aim of our study was to reduce the incidence of postoperative biliary fistulas after the suturing of cystobiliary communications by applying a bile leakage test.PATIENTS AND METHODS:A total of 133 hydatid liver cysts from 93 patients were divided into two groups, according to whether the test was performed. Tests were performed on 56 cysts from 34 patients, and the remaining 77 cysts from 59 patients were treated without the test. In both groups, all visible biliary orifices in the cysts were suture ligated, and drains were placed in all cysts. The visibility of the biliary orifices and postoperative biliary drainage through the drains were recorded. Patients in both groups were also compared with respect to the number of days living with the drains, the length of the hospital stay, and secondary interventions related to biliary complications.RESULTS:Biliary orifices were more visible in the tested cysts (13% vs. 48%; P <0.001). Fewer biliary complications occurred in the tested patients (8.8% vs. 27.7%, P = 0.033). The mean drain removal time (4.1±3.3 days vs. 6.8±8.9 days, P<0.05) and the length of the hospital stay (6.7±2.7 days vs. 9.7±6.3 days, P<0.01) were shorter for the tested patients. None of the patients in the test group required postoperative Endoscopic retrograde cholangiopancreaticography (ERCP) or nasobiliary drainage (0.0% vs. 8.4%, P = 0.09). There were no long-term biliary complications for either group after three years of follow-up.CONCLUSIONS:Identification of biliary orifices with a bile leakage test and the suturing of cystobiliary communications significantly reduced postoperative biliary complications following hydatid liver surgery.

Intrabiliary rupture of hepatic hydatid cyst: multidetector-row CT demonstration

Rupture of a hydatid cyst into the biliary tract, also known as cystobiliary communication, is the most common complication of hepatic hydatid cyst. This may lead to obstructive jaundice, pancreatitis, cholangitis, and sepsis with high mortality. Imaging plays an important role in the preoperative diagnosis of this condition which facilitates its management. We studied six patients with rupture of hepatic hydatid cyst into a large bile duct in whom multidetector-row CT (MDCT) suggested the diagnosis. The imaging findings included a single hepatic cyst less than 10 cm in diameter in all the cases; interruption of the cyst wall adjacent to a bile duct signifying cyst-bile duct communication was seen in five patients. The common bile duct was dilated in all the patients, with linear membranes in four and diffuse irregular high dense intrabiliary material observed within the common bile duct in two of them. Intrahepatic ducts were dilated in all the six cases and two patients showed linear dense contents within distended gallbladder. Subcapsular and intrathoracic rupture was associated in one patient each. MDCT demonstration of hydatid cyst in the liver together with a dilated common bile duct and distended gallbladder containing high density hydatid material suggest rupture of the cyst into biliary tree. MDCT enhances demonstration of the dilated common bile duct with hydatid material inside. The diagnosis is reinforced by the demonstration of the cystobiliary communication itself.

Comparison of Endoscopic Therapeutic Modalities for Postoperative Biliary Fistula of Liver Hydatid Cyst

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. 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. 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.

Spontaneous intraperitoneal rupture of hepatic hydatid cyst with biliary peritonitis: a case report

IntroductionSpontaneous intraperitoneal rupture with biliary peritonitis in a case of hepatic hydatid cyst is extremely rare but serious complication. It is a surgical emergency with high morbidity and mortality rates. Very few cases have been reported in the literature.Case presentationWe report an unusual case of a biliary peritonitis due to spontaneous rupture of hepatic hydatid cyst in a male patient of 34 years of age. He presented with acute peritonitis. Contrast enhanced computed tomography 2 days prior to laparotomy showed a dumbbell shaped hydatid cyst of right lobe of the liver with perihepatic fluid collection. At operation 1.5 L bile was found in the peritoneal cavity with rupture of the anterior wall of the cyst and large cystobiliary communication. He was managed with deroofing of the cyst, cholecystectomy, and placement of T tube in the cystobiliary communication and in the extrahepatic bile duct. He developed biliary fistula which was closed over a period of 34 days with conservative therapy. At 6 months follow up patient is well and free of recurrence.ConclusionThough rare, ruptured hydatid cyst should be considered in the differential diagnosis of acute abdomen in a patient residing in the endemic zone.

An algorithm for the treatment of the biliary complications of hepatic hydatid disease

Aim: The treatment of hepatic hydatid disease (HHD) is currently standardized. Biliary complications of HHD complicate both the treatment and course of the disease. Several investigations have been performed on the biliary complications of HHD and their treatment. We propose an algorithm for the treatment of the biliary complications of HHD based on our experience. Materials and methods: We investigated 148 patients that underwent endoscopic retrograde cholangiopancreatography (ERCP) due to complicated HHD between January 2000 and December 2006 at the endoscopy unit of the Department of Surgery of Atatürk University Medical School. Age, sex, indications for ERCP and endoscopic sphincterotomy (ES), ERCP findings, laboratory data, operative findings, postoperative complications, and additional interventions (surgical or percutaneous) were noted. Results: Twenty-six patients had not previously undergone surgery for HHD. While 23 of these patients underwent ERCP preoperatively, 3 underwent ERCP during both the pre- and postoperative periods. The remaining 122 patients underwent surgery for HHD and ERCP during the postoperative period. Indications for preoperative ERCP were cholangitis and various clinical signs of cysto-biliary communication (CBC), such as abnormal liver function test results (bilirubin, ALT, AST, GGT, and ALP), biliary colic, and obstructive jaundice. In this group of patients ERCP/ES was not successful in 2 patients that underwent surgery due to emergent circumstances, and another 3 patients developed postoperative biliary fistulae. Indications for postoperative ERCP were persistent bile leakage after surgical treatment for HHD, postoperative hyperbilirubinemia and cholangitis, and postoperative biloma formation in the cystic cavity. All patients with cholangitis experienced relief of symptoms after ERCP and ES, 1 patient with biloma formation and 5 patients with persistent biliary fistulae were operated on. Conclusion: ERCP and ES are highly effective in the treatment of the biliary complications of HHD. Repeat ERCP should be performed in patients that do not respond to the first intervention.

The Effects of Scolicidal Agent Propolis on Liver and Biliary Tree

BackgroundThis study was designed to examine the effects of propolis on the liver and biliary system when used as a scolicidal agent. Materials and MethodsThirty Wistar–Albino rats were divided into two groups. Propolis and 0.9% saline (NaCl) were injected into the biliary tract of the rats. Three rats from control group and four rats from propolis group died within 5 days after the procedure. Blood samples of remaining 23 rats were obtained 1 week after and at the end of the experimental study for liver function tests. Six months after the procedure, retrograde and magnetic resonance cholangiography were performed and liver, common bile duct, and duodenum were excised en bloc for histopathological examination. ResultsLiver function tests were slightly elevated 1 week after the procedure and were found to be normal at the end of the sixth month in both groups. No stricture in the biliary tree was found on the retrograde and magnetic resonance cholangiograms. The tissue samples of the propolis group showed no histomorphological difference from the control group. ConclusionsPropolis may be used as a scolicidal agent even in the case of cystobiliary communication with no side effects on liver and biliary tree.

Magnetic resonance cholangiopancreatography of biliary system abnormalities in children

The aim of this study was to assess the usefulness of magnetic resonance cholangiopancreatography (MRCP) with a single-shot fast spin-echo sequence as a noninvasive method to evaluate the biliary system in children. Twenty-five MRCP examinations of 23 patients were evaluated. On the basis of surgical (n=5), endoscopic retrograde cholangiopancreatography (n=4), liver biopsy (n=4), clinical data, and follow-up observation, 6 children were considered to have no significant abnormality. The other 17 children were found to have pancreaticobiliary disease, including choledochal cyst, biliary system dilatation, choledocholithiasis, biliary atresia, multiseptated gallbladder, anomalous pancreaticobiliary union, ruptured hydatic cyst, and biloma. The findings were correlated with the ultrasonography, computed tomography, surgical, and endoscopic retrograde cholangiopancreatography results. Magnetic resonance cholangiopancreatography showed the first branch of the intrahepatic duct, the common hepatic duct, the gallbladder, and the common bile duct in 14 children. Cystic duct was not seen in infants, but was partially visible in younger children. Although the main pancreatic duct was visible in head and body portions in 65% of the patients, it was visible in 17% of the patients in the tail. The diagnostic accuracy of MRCP was 100% in patients with choledochal cysts and stenoses. In a patient with hydatic cyst, cystobiliary communication was successfully demonstrated. Magnetic resonance cholangiopancreatography can be used effectively for the evaluation of the biliary system in children.

Results of Surgical, Laparoscopic, and Percutaneous Treatment for Hydatid Disease of the Liver: 10 Years Experience with 355 Patients

Selection of the most appropriate treatment to obtain the best results with the lowest rate of recurrence and minimal morbidity and mortality is mandatory for the management of hepatic hydatid disease. The surgical approach is the mainstay of treatment, and there has been a tendency toward laparoscopic surgery and, more recently, percutaneous treatment (PT), which has become increasingly popular with revolutions in techniques. We aimed to evaluate the results of current therapeutic methods in the context of a 10-year single-institution experience. Between 1992 and 2003, 355 patients with 510 hydatid cysts of the liver were treated by open operation, laparoscopic surgery, or PT. The series included 128 females and 227 males ranging in age from 10 years to 73 years. Preferred treatment modalities, perioperative complications, interventions, recurrences, and length of hospital stay were retrospectively analyzed. There were two postoperative deaths (1.08%) in the open surgery group. Biliary leakage was observed in 28 patients treated with open surgery, in 10 patients after PT, and in 2 after laparoscopic treatment. Recurrence rates were 16.2%, 3.3%, and 3.5% after open surgery, laparoscopic surgery, and percutaneous treatment, respectively. Characteristics of the cyst, presence of cystobiliary communications, and the availability of a multidisciplinary team are the factors that we believe directly affect the results. Radical surgery can be done safely for suitable cases; conventional procedures are associated with greater morbidity. Laparoscopic surgery seems effective and safe, with low morbidity and recurrence rates for type I-III cysts in accessible localizations. Our experience with PAIR (puncture, aspiration, injection, and reaspiration) and catheterization provides evidence that the procedure is an effective and safe option.

Treatment of Hydatid Disease of the Liver

Background: Hydatid disease of the liver though endemic in many countries, is rare in the UK. We evaluated a 16-year experience of treating hydatidosis using a management protocol combining surgery with anti-scolicidals. Patients and Methods: There were 30 patients. 14 (47%) males, median age 41 (range 25–72) years, of whom 21 (70%) were symptomatic. Diagnosis was by serological tests and imaging. All had disease confined to the liver and received peri-operative anti-scolicidal drug therapy. Results: The initial 4 (13%) patients received praziquantel combined with albendazole for 2 weeks and the following 26 (87%) patients received two cycles of albendazole 400 mg twice daily for 28 days, with a 14-day break in between. However, 2 (7%) patients could not tolerate albendazole, one due to GI side effects and the other developed deranged liver functions. These 2 patients subsequently received praziquantel for 2 weeks. All patients underwent surgery. Subtotal cystectomy was carried out on 29 (96%) patients and 1 patient required a segmentectomy. Cystobiliary communications were identified in 15 (50%) of patients which were oversewn using fine absorbable sutures. Of these, 7 had the bile ducts decompressed using a T tube, with only 1 developing a post-operative bile leak. In comparison, 8 were not drained of which 6 leaked (p = 0.03). The median post-operative hospital stay was 8 days (range 5–24). Patients who developed post-operative bile leaks, however, needed prolonged abdominal drainage for a median of 21 days (range 18–24). Two (7%) patients developed histologically proven recurrent disease. The median follow-up was 56 months (range 3–87). Conclusion: Surgery combined with anti-scolicidal therapy proved effective. Cystobiliary communications are common and, when identified, should result in the biliary system being drained, to avoid post-operative bile leaks.

Distribution of hydatid cysts into the liver with reference to cystobiliary communications and cavity-related complications

Background This study was designed to test a hypothesis that intrahepatic hydatid cyst location can effect the incidence of cystobiliary communications and the cavity-related complications. Methods A total of 121 cysts treated by conservative surgical methods in 113 patients were evaluated prospectively. Cysts were grouped as near to the liver hilum (segment I, III, IVb, V, and VI) and far from the hilum (segment II, IVa, VII, and VIII). Results There were 58 (48%) hilar and 63 (52%) peripheral cysts. We found more cystobiliary communications (48% versus 27%, P = 0.015), more biliary leakage (36% versus 10%, P <0.001), and more biliary fistula (12% versus 3%, P = 0.080) in the cysts near to the hilum than far from the hilum. Postoperative hospital stay was longer in the cysts near to the hilum (12.3 ± 3.1 days) than the cysts far from the hilum (7.7 ± 2.7 days, P = 0.022). Conclusions The location of the hydatid cyst near to the liver hilum is a risk factor for the cystobiliary communications and the cavity related complications.