The usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae

A Novel Technique for the Management of Persistent Biliary Fistulas Developing After Liver Hydatid Cyst Surgeries: Drain Clamping Technique

BACKGROUND

External biliary fistula, where the residual cyst is associated with the biliary tree, is one of the most common complications after liver hydatid cyst surgery. Surgical procedures become a consideration for patients in whom the biliary fistula persists despite all endoscopic procedures. However, reoperation for biliary fistula after hydatid cyst surgery leads to additional complications and increases morbidity and mortality.

AIM

This study aims to treat persistent biliary fistulas that develop after liver hydatid cyst surgery using a simple noninvasive technique.

MATERIALS AND METHODS

External drainage surgery was performed on 295 patients with liver hydatid cysts. Endoscopic treatment methods were used in patients who developed biliary fistula after surgery. Despite all endoscopic treatment methods, 14 patients developed persistent biliary fistulas. These patients were subsequently treated using the drain clamping technique.

FINDINGS

All persistent fistulas occluded in 11.86 days (with a range of 8-20 days). No complications were observed in the one-year follow-up visits.

CONCLUSION

Drain clamping, a novel approach to the treatment of persistent biliary fistulas developed despite all available endoscopic methods, can be safely used. This technique resulted in a complete recovery in patients without the need for surgical procedures.

Subadventitial cystectomy in the management of biliary fistula with liver hydatid disease

Biliary fistulas are the most common morbidity (8.2-26%) following hydatid liver surgery. The aim of this study was to evaluate the results of subadventitial cystectomy in the treatment of liver hydatid cyst associated with a biliocystic fistula. The medical records of 153 patients who underwent subadventitial cystectomy for a liver hydatid cyst between January 2006 and December 2010 were retrospectively reviewed. Cysts were located in the right lobe anterior segment 37 (24.2%) patients, right lobe posterior segment 59 (38.6%) patients, the left lobe in 26 (17.0%) patients, and both lobes in 6 (3.9%) patients. The surgical procedures performed were closed (non-incised) subadventitial total cystectomy in 74 patients (48.4%), open (incised) subadventitial total cystectomy in 30 patients (19.6%), and subadventitial subtotal cystectomy in 49 patients (32.0%). Biliocystic communication was found in 52 patients (34.0%), and 21 patients (13.7%) were treated with T-tube drainage. Two patients had performed biliodigestive anastomosis. Biliary fistula was detected in 9 patients after subtotal subadventitial cystectomy. Biliary fistulas closed spontaneously within 10 days and 61 days respectively and the amount of drainage varying between 50 and 400ml after the procedure. Postoperative complication and recurrence rates were 19.0% and 0.7%, respectively. The mortality rate was 0%. Subadventitial cystectomy should be the surgical treatment of choice for this disease because of its feasibility and low rates of recurrence, complications of the residual cavity, and incidence of associated biliary fistula.

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.

Endoscopic management of biliary parasitic diseases

AIM/MATERIALS AND METHODS: Between January 2000 and June 2007, 3,548 endoscopic retrograde cholangiopancreatography (ERCP) were performed for extrahepatic cholestasis, cholangitis, and choledocholithiasis. The results of ERCPs were evaluated retrospectively and examined carefully to investigate the management and endoscopic therapy of biliary parasites.

RESULTS

Of the 3,548 patients who underwent ERCP, 24 (0.66%) were found to have biliary parasitosis. The mean age of the biliary parasitosis patients (16 women) was 48.6 (15-77) years. Of these 24 cases, 16 patients had hydatid cystic disease (eight with partial obstruction of the biliary tract, and eight with ruptured cysts), four patients had Fasciola hepatica, and four patients had Ascaris lumbricoides infestation. Endoscopic sphincterotomy was performed, after which the choledochus was examined carefully by balloon catheter and basket procedure.

CONCLUSION

The ERCP procedure is very useful in the therapy of biliary parasitic infestations.