The use of ERCP in the study of patients with hepatic echinococcosis before and after surgical intervention

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.

Treatment of hepatic hydatid disease complications using endoscopic retrograde cholangiopancreatography procedures

BACKGROUND

Liver hydatidosis may lead to serious morbidity due to biliary complications, the management for which endoscopic sphincterotomy (ES) and biliary drainage are very efficient. We evaluated the effectiveness of endoscopic treatment for complications of hepatic hydatid disease.

METHODS

We retrospectively reviewed endoscopic retrograde cholangiopancreatography (ERCP) procedures performed between January 2000 and December 2009 and compared laboratory findings, localization of the lesions and ERCP procedures applied between patients with and without jaundice.

RESULTS

In all, 70 ERCP procedures were performed in 54 patients (24 men, 30 women). Of the 70 procedures, 24 were performed to treat jaundice. All patients with biliary fistulas and jaundice were managed with endoscopic procedures. The 70 ERCP procedures included sphincterotomy only (n = 40); sphincterotomy and stent placement (n = 7); stent placement only (n = 4); sphincterotomy and membrane extraction (n = 9); sphincterotomy, membrane extraction and pus drainage (n = 5); and sphincterotomy and pus drainage (n = 5). Laboratory results improved in 3-7 days, and bile leakage ceased in 2-21 days.

CONCLUSION

Endoscopic retrograde cholangiopancreatography is a safe and effective way to manage biliary complications of hepatic echinococcal disease. In most patients, ES is the most efficient treatment of postoperative external biliary fistulas, jaundice and accompanying cholangitis, as it enables clearing the bile ducts of hydatid remnants; ES should be performed since it accelerates the healing process by decreasing pressure in the choledochus.

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.

Role of endoscopic intervention in biliary complications of hepatic hydatid cyst disease

OBJECTIVE

Biliary complications of hepatic hydatidosis are often difficult to detect and manage. The aim of this study was to present our experience on the effectiveness of endoscopic treatment modalities in cases of biliary complications of hepatic hydatid cysts.

MATERIAL AND METHODS

Over the past 10 years, 15 patients diagnosed with hepatic hydatidosis and manifesting symptoms and signs indicative of biliary involvement were examined by means of endoscopic retrograde cholangiopancreatography (ERCP) in our Gastroenterology Endoscopic Unit; 7 patients had already been operated on for hepatic hydatid cysts; one of them had a concomitant hydatid cyst in the lung. Diagnosis of the disease was based on a combination of ultrasonography (US), computed tomography (CT) and specific immunologic and/or microbiologic studies.

RESULTS

Biliary complications of hydatid cysts were detected by ERCP in 9 patients (60%). Eight (88.9%) patients displayed a communication between the hydatid cyst or its residual cavity and the biliary tree; 5 patients had daughter cysts or residual hydatid material within the biliary tree, 1 patient had a biliocutaneous fistula, 1 patient a postoperative biliary leakage and 1 patient had only an opacification of the hydatid cyst during ERCP. In one patient, ERCP showed stenoses of both of the main hepatic ducts due to their compression by the cyst. Jaundice (88.9%), fever (33.3%) and right upper quadrant abdominal pain (88.9%) were the most frequent manifestations. These complications were demonstrated by US and CT imaging in only 25% of the cases. Four patients underwent ERCP before surgery and 5 after surgery. Endoscopic management was successful in all patients, resulting in clearance of the biliary tree, closure of fistulas, stopping of biliary leakage and jaundice remission. No serious endoscopy-related complications were recorded, with the exception of a pulmonary hydatid cyst rupture during ERCP.

CONCLUSIONS

This study suggests that endoscopic treatment modalities are helpful and safe methods in the treatment of biliary complications of hepatic hydatidosis before and after definitive surgical management of the hydatid cysts.

Endoscopic management of a relapsing hepatic hydatid cyst with intrabiliary rupture: a case report and review of the literature

Hydatid disease, although endemic mostly in sheep-farming countries, remains a public health issue worldwide, involving mainly the liver. Intrabiliary rupture is the most frequent complication of the hepatic hydatid cyst. Endoscopy is advocated, preoperatively, to alleviate obstructive jaundice caused by intracystic materials after a frank rupture and is also a useful and well-established adjunct in locating postoperative biliary fistulas. Endoscopic retrograde cholangiography with sphincterotomy has been successful as the sole and definitive means of treatment of intrabiliary ruptured hydatid cysts. A case of an elderly woman with frank rupture is presented, where the rupture was definitively managed endoscopically in conjunction with sphincterotomy to remove the intrabiliary obstructive daughter cysts and to achieve decontamination of the biliary tree. Endoscopic retrograde cholangiography provided an excellent diagnostic and therapeutic modality in the present case and, thus, it should be considered as definitive treatment in similar cases especially if surgical risk is anticipated to be high.

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

Hydatid disease is an important health problem in areas where it is endemic. There are several therapeutic modalities, the most important being surgery, antibiotherapy, and percutaneous treatment. In recent years percutaneous treatment has become popular, and for this method or surgery it is sometimes lifesaving to know the relation between the biliary ducts and the cyst cavity. The aim of this study was to examine the usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae before percutaneous or surgical treatment. A total of 72 patients diagnosed with hepatic hydatid disease via ultrasound and serologic tests were enrolled in the study. Endoscopic retrograde cholangiopancreatography was successfully performed in all patients. (99m)Tc-labeled albumin macroaggregates also were injected into cysts at a dose of 1.5-2 mCi just before the treatment. All but three patients were treated percutaneously. Scintigraphy of abdominal and thoracic areas was performed with a GE Starcam 3200 XC/T gamma camera at 30 and 120 min after Tc-labeled albumin macroaggregate injections. Endoscopic retrograde cholangiopancreatography revealed communications between biliary ducts and cyst cavities in nine patients (12.5%). However, (99m)Tc-labeled albumin macroaggregates showed not only leakage into the systemic circulation in nine patients but also into the biliary ducts in two (15.4%). In one patient, mild acute pancreatitis occurred as a complication of endoscopic retrograde cholangiopancreatography. No complications of (99m)Tc-labeled albumin macroaggregates injection were seen. Three patients were surgically treated because of clinically manifested cystobiliary fistulae. We conclude that endoscopic retrograde cholangiopancreatography is a gold standard technique for the diagnosis of communication between the biliary duct and the cyst cavity, and (99m)Tc-labeled albumin macroaggregate injection is useful for revealing leakage into the systemic circulation. The diagnosis of biliary fistulae before percutaneous treatment of hydatid disease may enable planning of the optimal therapy.

Endoscopic therapy of hepatic hydatid cyst disease in preoperative and postoperative settings

The most common and serious complication of hepatic hydatid cyst disease is the communication between the cyst and the biliary tree. The diagnosis and treatment of this condition poses various difficulties. Data from patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for hydatid cysts communicating with the bile ducts either in the preoperative or postoperative setting over a 2-year period have been analyzed. In the preoperative group (n=41), jaundice (n=18), biliary colic (n=11), and cholangitis (n=10) were the most common presentations. On the other hand, the most common indication for ERCP in the postoperative group (n=69) was biliocutaneous leaks (n=60) and cholangitis (n=9). All but 2 patients in the preoperative group were treated by endoscopic sphincterotomy and/or extraction of hydatid cyst remnants followed by the placement of nasobiliary drainage catheter for the patients who had filling defects on cholangiogram. Subsequently, these patients were referred for surgery. ERCP was a definitive treatment for the remaining 2 patients. Endotherapy was successful for the patients who developed leak or had cyst remnants following surgery, whereas long-term biliary stenting was required for those who developed bile duct stenosis. There was no ERCP-associated complication, except mild pancreatitis in a single patient and self-limited hemorrhage in 2 patients. ERCP is an efficacious and safe method for the diagnosis and management of biliary complications associated with hydatid cyst disease.

Endoscopic management of intrabiliary-ruptured hepatic hydatid cyst

BACKGROUND/AIM

Intrabiliary rupture of hepatic hydatid cyst causes serious morbidity and mortality. These patients are usually managed surgically. We evaluated the feasibility and outcome of an alternative method of treatment of these patients.

METHODS

Seven patients with ruptured hepatic hydatid into the biliary tract underwent endoscopic treatment consisting of endoscopic sphincterotomy, cyst material extraction and hypertonic saline lavage via nasocystic catheter.

RESULTS

Median age of patients was 40 years (range 17-50 years) with a male:female ratio of 2:5. Abdominal pain, jaundice and fever were seen in all patients. Six out of seven patients were positive for hydatid serology. All patients were successfully treated by endoscopic sphincterotomy, clearance of cyst material and hypertonic saline lavage. On a follow-up of 6 months to 4 years (median, 3.5 years), ultrasonography, computed tomography of the abdomen and magnetic resonance imaging of the abdomen showed a complete cure. There were no complications related to procedure.

CONCLUSIONS

This study demonstrates endoscopic treatment as one of the therapeutic options of ruptured hepatic hydatid cyst into the biliary tract.

Endoscopic stenting for selected cases of biliary fistula after hepatic hydatid surgery

BACKGROUND

Biliary fistula develops in 4%-28% of patients after hepatic hydatid disease (HHD) surgery. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) are helpful in the treatment of this complication, persistent fistulas may occur. We therefore conducted a study to evaluate the efficacy of endoscopic biliary stenting in the treatment of biliary fistulas after HHD.

METHODS

In this study, 84 patients who underwent ERCP for postoperative biliary fistula due to HHD were evaluated. Group I included 70 patients treated with only ES, and group II included 14 patients who underwent biliary stenting as their initial treatment. Demographic data, complications, the results of treatment and the reasons for the failure were compared between two groups.

RESULTS

Ninety-five ERCPs were performed. In 63 patients, biliary fistulas were successfully treated with only ERCP and ES. However, 7 patients underwent repeat ERCP and stent placement because of persistent fistula. Biliary stenting was initially performed in 14 patients. The average time for closure of the fistula was 14 +/- 10 days and 7 +/- 3 days in group I (7 patients with repeat ERCP were excluded) and group II, respectively (p = 0.007). There was no statistically significant difference in the complication rates between the groups.

CONCLUSIONS

Although ES is effective in the treatment of biliary fistula after HHD surgery, endoscopic biliary stenting may be considered as the initial procedure in patients with biliary stricture, incomplete clearance of hydatid material in the bile duct, and persisting biliary fistulas after treatment with ERCP and ES.

Classification of hydatid liver cysts

A number of investigations advocate various classification systems for liver hydatid cysts. However, none permits predicting the treatment outcome or making clinical decisions regarding medical treatment; open surgery; punction, aspiration, injection, reaspiration (PAIR); or laparoscopy. An international hydatid disease registry employing an uniform nomenclature and consistent reporting methods would allow more rational comparison of different management strategies. TN(R)C (topography, nature, recurrent, complication) classification is a comprehensive system based on four criteria: location (T), natural history (N), recurrence (R) and complications (C) of the cyst. This pictorial review illustrates the classification and puts accent of its clinical usefulness. The TN(R)C classification provides a standardized description formula of every liver hydatid cyst, permitting multiple comparisons and analyses.

Endoscopic diagnosis and management of tropical parasitic infestations

Biliary parasitosis is one of the common causes of biliary obstruction in developing countries and can often be confused with stone disease. With increased worldwide travel and immigration, these conditions are not limited to the developing countries alone. Ascariasis, hydatid liver disease, clonorchiasis, and fascioliasis are the commonly encountered parasitic infestations of the biliary tract usually presenting with biliary colic or cholangitis. Endoscopy has an important role in the diagnosis and emergent management of these conditions and in elective endoscopic therapy of associated complications. Endoscopic sphincterotomy and bile ductal clearance, along with pharmacotherapy, are the mainstays of treatment.

Diagnostic and therapeutic ERCP in hepatic hydatid disease

BACKGROUND

This retrospective study evaluated the use of diagnostic and therapeutic ERCP in pre- and postoperative patients with hepatic hydatid disease.

METHODS

For 8 years, ERCP was performed in 39 patients with hepatic echinococcal disease. Indications in the preoperative group of patients (n = 19) included a cholestatic enzyme profile in all cases; jaundice or acute cholangitis also was present in, respectively, 14 and 7 cases. In the postoperative group (n = 20), indications for ERCP included persistent external biliary fistula after surgery in 10 patients, jaundice in 8, acute cholangitis in 7, and right upper quadrant pain in 2 patients.

RESULTS

ERCP findings in the preoperative group included cystobiliary fistula (9 patients), external compression of the hepatic biliary system (5), hydatid vesicles and/or membranes within the biliary tract (3), intrahepatic duct stricture (1), and a normal cholangiogram (4). The most common ERCP finding in the postoperative group was external biliary fistula (10 patients); other findings consisted of hydatid cyst material within the bile duct (4), bile duct stenosis (2), cystobiliary fistula and hydatid cyst material in the bile duct (1), cystobiliary fistula (1), hydatid membranes in the gallbladder (1), extrinsic compression to bile ducts (1), and a normal cholangiogram (1). In the preoperative group, endoscopic sphincterotomy was performed in 11 patients, with balloon catheter extraction in 2; complete resolution of findings was achieved in 10 cases. In the postoperative group, sphincterotomy (with balloon or basket extraction as needed) was performed in 19 patients, stents were placed in 2 patients, 1 patient underwent balloon dilatation, and 1 had nasobiliary drainage; there was complete resolution of the findings in 14 of the 20 patients.

CONCLUSIONS

ERCP and related therapeutic maneuvers are safe and valuable in the pre- and postoperative management of patients with hepatic hydatid disease.

Endoscopic therapy in the management of hepatobiliary hydatid disease

Hydatid disease constitutes a serious public health problem throughout the world, especially in endemic areas, despite the use of various kinds of preventive measures. Currently, there are three treatment options for hepatic hydatid disease including surgery, PAIR (puncture, aspiration, injection, and re-aspiration), and chemotherapy with benzimidazole compounds. Each of these therapeutic modalities has limitations depending on the individual case. The authors review the use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary hydatid disease (HHD) to clarify its place in the treatment algorithm among surgical, medical, and percutaneous measures. ERCP in the preoperative period: (1) defines the cystobiliary relationship to help in surgery planning, (2) permits evaluation for acute conditions like cholangitis and obstruction so that subsequent surgery can be performed on an elective basis, (3) may give permanent cure specifically in cases of frank intrabiliary rupture if evacuation of biliary tract and cystic cavity is manageable, and (4) when combined with preoperative endoscopic sphincterotomy may decrease the incidence of the development of postoperative external fistula. ERCP in the postoperative period: (1) can help to clarify the causes of ongoing or recurrent symptoms or laboratory abnormalities, (2) may help to resolve the obstruction or cholangitis due to residual material in biliary ducts, (3) may provide the chance to manage postoperative external biliary fistulae, and (4) may be a realistic solution for secondary biliary strictures. Considering the current literature and adding this experience, the authors propose a new treatment algorithm in HHD including medical, surgical, PAIR, and ERCP-related therapies. To illustrate the algorithm, a case is presented of a patient who had a persistent external biliary fistula in the postoperative period and was managed successfully by endoscopic approach.

Treatment of complications of hepatic hydatid disease by ERCP

BACKGROUND

The aim of this study was to evaluate the effectiveness of endoscopic sphincterotomy for preoperative and postoperative complications of hepatic hydatid disease.

METHODS

Nineteen patients underwent endoscopic treatment for complications of hepatic hydatid disease. Indications for ERCP in 5 patients treated before surgery (Group A) were obstructive jaundice in 1 and acute cholangitis in 4. In 14 patients treated after surgery (Group B), the indication was acute cholangitis in 6, obstructive jaundice 2, and persistent external drainage in 6 patients.

OBSERVATIONS

In group A, ERCP detected hydatid vesicles within the bile duct. All patients underwent endoscopic sphincterotomy and clearance of the duct with no complications. The 6 patients in Group B with persistent external drainage had biliary fistulas that resolved after endoscopic treatment within 10 to 20 days. Among the 8 patients with postoperative obstructive jaundice or acute cholangitis, 7 had cyst remnants obstructing the bile duct and 1 had findings of sclerosing cholangitis. All underwent endoscopic sphincterotomy and clearance of the bile duct without complications. After treatment, all patients, with the exception of the one with sclerosing cholangitis, remained asymptomatic.

CONCLUSION

Endoscopic sphincterotomy is a safe and effective treatment for biliary complications of hepatic hydatid disease.