Treatment of hepatic hydatid disease complications using endoscopic retrograde cholangiopancreatography procedures

Optimized Strategies for Managing Abdominal Hydatid Cysts and Their Complications

Hepatic hydatid cysts are an example of a zoonosis with global distribution, but with endemic characteristics in certain geographic areas. Known since ancient times, this parasitic infection predominantly affecting the liver and lungs remains a challenge today in terms of diagnosis and the pharmacological, radiological, endoscopic, or surgical therapy. This study analyzed the complications associated with different procedures for treating hydatid cysts in 76 patients admitted to the County Clinical Emergency Hospital of Sibiu. Complications occurred in 18 patients (23.7%), with no significant correlation to age, gender, or residency (urban or rural). Patients undergoing open surgery exhibited the highest complication rate (61.1%) compared to those treated with other procedures. The most frequent complication was biliary duct rupture, occurring in 22.7% of cases. Our findings indicate that the presence of complications significantly prolongs hospitalization time [t df (75) = 12.14, p < 0.001]. Based on these findings, we conclude that the surgical approach for hydatid cysts should be meticulously tailored to each patient's specific circumstances to reduce the risk of complications and improve clinical outcomes.

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.

Cholangiohydatidosis. Clinical features, postoperative complications and hospital mortality. A systematic review

BACKGROUND

Cholangiohydatidosis (CH) is an evolutionary complication of hepatic cystic echinococcosis, associated with increased morbidity and mortality. The aim of this study was to describe the available evidence regarding clinical characteristics of CH, postoperative complications and hospital mortality.

METHODOLOGY/PRINCIPAL FINDINGS

Systematic review. Studies related to CH with no language or publication restriction were included. Sensitive searches were performed in Trip Database, SciELO, BIREME-BVS, WoS, PubMed, EMBASE and SCOPUS. MeSH and free terms were used, including articles up to April 2023. The main outcome variables were postoperative complications and hospital mortality; the secondary ones were publication year, origin and design of primary studies, main clinical manifestation, anatomical location and type of cysts, hospital stay, surgical procedure performed, reinterventions; and methodological quality of primary studies, which was assessed using MInCir-T and MInCir-P scales. Descriptive statistics, calculation of weighted averages and their comparison by least squares logistic regression were applied. 446 studies were retrieved from the searches performed, 102 of which met the inclusion and exclusion criteria. The studies analyzed represent 1241 patients. The highest proportion of articles was published in the last decade (39.2%). Reports are mainly from Turkey (28.4%), Greece (9.8%), Morocco and Spain (8.8% each). With a weighted mean of 14.3 days of hospital stance; it was verified that 26.2% of patients developed postoperative complications (74,3% Clavien y Dindo III y IV), 6.7% needed re-interventions, and 3.7% died. When comparing the variables age, postoperative complications, hospital mortality, and reinterventions in two periods of time (1982-2006 vs. 2007-2023), no statistically significant differences were found. When applying the MInCir-T and MInCir-P scales, the methodological quality of the primary studies was 9.6±1.1 and 14.5±4.3 points, respectively.

CONCLUSION/SIGNIFICANCE

CH is associated with severe postoperative complications and significant hospital mortality, independent of the development of therapeutic support associated with the passage of time.

Identification of infiltrating immune cell subsets and heterogeneous macrophages in the lesion microenvironment of hepatic cystic echinococcosis patients with different cyst viability

Human cystic echinococcosis (CE) is characterized by lesion microenvironment formation through gathering various immune cells, including macrophages. However, immune cell subsets and heterogeneous macrophages in CE lesion microenvironment are poorly defined. Massive infiltrating immune cells formed lesion microenvironment, among which CD4⁺T cells and CD19⁺B cells were predominant and CD68⁺ macrophages were more evident in patients with active cysts. Different degrees of liver fibrosis was observed in Peri-Lesion (PL) liver samples, which was more evident in patients with active cysts. Expression of both M1 and M2 macrophage markers was significantly increased in PL liver samples. Importantly, elevation of M1 macrophage markers was more obvious in patients with inactive cysts, whereas M2 macrophage markers represented dominant macrophage phenotype in patients with active cysts. Additionally, macrophage-derived MIF, TGF-β1 and ECM1 were also expressed at higher level in CE lesion microenvironment of patients with active cysts. Moreover, MIF was evidently enhanced in the serum of hepatic CE patients, which was also predominant in patients with active cysts. Correlation analysis demonstrated positive correlation between expression of macrophage-derived cytokines and liver fibrosis degree. Heterogeneous macrophages may play significant roles in liver fibrosis of CE lesion microenvironment through producing pro-fibrogenic cytokines.

Diagnosis and treatment modalities of hilar biliary duct stricture in hepatic cystic echinococcosis after endocystectomy

Aim: Hilar biliary duct stricture may occur in hepatic cystic echinococcosis (CE) patients after endocystectomy. This study aimed to explore diagnosis and treatment modalities. Methods: Clinical data of 26 hepatic CE patients undergoing endocystectomy who developed postoperative hilar biliary duct stricture were retrospectively analyzed and were classified into three types: type A, type B, and type C. Postoperative complications and survival time were successfully followed up. Results: Imaging showed biliary duct stenosis, atrophy of ipsilateral hepatic lobe, reactive hyperplasia, hepatic hilum calcification, and dilation or discontinuity of intrahepatic biliary duct. All patients received partial hepatectomy to resect residual cyst cavity and atrophic liver tissue, and anastomosis of hepatic duct with jejunum or common bile duct exploration was applied to handle hilar biliary duct stricture. Twenty-five patients were successfully followed up. Among type A patients, one patient died of organ failure, and upper gastrointestinal bleeding and liver abscess occurred in one patient. Moreover, calculus of intrahepatic duct was found in one type B and type C patient. Conclusion: Long-term biliary fistula, infection of residual cavity or obstructive jaundice in hepatic CE patients after endocystectomy are possible indicators of hilar bile duct stricture. Individualized and comprehensive treatment measures, especially effective treatment of residual cavity and biliary fistula, are optimal to avoid serious hilar bile duct stricture.

Echinococcosis: Advances in the 21st Century

Echinococcosis is a zoonosis caused by cestodes of the genus Echinococcus (family Taeniidae). This serious and near-cosmopolitan disease continues to be a significant public health issue, with western China being the area of highest endemicity for both the cystic (CE) and alveolar (AE) forms of echinococcosis. Considerable advances have been made in the 21st century on the genetics, genomics, and molecular epidemiology of the causative parasites, on diagnostic tools, and on treatment techniques and control strategies, including the development and deployment of vaccines. In terms of surgery, new procedures have superseded traditional techniques, and total cystectomy in CE, ex vivo resection with autotransplantation in AE, and percutaneous and perendoscopic procedures in both diseases have improved treatment efficacy and the quality of life of patients. In this review, we summarize recent progress on the biology, epidemiology, diagnosis, management, control, and prevention of CE and AE. Currently there is no alternative drug to albendazole to treat echinococcosis, and new compounds are required urgently. Recently acquired genomic and proteomic information can provide a platform for improving diagnosis and for finding new drug and vaccine targets, with direct impact in the future on the control of echinococcosis, which continues to be a global challenge.

Endoscopic retrograde cholangiopancreatography for biliary system parasites

OBJECTIVE

Endoscopic retrograde cholangiopancreatography may be useful in the diagnosis and management of biliary system parasites.

MATERIAL AND METHODS

Investigators retrospectively evaluated patients with biliary system parasites who underwent endoscopic retrograde cholangiopancreatography procedures over an eight-year period. We collected data regarding patient demographics, clinical features, and parasite type. We aimed to determine the utility of endoscopic retrograde cholangiopancreatography as a diagnostic and therapeutic intervention in patients with biliary system parasites.

RESULTS

We identified 22 patients with biliary system parasites from a total of 3,450 endoscopic retrograde cholangiopancreatography procedures performed during an eight-year period. Parasite types included Echinococcus granulosus (n=19), Fasciola hepatica (n=2), and Ascaris lumbricoides (n=1). Fifteen patients with liver hydatid cysts underwent endoscopic retrograde cholangiopancreatography prior to surgery due to obstructive jaundice. The endoscopic retrograde cholangiopancreatography procedure enabled definitive treatment without the need for surgery in the remaining two patients. Two patients with fascioliasis underwent endoscopic retrograde cholangiopancreatography due to clinical presentation of cholangitis, cholecystitis, and obstructive jaundice, leading to presumptive diagnosis of cholangiocarcinoma. However, the final diagnosis was made using endoscopic retrograde cholangiopancreatography following inspection of flat, leaf-shaped, motile flukes extracted from the bile duct. In one patient with ascariasis, a longitudinal tubular structure was identified in the bile duct; emergency surgery was required.

CONCLUSION

The diagnosis of parasitic diseases is clinically challenging, and definitive diagnosis requires endoscopic retrograde cholangiopancreatography in some cases. Moreover, endoscopic retrograde cholangiopancreatography provides a therapeutic option for ascariasis, fascioliasis, and some forms of hydatidosis. Accordingly, the use of endoscopic retrograde cholangiopancreatography may change preoperative management and treatment strategies for biliary system parasite infections.

Endoscopic retrograde cholangiopancreatography in ruptured liver hydatid cyst

One of the most common and serious complications of hepatic hydatid cyst disease is communication between the cyst and the biliary tree. Surgical management of biliary fistula is associated with high morbidity and mortality. We retrospectively reviewed the effectiveness of endoscopic treatment of ruptured hydatid cyst into intrahepatic bile ducts. Diagnosis of intrabiliary rupture of hydatid cyst was mostly suspected by acute cholangitis, jaundice, pain, and/or persistent external biliary fistula after surgery. The diagnosis was confirmed by radiology and endoscopic retrograde cholangiopancreatography (ERCP) findings. We retrospectively reviewed clinical, laboratory, imagery, and ERCP findings for all patients. The therapeutic methods performed were endoscopic sphincterotomy, extraction by balloon or Dormia basket, stenting, or nasobiliary drainage. Sixteen patients with ruptured hepatic hydatid cyst into bile ducts were seen in 9 years. Nine of 16 patients had a surgical history of hepatic hydatid cyst and three patients had a percutanous treatment history. We carried out ERCP with sphincterotomy and extraction of hydatid materials (extraction balloon n = 11; Dormia basket n = 5) or biliary drainage (nasobiliary drainage n = 1; biliary stenting n = 1). The fistula healed in 80 % of patients with a median time of 6 weeks [range, 1-12] after endoscopic treatment. ERCP was an effective method of treatment for hepatic hydatid cyst with biliary fistula.

The role of perioperative endoscopic retrograde cholangiopancreatography and biliary drainage in large liver hydatid cysts

Background. The best surgical technique for large liver hydatid cysts (LHCs) has not yet been agreed on. Objectives. The objective of this study was to examine the role of perioperative endoscopic retrograde cholangiopancreatography (ERCP) and biliary drainage in patients with large LHCs. Methods. A 20-year retrospective study of patients with LHCs treated surgically at the University Clinical Center of Kosovo (UCCK). We divided patients into 2 groups based on treatment period: 1981–1990 (Group I) and 2001–2010 (Group II). Demographic characteristics (sex, age), the surgical procedure performed, complications rate, and outcomes were compared. Results. Of the 340 patients in our study, 218 (64.1%) were female with median age of 37 years (range, 17 to 81 years). 71% of patients underwent endocystectomy with partial pericystectomy and omentoplication, 8% total pericystectomy, 18% endocystectomy with capitonnage, and 3% external drainage. In Group I, 10 patients underwent bile duct exploration and T-tube placement; in Group II, 39 patients underwent bile duct exploration and T-tube placement. In addition, 9 patients in Group II underwent perioperative ERCP with papillotomy. The complication rate was 14.32% versus 6.37%, respectively (P = 0.001). Conclusion. Perioperative ERCP and biliary drainage significantly decreased the complication rate and improved outcomes in patients with large LHCs.