|Year : 2015 | Volume
| Issue : 1 | Page : 37-40
Biliary duct communication in massive hepatic hydatidosis managed with minimally invasive techniques
Lovenish Bains, Kamal Kishore Gautam, Anubhav Vindal, Pawanindra Lal
Department of Surgery, Division of Minimal Access Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
|Date of Web Publication||27-Jan-2015|
Dr. Anubhav Vindal
Room No 215, Department of Surgery, BL Taneja Block, Maulana Azad Medical College, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
Hydatid cyst most commonly involves the liver. Intrabiliary rupture is one of the complications of hepatic hydatidosis. We present a case of 45-year-old lady with a large hydatid cyst occupying the left lobe of the liver with jaundice and upper gastrointestinal pressure symptoms. Contrast-enhanced computed tomography revealed a large hepatic cyst with rupture of contents into the left hepatic duct. The patient underwent laparoscopic excision of the cyst with closure of the biliary communication. Bilious drainage was observed from intra-cavitory drain in the postoperative period for which patient underwent endoscopic retrograde cholangiopancreatography with selective left duct stenting following which bile output decreased over 1-week. The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. Laparoscopic treatment is an effective mode of treatment for biliary fistulas complicating hepatic hydatid cyst in well-selected patients.
Keywords: Biliary communication, endoscopic retrograde cholangiopancreatography, hydatid cyst, laparoscopy
|How to cite this article:|
Bains L, Gautam KK, Vindal A, Lal P. Biliary duct communication in massive hepatic hydatidosis managed with minimally invasive techniques. MAMC J Med Sci 2015;1:37-40
|How to cite this URL:|
Bains L, Gautam KK, Vindal A, Lal P. Biliary duct communication in massive hepatic hydatidosis managed with minimally invasive techniques. MAMC J Med Sci [serial online] 2015 [cited 2020 Feb 21];1:37-40. Available from: http://www.mamcjms.in/text.asp?2015/1/1/37/150062
| Introduction|| |
Hydatid cyst involves the liver in 50-70% of the adult population. Intrabiliary rupture is the most common complication of hepatic hydatidosis with a reported incidence of cysto-biliary communications from 2.6% to 28.6%. , These communications occur after rupture of a cyst into the bile duct. Minor communications usually remain asymptomatic, but may manifest postoperatively by the presence of a bile leak, whereas major communications usually cause obstructive jaundice and cholangitis. Cysto-biliary communications can pose difficulty during the surgery for hydatid cyst and in the postoperative period.
| Case Report|| |
A 45-year-old lady presented with progressive upper abdominal distension since 1.5 years and early satiety since last 2 months. There was no history of fever, vomiting or trauma. On examination, the patient was average built, vitals were stable. Laboratory investigations and liver function tests were normal. On per abdominal examination, there was a large cystic swelling occupying the upper abdomen, mainly epigastrium measuring 20 × 14 cms [Figure 1]. Ultrasonography of the abdomen showed a large cystic lesion 18 × 11 cms with multiple cysts within suggestive of hepatic hydatid cyst. Hydatid serology was positive by ELISA. Upper gastrointestinal endoscopy performed to investigate early satiety revealed the extrinsic impression over the body of the stomach. Computerized tomography showed liver span of 22 cms, and a thin-walled cystic lesion measuring 18 × 11 cms with multiple daughter cysts within. The cyst was seen to involve the whole of left lobe and majority of the right lobe with sparing of segments VI and VII. The common bile duct was normal [Figure 2]. Patient was started on albendazole therapy (400 mg bd) for six weeks and followed in the outpatient department on a biweekly basis. After 2 months of initial presentation, patient started having features of cholangitis and deepening jaundice. Her blood investigations revealed serum bilirubin of 3.4 mg% and raised alkaline phosphatase of 283 IU/L (normal up to 117). Magnetic resonance cholangiopancreaticography (MRCP) revealed an enlarged liver with span of 27 cm with a large well defined complex cystic lesion of size 14.5 cm × 16 cm × 15 cm with multiple small daughter cysts and floating membranes within. The lesion was seen to communicate with left hepatic duct with mild intrahepatic biliary dilatation [Figure 3]. Patient underwent laparoscopic exploration after cholangitis was treated. Intraoperative, a large cystic lesion was seen to be arising from the liver anteriorly involving left lobe and most of the right lobe [Figure 4] and [Figure 5]. The patient underwent laparoscopic deroofing of the cyst and evacuation of cyst contents with closure of the biliary communication. Hypertonic saline (3%) along with povidone-iodine (10%) was used as the scolicidal agent. Intra operatively, the cysto biliary communication was identified by bile leak from the cyst wall and closed laparoscopically using 3-0 polygalactin. A sutured omentopexy and intra-cavitory drain placement were performed [Figure 6] and [Figure 7]. The drain output was serosanguineous 100-200 ml/day which changed to bilious from the 4 th day. The output increased to 100-400 ml/day in the next 3 weeks and plateaued around 200 ml. Patient underwent endoscopic retrograde cholangiopancreatography with selective left duct stenting following which the bile output decreased over the next 1-week. Intra-cavitory drain was then removed, and the patient discharged and is presently asymptomatic in follow-up.
|Figure 3: Magnetic resonance cholangiopancreatography with arrow showing the communication of cyst with left hepatic duct|
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| Discussion|| |
Hydatid disease is a zoonotic parasitic disease caused by a tapeworm, mainly by Echinococcus granulosus and liver is the most common organ involved. The larval stage of the disease develops into a hydatid cyst and humans are accidental intermediate hosts. Communication between the hydatid cyst and the biliary tree varies from a small communication to frank intrabiliary rupture. The true percentage of cysto-biliary communication is not known as there is no accepted definition. The percentage varies from 5% to 25% of patients and the incidence of clinically apparent biliary leakage at 26%. ,,
The presentation is usually asymptomatic in occult communications which may manifest postoperatively by the presence of a bile leak. However, major communications present with obstructive jaundice and cholangitis. Hydatid cyst growth causes displacement, distortion, and stenosis of the hepatic ductules with impaired bile drainage. Long-term compression renders the hepatic ductule atrophic, and liable to rupture, forming a hydatid cyst-biliary fistula.  Rupture of hydatid cyst into biliary tree leads to a flow from a high pressure zone (cyst) to low pressure zone (biliary tree) following which the fragments of cyst wall or small daughter cysts may enter the biliary tree leading to cholestasis, jaundice and cholangitis. This "frank biliary rupture" can be diagnosed preoperatively by history, biochemical and radiological investigations.  Sonography and computerized tomography remain the primary investigations supplemented by MRCP in cases of jaundice. Unalp et al. has found independent clinical predictors of cysto-biliary communications as alkaline phosphatase >133 U/L (normal upto 98), total bilirubin levels >1.2 mg/dl, white blood cell count >10,000/mm and cyst diameter >10 cm. 
Centrally placed large cysts and near the liver hilum are more likely to have cysto-biliary communication and related complications.  Radiologic and intraoperative findings may not be helpful to detect cysto-biliary communications in most asymptomatic patients with liver hydatidosis. Biliary leakage is a troubling complication that arises after conservative surgery like deroofing of cyst in patients who have occult cysto-biliary communications. A communication of more than 5 mm in diameter or with a major bile duct is known as "major biliary communication" with a reported incidence of 5-10%. 
In our case, the cyst was placed centrally and toward hilum and later development of jaundice and cholangitis was suggestive of a possible cysto-biliary communication which was established by MRCP. A careful search was made for the communication intraoperatively and was closed; however, persistent biliary drainage prompted for endoscopic management and with stent placement it was successfully treated.
The therapeutic options for cysto-biliary communications are multiple and related to the size of the communication, the location of the cyst, and the experience of the surgeon. They vary from closure of communication, common bile duct exploration, T-tube drainage, choledochoduodenostomy, hepatico-jejunostomy, and pericysto-jejunostomy.  Many case reports and series have been published establishing the role of laparoscopic surgery in uncomplicated hepatic cysts, however very few report about laparoscopy in complicated hepatic cysts with cysto-biliary communication.  In our case, minimally invasive technique was were successfully utilized for the treatment.
Endoscopic retrograde cholangiopancreatography with sphincterotomy or stenting is valuable in the postoperative management of biliary fistulae in the hepatic hydatid disease.  Sphincterotomy alone or a combination of sphincterotomy and stenting has been used an adjunct in treating complications due to cysto-biliary communications in both pre- and post-operative period. Endoscopic biliary procedures have become the treatment of choice for the management of biliary fistulae. Drainage of infected cysts in moribund patients can be life-saving. ,
| Conclusion|| |
Laparoscopic treatment is an effective mode of treatment for complicated hepatic hydatidosis with biliary rupture in well-selected patients. The crucial steps remain as evacuation of the cyst contents without spillage, sterilization of the cyst cavity with scolicidal agents and cavity management using established surgical techniques along with the closure of the communication.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]