Cystobiliary fistula in hepatic hydatid disease: diagnostic and therapeutic challenge

In Hydatid disease of the liver cystobiliary fisula [CBF] constitutes an anatomic and a clinicopdthologic entity characterized by the occurrence of a life-threatening cholangitis with increased morbidity and the prolongation of hospital stay. An accurate preoperative diagnosis of this complication is essential for its prompt surgical management. The diagnosis of hydatid disease and the existence of CBF is based primarily on both of the clinical presentation and the characteristic appearance on ultrasonographic [US] and/or computed tomographic [CT] imaging, and confirmed by endoscopic retrograde cholangiography [ERC]. The aim of this work was to study the different diagnostic and therapeutic aspects of cystobiliary fistula in hydatid disease of the liver. From 1996 to 2003, among 63 patients treated for hydatid cysts of the liver, 17 with complicated cysts were included in the current study. They were 11 males and 6 females with a mean age of 34.5 years [ranged from 12 to72 yrs]. According to the clinical presentation, they were divided into 3 groups; group A: nine patients presented with cholangitis, group B: five patients had history of jaundice and group C: three patients presented with jaundice. In 14 patients [groups A and B], the diagnosis of CBF was suspected by abdominal US and/or CT imaging and confirmed by ERC. In the remaining 3 patients [group C], CBF was not documented and they were excluded. Preoperative endoscopic sphencterotomy ES was done in group A with retrieval of hydatid daughter cysts. Among the patients of group A, Seven patients [subgroup Al] were subsequently submitted to surgery entailing endocystectomy in 5 and hepatic resection in two. The remaining 2 patients in group A [subgroup A2] were managed by endoscopic therapy only. Patients of group B [n = 5], were not submitted to preoperative ES and were subsequently managed by hepatic resection in one patient and endocystectomy in four. There was no mortality in the studied group. Postoperative bile leak occurred in four cases; one after hepatic resection and three after endocsytectomy in group B for whom preoperative endoscopic sphincterotmy [ES] was not done. In contrast, none of the patients who were submitted to preoperative ES [subgroup Al] had bile leak. Postoperative wound infection was reported in three patients and minimal subphrenic collection that was aspirated under US guidance was in two. A chest complication in the form of atelecatasis was recorded in one patient. The mean hospital stay was 12.4 days. All patients received albendazole treatment. Surgery still remains the treatment of choice for hydatid cysts of the liver complicated with cystobiliary fistula [CBF]. The results of this work highlight the validity of diagnostic ERC in confirming the diagnosis of CBF in suspected patients with complicated hydatid cysts of the liver. Also, therapeutic ERC has a place in the treatment algorithm of CBF as it was found to be a safe and a reliable therapeutic alternative especially in high risk patients for surgery

Ultrasonographic triangular cord [TC] sign: a predictor of the type and outcome of biliary atresia

To study the accuracy of triangular cord [TC] sign in the diagnosis of biliary atresia [BA], and its validity in predicting the type and outcome of BA, patients treated for BA at the department of surgery. National Liver Institute, were included. Pre-operatively, the same radiologist examined all patients, with special emphasis on detecting the triangular cord [TC] sign if present. Operative findings included the presence or absence of fibrotic remnants at the porta-hepatis for correlation with the TC sign detected by ultrasound [US]. The type of biliary atresia [BA] was diagnosed and confirmed after intra-operative cholangiography. Postoperative data included routine laboratomy work-up, which was done weekly for a month, and monthly thereafter. The outcome was evaluated regarding achievement or not of restoration of bile drainage, frequency of postoperative cholangitic attacks, other morbidity and mortality. Thirty-eight patients treated for BA were included. They were 21 males and 17 females with a mean age of 8l.4 days [range 50-130]. The TC sign was detected in 93.3% of infants with type III BA, and absent in all cases of type II and I. The sensitivity and specificity of the TC sign in the diagnosis of type III BA were 93.3% and 100% respectively. The positive and negative predictive values were 100% and 80% respectively. The outcome of patients was categorized according to the achievement of bile flow restoration, and the presence or absence of jaundice into three groups: group A; became non-icteric [n = 7], group B; stool became colored but remained icteric [n = 23], and group C; remained icteric with clay stool [n = 5].Attack of acute cholangitis were more frequent [17/28:60.7%] among the icteric patients in groups B and C than the non-icteric patients in group A [2/7:28.6%]. Among the patients with type III BA, the TC sign usually indicates advanced fibrosis. All patients older than 60 days had a positive TC sign, and in whom, only 1 out of 2 7 patients [3.7%] achieved complete biliary drainage. Two of the 3 patients with a negative TC sign and type III BA achieved complete biliary flow restoration. Overall mortality was 16 out of 38 [42.1%]; four of them were lost during follow-up and considered as mortality. This study showed that detecting the triangular cord [TC] sign ultrasonographically might be a bad prognostic index, predicting failure of restoring biliary flow after surgery. Further large studies with longer follow-up period are recommended