Cystobiliary fistula in hepatic hydatid disease: diagnostic and therapeutic challenge

ABSTRACT

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