Bile leaks following surgery for hepatic hydatid disease - medIND

Bile leaks following surgery for hepatic hydatid diseaseShaleen Agarwal, Sadiq Saleem Sikora, Ashok Kumar,Rajan Saxena, Vinay Kumar KapoorDepartment of Surgical Gastroenterology,Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 220 014Background: Conservative surgery (cyst evacuationand partial pericystectomy) for hydatid cysts of theliver is known to be safe but is often associated withbile leak and its sequelae. Methods: Case records of86 patients undergoing surgery for hydatid cysts ofthe liver at a tertiary-care center in northern Indiaover a 14-year period were reviewed retrospectively.Results: Sixteen (18%) patients had jaundice and36 (42%) had a cyst-biliary communication detectedat surgery. Biliary complications developed in 14 (16%)patients. Bile leaks and bilio-cutaneous fistulae wereobserved in 11 (13%) patients; the fistula output waslow (

C M Y KAgarwal, Sikora, Kumar, Saxena, KapoorBile leaks following surgery for hydatid cystpresent in 29 (34%) and 16 (18%) patients, respectively.Cysts were localized to the right lobe of the liver in 55(64%) patients, to the left lobe in 25 (29%) patients, andinvolved both lobes in 6 (7%) patients; 18 (21%) patientshad multiple cysts. Additional sites of cysts includedthe lungs (n=3) and spleen (n=1); 5 patients haddisseminated peritoneal disease.Pre-operative ERC and biliary drainage were performedin 4 patients presenting with jaundice and cholangitis.Radical surgical procedures like cystopericystectomy(n=12) and anatomical hepatic resection (n=2) were performedin 14 (16%) patients; a majority of patients (n=72,84%) underwent conservative procedures that includedcyst evacuation and partial pericystectomy (n=57) orcapsulorrhaphy (n=15). Internal drainage of the residualcavity in the form of Roux-en-Y cysto-jejunostomy wasperformed after partial pericystectomy in 12 patients,while the cavity was drained externally in 8 patients.Cyst-biliary communications were detected in 36 (42%)patients and these were individually ligated with syntheticabsorbable suture; in 16 (18%) patients, CBDexploration and T-tube drainage was also done. Cholecystectomywas added to the surgical procedure in 24(28%) patients either because of the presence of gallbladder calculi (n=13) or because of the gall bladderwas densely adherent to the cyst (n=11). External drainagewas performed in patients with infected cysts.Postoperative bile leaks occurred in 14 (16%) patients;none of these patients had undergone a cystexcisionprocedure (cysto-pericystectomy or left lateralsegmentectomy). Cyst-biliary communication had beendetected at the time of surgery in 11 of 14 patients; in4 of these patients, in addition to suture ligation ofcyst-biliary communication, a biliary decompressionprocedure (CBD exploration and T-tube drainage) hadbeen performed (Fig). One patient died in hospital of anunrelated medical condition (dilated cardiomyopathy withcongestive heart failure). Right lobar cysts, cysts withbiliary communications, and those undergoing externalTable: Clinical features of patients with and without postoperativebile leaksPatients with Patients withoutbile leak (n=14) bile leak (n=72)Jaundice 3 13Fever 6 22Mean diameter of cyst (cm) 11.9 10.4Site of cystRight lobe 12 43*Left lobe 1 24Both lobes 1 5Cyst-biliary communication at surgery 11 25*External drainage of cyst 6 2*Internal drainage (cysto-jejunostomy) 2 10*p

Agarwal, Sikora, Kumar, Saxena, KapoorBile leaks following surgery for hydatid cystConservative procedures are safe and technicallysimple, and are useful in the management of uncomplicatedhydatid cysts. 6 However, their main disadvantageis the high frequency of postoperative complications,the most common being bile leak from a cyst-biliarycommunication and its sequelae like bilio-cutaneous fistulae,bilomas and bile peritonitis (4%-28%). 5,7,9 Thefrequency of biliary complications in our series was16%, similar to those in other series with predominantlyconservative surgical techniques of management. 5-9In order to reduce postoperative bile leaks, all effortsshould be made during surgery to detect cystbiliarycommunications. The various techniques that helpin this include: i) avoiding the use of colored scolicidalagents like povidone-iodine since they interfere withidentification of cyst-biliary communications; ii) meticulousinspection of the residual cavity after evacuationof cyst contents; iii) placing a white laparotomy pad inthe residual cavity for few minutes and then inspectingit for evidence of bile staining; and, iv) injecting acolored dye into the biliary tree and looking for stainingin the residual cavity. An intra-operative cholangiogrammay also be useful. All cyst-biliary communicationsidentified should be meticulously ligated using sutures.Biliary decompression should be performed in patientswith large cyst-biliary communications or when closureis unsatisfactory. A recent report has suggested thatroutine biliary decompression with a T-tube in patientswith cyst-biliary complications may reduce the frequencyof postoperative bile leaks. 10External biliary fistulae following surgery for liverhydatid disease tend to close spontaneously. In a reviewof 304 cases, all the 10 external biliary fistulaeclosed spontaneously over a period of 2-4 months. 11 Inanother series, 7 of 12 fistulae closed spontaneously,with the maximum time to closure being 38 days. 12Though most fistulae close spontaneously, the prolongedbiliary drainage causes significant morbidity. In our series,the median hospital stay in patients with bile leaks was18 days as compared to 7 days in those without biliarycomplications. Re-exploration was usually not requiredin these patients and most of them were managed successfullyby percutaneous and/or endoscopic methods.Most series on hepatic hydatid disease report ona small number of patients with postoperative externalbiliary fistulae; it is generally accepted that endoscopicmanagement in the form of endoscopic sphincterotomy,with or without stenting or naso-biliary drainage, playsa key role in the management of such patients. 13,14,15Endoscopic sphincterotomy is believed to reduce thehigh intra-biliary pressure, and promote early closure ofthese fistulae even in the absence of distal biliary obstruction.13No guidelines are available regarding the mostappropriate timing of endoscopic intervention. The timeof intervention has varied from a few days to severalmonths after surgery. The time taken for closure offistulae after endoscopic intervention too has variedwidely (2 to 30 days) in different reports. 14-18 In ourseries, it was about 2 weeks after biliary decompression(surgical or endoscopic). The reason for this delay maylie in the nature of underlying disease. The fibrotic andchronically inflammed pericyst may prevent the collapseof the residual cavity and delay the closure of cystbiliarycommunications.Some authors 19 have classified post-operative biliaryfistulae in these patients into high- and low-outputcategories to help in making treatment decision. Whereasearly endoscopic biliary decompression has been recommendedfor high-output fistulae, no or delayed interventionhas been adopted for low-output fistulae.In our patients, per-operative biliary decompressionusing a T-tube was associated with a quicker fistulaclosure. It may thus be expected that early postoperativeendoscopic biliary decompression will also hastenfistula closure. In fact, a recent report suggestedthat routine biliary decompression using a T-tube inpatients with cyst-biliary complications was associatedwith lower incidence of postoperative bile leaks. 10 Themedian closure time of high-output fistulae after endoscopicintervention in our study was 18 days.We conclude that bile leaks are not uncommonafter conservative surgery for hepatic hydatid disease.Patients with high-output fistulae should undergo earlyendoscopic biliary decompression in order to hastenfistula closure and to reduce morbidity. In contrast, amajority of low-output fistulae close spontaneously withconservative management; however, even these maybenefit from early endoscopic intervention.References1. Eckert J, Gemmel MA, Matyas Z, Saulsby EJ. Guidelinesfor Surveillance, Prevention and Control of Echinococcosis/Hydatidosis. Geneva, Switzerland: World Health Organization.1984: p. 1-5.2. Belli L, Favero E, Marni A, Romani F. Resection versuspericystectomy in the treatment of hydatidosis of the liver.Am J Surg 1983;145:239-42.3. Pissiotis CA, Wander JU, Condon RE. Surgical treatment ofhydatid disease: prevention of complications and recurrence.Arch Surg 1972;104:454-9.4. Ekrami Y. Surgical treatment of hydatid disease of the liver.Arch Surg 1976;111:1350-2.5. Barros JL. Hydatid disease of the liver. Am J Surg1978;135:597-600.6. Dawson JL, Stamatakis JD, Stringer MD, Williams R. Surgicaltreatment of hepatic hydatid disease. Br J Surg1988;75:946-50.7. Gonzales EM, Selas PR, Martinez B, Pascual MH. Resultsof surgical treatment of hepatic hydatidosis: current therapeuticmodifications. World J Surg 1991;15:254-63.Indian Journal of Gastroenterology 2005 Vol 24 March - April 57

Agarwal, Sikora, Kumar, Saxena, KapoorBile leaks following surgery for hydatid cyst8. Magistrelli P, Masetti R, Coppola R, Picciocchi A. Surgicaltreatment of hydatid disease of the liver: a 20-year experience.Arch Surg 1991;126:518-23.9. Alper A, Ariogul O, Emre A, Uras A, Okten A.Choledochoduodenostomy for intrabiliary rupture of hydatidcysts of the liver. Br J Surg 1987;74:243-5.10. Silva MA, Mirza DF, Bramhall SR, Mayer AD, McMasterP, Buckels JAC. Treatment of hydatid disease of the liver.Dig Surg 2004;21:227-34.11. Balik AA, Basoglu M, Celebi F, Oren D, Polat KY, AtamanalpSS, et al. Surgical treatment of hydatid disease of the liver.Arch Surg 1999;134:166-9.12. Vagioanos C, Androulakis JA. Capsectomy and drainage inhepatic hydatidosis. Dig Surg 1997;14:241-4.13. Vignote ML, Mino G, de Dios JF, Gomez F. Endoscopicsphincterotomy in hepatic hydatid disease open to thebiliary tree. Br J Surg 1990;77:30-1.14. Dumas R, Gall PL, Hastier P, Buckley MJM, Conio M,Delmont JP, et al. The role of endoscopic retrogradecholangiopancreatography in the management of hepatichydatid disease. Endoscopy 1999;31:242-7.15. Rodriguez AN, Sanchez AL, Alguacil LV, Fugarolas GM.Effectiveness of endoscopic sphincterotomy in complicatedhepatic hydatid disease. Gastrointest Endosc 1998;48:593-7.16. Bilsel Y, Bulut T, Yamaner S, Buyukuncu Y, Bugra D,Akyuz A, et al. ERCP in the diagnosis and management ofcomplications after surgery for hepatic echinococcosis.Gastrointest Endosc 2003;57:210-3.17. Tekant Y, Bilge K, Alper A, Emre A. Endoscopic sphincterotomyin the treatment of postoperative biliary fistulasof hepatic hydatid disease. Surg Endosc 1996;10:909-11.18. Akoglu M, Hilmioglu F, Balay AR, Sahin B, Davidson BR.Endoscopic sphincterotomy in the hepatic hydatid diseaseopen to biliary tree. Br J Surg 1990;77:1073.19. Skroubis G, Vagianos C, Polydorou A, Androulakis J. Significanceof bile leaks complicating conservative surgery forliver hydatidosis. World J Surg 2002;26:704-8.Correspondence to: Dr Sikora, Additional Professor. E-mail:sadiqss@sgpgi.ac.in. Fax: (522) 266 8017, 266 8129Received August 16, 2004. Received in final revised formDecember 23, 2004. Accepted December 28, 2004AcknowledgementThe Editorial Board of the Journal expresses sincere gratitude to Dr Ramesh Roop Raiand the Organizing Committee of the 45th Annual Conference of the Indian Society ofGastroenterology, Jaipur for the generous contribution of Rs 200,000 to the JournalIndian Journal of GastroenterologyJ Mitra Memorial AwardThe Indian Journal of Gastroenterology bestows this award for the best originalscientific contribution published in the Journal during the yearThis award carries a prize of Rs 20 000, and will be given to the department(s) submittingthe selected paper. The paper will be selected by a scientific committee appointed by theEditor, from among all the Original Articles published in the Journal during the year.In the event of a tie, the award will be distributed equally. Terms for eligibilty will apply.The award has been made possible by a generous endowment fromM/s J Mitra and Co Ltd, New Delhi58 Indian Journal of Gastroenterology 2005 Vol 24 March - April