Original Paper Received: November 8, 2000 Accepted: May 2, 2001
Dig Surg 2001;18:289–293
Surgical Treatment of Intrabiliary Rupture of Hydatid Cysts of Liver: Comparison of Choledochoduodenostomy with T-Tube Drainage Orhan Elbir Haldun Gundogdu Mehmet Caglikulekci Cuneyt Kayaalp Fuat Atalay Metin Savkilioglu Canbek Seven Department of Gastrointestinal Surgery, Yuksek Ihtisas Hospital, Ankara, Turkey
Key Words Surgical treatment W Intrabiliary rupture W Liver hydatid cyst W T-tube W Choledochoduodenostomy
was treated with CD died postoperatively. Conclusion: Our results suggest that T-tube drainage is superior to CD for intrabiliary rupture of LHC in most cases. Copyright © 2001 S. Karger AG, Basel
Abstract Background: Intrabiliary rupture is one of the most serious complications of liver hydatid cysts (LHC). The kind of surgery for these patients is still controversial. T-tube drainage and choledochoduodenostomy (CD) are used by most of the surgeons. But there is no comparative study in the literature. Methods: Eighty patients with symptomatic intrabiliary rupture were treated between 1980 and 1995. All patients had jaundice. In addition to treatment of the cyst cavity, T-tube drainage of the common bile duct (CBD) was performed in 53 patients, 25 patients underwent a CD for biliary drainage and two patients were treated by a T-tube placed in the CBD without treating the cyst. The T-tube drainage and CD groups were compared in regard to morbidity, mortality, duration of the operation, rate of relaparatomy and duration of postoperative hospital stay. Results: The morbidity rate was 40% (10/25) after CD and 18.1% (10/55) after Ttube drainage. Relaparatomy was necessary in 8% (2/25) and 1.8% (1/55) of patients treated with CD and T-tube drainage, respectively. T-tube drainage was performed much more rapidly than CD (p ! 0.05). The length of hospital stay for both groups was the same. One patient who
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Introduction
The most common complication of liver hydatid cysts (LHC) is intrabiliary rupture which has an incidence of 2.5–34%. Ninety percent of all hepatic cysts sooner or later either leak into a small duct or frankly rupture into a large one [1–3]. Intrabiliary rupture was first reported in 1928 by Dew [4]. The pressure inside the cysts in always higher than the pressure in the biliary tract. After rupture, the cyst elements pass into the biliary ducts and may cause obstruction and cholangitis. The communication with the bile duct can be tangential (side to side) or terminal (end to side). Depending on the site of the cyst, a cystobiliary communication can involve a peripheral, smallcaliber bile duct (generally end to side) or a major segmental duct including the right or left hepatic ducts. Simple communications are frequently found during surgery and may cause postoperative biliary fistula unless they are properly treated by closing the openings. Frank intrabiliary rupture should be diagnosed preoperatively and explored carefully during surgery. There are two stages of the operations in patients with intrabiliary rupture: the
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Table 1. Summary of previous reports of
the intrabiliary rupture of hydatid cysts
Author
Year
Cases (%)
Total cases of Main method of Mortality hydatid cysts biliary drainage (%)
Kattan [27] Lygidakis [24] Dadoukis [6] Akinoglu [21] Alper [5] Kayabali [20] Magistrelli [13] Gonzales [14] Safioleas [19] Ulualp [18] Kornaros [2]
1975 1984 1984 1985 1987 1990 1991 1991 1994 1995 1996
15 (11) 39 (9.3) 45 (17) 29 (20.3) 28 (16) 32 (3.3) 44 (33) 86 (20.9) 24 (18.2) 36 27 (13)
136 417 265 143 174 948 135 410 132
treatment of the cyst and the exploration and drainage of the common bile duct (CBD) [1–3, 5–7]. While there are various reports on drainage of the CBD (table 1), no comparative study exists. We present a series of 80 patients with symptomatic biliary rupture of LHC, treated either with choledochoduodenostomy (CD) or T-tube drainage in addition to cavity management.
208
T-tube T-tube T-tube T-tube CD T-tube T-tube T-tube T-tube T-tube T-tube
0 2.56 2.2 – 3.9 0 4.5 – – 0 0
Table 2. Operations used to treat the cyst cavity
Operation
Patients
Pericystectomy Partial cystectomy + capittonage Partial cystectomy + intraflexion External drainage Drainage via common bile duct
10 37 15 16 2
Methods 715 patients were treated surgically for LHC between 1.1.1980 and 31.12.1995. Eighty (11.19%) of these patients had obstructive jaundice due to intrabiliary rupture. There were 61 females and 19 males with an age range of 18–71 years (mean 38). The duration of symptoms ranged from 15 days to 14 months. All patients complained of abdominal pain, jaundice and itching. The main diagnostic investigations were ultrasonography (US), computed tomography (CT), endosonography, and since 1985 endoscopic retrograde cholangiopancreatography (ERCP) in 46 of these patients. All patients were diagnosed preoperatively. 72 patients had a single cyst, 7 patients had double cysts and 1 patient had three cysts. 66 (82.5%) of the cysts were located in the right lobe of the liver, 13 (16.2%) in the left lobe and 1 in both lobes. In 37 patients whose direct bilirubin was 15 mg/dl, endoscopic sphincterotomy (ES) was performed at the time of ERCP prior to surgery in order to achieve biliary decompression. A 7-10 F nasobiliary drain was inserted in 28 of the patients. The CBD was washed during the procedure, and the vesicles and debris were removed. The nasobiliary drain remained in effective use without causing obstruction for a period of 4.5 days on average. The surgical operations were performed by surgeons who had alredy completed their residency. First- or second-generation cephalosporins were used during anesthetic induction. Right transrectus, right subcostal, and median incisions were utilized in 43, 32 and 14 patients respectively. In 8 of the patients who underwent surgery after 1991, intraoperative US was utilized. At surgery, the cyst was opened and cleaned of all hydatid material, the cavity was investigated to detect the biliary openings through which bile leaked and if found, it was sutured with absorbable material. The CBD was explored, and hydatid debris was removed. The
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common, right and left bile ducts were irrigated with isotonic saline solution. In 18 patients who underwent surgery after 1992, choledochoscopy was used to ensure the hydatid material had been removed. Management of the cysts is shown in table 2. If a cavity remained a rubber drain was placed. CD was performed in 25 patients, and Ttube drainage was performed in 55 patients for the drainage of the CBD. In the patients who had CBD width more than 20 mm and were more than 40 years old, a side-to-side CD was performed. A T-tube drainage was performed in younger patients (! 40 years) or in the narrower CBD (! 20 mm) cases. In the CD group, 19 of the 25 patients were women and 6 were men, and their ages ranged from 40 to 71 years (mean 53). In the T-tube group, forty-two of the 55 patients were women and 13 were men, and their ages ranged from 18 to 65 years (mean 32). In two patients, the cyst cavity opened directly into the main bile duct, and thorough cleaning of the cavity was achieved through the choledochotomy. After this was confirmed by choledochoscopy, the upper part of the T-tube was left in the cyst cavity and the cyst was not treated. On the sixth to eighth postoperative days, a pouchgraphy was performed through the external drains to control the cyst cavity (fig. 1). A cholangiography was also performed in patients with a T-tube. The T-tube was closed and later removed when cholangiography and pouchgraphy showed that there was no communication between the cyst cavity and the bile duct. When pouchgraphies performed periodically revealed that the cavity had decreased in size, the cavity drain was also removed. The two groups were compared in regard to morbidity, mortality, duration of the operation, rate of relaparatomy and duration of postoperative hospital stay. The rates of morbidity, mortality and relapa-
Elbir/Gundogdu/Caglikulekci/Kayaalp/ Atalay/Savkilioglu/Seven
Fig. 1. The communication seen on the pouchgraphy taken via the drain in the cavity still going on during the postoperative period.
Table 3. Postoperative complications
Complication
T-tube CD
Biliary fistula Wound infection Pulmonary complications Bilioma Postoperative hemorrhage Subhepatic abscess
2 3 2 2 – 1
2 2 1 2 1 2
rotomy in the two groups were compared by means of ¯2 test. Student’s t test was used to compare the duration of the operation and the length of hospital stay; a p value of less than 5% was accepted as significant.
The overall morbidity rate was 25%. The main postoperative complications were wound infection, biliary fistula and bilioma (table 3). Comparison of complications in the two groups revealed no significant statistical differences (p = 0.0702). One patient in the T-tube group developed biliary fistula which resisted conservative treatment and remained functioning for 6 months. As no biliary tract communication could be identified, it was concluded that the fistula functioned autonomously and a fistulojejunostomy was performed. The patient was living problem-free at followup at 6 years. One patient in the CD group who had undergone total cystectomy required reoperation for hemostasis on the first postoperative day. Three patients with subhepatic collection underwent percutaneous drainage under US guidance. One patient in the CD group and one in the T-tube group required relaparatomy and drainage because of ineffective treatment. Since the length of time required to treat the cyst varied with the size, number and site of the cysts, only the duration of the exploration of the CBD and drainage was taken into account while assessing the duration of operation. The average operation time was 27.3 B 3.2 min for patients who underwent T-tube drainage, whereas it was 63.7 B 4 min for patients who underwent CD (p = 0.012). There was no significant difference between the two groups with regard to the period of hospitalization. The average period of hospitalization was 11.2 days (7–22) in the CD group and 12.6 (8–19) in the T-tube group. All the patients were followed up except four patients, who died of other reasons (cardiac, trauma). No recurrences were encountered on long-term (5–20, mean 11.4 years) follow-up. No recurrences were encountered on long-term follow-up. No patients developed cholangitis.
Discussion
High levels of alkaline phosphatase and bilirubin were present in all patients. The overall mortality was 1.25%. One patient in the CD group who had previously undergone an atrial valve replacement died due to cardiac problems in the postoperative period.
Preoperative diagnosis of intrabiliary rupture of LHC is crucial in planning the strategy of surgical management. A definite preoperative diagnosis requires extensive diagnostic evaluation. US was used for screening in all of our patients presenting with different levels of jaundice. Twenty-two patients received an additional CT scan to confirm the diagnosis. However, CT was unable to distinguish daughter vesicles from fragmented membranes [3, 8]. Sonographic and CT evidence of hydatid cyst rupture
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Results
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into the biliary tree depends on the demonstration of intrabiliary hydatid contents [2, 3, 8, 9]. ERCP has proved to be a valuable tool for the diagnosis of rupture into the biliary tract. In 1985, Al Karawi [10] reported the first case of complete endoscopic management of a liver cyst which had ruptured into the biliary tree. More recently, ES has proved a valid alternative in the treatment of LHC opening to the biliary tree, both in the preoperative and postoperative situation. After surgery ERCP may allow the definitive treatment of surgical complications and obviate the need for a second operation [8–12]. Any of the standard methods can be used in the treatment of the cyst. Lobectomy and pericystectomy are radical operations, but due to the high rates of morbidity and mortality, they should only be used in appropriate cases [3, 7, 13–16]. In this series, ten of the 80 patients underwent pericystectomy. Those patients had cysts located peripherically with diameters over 10 cm, and their overall condition was favorable. When cavity management techniques are employed, the management of the residual cavity after removal of all parasitic elements can be a problem, especially in patients with infected cysts. It is difficult to achieve complete closure of the cavity by suturing thick walls. We attempted to reduce the size of the residual cavity by partial cystectomy. Drainage of the residual cavity is mandatory in most cases because of its communication with the biliary tree and the possibility of concomitant cholangitis. Satisfactory results have been reported with this policy [2, 6, 14, 16–18]. Intrabiliary rupture with resultant cholangitis demands early surgical intervention. Delay may cause liver abscess and suppurative cholangitis, both of which are life-threatening. An infected cyst should be treated like a liver abscess [1, 6, 19, 20]. Once the cyst has been opened and cleaned of debris, an attempt should be made to identify the communication between the cyst and the biliary tree. In the past, we tried to identify the rupture by careful inspection. In recent years, choledochoscopy and laparoscopy have made it much easier to identify the rupture, for these methods provide twenty times enlarged views on the monitor. When a biliary communication is detected, it can be sutured using absorbable sutures without causing obstruction, provided that the cyst is located peripherically and the duct is small [1, 2, 13, 17, 21]. Cysts located centrally, however, should be handled with the greatest care. Moreover, it should always be kept in mind that a single cyst can have more than one communication. If the cyst is located centrally and close of the porta hepatis, it is risky and difficult to remove the cystic elements by resect-
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Fig. 2. T-tube cholangiography on the 7th
postoperative day.
ing the liver parenchyma. In such cases, an attempt can be made to remove the cystic elements through the dilated CBD [2, 6, 7]. This method was used in two of our patients [22]. After the removal of the cystic elements, a choledochoscopy was performed to confirm that no elements had remained in the bile ducts, and the patients were left with only a T-tube (fig. 2). No complications were encountered in the follow-up period of 76 and 78 months. The biliary tract should be washed thoroughly with serum saline after it has been explored and all cystic elements have been removed. It is important to confirm that there is no residual debris in the ducts after exploration by a T-tube cholangiogram or preferably a choledochoscopy [3, 7, 15, 18, 23–25]. The main problem after this stage is the management of the functional spasm in the Oddi sphincter. This is a severe spasm, in other words a functional obstruction, resulting from allergic reactions caused by the ‘eau de roche’ that passes into the CBD from the cyst rupturing into the biliary tree. This occurrence was first pointed out by Goinard in 1955 who defined it as ‘Oddi fibrosis caused by hydatid cysts’ [20]. In fact, this is not an organic fibrosis, but a functional and temporary spasm. It disappears soon after the hydatid cyst has been treated and the flow of ‘eau de roche’ into the CBD has stopped. If this spasm is not treated, troublesome and permanent external fistula with high flow develops from the cyst cavity. The
Elbir/Gundogdu/Caglikulekci/Kayaalp/ Atalay/Savkilioglu/Seven
flow of bile should be redirected temporarily and the Oddi should be left to rest so that the disrupted bile hemodynamics in the CBD will return to normal [20, 26]. A simple T-tube drainage instead of complicated operations is sufficient for this purpose. Authors who prefer CD refer to disadvantages of T-tube drainage [5, 14]. According to these authors, the T-tube itself can even cause obstruction in the postoperative period because its diameter is always smaller than that of the duct. T-tube drainage is, in addition, a source of infection in the biliary tree, causes loss of bile, and lengthens hospital stay. In this study, there was no difference with regard to the length of hospital stay between the two groups. Moreover, cholangitis due to T-tube was not observed. We prefer CD especially in old and high-risk patients such as those with pulmonary problems, particulary when a dilated CBD allows a wide anastomosis. If it is suspected that there is residual debris in spite of repeated and careful irrigation, CD should be performed [2, 5, 6], because secondary operations carry serious risks for highrisk patients. Unsuccessful preoperative ERCP warrants CD, too.
Most authors prefer T-tube drainage [6, 17–20, 27]. The advantage of T-tube drainage is that it does not damage the structure of the Oddi sphincter and the normal anatomophysiology. Moreover, T-tubes provide means to perform cholangiographies. They can also assist endoscopic removal of any residual debris in the CBD during the postoperative period. In rare cases in which endoscopy is not successful in removing the residual debris, it is possible to clean the CBD by means of a guide and a balloon inserted through the T-tube tract. How long the drainage tube and the T-tube should remain in place would depend on the rate of shrinkage of the cavity as seen on radiograms. There is no strict and fast rule, and the best policy is to decide upon what seems reasonable and then wait a while longer [6, 7, 20]. One of the significant results of this study is that it has demonstrated that T-tube drainage can be performed in a much shorter time than CD. In this comparative series, better results have been obtained with T-tube drainage than with CD. Therefore, T-tube drainage is our treatment of choice in many of our cases.
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