- Email: [email protected]
ERCP in the diagnosis and management of complications after surgery for hepatic echinococcosis
ERCP in the diagnosis and management of complications after surgery for hepatic echinococcosis Yilmaz Bilsel, MD, Turker Bulut, MD, Sumer Yamaner, MD, Yilmaz Buyukuncu, MD, Dursun Bugra, MD, All Akyuz, MD, Necmettin Sokucu, MD Istanbul, Turkey Background: Surgery for liver hydatidosis can result in serious morbidity and mortality. The role and efficacy of ERCP in the management of these complications was reviewed. Methods: Retrospective analysis of 79 patients with liver hydatidosis who underwent ERCP for postoperative complications. Results: All patients with biliary fistulas (n = 50) were managed by endoscopic sphincterotomy, although 9 (18%) also required a biliary endoprosthesis. Surgical reintervention was avoided in 46 (92%) patients with subsequent surgery required in only in 4 (8%).The mean time to fistula closure was 13.3 days. Patients with daughter cysts in the bile ducts (n = 7) were also treated by endoscopic sphincterotomy and evacuation of obstructing cyst material. Seven patients with elevated liver enzymes or biliopancreatic symptoms but normal ERCP findings also underwent endoscopic sphincterotomy with normalization of biochemical tests. Conclusions: ERCP is valuable for detecting and treating postoperative biliary complications after surgery for hepatic echinococcal disease. In the majority of patients, endoscopic sphincterotomy allows healing of postoperative external biliary fistulas, and should be performed as early as possible. In some cases, a biliary prosthesis may be required. Endoscopic sphincterotomy also enables clearing of the bile ducts of hydatid remnants. (Gastrointest Endosc 2003;57:210-3.)
Liver hydatidosis is a widespread parasitic infection caused by the tapeworm Echinococcosis granulosus. The disease is endemic in some cattle and sheep-herding areas of the world, and is prevalent in M e d i t e r r a n e a n c o u n t r i e s s u c h as T u r k e y . T h e
liver, the most common site of involvement, is infested in 50% to 70% of patients. Surgery is indicated for patients with symptoms, for complications of h y d a t i d disease, and for a s y m p t o m a t i c patients unresponsive to t r e a t m e n t with systemic antihelminthics, i The specific operative approach depends on the number and location of the cysts and associated complications. The most frequent category of complication of the hydatid cyst is an adverse effect on the biliary tree (80%-90%). If biliary communications persist, bile collections or fistulas m a y develop after surgery. Persistent postoperative biliary fistula is a serious complication t h a t often necessitates surgery. Intrabiliary r u p t u ~ of the cyst Received April 15, 2002. For revision August 26, 2002. Accepted October 23, 2002. Currentaffiliations: Istanbul University, Istanbul Medical Faculty, General Surgery Department, Gastrointestinal Surgery and Surgical Endoscopy Unit, Istanbul, Turkey. Presented at the 20th International Congress of Hydatidology, June 4-8, 2001, Kusadasi, Turkey. Reprint requests: Yilmaz Bilsel, MD, Erzurum sitesi, Altunizade, Palandoken sokak, No: 18/8, 81180, Uskudar-Istanbul, Turkey. Copyright 9 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067 / mge.2003.64 210
GASTROINTESTINAL ENDOSCOPY
results subsequently in fistula formation in 5% to 25% of all cases.2, 3 Endoscopic methods are reportedly an effective alternative to surgery for treatment of such complications, with lower morbidity and reductions in hospital stay. 4-6 The r e s u l t s . o f endoscopic t r e a t m e n t in a series of patients who u n d e r w e n t s u r g e r y for liver hydatidosis are presented in this report. PATIENTS AND METHODS Over a period of 8 years (December 1992 to January 2001), 3608 ERCPs were performed in our unit, a tertiary referral center for the Marmara area of~Turkey. During that period, 79 patients (47 women [59.4%], 32 men [40.5%]; mean age 44 [11] years, range 15 to 68 years) underwent ERCP for the diagnosis and treatment of several types of complication due to surgery for hepatic echinococcosis. Complications developed in 11 (14%) of 69 patients who underwent operation for hepatic hydatid disease in our unit; 68 patients (86%) had surgery at another hospital and were referred to our unit. Surgical procedures varied from simple drainage to formal hepatic resections (Table 1). The interval from surgery to referral ranged from 5 days to 10 months with a mean of 36 (45) days for all patients. The indications for ERCP were as follows: external biliary fistulas, 62 cases (78.4%); alter laboratory parameters of liver function, 20 (25.3%); cholangitis, 10 (12.6%); jaundice, 9 (11.3%); biliary colic, 7 (8.8%); abnormal US or T-tube cholangiography findings, 7 (8.8%); and postoperative pancreatitis, 1 (1.3%). For 47 patients (59.4%), there was a single indication for ERCP; 32 (40.5%) had more than one indication. VOLUME 57, NO. 2, 2003
Hepatic echinococcosis: ERCP and management of surgical complications
Y Bilsel, T Bulut, S Yamaner, et al.
Table 1. Surgical procedures, associated complications, and endoscopic interventions Primary surgical technique
n
Biliary fistula
Vesiclesin bile duct
Stonesm bile duct
Retained cysts
Cystotomy& drainage Marsupialization Intraflexion,capittonage, or omentoplasty Pericystectomy,hepatectomy Total Endoscopicinterventions
48 6 21
33 4 12
5 1 1
2 1 2 ~-
2
6
1
5
4 79 79
1 50 (63.2) ES: 41; stent: 9
7 (8.8) 5 (6.3) Extraction: Extraction: 7 5
3 (3,7~ ES: 3
CBD stricture
1 1 (L3) Stent: 1
Normal findings
2 13 (16.4) ES: 7: cholangiography:,6
Values in parentheses are percentages. CBD, Commonbile duct. Patients were sedated by intravenous administration of midazolam and meperidine, and duodenal peristalsis was suppressed with hyoscine N-butyl bromide. ERCP was performed with the patient in the prone position with standard fiberoptic duodenoscopes (FD 7XT2, ED 310XU, 200XT, Fujinon, Tokyo, Japan). Endoscopic sphincter• otomy (ES) was performed in a standard manner by using a variety of papillotomes. If stent insertion was required, a Tannenbaum-type stent was used (Wilson-Cook, Inc., Winston-Salem, N,C.). A short sphincterotomy was almost always performed as part of the stent insertion procedure. After ES, either a Dormia basket or an extraction balloon catheter was used to remove the daughter vesicles or stones from the biliary tract. Patients in whom remnants of the echinococcal material were removed from the bile duct were also treated with albendazole (10 mg/kg) to prevent spread of the disease. Follow-up consisted of clinical, biochemical, and US monitoring. Descriptive data are expressed as mean, or ranges for continuous variables, and proportions for categorical variables. All data are shown solely for descriptive purposes.
RESULTS Overall, 88 ERCP procedures were a t t e m p t e d for 79 patients. ERCP was repeated for different reasons in 7 patients (3 unsuccessful cannulation, 4 technical or c o n c u r r e n t medical problems). In 50 p a t i e n t s (63.2%), a fistula was p r e s e n t bet w e e n the biliary tract and cyst cavity (Fig. 1). H ydat i d vesicles and membranes were observed inside the biliary tract in 7 patients (8.8%). There were also 5 cases (6.3%) of choledocholithiasis, 3 (3.7%) of bile duct compression from a previously unrecognized echinococcal cyst, and 1 common bile duct stricture (1.3%). ERCP was normal ~n 13 (16.4%) patients. All patients with b~liary fistulas u n d e r w e n t ES. Nine (18%) also required a biliary prosthesis, either because of high output bile leakage, or because the fistula h ad been present for a long duration of time. Before ES, th e m e a n daily v o l u m e of bile flow through a drain or a cutaneous fistula was 105 (10) mL, and the m e a n duration of time during which fistulas wer e p r e s e n t was 34 (12) days. All of t h e s e patients were observed for i to 3 months. The m e a n VOLUME 57, NO. 2, 2003
time for fistula closure was 13.3 (1) days (range 2-60 days). In 4 patients (8%), persistent postoperative drainage was not resolved by endoscopic methods; all u n d e r w e n t surgery. Five p a t i e n t s found to have choledocholithiasis u n d e r w e n t ES and stone extraction. Pat i ent s with d a u g h t e r cysts in bile ducts were also t r e a t e d by ES a n d e v a c u a t i o n of o b s t r u c t i n g cyst m a t e r i a l (Fig. 2). P a t i e n t s in w hom u n r e c o g n i z e d cysts caused e x t e r n a l compression of the bile duct were m a n a g e d by ES and p e r c u t a n e o u s drainage of the cysts. None of t he p a t i e n t s w i t h stones or e x t e r n a l biliary compression r e q u i r e d surgery. The p a t i e n t with a common bile duct st ri ct ure caused by sclerosing cholangitis, p r e s u m a b l y t he resul t of intracystic i nj ect i on of a scolicidal a g e n t ( h y p e r t o n i c saline solution), was m a n a g e d by balloon dilatation and s t e n t insertion. This p a t i e n t with a d o m i n a n t e x t r a h e p a t i c s t r i c t u r e was t r e a t e d by r e p e a t e d dilatation in a n o t h e r center, and to our knowledge h a s not d e v e l o p e d a d v a n c e d liver d i s e a s e at 5 years' follow-up. Seven patients with normal ERCP findings with either elevated biochemical tests of liver function or biliary colic u n d e r w e n t ES. There was no recurrence of t hese p r e s e n t i n g manifestations. P a t i e n t s w ith objective clinical c r i t e r i a of funct i onal bilia ry obstruction (dilated bile duct, abnormal liver tests) were particularly improved. T he r a t e of E R C P - r e l a t e d complications was 2.5%; 2 p a t i e n t s developed mild p a n c r e a t i t i s t h a t resolved with conservative t r e a t m e n t .
DISCUSSION ERCP is an effective and safe method for detecting and t reat i ng postoperative complications involving the biliary tree in patients who undergo surgery for liver hydatidosis. The presenting manifestations in these patients are external biliary fistula, jaundice, cholangitis, or biliary colic. The type of complication and its frequency vary, but the t h e r a p e u t i c approach is similar and mainly consists of ES. GASTROINTESTINAL ENDOSCOPY 211
Y Bilsel, T Bulut, S Yamaner, et al.
Hepatic echinococcosis: E R C P and management of surgical complications
Figure 2. Endoscopic view showing extraction of hydatid vesicle from distal bile duct.
Figure 1. Retrograde cholangiogram showing opacification of cyst cavity with wide communication with right main hepatic duct and dilatation of intrahepatic and extrahepatic bile ducts. Although surgical treatment of a fistula between a hydatid cyst and the biliary tract m a y be effective, it often leads to prolonged hospitalization and increased morbidity. 7 Surgery often involves reoperation with biliary tract drainage, usually by sphincteroplasty or biliodigestive anastomosis, especially if a T-tube was not placed at the previous operation. Even in these cases, fistula closure may be slow.5, s-lo However, in small groups of patients, endoscopic t r e a t m e n t h a s allowed m a n a g e m e n t of complications arising from rupture of cysts into the biliary tract, with low morbidity and r e d u c e d - h o s p i t a l stay.S,u, 12 Postoperative biliary fistulas can be treated by ES alone, which decreases the pressure gradient between duodenum and biliary tract and thereby promotes ultimate closure of the fistula by increasing the bile flow into the duodenum. The nasobiliary drain or biliary stent m a y be used in conjunction with or as an alternative to ES. Akoglu et al. 13 reported success in 4 patients with biliary fistulas in whom the drain was placed without ES. Vagianos et al. 14 also reported that nasobiliary drainage with continuous suction led to healing of a fistula that had not resolved after ES alone. Placement of the nasobiliary drain proximal to the defect allows continuous aspiration, and is especially effective w h e n the fistula originates from the intrahepatic biliary tract. The nasobiliary drain also allows monitoring of the fistula by cholangiography. However, these drains are often poorly tolerated by patients, are subject to dislodgement, and their use may prolong hospitalization. Therefore, this method of t r e a t m e n t is not preferred. 212
GASTROINTESTINAL ENDOSCOPY
Biliary stent insertion is known to be highly effective in the treatment of postcholecystectomy biliary fistula. In patients with hydatidosis, however, ES is p r e f e r a b l e because of the f r e q u e n t occurrence of papillary stenosis or associated difficulties w i t h drainage of bile. In contrast to the postcholecystectomy fistula, which closes rapidly after ES, and occa: sionally even closes spontaneously, hydatid fistulas are more resistant and rarely close spontaneously w i t h o u t decompression of the biliary tract. 15 However, stent insertion is expensive and requires further ERCP procedures for exchange and ultimate removal. In the majority of patients, ES is therefore performed for t r e a t m e n t of biliary fistulal An endoprosthesis is placed as an adjunct to ES only if there is a high output Chronic fistula. The etiology of postoperative external biliary fistulas may be extremely peculiar. In this group of patients, although uncommon, echinococcal material or even stones may be present in the bile duct. ERCP also enables clearance of such debris from the ducts by using a balloon catheter, Dormia basket, or irrigation with hypertonic saline solution by means of a nasobiliary drain, as suggested byAl Karawi et alJ ~ However, because of the risk of developing sclerosing cholangitis, lavage is not performed with any of the scolicidal agents. Rather, in these patients, treatment with albendazole (10 mg/kg/day) for 3 months is preferred. Seven patients had normal ERCP findings i n the present series, but with elevated biochemical tests of liver function or symptoms suggestive of a biliopancreatic origin, and were also treated with ES. A possible criticism may pertain to whether ES was really necessary for these patients. Our results and observations show that this approach is associated with a clinical response; most of the patients responded with complete resolution of symptoms or biochemical abnormalities. E R C P has an essential therapeutic role in the m a n a g e m e n t of p a t i e n t s w i t h postoperative compliVOLUME 57, NO. 2, 2003
Hepatic echinococcosis: E R C P and management of surgical complications
cations after surgery for hydatid disease. ES should be the first line of t r e a t m e n t in patients with an external biliary fistula t h a t has been p r e s e n t for more than 10 days after surgery. If output of the fistula is high (>300 mL/day), indicating a major cystobiliary communication, or if the fistula is chronic (present >1 month), ES may be insufficient. In such cases, insertion of a stent in addition to ES m a y be helpful. If a cyst has ruptured into the bile ducts, ERCP with ES allows clearing of the ducts of hydatid remnants. ERCP with ES should be considered in postoperative patients without established complications, b u t with r e c u r r e n t biliopancreatic signs and symptoms. REFERENCES 1. Taylor BR, Langer B. Current surgical management of hepatic cyst disease. Adv Surg 1997;31:127-48. 2. Sayek I, Yalin R, Sanac Y. Surgical treatment of hydatid disease of the liver. Arch Surg 1980;115:847-50. 3. Alper A, Ariogul O, Emre A, Uras A, Okten A. Choledochoduodenostomy for intrabiliary rupture of hydatid cysts of liver. Br J Surg 1987;74:243-5. 4. Vignote ML, Mino G, de La Mata M, Dios JF, Gomez F. Endoscopic sphincterotomy in hepatic hydatid disease open to biliary tree. Br J Surg 1990;77:30-1. 5. Iscan M, Duren M. Endoscopic sphincterotomy in the management of postoperative complications of hepatic hydatid disease. Endoscopy 1991;23:282-3. 6. Tekant Y, Bilge O, Acarli K, Alper A, Emre A, Ariogul O. Endoscopic sphincterotomy in the treatment of postoperative
VOLUME 57, NO. 2, 2003
Y Bilsel, T Bulut, S Yamaner, et al.
biliary fistulas of hepatic hydatid disease. Surg Endosc 1996;10:909-11. 7. Dawson JL, Stamatakis JD, Stringer MD, Williams R. Surgical treatment of hepatic hydatid disease. Br J Surg 1988;75:946-50. 8. Moreno GE, Rico SP, Bercedo MJ, Garcia GI, Palma CF, Hidalgo PM. Results of surgica[treatment of hepatic hydati-dosis: current therapeutic modifications. World J Surg 1991; 15:254-63. 9. Ulualp KM, Aydemir I, Senturk H, Eyuboglu E, Cebeci H, Unal H. Management of intrabiliary rupture of hydatid cyst of the liver. World J Surg 1995;19:720-4. 10. A1 Karawi MA, Yasawi MI, E1-Shieck-Mohamed AR. Endoscopic management ofbiliary hydatid disease: report of six cases. Endoscopy 1991;23:278-81. 11. Ponchon T, Bory R, Chavallion A. Endoscopic retrograde Cholangiography and sphincterotomy for complicated hepatic hydatid cyst. Endoscopy 1987;19:174-7. 12. Del Olmo L, Merono E, Moreira VF, Garcia T, Garcia-Plaza A. Successful treatment of postoperative external biliary fistulas by endoscopic sphincterotomy. Gastrointest Endosc 1988; 34:307-9. 13. Akoglu M, Hilmioglu F, Balay AR, Sahin B, Davidson BR. Endoscopic Sphincterotomy in hepatic hydatid disease open to biliary tree [letter]. Br J Surg 1990;77:1073. 14. Vagianos C, Polydorou A, Karatzas T, Vagenas ;C, Stravropoulas M, Androulakis J. Successful treatment of postoperative external biliary fistula by selective nasobiliary drainage. HPB Surg 1992;6:115-24. 15. Rodriguez AN, Sanchez del Rio AL, Alguacil LV, De Dios Vega JF, Fugarolas GM. Effectiveness of endoscopic sphincterotomy in complicated hepatic hydatid disease. Gastrointest Endosc 1998;48:593-7.
GASTROINTESTINAL ENDOSCOPY
213
Liver hydatidosis is a widespread parasitic infection caused by the tapeworm Echinococcosis granulosus. The disease is endemic in some cattle and sheep-herding areas of the world, and is prevalent in M e d i t e r r a n e a n c o u n t r i e s s u c h as T u r k e y . T h e
liver, the most common site of involvement, is infested in 50% to 70% of patients. Surgery is indicated for patients with symptoms, for complications of h y d a t i d disease, and for a s y m p t o m a t i c patients unresponsive to t r e a t m e n t with systemic antihelminthics, i The specific operative approach depends on the number and location of the cysts and associated complications. The most frequent category of complication of the hydatid cyst is an adverse effect on the biliary tree (80%-90%). If biliary communications persist, bile collections or fistulas m a y develop after surgery. Persistent postoperative biliary fistula is a serious complication t h a t often necessitates surgery. Intrabiliary r u p t u ~ of the cyst Received April 15, 2002. For revision August 26, 2002. Accepted October 23, 2002. Currentaffiliations: Istanbul University, Istanbul Medical Faculty, General Surgery Department, Gastrointestinal Surgery and Surgical Endoscopy Unit, Istanbul, Turkey. Presented at the 20th International Congress of Hydatidology, June 4-8, 2001, Kusadasi, Turkey. Reprint requests: Yilmaz Bilsel, MD, Erzurum sitesi, Altunizade, Palandoken sokak, No: 18/8, 81180, Uskudar-Istanbul, Turkey. Copyright 9 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067 / mge.2003.64 210
GASTROINTESTINAL ENDOSCOPY
results subsequently in fistula formation in 5% to 25% of all cases.2, 3 Endoscopic methods are reportedly an effective alternative to surgery for treatment of such complications, with lower morbidity and reductions in hospital stay. 4-6 The r e s u l t s . o f endoscopic t r e a t m e n t in a series of patients who u n d e r w e n t s u r g e r y for liver hydatidosis are presented in this report. PATIENTS AND METHODS Over a period of 8 years (December 1992 to January 2001), 3608 ERCPs were performed in our unit, a tertiary referral center for the Marmara area of~Turkey. During that period, 79 patients (47 women [59.4%], 32 men [40.5%]; mean age 44 [11] years, range 15 to 68 years) underwent ERCP for the diagnosis and treatment of several types of complication due to surgery for hepatic echinococcosis. Complications developed in 11 (14%) of 69 patients who underwent operation for hepatic hydatid disease in our unit; 68 patients (86%) had surgery at another hospital and were referred to our unit. Surgical procedures varied from simple drainage to formal hepatic resections (Table 1). The interval from surgery to referral ranged from 5 days to 10 months with a mean of 36 (45) days for all patients. The indications for ERCP were as follows: external biliary fistulas, 62 cases (78.4%); alter laboratory parameters of liver function, 20 (25.3%); cholangitis, 10 (12.6%); jaundice, 9 (11.3%); biliary colic, 7 (8.8%); abnormal US or T-tube cholangiography findings, 7 (8.8%); and postoperative pancreatitis, 1 (1.3%). For 47 patients (59.4%), there was a single indication for ERCP; 32 (40.5%) had more than one indication. VOLUME 57, NO. 2, 2003
Hepatic echinococcosis: ERCP and management of surgical complications
Y Bilsel, T Bulut, S Yamaner, et al.
Table 1. Surgical procedures, associated complications, and endoscopic interventions Primary surgical technique
n
Biliary fistula
Vesiclesin bile duct
Stonesm bile duct
Retained cysts
Cystotomy& drainage Marsupialization Intraflexion,capittonage, or omentoplasty Pericystectomy,hepatectomy Total Endoscopicinterventions
48 6 21
33 4 12
5 1 1
2 1 2 ~-
2
6
1
5
4 79 79
1 50 (63.2) ES: 41; stent: 9
7 (8.8) 5 (6.3) Extraction: Extraction: 7 5
3 (3,7~ ES: 3
CBD stricture
1 1 (L3) Stent: 1
Normal findings
2 13 (16.4) ES: 7: cholangiography:,6
Values in parentheses are percentages. CBD, Commonbile duct. Patients were sedated by intravenous administration of midazolam and meperidine, and duodenal peristalsis was suppressed with hyoscine N-butyl bromide. ERCP was performed with the patient in the prone position with standard fiberoptic duodenoscopes (FD 7XT2, ED 310XU, 200XT, Fujinon, Tokyo, Japan). Endoscopic sphincter• otomy (ES) was performed in a standard manner by using a variety of papillotomes. If stent insertion was required, a Tannenbaum-type stent was used (Wilson-Cook, Inc., Winston-Salem, N,C.). A short sphincterotomy was almost always performed as part of the stent insertion procedure. After ES, either a Dormia basket or an extraction balloon catheter was used to remove the daughter vesicles or stones from the biliary tract. Patients in whom remnants of the echinococcal material were removed from the bile duct were also treated with albendazole (10 mg/kg) to prevent spread of the disease. Follow-up consisted of clinical, biochemical, and US monitoring. Descriptive data are expressed as mean, or ranges for continuous variables, and proportions for categorical variables. All data are shown solely for descriptive purposes.
RESULTS Overall, 88 ERCP procedures were a t t e m p t e d for 79 patients. ERCP was repeated for different reasons in 7 patients (3 unsuccessful cannulation, 4 technical or c o n c u r r e n t medical problems). In 50 p a t i e n t s (63.2%), a fistula was p r e s e n t bet w e e n the biliary tract and cyst cavity (Fig. 1). H ydat i d vesicles and membranes were observed inside the biliary tract in 7 patients (8.8%). There were also 5 cases (6.3%) of choledocholithiasis, 3 (3.7%) of bile duct compression from a previously unrecognized echinococcal cyst, and 1 common bile duct stricture (1.3%). ERCP was normal ~n 13 (16.4%) patients. All patients with b~liary fistulas u n d e r w e n t ES. Nine (18%) also required a biliary prosthesis, either because of high output bile leakage, or because the fistula h ad been present for a long duration of time. Before ES, th e m e a n daily v o l u m e of bile flow through a drain or a cutaneous fistula was 105 (10) mL, and the m e a n duration of time during which fistulas wer e p r e s e n t was 34 (12) days. All of t h e s e patients were observed for i to 3 months. The m e a n VOLUME 57, NO. 2, 2003
time for fistula closure was 13.3 (1) days (range 2-60 days). In 4 patients (8%), persistent postoperative drainage was not resolved by endoscopic methods; all u n d e r w e n t surgery. Five p a t i e n t s found to have choledocholithiasis u n d e r w e n t ES and stone extraction. Pat i ent s with d a u g h t e r cysts in bile ducts were also t r e a t e d by ES a n d e v a c u a t i o n of o b s t r u c t i n g cyst m a t e r i a l (Fig. 2). P a t i e n t s in w hom u n r e c o g n i z e d cysts caused e x t e r n a l compression of the bile duct were m a n a g e d by ES and p e r c u t a n e o u s drainage of the cysts. None of t he p a t i e n t s w i t h stones or e x t e r n a l biliary compression r e q u i r e d surgery. The p a t i e n t with a common bile duct st ri ct ure caused by sclerosing cholangitis, p r e s u m a b l y t he resul t of intracystic i nj ect i on of a scolicidal a g e n t ( h y p e r t o n i c saline solution), was m a n a g e d by balloon dilatation and s t e n t insertion. This p a t i e n t with a d o m i n a n t e x t r a h e p a t i c s t r i c t u r e was t r e a t e d by r e p e a t e d dilatation in a n o t h e r center, and to our knowledge h a s not d e v e l o p e d a d v a n c e d liver d i s e a s e at 5 years' follow-up. Seven patients with normal ERCP findings with either elevated biochemical tests of liver function or biliary colic u n d e r w e n t ES. There was no recurrence of t hese p r e s e n t i n g manifestations. P a t i e n t s w ith objective clinical c r i t e r i a of funct i onal bilia ry obstruction (dilated bile duct, abnormal liver tests) were particularly improved. T he r a t e of E R C P - r e l a t e d complications was 2.5%; 2 p a t i e n t s developed mild p a n c r e a t i t i s t h a t resolved with conservative t r e a t m e n t .
DISCUSSION ERCP is an effective and safe method for detecting and t reat i ng postoperative complications involving the biliary tree in patients who undergo surgery for liver hydatidosis. The presenting manifestations in these patients are external biliary fistula, jaundice, cholangitis, or biliary colic. The type of complication and its frequency vary, but the t h e r a p e u t i c approach is similar and mainly consists of ES. GASTROINTESTINAL ENDOSCOPY 211
Y Bilsel, T Bulut, S Yamaner, et al.
Hepatic echinococcosis: E R C P and management of surgical complications
Figure 2. Endoscopic view showing extraction of hydatid vesicle from distal bile duct.
Figure 1. Retrograde cholangiogram showing opacification of cyst cavity with wide communication with right main hepatic duct and dilatation of intrahepatic and extrahepatic bile ducts. Although surgical treatment of a fistula between a hydatid cyst and the biliary tract m a y be effective, it often leads to prolonged hospitalization and increased morbidity. 7 Surgery often involves reoperation with biliary tract drainage, usually by sphincteroplasty or biliodigestive anastomosis, especially if a T-tube was not placed at the previous operation. Even in these cases, fistula closure may be slow.5, s-lo However, in small groups of patients, endoscopic t r e a t m e n t h a s allowed m a n a g e m e n t of complications arising from rupture of cysts into the biliary tract, with low morbidity and r e d u c e d - h o s p i t a l stay.S,u, 12 Postoperative biliary fistulas can be treated by ES alone, which decreases the pressure gradient between duodenum and biliary tract and thereby promotes ultimate closure of the fistula by increasing the bile flow into the duodenum. The nasobiliary drain or biliary stent m a y be used in conjunction with or as an alternative to ES. Akoglu et al. 13 reported success in 4 patients with biliary fistulas in whom the drain was placed without ES. Vagianos et al. 14 also reported that nasobiliary drainage with continuous suction led to healing of a fistula that had not resolved after ES alone. Placement of the nasobiliary drain proximal to the defect allows continuous aspiration, and is especially effective w h e n the fistula originates from the intrahepatic biliary tract. The nasobiliary drain also allows monitoring of the fistula by cholangiography. However, these drains are often poorly tolerated by patients, are subject to dislodgement, and their use may prolong hospitalization. Therefore, this method of t r e a t m e n t is not preferred. 212
GASTROINTESTINAL ENDOSCOPY
Biliary stent insertion is known to be highly effective in the treatment of postcholecystectomy biliary fistula. In patients with hydatidosis, however, ES is p r e f e r a b l e because of the f r e q u e n t occurrence of papillary stenosis or associated difficulties w i t h drainage of bile. In contrast to the postcholecystectomy fistula, which closes rapidly after ES, and occa: sionally even closes spontaneously, hydatid fistulas are more resistant and rarely close spontaneously w i t h o u t decompression of the biliary tract. 15 However, stent insertion is expensive and requires further ERCP procedures for exchange and ultimate removal. In the majority of patients, ES is therefore performed for t r e a t m e n t of biliary fistulal An endoprosthesis is placed as an adjunct to ES only if there is a high output Chronic fistula. The etiology of postoperative external biliary fistulas may be extremely peculiar. In this group of patients, although uncommon, echinococcal material or even stones may be present in the bile duct. ERCP also enables clearance of such debris from the ducts by using a balloon catheter, Dormia basket, or irrigation with hypertonic saline solution by means of a nasobiliary drain, as suggested byAl Karawi et alJ ~ However, because of the risk of developing sclerosing cholangitis, lavage is not performed with any of the scolicidal agents. Rather, in these patients, treatment with albendazole (10 mg/kg/day) for 3 months is preferred. Seven patients had normal ERCP findings i n the present series, but with elevated biochemical tests of liver function or symptoms suggestive of a biliopancreatic origin, and were also treated with ES. A possible criticism may pertain to whether ES was really necessary for these patients. Our results and observations show that this approach is associated with a clinical response; most of the patients responded with complete resolution of symptoms or biochemical abnormalities. E R C P has an essential therapeutic role in the m a n a g e m e n t of p a t i e n t s w i t h postoperative compliVOLUME 57, NO. 2, 2003
Hepatic echinococcosis: E R C P and management of surgical complications
cations after surgery for hydatid disease. ES should be the first line of t r e a t m e n t in patients with an external biliary fistula t h a t has been p r e s e n t for more than 10 days after surgery. If output of the fistula is high (>300 mL/day), indicating a major cystobiliary communication, or if the fistula is chronic (present >1 month), ES may be insufficient. In such cases, insertion of a stent in addition to ES m a y be helpful. If a cyst has ruptured into the bile ducts, ERCP with ES allows clearing of the ducts of hydatid remnants. ERCP with ES should be considered in postoperative patients without established complications, b u t with r e c u r r e n t biliopancreatic signs and symptoms. REFERENCES 1. Taylor BR, Langer B. Current surgical management of hepatic cyst disease. Adv Surg 1997;31:127-48. 2. Sayek I, Yalin R, Sanac Y. Surgical treatment of hydatid disease of the liver. Arch Surg 1980;115:847-50. 3. Alper A, Ariogul O, Emre A, Uras A, Okten A. Choledochoduodenostomy for intrabiliary rupture of hydatid cysts of liver. Br J Surg 1987;74:243-5. 4. Vignote ML, Mino G, de La Mata M, Dios JF, Gomez F. Endoscopic sphincterotomy in hepatic hydatid disease open to biliary tree. Br J Surg 1990;77:30-1. 5. Iscan M, Duren M. Endoscopic sphincterotomy in the management of postoperative complications of hepatic hydatid disease. Endoscopy 1991;23:282-3. 6. Tekant Y, Bilge O, Acarli K, Alper A, Emre A, Ariogul O. Endoscopic sphincterotomy in the treatment of postoperative
VOLUME 57, NO. 2, 2003
Y Bilsel, T Bulut, S Yamaner, et al.
biliary fistulas of hepatic hydatid disease. Surg Endosc 1996;10:909-11. 7. Dawson JL, Stamatakis JD, Stringer MD, Williams R. Surgical treatment of hepatic hydatid disease. Br J Surg 1988;75:946-50. 8. Moreno GE, Rico SP, Bercedo MJ, Garcia GI, Palma CF, Hidalgo PM. Results of surgica[treatment of hepatic hydati-dosis: current therapeutic modifications. World J Surg 1991; 15:254-63. 9. Ulualp KM, Aydemir I, Senturk H, Eyuboglu E, Cebeci H, Unal H. Management of intrabiliary rupture of hydatid cyst of the liver. World J Surg 1995;19:720-4. 10. A1 Karawi MA, Yasawi MI, E1-Shieck-Mohamed AR. Endoscopic management ofbiliary hydatid disease: report of six cases. Endoscopy 1991;23:278-81. 11. Ponchon T, Bory R, Chavallion A. Endoscopic retrograde Cholangiography and sphincterotomy for complicated hepatic hydatid cyst. Endoscopy 1987;19:174-7. 12. Del Olmo L, Merono E, Moreira VF, Garcia T, Garcia-Plaza A. Successful treatment of postoperative external biliary fistulas by endoscopic sphincterotomy. Gastrointest Endosc 1988; 34:307-9. 13. Akoglu M, Hilmioglu F, Balay AR, Sahin B, Davidson BR. Endoscopic Sphincterotomy in hepatic hydatid disease open to biliary tree [letter]. Br J Surg 1990;77:1073. 14. Vagianos C, Polydorou A, Karatzas T, Vagenas ;C, Stravropoulas M, Androulakis J. Successful treatment of postoperative external biliary fistula by selective nasobiliary drainage. HPB Surg 1992;6:115-24. 15. Rodriguez AN, Sanchez del Rio AL, Alguacil LV, De Dios Vega JF, Fugarolas GM. Effectiveness of endoscopic sphincterotomy in complicated hepatic hydatid disease. Gastrointest Endosc 1998;48:593-7.
GASTROINTESTINAL ENDOSCOPY
213