Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts

Purpose. The most common complication of hydatid liver cysts is spontaneous rupture into the biliary tract. This study was conducted to evaluate the surgical management of spontaneous intrabiliary rupture of a hydatid liver cyst in 41 patients. Methods. The preoperative diagnosis was confirmed by ultrasound in all 41 patients, 37 of whom were jaundiced. Results. According to Gharbi's classification, 39% of the cysts were type III and they ranged from 3 to 18cm in diameter, with a mean diameter of 9cm. The mean total bilirubin and alkaline phosphatase values were 6.3mg/dl and 450IU, respectively. Partial cystectomy, cholecystectomy, and common bile duct exploration were performed in all patients. In seven patients, the visible biliary duct within the cyst cavity was sutured with 2/0 silk. Intraoperative cholangiography was performed in all patients, and choledochoscopy was performed in 11 patients. A T-tube was inserted after the biliary tract content was thought to have been totally cleaned out in 38 patients (93%), and a choledochoduodenostomy was performed in 3 patients (7%). An external biliary fistula developed in five patients, persisting for 11-25 days. The fistulae healed within a mean period of 5 days after endoscopic sphincterotomy (EST). For patients without a fistula the mean hospitalization time was 8 days and there was no mortality. Conclusion. These results suggest that when a hydatid liver cyst ruptures into the biliary tract, common bile duct exploration should be conducted using intraoperative cholangiography and choledochoscopy. If the biliary tract is cleaned of all cystic content, T-tube drainage should be sufficient, but EST is an effective technique for treating persistent extended external biliary fistulae.