STUDY OF BILE LEAK AFTER HEPATIC HYDATID CYST SURGERY IN BASRAH

Conservative surgery (partial peri-cystectomy and cyst contents evacuation with cavity management by external drainage, omentoplasty or capitonnaige) for uncomplicated hydatid cysts of the liver is known to be safe but is often associated with bile leak in rate of 18.81% and its sequela. The cause of bile leak is almost always due to cysto-biliary communication, this is usually occult and difficult to be diagnosed pre-operatively, if remain undiagnosed intra-operatively it will be presented as post-operative bile leak. In this study, several laboratory and radiological predictors used to evaluate those patients having high risk of bile leak after conservative hepatic hydatid cyst surgery. Also it aimed to study the fate of bile leak, it’s complications, how to avoid it and the way of management. This study is a combined prospective (from 2004-2010) & retrospective cases study performed in basrah hospitals, Iraq; (Al-Mawani Hospital, Basrah General Hospital, Al-Sader Teaching Hospital, and some of Private Hospitals); we analyzed records of 183 cases of hepatic hydatid cyst undergoing conservative surgery, of them 15 patient had bile leak intra-operatively and 20 patients had bile leak post-operatively. Patients with intra-biliary rupture of hydatid cyst or obstructive jaundice are excluded from this study. Bile leak occur in 35 patients (18.81%) from total 183 patients of which intra-operative bile leak seen in 15 patients (43%) and 20 patients (57%) as post-operative bile leak represented as external biliary fistula. L aboratory predictors of biliary leakage were alkaline phosphatase >250 U/L, total serum bilirubin >17 umol/l, cyst diameter >8 cm, multilocular or degenerative cyst also increase risk of bile leak. Post-operative complications are more in patients with bile leak (57%) than those without bile leak (12%). Hospital stay is longer in patients with bile leak 4.9 weeks while it is 1.06 week in those without bile leak. In conclusion, bile leak is not uncommon after hepatic hydatid cyst surgery, it can be predicted by certain laboratory and radiological factors thus indicate the need for additional procedures during operation to detect the cysto-biliary communication and manage the biliary leakage and its complications. Introduction iver hydatid disease is a common health problem in the middle east including Iraq, it is caused by larval stage of a tape worm, Echinococcus granulosus, and in 70-80% of cases occur in the liver 1-6 . Surgery is the mainstay of treatment and it is the only curative approach, medical treatment (albendazol, mebendazol) is of limited use 1-3,6,7 . The objectives of surgical approach are: inactivate scolices, prevent spillage of cyst contents, eliminate viable daughter cysts and manage the residual cavity by external drainage, omentoplasty or capitonnage 1,6 . The safest surgical approach is open partial peri-cystectomy (de-roofing) with endo-cystectomy (complete cyst evacuation) and external drainage, L Study of bile leak after hepatic hydatid cyst surgery in Basrah Nazar J. Sawady & Zaki Al-Faddagh Bas J Surg, March, 18, 2012 41 although this surgery is safe, simple, faster, easier, less blood loss, used in very large cyst and used in management of deep cysts of liver hydatidosis, but it has variaties of complications 1,2,8,9 . The most common complication is being bile leak from a cysto-biliary communication and its sequels like prolong biliary-cutaneous fistula through the drain placed during surgery 2,7,8 . Pathophysiology of bile leak: intra-cystic pressure is 30-80mm H2O, while normal biliary pressure is 15-20 mmH2O so the flow is toward biliary system into duodenum through ampulla of Vater; the pericyst acts as a mechanical barrier, after surgery this pressure gradient will be reversed &bile leak occur if there is cysto-biliary communication 1,4 . Almost always, cases of the bile leak is due to cysto-biliary communication, the clinical findings and radiological features (U/S,CT-scan, MRI) are non specific and non valuable in detecting occult cystobiliary communication pre-operatively 2,6 . The occult cysto-biliary communication may be diagnosed at surgery and managed intra-operatively, but if remain undetected &unrepaired, postoperative bile leak will ensue this will result in prolong biliary drainage and it will increase morbidity & hospital stay 8,9 . Thus it is important to predict cystobiliary communication pre-operatively and concentrate on intra-operative diagnosis to prevent post-operative bile leak 8-10 . Intra-operative bile leak may be seen when bile stained aspirate is found or swapping of the cavity or direct bile leak seen in the cavity from a small or a large bile ducts after endocystectomy 7,8,11 . Small intra-operative bile leak is managed by suturing of cysto-biliary communication with external drainage or omentoplasty or capitonnaige. Large intra-operative bile leak managed by internal drainage (cysto-enterostomy) 12,13 . These management are successful in prevention of post-operative bile leak in most cases of intra-operative bile leak 7,8,11-13 . Post-operative bile leak appears as controlled external fistula in most cases, it may be presented as bilioma (intraabdominal bile collection) or biliary peritonitis especially when drain is removed.other clinical findings also common like right upper quadrant pain, fever and leucocytosis 7,9 . There are several laboratory predictors pre-operatively that can predict biliary leakage due to occult cysto-biliary communication these are: alkaline phosphatase >250 u/l; total serum bilirubin >17 umol/l; alanine aminotransferase (ALT) >33.5 u/l; aspartate aminotransferase (AST) >29.5 u/l elevation above these. Limits are found to be associated with increase post-operative bile leak 6,7,13 ; Certain Radiological features of the hydatid cyst of liver e.g Cyst diameter >8cm; multilocular cyst and degenerative cysts are also associated with high risk of bile leak 7,6,14 . No relation between bile leak and age, sex, region and symptoms; also no difference was found in terms of nature of cyst whether primary or recurrent; single or multiple; and their location (right, left or both) these did not affect the risk of biliary leakage in most of series 6,15,16 . The major morbidity of conservative surgery is post-operative bile leak its incidence is ~25%; other complications may occur e.g; wound infection; subhepatic abscess; cavity infection and others (pulmonary complications e.g atelectasis or pneumonia) 1,6,7,13,15 . Fate of post-operative bile leak: most series suggest spontaneous closure of bilio-cutaneous fistula in median time 40120 days 6,9,13,15,16 . If fistula did not close or it is of high output (>300ml/day), this suggest a large cysto-biliary communication and it need ERCP for confirmation of diagnosis & treatment by endoscopic sphincterotomy and the success rate 90-100% 7-9 . Study of bile leak after hepatic hydatid cyst surgery in Basrah Nazar J. Sawady & Zaki Al-Faddagh Bas J Surg, March, 18, 2012 42 Patients with prolonged bile leak may need re-operation for suturing of cystobiliary fistula if visible; or biliary decompression procedures e.g (t.tube drainage; trans-duodenal sphincterotomy; choledocho-duodenostomy); or may need internal drainage (cysto-enterostomy) 1,3,7,9 .