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 ¤ Introduction
 ¤ Patients and Methods
 ¤ Results
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 Table of Contents     
Year : 2018  |  Volume : 14  |  Issue : 3  |  Page : 230-235

Liver hydatid cyst with cystobiliary communication: Laparoscopic surgery remains an effective option

1 Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Human Organ Transplant, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission02-May-2017
Date of Acceptance10-Jun-2017
Date of Web Publication6-Jun-2018

Correspondence Address:
Dr. Vivek Gupta
Department of Human Organ Transplant, Ground Floor, Shatabdi Hospital-Phase 1, King George's Medical University, Lucknow-226003, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_81_17

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 ¤ Abstract 

Introduction: Most centres offer laparoscopic treatment for liver hydatid cyst (LHC). There have been concerns about the management of intra-peritoneal spillage, bleeding, and cystobiliary communication (CBC) during laparoscopic surgery for LHC. CBC can exist in 13%–37% of cases of LHC. No randomised studies have compared open versus laparoscopic approach for the treatment of LHC. We specifically analysed the outcomes of laparoscopic treatment of LHC with special reference to associated biliary complications.
Patients and Methods: We analysed our prospectively collected data of patients undergoing laparoscopic treatment of LHC from 2009 to 2016. Patients undergoing open surgery or interventional radiology procedures were not included. Data analysed included demographic profile, investigational parameters, intra-operative findings and postoperative results with special reference to biliary complications and presence/management of CBC.
Results: A total of 41 patients underwent laparoscopic treatment of LHC. History of jaundice was present in 5 (12.2%) patients. CBC was documented in 16 (39.02%) patients. In 11 patients, CBC was detected intra-operatively as visible communication, which was suture ligated or clipped. Five patients had occult CBC, detected as bile leak in the post-operative period. The leak resolved spontaneously in 7 patients and with biliary stenting in 2 patients. Only one patient had a persistent biliary leak. Postoperative bile leak was more common in patients with raised alkaline phosphatase. No statistically significant association was seen with size or location of the cyst, number of cysts and World Health Organisation classification.
Conclusion: Laparoscopic treatment of LHC with associated CBC provides acceptable results.

Keywords: Cystobiliary communication, laparoscopic surgery, liver hydatid cyst

How to cite this article:
Chopra N, Gupta V, Rahul, Kumar S, Joshi P, Gupta V, Chandra A. Liver hydatid cyst with cystobiliary communication: Laparoscopic surgery remains an effective option. J Min Access Surg 2018;14:230-5

How to cite this URL:
Chopra N, Gupta V, Rahul, Kumar S, Joshi P, Gupta V, Chandra A. Liver hydatid cyst with cystobiliary communication: Laparoscopic surgery remains an effective option. J Min Access Surg [serial online] 2018 [cited 2022 Aug 17];14:230-5. Available from:

 ¤ Introduction Top

Liver hydatid cyst (LHC) is an endemic disease in central India.[1] Left untreated, LHC may give increase to various complications such as intra-abdominal rupture, pressure effects to adjacent organs, cystobiliary and cystobronchial fistula, etc.[2],[3] Jaundice is seen in 8.9%–17% of patients and cystobiliary communication (CBC) can exist in 13%–37% of cases of LHC.[3],[4],[5] Biliary complications associated with LHC can increase the morbidity and mortality associated with this disease.

Surgery for LHC can be either conservative like partial cystectomy and cyst deroofing or radical including pericystectomy and hepatectomy. Most centres now offer laparoscopic treatment for LHC.[6],[7],[8] There have been concerns about limitations of the laparoscopic approach to LHC like increased chances of intraoperative spillage of cyst contents, control of bleeding and management of CBC.[7] Recently, single incision and robotic-assisted surgery have also been introduced for the treatment of LHC.[6] Till date, no randomised studies have compared laparoscopic and open approach for the treatment of LHC.[6]

Our centre offers laparoscopic treatment for LHC. In this report, we have analysed the outcomes of laparoscopic treatment of LHC with special reference to patients with jaundice or CBC.

 ¤ Patients and Methods Top

The study was conducted at a tertiary care centre in North India. It is a retrospective analysis of patients who underwent laparoscopic treatment of LHC in our department between April 2009 and April 2016.

Inclusion criteria

All patients of LHC who underwent total laparoscopic surgery.

Exclusion criteria

Patients in whom conversion to open surgery was required.

Data collected

Data were extracted from a prospectively managed computerised patient database. The demographic profile of the patients, symptoms at presentation, routine haematological investigation, serological tests, radiology findings (ultrasonography, computed tomography or magnetic resonance imaging) was recorded. Details were sought regarding any past interventional or surgical procedure performed. Cysts were classified according to World Health Organisation (WHO) classification.[2]

Patients with a history of jaundice were evaluated using magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic stenting or percutaneous transhepatic biliary drainage was done if indicated. Patients with cholangitis were managed by antibiotics with or without biliary drainage depending on the severity of cholangitis. Piperacillin-tazobactam was started as empirical therapy and was modified according to culture-sensitivity and clinical response. Surgery was considered in these patients after 6 weeks of resolution of cholangitis.

Surgical procedure

All patients selected for operative treatment of LHC were offered laparoscopic treatment if possible. Contraindications for laparoscopic surgery were either related to the inaccessible location of cyst or contraindications for general anaesthesia. Multiple cyst or size of the cyst was not considered contraindication for laparoscopic surgery. Medical management was the treatment of choice for CE1 cysts. No interventions were performed for CE5 cysts and were considered as an inactive cyst. Surgery was mainly reserved for CE2, CE3 and selected patients with symptomatic CE4 cysts.

Diagnostic laparoscopy was performed in all cases. After confirming the findings, 2 or 3 additional ports were placed as shown in [Figure 1]. Hypertonic saline was used as a scolicidal agent. Long gauge pieces soaked in scolicidal agent were placed around the cyst. The cyst was first aspirated using aspiration needle in an antigravity fashion to reduce intracystic pressure and prevent uncontrolled spillage. The colour of the cyst fluid was noted to anticipate CBC. After decompression, the cyst wall was opened using the harmonic scalpel in an antigravity fashion, and a small circular piece of cyst wall was excised. The daughter cysts were suctioned using high power ten mm suction. Another suction was kept at the liver surface near the excised wall to prevent inadvertent spillage. After thorough suctioning, the scope was introduced into the cavity, and cyst cavity examined to detect CBC (bile leak) and residual daughter cysts. Residual cysts were suctioned under direct vision. All CBC were closed with figure of 8 intracorporeal polypropylene stitches. The scolicidal agent was introduced after ensuring ligation of all visualised CBC and no active bile leak. Intraoperative cholangiogram was not performed. Contact period of 20 min with scolicidal agent was ensured. The cyst was then de-roofed to ensure effective drainage. Omentum was used to pack the remaining cavity, and 16 Fr drain was placed in the cavity in all the patients and left to gravity.
Figure 1: (a) Port position. (b) Laparoscopic visualisation of cystobiliary communication. (c) Magnetic resonance cholangiographic image of cystobiliary communication. (d) Ligated cystobiliary communication

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Postoperative data included presence and duration of biliary leak, postoperative morbidity as per Clavien Dindo Classification,[9] duration of hospital stay and postoperative interventions if any.

Follow-up data were obtained from outpatient visits and telephonic interviews. Patients were followed at minimum 6 monthly intervals.

Albendazole therapy

All patients were prescribed preoperative albendazole therapy for sterilisation of the cyst for a minimum of 7 days. Postoperative albendazole therapy was advised to all the patients. The regimen used was three courses of 4 weeks of albendazole with a 2 week gap as recommended by the WHO.[10]

Statistical analysis

Data collected were analysed using GraphPad Prism Version 5.0 by GraphPad Software Inc. California, USA. Patient characteristics are expressed as the mean ± standard deviation for parametric continuous data and as the median for non-parametric. Categorical data are expressed as numbers with percentages. Fisher's exact test/Chi-square test was used to compare the differences in categorical variables. Student t-test was used for quantitative variables. The value of P < 0.05 was considered statistically significant. Data were analysed for the presence of CBC and persistence of biliary leak beyond 7 days.

 ¤ Results Top

Forty-one patients underwent total laparoscopic surgery for LHC at our centre during the study duration. [Table 1] represents the demographic profile and presenting symptoms of the patients. Median age was 35 year. Females were predominantly affected (F:M = 2.7:1). Most of the patients (75.61%) belonged to low socioeconomic class as per BG Prasad Classification.[11]
Table 1: Baseline and pre-operative characteristics of patients (n=41)

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Pain was the main presenting symptom (90.24%, n = 37). History of jaundice was present in 5 (12.2%) patients. [Table 1] summarises the clinical presentation and workup. Single cyst was present in 27 (65.85%) patients. The median diameter of the largest cyst was 87 mm. As per the WHO classification, CE-2 cysts were present in 51.22%, CE-3 in 43.9% of the patients.

Cyst characteristics and surgery performed

LHC was most common in right lobe of liver (58.5%, n = 24). The most common location was segment 7 of the liver. Median size was 87 mm. No evidence of liver atrophy was seen. Forty patients underwent conservative surgery while left lateral sectionectomy was done in one patient.

Cystobiliary communication

Overall the incidence of CBC was 16/41 (39.02%). Intra-operatively, CBC was detected in 11 of patients [Figure 1]. Eight patients had single CBC and one patient had two CBC. Intraoperative ligation of CBC was done in all the patients [Figure 1]. Bilio-enteric anastomosis was not performed in any patient. In two patients, bile stained fluid was present in the cyst cavity, but no CBC was identified intra-operatively.

In the postoperative period, five out of the 11 patients with intra-operatively detected CBC had a biliary leak. In one patient, drain output converted to serous spontaneously and drain was removed on postoperative day three. Remaining four patients were discharged with a drain in situ and were followed up on OPD basis. One patient had spontaneous resolution and drain was removed at 3 weeks. Remaining three patients had persistent bilious output even after 4 weeks of surgery. One underwent an exchange of preoperatively placed biliary stent, and the other underwent ERC stent placement leading to healing of biliary fistula. The drain was subsequently removed. Only one patient in our series developed persistent external biliary fistula beyond 6 month of follow-up. In this patient, ERCP was tried postoperatively, but common bile duct (CBD) couldn't be cannulated.

Twenty-seven patients had no intraoperative evidence of CBC. Out of them, five patients had postoperative biliary leak (occult CBC). In three patients, drain output converted to serous spontaneously and were discharged after drain removal. Remaining two patients were discharged with drain due to the persistent biliary fistula. Both the patients had a spontaneous conversion of drain output to serous and drain was removed during follow-up visits. None of the patients had persistent bilious discharge beyond 4 weeks, and intervention was not required.

Jaundice with liver hydatid cyst

Overall five patients had a history of jaundice along with LHC. Two patients had spontaneous resolution of jaundice during the work up. In both of these patients, MRCP done just before surgery showed normal CBD with the return of LFT to normal. Two patients underwent biliary stenting as cholangiogram showed evidence of CBC above biliary confluence in one and external compression due to a cyst in other. The fifth patient had evidence of CBC based on preoperative MRCP [Figure 1]. ERCP stenting was tried preoperatively as well as postoperatively, but CBD could not be cannulated. This patient continues to have external biliary fistula at around 1 year of follow-up as mentioned above.

Among these patients, CBC was diagnosed intraoperatively in four patients and repaired. Two patients in this group had persistent bilious drain output in the post-operative period. One patient had successful ERC stenting and drain was subsequently removed. Cannulation failed in the other patient as explained above. Surgery couldn't be offered because of poor performance status.

Postoperative morbidity

[Table 1] shows the postoperative morbidity of the patients. Major morbidity (> CD 3a) was seen in 4 (9.76%) patients. No postoperative mortality was seen. One patient still has persistent external fistula as mentioned above.

Liver hydatid cyst recurrence

Complete follow-up data were available for 29 (76.38%) patients. Median follow-up duration was 30 month (range: 3–65). Only one patient had evidence of recurrence of cyst in the follow-up period and is planned for redo surgery.

Statistical analysis

Out of 41 patients, who underwent successful laparoscopic surgery, 16 patients had CBC, ten patients had bile leak postoperatively, six patients were discharged with a drain in situ and one patient had a persistent biliary fistula. [Table 2] and [Table 3] represents the statistical analysis. On statistical analysis, the size of cyst had no relation to the presence of CBC. Postoperative bile leak was more commonly seen in patients with raised alkaline phosphatase (P = 0.045). Raised alkaline phosphatase was also found to be a significant predictor for persistent drain output beyond 7 days (P = 0.009). No statistically significant association was seen with size or location of the cyst, number of cysts and WHO classification.
Table 2: Statistical analysis regarding the effect of various factors on the presence of cystobiliary communication (n=16/41)

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Table 3: Statistical analysis regarding the effect of various factors on persistent biliary output beyond 7 day (n=6/41)

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 ¤ Discussion Top

More and more centres are now offering a laparoscopic approach for LHC. Advantages include better cosmetic results, decreased hospital stay and reduced analgesic requirement.[12] Specific advantages of laparoscopy in surgery for hydatid cyst include direct visualisation of the cyst cavity for CBC and remnant germinal layer.[7] In this article, we focused mainly on biliary complications (CBC and jaundice) associated with LHC and their outcomes after laparoscopic surgery.

In the preoperative period, CBC can manifest as biliary colic, obstructive jaundice and cholangitis due to obstruction of CBD by daughter cysts. These patients should undergo biliary imaging and biliary stenting if required. Intraoperative, CBC can manifest as presence of bile in cyst cavity and/or visible CBC. In such cases, they can be repaired by direct ligation. Occult CBC can manifest in the postoperative period as bile leak.[13]

The incidence of CBC has been documented between 36.2% and 28.4% in various studies.[4],[13] Occult CBC usually manifest as postoperative bile leak. In a study by Unalp et al., occult CBC was found in 13.1% of the patients.[13] On comparison, the incidence of CBC in our study is similar to the mentioned studies. Intraoperative CBC was found in 28.95% (n = 11) of patients while occult CBC was seen in 12.2% (n = 5) patients.

Cyst location in right lobe of liver, Gharbi stage three, cyst diameter >10 cm, high bilirubin, leucocytosis (>10000/cmm) alkaline phosphatase >133U/L and gamma-glutamyl transferase values have been found to be predictors of CBC and postoperative bile leak.[4],[13] We analysed the effect of various factors on the presence of CBC, postoperative bile leak and persistent biliary output beyond 7 days. Preoperative raised alkaline phosphatase was found to be a significant predictor for postoperative bile leak and persistent biliary output. None of the other factors was found to be important in terms of presence of CBC.

In a study done by Demircan et al., postoperative bile leak was seen in 21.5% of patients undergoing open surgery for LHC, mostly presenting as external biliary fistula.[4] Out of these patients, 61.3% closed spontaneously while 38.7% required ERC sphincterotomy. In our study, postoperative bile leak was seen in 26.32% (n = 10) patients, spontaneous closure was seen in 70% of them. Three patients (30%) had persistent biliary fistula requiring ERCP. Two patients underwent successful sphincterotomy and fistula closed. However, one patient had failed cannulation and is having persistent biliary fistula even after 1 year of follow-up.

There were concerns in laparoscopic surgery regarding intraoperative spillage as compared to open surgery. However, published literature has shown comparable recurrence rates.[5],[6],[7],[8],[14],[15],[16] Laparoscopic surgery should be tailored to prevent any spillage. Palanivelu et al. have developed “Palanivelu hydatid system” which includes a complex system involving fenestrated trocar and cannulas to avoid any peritoneal spillage.[17] It prevents any fluid spillage and assists in complete evacuation and effective visualisation of the CBC. At our centre, we perform initial decompression followed by antigravity suction using large bore (10 mm channel) connected to a high power suction device. Another suction is placed at the opening of the cyst wall to further reduce spillage. In this study, median follow-up duration was 30 months (3–65 month). The recurrence rate was 2.44%. The recurrence rate in published literature is 0%–30% in open series and 0%–9% in laparoscopic series.[7] The low recurrence rate seen in our study reconfirms the effectiveness of this technique.

Tuxun et al. conducted a review of the literature regarding the laparoscopic treatment of LHC.[6] Total 914 patients were included in the study with the most common procedure performed being cystectomy (60.3%) followed by partial pericystectomy (14.7%). Even extensive liver resections were performed. Conversion rate was 4.9%. The most common cause of conversion was inaccessible location. Overall mortality was 0.2% and morbidity was 15.07%. The recurrence rate was 1.09%.

There have been no randomised trials comparing open and surgical treatment of hydatid cyst.[6] Various series have been published regarding laparoscopic treatment of hydatid cyst. One of the largest series was published by Zaharie et al.[7] Study included 59 patients undergoing laparoscopic drainage and 172 patients undergoing the conventional open procedure. In the laparoscopic group, conservative procedure (partial pericystectomy) was done in 91.5% of the cases, and total pericystectomy was done in 8.48% of cases. Morbidity rates were acceptable in the laparoscopic group (10.7%).

Percutaneous treatment of hydatid cyst was first done by Mueller et al. in 1985.[18] PAIR has also been effectively utilised for the treatment of LHC. This technique involves aspiration of the cyst content followed by instillation of scolicidal agent. After adequate contact period, the scolicidal agent is reaspirated. In a study performed by Rajesh et al., PAIR was done in 15 patients and was followed up for 1 year.[19] None of the patients were found to have anaphylaxis, recurrence or peritoneal seeding. They concluded that PAIR is an effective modality for minimally invasive treatment for LHC with less hospital stay. No study was found in literature search detailing the use of the percutaneous technique in patients with jaundice or CBC associated with LHC.

We could successfully manage LHC with associated CBC through laparoscopic approach. Postoperative bile leaks were managed conservatively in most of the patients with few requiring ERCP stenting.

 ¤ Conclusion Top

Laparoscopic treatment of hydatid cyst can be effectively applied to patients providing all the benefits of laparoscopic approach and acceptable results. Complications arising can be effectively managed with minimal morbidity, thus preserving the benefits of minimally invasive procedures.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 ¤ References Top

Akther MJ, Khanam N, Rao S. Clinico epidemiological profile of hydatid diseases in central India, a retrospective and prospective study. Int J Biol Med Res 2011;2:603-6.  Back to cited text no. 1
Anand S, Rajagopalan S, Mohan R. Management of liver hydatid cysts – Current perspectives. Med J Armed Forces India 2012;68:304-9.  Back to cited text no. 2
Avgerinos ED, Pavlakis E, Stathoulopoulos A, Manoukas E, Skarpas G, Tsatsoulis P. Clinical presentations and surgical management of liver hydatidosis: Our 20 year experience. HPB (Oxford) 2006;8:189-93.  Back to cited text no. 3
Demircan O, Baymus M, Seydaoglu G, Akinoglu A, Sakman G. Occult cystobiliary communication presenting as postoperative biliary leakage after hydatid liver surgery: Are there significant preoperative clinical predictors? Can J Surg 2006;49:177-84.  Back to cited text no. 4
Duta C, Pantea S, Lazar C, Salim A, Barjica D. Minimally invasive treatment of liver hydatidosis. JSLS 2016;20. pii: E2016.00002.  Back to cited text no. 5
Tuxun T, Zhang JH, Zhao JM, Tai QW, Abudurexti M, Ma HZ, et al. World review of laparoscopic treatment of liver cystic echinococcosis-914 patients. Int J Infect Dis 2014;24:43-50.  Back to cited text no. 6
Zaharie F, Bartos D, Mocan L, Zaharie R, Iancu C, Tomus C. Open or laparoscopic treatment for hydatid disease of the liver? A 10-year single-institution experience. Surg Endosc 2013;27:2110-6.  Back to cited text no. 7
Koea JB. Laparoscopic treatment of hepatic hydatid disease. ANZ J Surg 2012;82:499-504.  Back to cited text no. 8
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13.  Back to cited text no. 9
Guidelines for treatment of cystic and alveolar echinococcosis in humans. WHO Informal Working Group on Echinococcosis. Bull World Health Organ 1996;74:231-42.  Back to cited text no. 10
Shaikh Z, Pathak R. Revised Kuppuswamy and B G Prasad socio-economic scales for 2016. Int J Community Med Public Health 2017;4:997-9.  Back to cited text no. 11
Agha R, Muir G. Does laparoscopic surgery spell the end of the open surgeon? J R Soc Med 2003;96:544-6.  Back to cited text no. 12
Unalp HR, Baydar B, Kamer E, Yilmaz Y, Issever H, Tarcan E. Asymptomatic occult cysto-biliary communication without bile into cavity of the liver hydatid cyst: A pitfall in conservative surgery. Int J Surg 2009;7:387-91.  Back to cited text no. 13
Gomez I Gavara C, López-Andújar R, Belda Ibáñez T, Ramia Ángel JM, Moya Herraiz Á, Orbis Castellanos F, et al. Review of the treatment of liver hydatid cysts. World J Gastroenterol 2015;21:124-31.  Back to cited text no. 14
Jabbari Nooghabi A, Mehrabi Bahar M, Asadi M, Jabbari Nooghabi M, Jangjoo A. Evaluation and comparison of the early outcomes of open and laparoscopic surgery of liver hydatid cyst. Surg Laparosc Endosc Percutan Tech 2015;25:403-7.  Back to cited text no. 15
Bostanci O, Kartal K, Yazici P, Karabay O, Battal M, Mihmanli M. Laparoscopic versus open surgery for hydatid disease of the liver. A single center experience. Ann Ital Chir 2016;87:237-41.  Back to cited text no. 16
Palanivelu C, Senthilkumar R, Jani K, Rajan PS, Sendhilkumar K, Parthasarthi R, et al. Palanivelu hydatid system for safe and efficacious laparoscopic management of hepatic hydatid disease. Surg Endosc 2006;20:1909-13.  Back to cited text no. 17
Mueller PR, Dawson SL, Ferrucci JT, Nardi GL. Hepatic echinococcal cysts: Successful percutaneous drainage. Radiology 1985;155:627-8.  Back to cited text no. 18
Rajesh R, Dalip DS, Anupam J, Jaisiram A. Effectiveness of puncture-aspiration-injection-reaspiration in the treatment of hepatic hydatid cysts. Iran J Radiol 2013;10:68-73.  Back to cited text no. 19


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  [Table 1], [Table 2], [Table 3]

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