T-tube drainage vs choledochoduodenostomy or pre - operative ercp for the management of intrabiliary rupture of hydatid cyst of the liver

Abstract EN

Background: Intrabiliary rupture is one of the common complications of hydatid cyst of the liver, with its possible sequel of obstruction, cholangitis and post-operative biliary fistula.

It should be managed properly, with accurate pre operative diagnosis and proper surgery, both for the cyst and some sort of biliary drainage with the available alternatives common bile duct exploration and T-tube drainage, choledochoduodenostomy or a pre-operative endoscopic sphincterotomy, the choice is a matter of controversy.

Objectives: To evaluate three methods of biliary drainage, (T-tube, choledochoduodenostomy, or preoparative endoscopic sphincterotomy) during management of intrabiliary rupture of hydatid cyst of the liver, in terms of morbidity and mortality rates.

Methods: During the period between October 2001 till October 2007.

92 patients attending Baghdad and Al-Diwaniya Teaching Hospitals, presented with symptomatic intrabiliary rupture of hydatid cyst liver disease were included in the study, they complained from abdominal pain and jaundice, all patients were diagnosed preoperatively by ultrasonography, CT scan and Magnetic resonance cholangiopancreatography (MRCP) was performed in selected patients, 42 patients were selected randomly and subjected preoperatively to ERCP and sphincterotomy, in whom it was successful in only 36 patients.

During surgery, the cyst and the associated biliary communication was managed according to the operative circumstances.

The common bile duct was explored thoroughly and cleaned of hydatid element.

In patient with CBD diameter > 20 mm side to side choledochoduodenostomy was performed ( 7 patients ), while T- tube drainage was performed in younger age patients with mildly dilated CBD ( 49 patients ).

Those patients in whom a preoperative ERCP and sphincterotomy was successful, surgery was limited to hepatic hydatid cyst only (36 patients).

Results : the overall mortality was 1.1%, the morbidity rate was significantly higher in the CD (71.4%) and pre-operative ERCP group (47.2%) than the T-tube drainage group (26.5%).

There was no significant difference in the rate of development of biliary fistula in the 3 different procedures.

Conclusion : T-tube drainage is safe and effective method of biliary drainage during the management of intrabiliary rupture of hydatid cyst of the liver, in terms of morbidity and mortality rates.

Pre operative endoscopic sphincterotomy is good alternative in experienced hands.