Biliary Fistula and Late Recurrence of Liver Hydatid Cyst: Role of Cysto-biliary Communication - A Prospective Multicenter Study.

Hydatid cyst disease (HCD) is a zoonotic illness caused by Echinococcus Granulosus that infects humans via ingestion of eggs and primarily affects the liver (50-70%), followed by the lungs, brain, and other viscera . To facilitate consistent diagnosis, treatment, and follow-up, the World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) arranged a standardized ultrasonography staging based on the cyst's active-transitional-inactive stage .

Various therapy options for hydatid cyst management range from medical treatment alone, which has been shown to be ineffective in curing the condition , to surgical treatment, which is considered the primary therapeutic option [6]. For hydatid cysts, laparoscopic surgery is both safe and successful. Laparoscopic procedures range from conservative procedures such as laparoscopic partial cystectomy and omentoplasty to obliterate the residual cavity to radical procedures such as pericystectomy or hepatic resection . The type of surgery to be performed is determined by the location, size, and presence of cyst complications .

Cysto-biliary communication (CBC) is a common complication after hepatic HCD surgery that occurs when a cyst bursts into the biliary system , with a reported incidence of 13%-37% and can manifest as frank or occult (silent) CBC . Cyst fluid, scolices, small daughter cysts, and minor fragments of the endocyst membranes migrate into the biliary tract in occult or silent CBC, but neither clinically nor radiologically can be detected . Postoperative biliary leakage will occur if Occult CBC is overlooked during surgery, and will manifest as biliary drainage, biliary peritonitis, and biliary abscess. . Another issue is recurrence after hydatid cyst surgery, which has a range of (0-22 percent) .

Aim of the study, gap statement, and study strength:

Although several studies have looked at the results of laparoscopic partial cystectomy with omentoplasty in terms of postoperative biliary fistula and recurrence, no investigations into the link between occult cysto-biliary communication and late recurrence have been published. Furthermore, no studies have looked into the value of cystic fluid analysis in detecting occult cysto-biliary communication, which can lead to biliary leakage and recurrence after surgery. The primary goals of this study were to determine the prevalence and risk factors of occult CBC and recurrence, as well as the relationship between occult cysto-biliary communications manifested as postoperative biliary leakage and recurrence. The secondary goal was to use chemical analysis of hydatid cyst fluid to assess excessive bilirubin and alkaline phosphatase levels as predictors of fistula and recurrence.