Copyright © 2005 by Indian Society of Gastroenterology
Background: Conservative surgery (cyst evacuation
and partial pericystectomy) for hydatid cysts of the
liver is known to be safe but is often associated with
bile leak and its sequelae. Methods: Case records of
86 patients undergoing surgery for hydatid cysts of
the liver at a tertiary-care center in northern India
over a 14-year period were reviewed retrospectively.
Results: Sixteen (18%) patients had jaundice and
36 (42%) had a cyst-biliary communication detected
at surgery. Biliary complications developed in 14 (16%)
patients. Bile leaks and bilio-cutaneous fistulae were
observed in 11 (13%) patients; the fistula output was
low (<300 mL/day) in 8 of these. Three patients had
localized intra-abdominal bile collections; all 3 underwent
percutaneous drainage of biloma (subsequent
laparotomy and lavage was required in one patient
due to failure of percutaneous drainage), producing
controlled low-output bilio-cutaneous fistulae in all.
All low-output fistulae closed spontaneously after a
mean duration of 4 weeks. Patients with high-output
fistulae underwent endoscopic intervention (stenting
/ naso-biliary drainage), resulting in the conversion
of these fistulae to low-output category and eventual
closure after a mean duration of 7.5 weeks. Conclusion:
Postoperative bile leaks lead to significant morbidity
after surgical management of hydatid cysts of liver. A
majority of them resolve spontaneously. Biliary drainage
(endoscopic or surgical) hastens the closure of these
bilio-cutaneous fistulae. [Indian J Gastroenterol
Mediterranean countries, the Middle East and South
America.1 Humans are not a part of the natural life cycle
of the parasite Echinococcus granulosus. Incidental human
infestation with larval form results in formation of hydatid
cysts in various parts of the body, the liver being the
most common site (70%-75% of cases).
Several surgical techniques, ranging from formal
hepatic resection2,3 to simple cyst evacuation and par-
tial pericystectomy4,5 have been used for the treatment
of hepatic hydatid cysts. Conservative operations, al-
though safe and easy, have been criticized for a high
frequency of postoperative bile leaks and disease recur-
rence.6 We report our experience with the management
ydatid disease is an important health problem
worldwide, especially in endemic regions like the
and outcome of biliary complications associated with
surgery for hepatic hydatid cysts.
Records of 89 consecutive patients with hydatid disease
of liver who underwent treatment in the Department of
Surgical Gastroenterology of our hospital – a tertiary-
care institution in northern India – between January
1989 and December 2002 were reviewed retrospectively.
Three patients had been treated with percutaneous pro-
cedures alone. Data on the remaining 86 patients (age
range 7-62 years, mean [SD] 35.5 [11.5] years; 51 women)
who underwent surgical management were analyzed.
Pre-operative evaluation had included liver func-
tion tests, and imaging in the form of abdominal ultra-
sonography and contrast-enhanced CT. In addition,
endoscopic retrograde cholangiography (ERC) and bil-
iary drainage had been done in patients presenting with
jaundice and/or cholangitis. Patients with past history
of jaundice but with no icterus, normal liver function
tests, and no evidence of biliary obstruction on imaging
at the time of presentation did not undergo any further
The type of surgical procedure was based on the
site of the cyst, and presence or absence of infection
and of cyst-biliary communication. The common bile duct
(CBD) was explored only in the following situations: i)
dilated CBD on pre- or intra-operative evaluation with or
without evidence of filling defects; and, ii) for biliary
decompression in patients with large cyst-biliary com-
munications, especially those not amenable to closure
during surgery. Intra-operative cholangiogram was not
Any patient found to have leakage of bile exceed-
ing 30 mL/day lasting more than 3 days through the
drain in the postoperative period was considered to have
a bile leak. The fistulae were categorized into low- and
high-output types depending on whether the fistula output
was less than or greater than 300 mL/day, respectively.
Statistical analysis was done using the Mann-
Upper abdominal pain was the most common presenting
symptom (n=75, 87%); history of fever and jaundice was
Bile leaks following surgery for hepatic hydatid disease
Shaleen Agarwal, Sadiq Saleem Sikora, Ashok Kumar,
Rajan Saxena, Vinay Kumar Kapoor
Department of Surgical Gastroenterology,
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 220 014
Bile leaks following surgery for hydatid cyst
56 Indian Journal of Gastroenterology 2005 Vol 24 March - April
Agarwal, Sikora, Kumar, Saxena, Kapoor
present in 29 (34%) and 16 (18%) patients, respectively.
Cysts were localized to the right lobe of the liver in 55
(64%) patients, to the left lobe in 25 (29%) patients, and
involved both lobes in 6 (7%) patients; 18 (21%) pa-
tients had multiple cysts. Additional sites of cysts in-
cluded the lungs (n=3) and spleen (n=1); 5 patients had
disseminated peritoneal disease.
Pre-operative ERC and biliary drainage were per-
formed in 4 patients presenting with jaundice and cho-
Radical surgical procedures like cystopericystectomy
(n=12) and anatomical hepatic resection (n=2) were per-
formed in 14 (16%) patients; a majority of patients (n=72,
84%) underwent conservative procedures that included
cyst evacuation and partial pericystectomy (n=57) or
capsulorrhaphy (n=15). Internal drainage of the residual
cavity in the form of Roux-en-Y cysto-jejunostomy was
performed after partial pericystectomy in 12 patients,
while the cavity was drained externally in 8 patients.
Cyst-biliary communications were detected in 36 (42%)
patients and these were individually ligated with syn-
thetic absorbable suture; in 16 (18%) patients, CBD
exploration and T-tube drainage was also done. Chole-
cystectomy was added to the surgical procedure in 24
(28%) patients either because of the presence of gall
bladder calculi (n=13) or because of the gall bladder
was densely adherent to the cyst (n=11). External drain-
age was performed in patients with infected cysts.
Postoperative bile leaks occurred in 14 (16%) pa-
tients; none of these patients had undergone a cyst-
excision procedure (cysto-pericystectomy or left lateral
segmentectomy). Cyst-biliary communication had been
detected at the time of surgery in 11 of 14 patients; in
4 of these patients, in addition to suture ligation of
cyst-biliary communication, a biliary decompression
procedure (CBD exploration and T-tube drainage) had
been performed (Fig). One patient died in hospital of an
unrelated medical condition (dilated cardiomyopathy with
congestive heart failure). Right lobar cysts, cysts with
biliary communications, and those undergoing external
drainage were significantly more often associated with
bile leaks (Table).
Bile leaks manifested as controlled external biliary
fistula through the drain placed during surgery in 11
and as postoperative intra-abdominal bile collection
(biloma) in 3 patients. The latter three patients under-
went percutaneous drainage of the biloma (subsequent
laparotomy and lavage was required in one patient due
to failure of percutaneous drainage). Thus a controlled
external biliary fistula was finally established in all the
Median fistula output was 75 mL/day (range 50-
500); the fistulae had a low output in 11 patients and
high output in 3 patients. The median fistula closure
time was 30 days. All the 11 low-output fistulae closed
spontaneously after 11 to 84 days (median 30); the time
to closure was significantly shorter (p=0.04) in 4 pa-
tients with peroperative T-tube drainage (median 13 days)
than in the 7 patients without biliary drainage (35 days).
The 3 patients with high-output bilio-cutaneous
fistulae underwent endoscopic stenting or endo-nasal
biliary drain placement within 2 weeks of surgery that
led to immediate reduction in fistula output and fistula
closure at 17, 18 and 90 days, respectively. This was not
different from the time to closure for low-output fistulae
with T-tube drainage (p=0.23).
Surgical management of hepatic hydatid disease has
ranged from radical procedures like hepatic resection2,3
and total cystopericystectomy7,8 to conservative ones
like cyst evacuation followed by capsulorrhaphy4 or
external drainage.5 The aim is to remove the entire dis-
ease while minimizing complications.
Table: Clinical features of patients with and without post-
operative bile leaks
Patients with Patients without
bile leak (n=14) bile leak (n=72)
Mean diameter of cyst (cm)
Site of cyst
Cyst-biliary communication at surgery 11
External drainage of cyst
Internal drainage (cysto-jejunostomy)
Fig: T-tube cholangiogram showing contrast leak (arrow)
C M Y K
Bile leaks following surgery for hydatid cyst
Indian Journal of Gastroenterology 2005 Vol 24 March - April 57
Agarwal, Sikora, Kumar, Saxena, Kapoor
Conservative procedures are safe and technically
simple, and are useful in the management of uncompli-
cated hydatid cysts.6 However, their main disadvantage
is the high frequency of postoperative complications,
the most common being bile leak from a cyst-biliary
communication and its sequelae like bilio-cutaneous fis-
tulae, bilomas and bile peritonitis (4%-28%).5,7,9 The
frequency of biliary complications in our series was
16%, similar to those in other series with predominantly
conservative surgical techniques of management.5-9
In order to reduce postoperative bile leaks, all ef-
forts should be made during surgery to detect cyst-
biliary communications. The various techniques that help
in this include: i) avoiding the use of colored scolicidal
agents like povidone-iodine since they interfere with
identification of cyst-biliary communications; ii) meticu-
lous inspection of the residual cavity after evacuation
of cyst contents; iii) placing a white laparotomy pad in
the residual cavity for few minutes and then inspecting
it for evidence of bile staining; and, iv) injecting a
colored dye into the biliary tree and looking for staining
in the residual cavity. An intra-operative cholangiogram
may also be useful. All cyst-biliary communications
identified should be meticulously ligated using sutures.
Biliary decompression should be performed in patients
with large cyst-biliary communications or when closure
is unsatisfactory. A recent report has suggested that
routine biliary decompression with a T-tube in patients
with cyst-biliary complications may reduce the frequency
of postoperative bile leaks.10
External biliary fistulae following surgery for liver
hydatid disease tend to close spontaneously. In a re-
view of 304 cases, all the 10 external biliary fistulae
closed spontaneously over a period of 2-4 months.11 In
another series, 7 of 12 fistulae closed spontaneously,
with the maximum time to closure being 38 days.12
Though most fistulae close spontaneously, the prolonged
biliary drainage causes significant morbidity. In our series,
the median hospital stay in patients with bile leaks was
18 days as compared to 7 days in those without biliary
complications. Re-exploration was usually not required
in these patients and most of them were managed suc-
cessfully by percutaneous and/or endoscopic methods.
Most series on hepatic hydatid disease report on
a small number of patients with postoperative external
biliary fistulae; it is generally accepted that endoscopic
management in the form of endoscopic sphincterotomy,
with or without stenting or naso-biliary drainage, plays
a key role in the management of such patients.13,14,15
Endoscopic sphincterotomy is believed to reduce the
high intra-biliary pressure, and promote early closure of
these fistulae even in the absence of distal biliary ob-
No guidelines are available regarding the most
appropriate timing of endoscopic intervention. The time
of intervention has varied from a few days to several
months after surgery. The time taken for closure of
fistulae after endoscopic intervention too has varied
widely (2 to 30 days) in different reports.14-18 In our
series, it was about 2 weeks after biliary decompression
(surgical or endoscopic). The reason for this delay may
lie in the nature of underlying disease. The fibrotic and
chronically inflammed pericyst may prevent the collapse
of the residual cavity and delay the closure of cyst-
Some authors19 have classified post-operative bil-
iary fistulae in these patients into high- and low-output
categories to help in making treatment decision. Whereas
early endoscopic biliary decompression has been rec-
ommended for high-output fistulae, no or delayed inter-
vention has been adopted for low-output fistulae.
In our patients, per-operative biliary decompres-
sion using a T-tube was associated with a quicker fis-
tula closure. It may thus be expected that early postop-
erative endoscopic biliary decompression will also has-
ten fistula closure. In fact, a recent report suggested
that routine biliary decompression using a T-tube in
patients with cyst-biliary complications was associated
with lower incidence of postoperative bile leaks.10 The
median closure time of high-output fistulae after endo-
scopic intervention in our study was 18 days.
We conclude that bile leaks are not uncommon
after conservative surgery for hepatic hydatid disease.
Patients with high-output fistulae should undergo early
endoscopic biliary decompression in order to hasten
fistula closure and to reduce morbidity. In contrast, a
majority of low-output fistulae close spontaneously with
conservative management; however, even these may
benefit from early endoscopic intervention.
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Correspondence to: Dr Sikora, Additional Professor. E-mail:
email@example.com. Fax: (522) 266 8017, 266 8129
Received August 16, 2004. Received in final revised form
December 23, 2004. Accepted December 28, 2004
Indian Journal of Gastroenterology
J Mitra Memorial Award
The Indian Journal of Gastroenterology bestows this award for the best original
scientific contribution published in the Journal during the year
This award carries a prize of Rs 20 000, and will be given to the department(s) submitting
the selected paper. The paper will be selected by a scientific committee appointed by the
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The award has been made possible by a generous endowment from
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and the Organizing Committee of the 45th Annual Conference of the Indian Society of
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