Management of a patient with hepatic-thoracic-pelvic and omental hydatid cysts and post-operative bilio-cutaneous fistula: A case report

Abstract

In humans, most hydatid cysts occur in the liver and 75% of these are single. Our patient was a 31 year-old male. His magnetic resonance imaging (NIR) showed one cyst (15x20cm) in the right lobe and three cysts (5x6cm, 8x6cm, and 5x5cm) in the left lobe of the liver, two cysts (4x5cm and 5x5cm) on the greater omentunn, and two cysts (15x10 and 10x10cm) in the pelvis. The abdomen was entered first by a bilateral subcostal incision and then by st Phennenstiel incision. Partial cystectomy + capitonnage was done on the liver cysts; the cysts on the omentum were excised, and the pelvic cysts were enucleated. The cyst in the right lobe of the liver was in communication with a thoracic cyst, An air leak developed from the thoracic cyst which had underwater drainage and bile drainage from the drain in the cavity of the right lobe cyst. Sphincterotomy was done on the seventh post-operative day by endoscopic retrograde cholangiopancreaeography (ERCP). No significant effect on mean bile output from the fistula occurred. Octreotide therapy was initiated, but due to abdominal pain and gas bloating the patient felt and could not tolerate, it was stopped on the fourth day; besides, it had no decreasing effect on bile output during the 4 days. Because air and bile leak continued and he had bile stained sputum, he was operated on on post-operative day 18. By right thoracotomy, the cavity and the leaking branches were closed. By right subcostal incision, cholecystectomy and T-tube drainage of the choledochus were done. On post-operative day 30, he was sent home with the T-tube and the drain in the cavity. After 3 months post-operatively, a second T-tube cholangiography was done, and. a narrowing in the distal right hepatic duct and a minimal narrowing in the distal left hepatic duct were exposed. Balloon dilatation was done by way of a T-tube. Bile drainage ceased. There was no collection in the cavity in follow-up CT scanning, so the drain in the cavity, and the drainage catheter in the right hepatic duct were extracted. Evaluation of the biliary ductal system is important in bilio-cutaneous fistulas, and balloon dilatation is very effective in fistulas due to narrowing of the ducts.