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

In humans, most hydatid cysts occur in the liver and 75% of these are singl e. 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 t he greater omentunn, and two cysts (15x10 and 10x10cm) in the pelvis. The a bdomen was entered first by a bilateral subcostal incision and then by st P hennenstiel incision. Partial cystectomy + capitonnage was done on the live r cysts; the cysts on the omentum were excised, and the pelvic cysts were e nucleated. The cyst in the right lobe of the liver was in communication wit h a thoracic cyst, An air leak developed from the thoracic cyst which had u nderwater drainage and bile drainage from the drain in the cavity of the ri ght lobe cyst. Sphincterotomy was done on the seventh post-operative day by endoscopic retrograde cholangiopancreaeography (ERCP). No significant effe ct on mean bile output from the fistula occurred. Octreotide therapy was in itiated, but due to abdominal pain and gas bloating the patient felt and co uld not tolerate, it was stopped on the fourth day; besides, it had no decr easing effect on bile output during the 4 days. Because air and bile leak c ontinued and he had bile stained sputum, he was operated on on post-operati ve day 18. By right thoracotomy, the cavity and the leaking branches were c losed. 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 righ t 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 cea sed. 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 w ere extracted. Evaluation of the biliary ductal system is important in bili o-cutaneous fistulas, and balloon dilatation is very effective in fistulas due to narrowing of the ducts.