Therapeutic endoscopic retrograde cholangiopancreatography and related modalities have many roles in hepatobiliary hydatid disease

Abstract

The authors report their experience about 8 cases of intrabiliary rupture of hepatobiliary hydatid disease, and add an algorithm for treatment. To our opinion, the use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary hydatid disease was not stated properly in their proposed algorithm. According to the algorithm, the use of ERCP and related modalities was only stated in the case of postoperative biliary fistulae. We think that postoperative persistant fistula is not a sole indication, there are many indications for ERCP and related techniques namely sphincterotomy, extraction, nasobiliary drainage and stenting, in the treatment algorithm before or after surgery.

Key Words: Therapeutic endoscopic retrograde cholangiopancreatography; Hepatobiliary; Hydatid

TO THE EDITOR

We have read with great interest the article titled “Intrabiliary rupture: an algorithm in the treatment of controversial complication of hepatic hydatidosis”[1]. The authors reported their experience about 8 cases of intrabiliary rupture of hepatobiliary hydatid disease, and added an algorithm for treatment. To our opinion, the use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary hydatid disease was not stated properly in their proposed algorithm. According to the algorithm, in a case of preoperative suspicion of intrabiliary rupture due to various reasons, such as cystic content in common bile duct (CBD), dilated CBD and obstructive jaundice, surgery was proposed without prior to ERCP. The use of ERCP and related modalities was only stated in the case of postoperative biliary fistula. Many reports[2-4] including ours[5,6] are published in English literature about the use of ERCP in the management of hydatid disease. Our former report[5] has reviewed a total of 294 cases, after collecting 273 cases in 26 articles and 6 abstracts from literature and adding 21 cases of our own experience. Considering the current literature[7,8] and our experience, we think that postoperative persistant fistula is not a sole indication, there are many indications for ERCP and related techniques namely sphincterotomy, extraction, nasobiliary drainage and stenting, in the treatment algorithm before or after surgery.

ERCP in the preoperative period[2] I- defines the cystobiliary relationship to help in surgery planning, II- permits evaluation of acute conditions like cholangitis and obstruction so that subsequent surgery can be performed on an elective basis, III- may give permanent cure specifically in cases of frank intrabiliary rupture if evacuation of biliary tract and cystic cavity is manageable, and IV- when combined with preoperative endoscopic sphincterotomy may decrease the incidence of the development of postoperative external fistulae. While the first three statements have been studied extensively, the fourth statement may warrant further studies to clarify the criteria of selection of appropriate cases. The only study regarding this issue performed by Galati et al[7], reported a significant decrease in postoperative fistulae in cases that underwent selective preoperative ERCP (3.8% versus 7.4%).

ERCP in the postoperative period[2] I- can help to clarify the causes of ongoing or recurrent symptoms or laboratory abnormalities, II- may help to resolve the obstruction or cholangitis due to residual material in biliary ducts, III- may provide the chance to manage postoperative external biliary fistulae, and IV- may be a realistic solution for secondary biliary strictures[8].

Since hydatid disease is a serious public health problem despite the use of various kinds of preventive measures, we greatly appreciate every kind of studies regarding the issue to solve the controversions. Endoscopic therapy should be incorporated into the other treatment options including surgery, percutaneous measures and chemotherapy with benzimidazole compounds. The exact place of each therapeutic modality in a particular case should be decided on the basis of expanding current literature.