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©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
Endoscopic retrograde cholangiopancreatography for the management of biliary fistula following liver hydatid cyst related surgery or radiological interventions
Mahmut Polat, Ersin Batıbay, Fırat Erkmen, Osman Yüksekyayla, Mehmet Emin Boleken, Idris Kırhan, Bilal Celik, Servet Sürmeli, Zahit Akkoyun, Ibrahim Atlas, Ahmet Atlas, Osman Dere, Veysel Kaya, Serkan Dumanlı, Kenan Moral, Murat Kekilli, Cem Şimşek, Cumali Efe
Mahmut Polat, Ersin Batıbay, Osman Yüksekyayla, Cumali Efe, Department of Gastroenterology, Harran University Faculty of Medicine, Şanlıurfa 63100, Türkiye
Fırat Erkmen, Department of General Surgery, Harran University Faculty of Medicine, Şanlıurfa 63100, Türkiye
Mehmet Emin Boleken, Department of Pediatric Surgery, Harran University Faculty of Medicine, Şanlıurfa 63100, Türkiye
Idris Kırhan, Department of Internal Medicine, Harran University Faculty of Medicine, Şanlıurfa 63100, Türkiye
Bilal Celik, Servet Sürmeli, Zahit Akkoyun, Ibrahim Atlas, Ahmet Atlas, Department of Anestesiology, Harran University Faculty of Medicine, Şanlıurfa 63100, Türkiye
Osman Dere, Veysel Kaya, Department of Radiology, Harran University Faculty of Medicine, Şanlıurfa 63100, Türkiye
Serkan Dumanlı, Kenan Moral, Murat Kekilli, Department of Gastroenterology and Hepatology, Gazi University, Ankara 06560, Türkiye
Cem Şimşek, Department of Gastroenterology, Hacettepe University Faculty of Medicine, Ankara 06100, Türkiye
Author contributions: Polat M, Batıbay E, Erkmen F, Yüksekyayla O, Emin Boleken M, Kırhan I, Celik B, Sürmeli S, Akkoyun Z, Atlas I, Atlas A, Dere O, Kaya V, Dumanlı S, Moral K, Şimşek C, Kekilli M and Efe C collected and analyzed data; Şimşek C, Kekilli M and Efe C interpreted data and prepared manuscript; all authors approved the final version of the manuscript.
Institutional review board statement: The Institutional Review Board of Harran University provided approval for this study (IRB No. HRU/21.08.22).
Informed consent statement: This is a retrospective study and no informed consent is required.
Conflict-of-interest statement: The authors declare no conflicts of interest.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Data sharing statement: All data that support the findings of this study are presented in the manuscript.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Cumali Efe, MD, Head Professor, Department of Gastroenterology, Harran University Faculty of Medicine, Gülveren mahallesi, Osmanbey Kmpüs, Küme evleri F blok No. 4, Şanlıurfa 06100, Türkiye.
scumaliefe@gmail.com
Received: July 17, 2025
Revised: July 28, 2025
Accepted: September 26, 2025
Published online: November 27, 2025
Processing time: 132 Days and 11 Hours
BACKGROUND
Surgery and percutaneous radiological methods [puncture, aspiration, injection, re-aspiration (PAIR)] are the current invasive treatment strategies for patients with hepatic hydatid cyst (HHC). Biliary leak is a common complication in patients who underwent these treatments of HHC. Bile leak should be treated effectively as uncontrolled biliary fistula may lead to life-treating conditions such as severe cholangitis, intraabdominal abscesses and septicemia. Endoscopic retrograde cholangiopancreatography (ERCP) has become the main treatment of post-interventional biliary fistula.
AIM
To evaluate the efficacy and safety of ERCP in the management of biliary fistula following HHC-related surgery or PAIR.
METHODS
We evaluated data of patients who developed bile leakage following HHC-related interventions from endemic area during the period of March 2017 and February 2025. We included 88 patients (50 female, 57%) with a median age of 33 years (range: 8-83 years) at the time of ERCP. Bile leak occurred following surgery in 72 (82%) patients and after PAIR in 16 (18%) patients. Low-grade leakage (< 400 mL/day) was identified in 46 (52%) patients.
RESULTS
Initial mode of ERCP was endoscopic sphincterotomy (ES) with biliary drainage (plastic stent or nasobiliary drain) in 73 (83%) patients and ES alone in remaining 15 (17%) patients. Six patients who initially treated by ES alone had persistent fistula and underwent repeat ERCP with stent placement. ERCP type (ES + biliary stenting) and fistula flow rate (< 400 mL/day) were significantly associated with 20-days complete closure of the fistula [P = 0.020; odds ratio (OR) = 5.27, 95% confidence interval (95%CI): 1.30-21.37] and (P = 0.008; OR = 3.43, 95%CI: 1.37-8.55), respectively. ERCP-related complications were mild pancreatitis in 5 (5.9%) patients and minor bleeding in 4 (4.7%) patients and mild-moderate cholangitis in 4 (4.7%) patients.
CONCLUSION
This case based-study from endemic area demonstrates that ERCP is highly effective and safe for managing bile leakage following both surgery and PAIR. ES + biliary stenting seems better mode of ERCP procedure.
Core Tip: Liver is the most commonly affected organ of hydatid cyst involvement. Majority of patients with hepatic hydatid cysts (HHCs) are diagnosed incidentally or when HHCs-related complications occur. Rupture into intrahepatic bile ducts is the common and serious complication in individuals with HHCs. Surgery and percutaneous radiological methods [puncture, aspiration, injection, re-aspiration (PAIR)] are the current standard treatment strategies for patients with HHC. Biliary leak is a common complication in patients who underwent surgery or PAIR. We investigated efficacy and safety of ERCP in the management of biliary fistula following HHC-related surgery and PAIR.
