Published online Nov 27, 2025. doi: 10.4240/wjgs.v17.i11.112025
Revised: July 28, 2025
Accepted: September 26, 2025
Published online: November 27, 2025
Processing time: 132 Days and 18.4 Hours
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.
To evaluate the efficacy and safety of ERCP in the management of biliary fistula following HHC-related surgery or PAIR.
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.
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.
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.