Biliary fistula and late recurrence of liver hydatid cyst: Role of cysto-biliary communication: A prospective multicenter study

Table 1 Demographic and preoperative characteristics of the patients (n = 244), n (%)

Characteristics	n = 244
Age (year) mean ± SD	42.67 ± 9.97
≤ Median (43)	136 (55.7)
> Median (43)	108 (44.3)
Sex
Male	163 (66.8)
Female	81 (33.2)
ASA
I	176 (72.1)
II	47 (19.3)
III	21 (8.6)
Positive family history	15 (6.1)
Clinical presentation
Asymptomatic	19 (7.8)
Pain	125 (51.2)
Mass	48 (19.7)
Nausea & vomiting	32 (13.1)
Dyspepsia	20 (8.2)
Cyst size (cm) mean ± SD	9.49 ± 3.54
≤ Median (9)	130 (53.3)
> Median (9)	114 (46.7)
Cyst site
Right lobe	184 (75.4)
Left lobe	60 (24.6)
Cyst stage
CE2	61 (25)
CE3b	183 (75)

ASA: American Society of Anesthesiologists; CE: Cystic echinococcosis.

Table 2 Intraoperative and postoperative outcomes (n = 244), n (%)

Intraoperative outcome	n = 244
Operative time (min) (mean ± SD)	107.32 ± 6.92
≤ Median (106)	126 (51.6)
> Median (106)	118 (48.4)
Blood transfusion
1 unit	4 (1.6)
2 units	2 (0.8)
Cystic fluid spillage	12 (4.9)
Conversion	7 (2.9)
Causes of conversion
Extensive adhesion	5 (2.1)
Organ injury	1 (0.4)
Difficult cyst detection	1 (0.4)
Anaphylaxis	2 (0.8)
Cyst fluid biochemical indices
High both bilirubin-high alkaline phosphatase	15 (6.1)
Postoperative outcomes	n = 244
Postoperative hospital stay (days) mean ± SD	3.44 ± 2.51, 3 (2-20)
ICU admission	9 (3.7)
Early postoperative complications	28 (11.5)
Type of early postoperative complications
Wound infection	7 (2.9)
Cyst cavity bile collection	6 (2.5)
Ileus	2 (0.8)
Subphrenic abscess	4 (1.6)
Subphrenic hematoma	3 (1.2)
Cholangitis	4 (1.6)
Pneumonia	1 (0.4)
Atelectasis	1 (0.4)
None	215 (88.1)
Clavien-Dindo classification
0	213 (87.3)
I	8 (3.3)
II	11 (4.5)
III	12 (4.9)
Biliary complications	16 (6.6)
Late postoperative complications
Port/incisional site hernia	7 (2.9)
Recurrence	30 (12.3)

ICU: Intensive care unit.

Table 3 Characteristics of biliary complications and recurrence (N = 16), n (%)

Biliary complications	n = 16
Type
External biliary fistula	9 (56.2)
Cyst cavity biliary abscess	4 (25)
Biliary peritonitis	3 (18.8)
Grade
Grade A	6 (37.5)
Grade B	7 (43.7)
Grade C	3 (18.8)
Time of development (days) mean ± SD	3.13 ± 1.78
Treatment
Conservative	6 (37.5)
Ultrasound guided percutaneous drainage	7 (43.7)
Reoperation	3 (18.8)
Time to leakage cessation (days) mean ± SD	14.38 ± 6.12
Recurrence	n = 30
Site
Right lobe	18 (60)
Left lobe	6 (20)
Peritoneum	4 (13.3)
Spleen	2 (6.7)
Clinical presentation
Asymptomatic	7 (23.3)
Pain	13 (43.3)
Mass	4 (13.3)
Nausea & vomiting	2 (6.7)
Infection	2 (6.7)
Rupture	1 (3.3)
Jaundice	1 (3.3)
Time to diagnosis (yr) mean ± SD	2.48 ± 0.98
Size (cm) mean ± SD	4.93 ± 2.72
Stage
CE2	25 (83.3)
CE3b	5 (16.7)
Treatment
Pericystectomy	17 (56.7)
Left hepatectomy	6 (20)
Abdominal exploration and excision of recurrent abdominal HCD	4 (13.3)
Splenectomy (for recurrent splenic HCD)	2 (6.7)
CBD stent + pericystectomy	1 (3.3)

CE: Cystic echinococcosis; CBD: Common bile duct; HCD: Hydatid cyst disease.

Table 4 Relation between the independent factors and development of biliary complications among the studied patients by univariate analysis (n = 244)

Factors	Biliary complications (n = 16)		No biliary complications (n = 228)		P value	Univariate OR (95%CI)
	n	%	n	%
Sex
Male (n = 163)	9	5.5	154	94.5	0.3541	Reference
female (n = 81)	7	8.6	74	91.4		1.62 (0.58-4.52)
ASA
I (n = 176)	9	5.1	167	94.9	0.1601	1.08 (0.12-8.96)
II (n = 47)	6	12.8	41	87.2		2.93 (0.33-25.98)
III (n = 21)	1	4.8	20	95.2		Reference
Family history
+ ve (n = 15)	8	53.3	7	46.7	< 0.0012, b	31.6 (9.18-108.6)
- ve (n = 229)	8	3.5	221	96.5		Reference
Cyst size (cm)
≤ 9 cm (n = 130)	3	2.3	127	97.9	0.0041, a	Reference
> 9 cm (n = 114)	13	11.4	101	88.6		5.45 (1.51-19.64)
Cyst site
Right lobe (n = 184)	13	7.1	171	92.9	0.5752	1.44 (0.39-5.25)
Left lobe (n = 60)	3	5	57	95		Reference
Cyst stage
CE2 (n = 61)	15	24.6	46	75.4	< 0.0012, b	59.3 (7.64-460.9)
CE3b (n = 183)	1	0.5	182	99.5		Reference
Operative time (min)
≤ 106 min (n = 126)	9	7.1	117	92.9	0.7031	1.22 (0.44-3.39)
> 106 min (n = 118)	7	5.9	111	94.1		Reference
Blood transfusion
Yes (n = 6)	4	66.7	2	33.3	< 0.0012, b	37.7 (2.26-226.5)
No (n = 238)	12	5	226	95		Reference
Cystic fluid spillage
Yes (n = 12)	2	16.7	10	83.3	0.1472	3.11 (0.62-15.60)
No (n = 232)	14	6	218	94		Reference
Conversion
Yes (n = 7)	5	71.4	2	28.6	< 0.0012, b	51.4 (8.94-294.9)
No (n = 237)	11	4.6	226	95.4		Reference
Anaphylaxis
Yes (n = 2)	0	0	2	100	0.7071	Reference
No (n = 244)	16	6.6	226	93.4		0.14 (0.01-1.65)
Cyst fluid biochemical indices
High bilirubin-alkaline phosphatase (n = 15)	15	100	0	0.0	< 0.0012, b	3405 (202-57164)
Not high (n = 229)	1	0.4	228	99.6		Reference
Hospital stay (days)
≤ 3 d (n = 184)	0	0.0	184	100	< 0.0012, b	Reference
> 3 d (n = 60)	16	26.7	44	73.3		67 (8.64-518.15)
ICU admission
Yes (n = 9)	5	55.6	4	44.4	< 0.0012, b	25.5 (5.99-108.24)
No (n = 235)	11	4.7	224	95.3		Reference
Early postoperative complications
Yes (n = 28)	13	46.4	15	53.6	< 0.0012, b	61.5 (15.8-239.8)
No (n = 216)	3	1.4	213	98.6		Reference

¹Chi square test (χ²).

²Fisher’s exact test.

^aP ≤ 0.05: Statistically significant.

^bP ≤ 0.001: Highly statistically significant.

OR: Odds Ratio; ICU: Intensive care unit, ASA: American Society of Anesthesiologists; CE: Cystic echinococcosis; + ve: Positive family history; - ve: Negative family history.

Table 5 Relation between the independent factors and recurrence of hydatid cyst by univariate analysis (n = 244)

Factors	Recurrence (n = 30)		No recurrence (n = 214)		P value	Univariate OR (95%CI)
	n	%	n	%
Sex
Male (n = 163)	18	0.11	145	0.89	0.3981	Reference
Female (n = 81)	12	0.148	69	0.852		1.40 (0.62-3.07)
ASA
I (n = 176)	21	0.119	155	0.881	0.7921	1.29 (0.28-5.924)
II (n = 47)	7	0.149	40	0.851		1.66 (0.31-8.78)
III (n = 21)	2	0.095	19	0.905		Reference
Family history
+ve (n = 15)	15	1	0	0	< 0.0012, b	214 (26.45-1731.7)
-ve (n = 229)	15	0.066	214	0.934		Reference
Cyst size (cm)
≤ 9 cm (n = 130)	7	0.054	123	0.946	< 0.0011, b	Reference
> 9 cm (n = 114)	23	0.202	91	0.798		4.44 (1.83-10.80)
Cyst site
Right lobe (n = 184)	23	0.125	161	0.875	0.8641	1.08 (0.44-2.66)
Left lobe (n = 60)	7	0.117	53	0.883		Reference
Cyst stage
CE2 (n = 61)	27	0.443	34	0.557	< 0.0011, b	47.7 (13.7-165.95)
CE3b (n = 183)	3	0.016	180	0.984		Reference
Operative time (min)
≤ 106 min (n = 126)	16	0.127	110	0.873	0.8431	1.08 (0.50-2.324)
> 106 min (n = 118)	14	0.119	104	0.881		Reference
Blood transfusion
Yes (n = 6)	5	0.833	1	0.167	< 0.0012, b	42.6 (4.78-397.4)
No (n = 238)	25	0.105	213	0.895		Reference
Cystic fluid spillage
Yes (n = 12)	12	1	0	0	< 0.0012, b	142 (17.5-1160.4)
No (n = 232)	18	0.078	214	0.922		Reference
Conversion
Yes (n = 7)	6	0.857	1	0.143	< 0.0012, b	53.3 (6.15-461.2)
No (n = 237)	24	0.101	213	0.899		Reference
Anaphylaxis
Yes (n = 2)	2	1	0	0	< 0.0012, b	15.3 (1.34-174.1)
No (n = 244)	28	0.116	214	0.884		Reference
Cyst fluid biochemical indices
High bilirubin-alkaline phosphatase (n = 15)	15	1	0	0	< 0.0012, b	214 (26.45-1731.7)
Not high (n = 229)	15	0.066	214	0.934		Reference
Hospital stay (days)
≤ 3 d (n = 184)	10	0.054	174	0.946	< 0.0011, b	Reference
> 3 d (n = 60)	20	0.333	40	0.667		8.7 (3.78-20.02)
ICU admission
Yes (n = 9)	8	0.889	1	0.111	< 0.0012, b	77.5 (9.25-648.4)
No (n = 235)	22	0.094	213	0.906		Reference
Early postoperative complications
Yes (n = 28)	22	0.786	6	0.214	< 0.0012, b	95.33 (30.3-299.9)
No (n = 216)	8	0.037	208	0.963		Reference
Biliary complications
Yes (n = 16)	16	1	0	0	< 0.0012, b	244.6 (30.21-1981)
No (n = 228)	14	0.061	214	0.939		Reference
Port/incisional site hernia
Yes (n = 7)	7	1	0	0	< 0.0012, b	65.13 (7.67-553.1)
No (n = 237)	23	0.097	214	0.903		Reference

¹Chi square test (χ²).

²Fisher’s exact test.

^aP ≤ 0.05: Statistically significant.

^bP ≤ 0.001: Highly statistically significant.

OR: Odds Ratio; ICU: Intensive care unit; ASA: American Society of Anesthesiologists; CE: Cystic echinococcosis; + ve: Positive family history; - ve: Negative family history.