Management of liver hydatid cysts with a large biliocystic fistula: multicenter retrospective study. Tunisian Surgical Association.

The large biliocystic fistula (> 5 mm) encountered with hydatic cyst of the liver produces clinical manifestations only when it allows the hydatic cyst content to pass into the common bile duct. Various therapeutic problems occur. The aim of this study was to evaluate the results of the therapeutic methods used by 14 Tunisian centers to treat this specific aspect of the hydatic cyst of the liver associated with a large biliocystic fistula. This study concerned a period of 5 years between January 1988 and December 1992, and it included 244 cases associated with hydatic content in the common bile duct (158 cases) and with cholelithiasis and choledocholithiasis (2 cases); 127 patients underwent an emergency operation (52%). The surgical procedures performed consisted in radical procedures (24 cases, 9.8%) and conservative procedures (220 cases, 90.2%). The latter included 52 cases of internal transfistulary drainage, 140 unroofing procedures associated in 20 cases with the fistula, in 93 cases with suture of the fistula, and in 27 cases with direct fistulization. In the 28 remaining cases, through the choledoctomy evacuation of the parasite was performed. The common bile duct was approached in 180 cases (73.7%). The postoperative course was uneventful in 57% of the cases and complicated in 38.5% others. The mortality rate was 4.5%. In conclusion, the presence (or not) of hydatic material in the common bile duct did not seem to be a determinant of the surgical procedure choice and did not influence the results. The only difficulty with treatment was the large biliocystic fistula itself. The internal transfistulary drainage on one part, and the unroofing procedure associated with suturing healthy fistula tissue and to omentoplasty or capitonnage of the remaining cavity on the other part, were easily performed and constituted efficient methods. Radical methods constituted operations that had excellent results, but they were feasible in only 10% of the cases.