title: Asymptomatic occult cysto-biliary communication without bile into cavity of the liver hydatid cyst: a pitfall in conservative surgery.
abstract: BACKGROUND
  An occult cysto-biliary communication in liver hydatid disease is still a major problem in surgical practice. Radiologic and intraoperative findings may not be helpful to detect cysto-biliary communications in some asymptomatic patients with liver hydatid disease. Biliary leakage is a troubling complication that arises after conservative surgery in patients who have occult "insidious" cysto-biliary communications. We aimed to identify the factors which are associated with the risk of occult insidious cysto-biliary communications in patients preoperatively who developed biliary leakage after surgery.
  
  
  METHODS
  We investigated the records of 183 asymptomatic patients treated for liver hydatid cyst and analyzed potential predictors of occult insidious cysto-biliary communication, retrospectively.
  
  
  RESULTS
  There were 115 female and 68 male patients; the mean age was 42.3 years. Occult insidious cysto-biliary communications which presented as postoperative biliary leakage found in 24 (13.1%). Independent clinical predictors were alkaline phosphatase >133 U/L, total bilirubin levels >1.2 mg/dL, white blood cell count >10,000/mm(3) and cyst diameter >10 cm on multivariate analysis. Seventeen of 24 were low output biliary fistula which resolved spontaneously within 9.2 days. The remaining 7 were high output biliary fistula for which endoscopic sphincterotomy was performed in all patients, fistulas resolved within 22.6 days. Average interval between endoscopic sphincterotomy and fistula closure was 10.3 days. Mean hospital stay was longer in patients with biliary leakage than in those without (9.8 vs. 4.2 day p<0.001). There was no hospital mortality.
  
  
  CONCLUSIONS
  The predictors demonstrated in this study should allow the likelihood of occult insidious cysto-biliary communication to be determined and, thus, indicate the need for additional procedures during operations to prevent the complications of biliary leakage.
authors: Izmir Ataturk Training and Research Hospital, 4th General Surgery Clinic, Basinsitesi, Izmir, Turkey. halukunalp@gmail.com
authors: Haluk Recai
authors: HR
authors: Unalp
authors: Behlul
authors: B
authors: Baydar
authors: Erdinc
authors: E
authors: Kamer
authors: Yeliz
authors: Y
authors: Yilmaz
authors: Halim
authors: H
authors: Issever
authors: Ercument
authors: E
authors: Tarcan
mesh_terms: D000328:Adult; D000368:Aged; D001646:Bile; D001658:Biliary Fistula / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D015331:Cohort Studies; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D004444:Echinococcosis, Hepatic / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care; D011183:Postoperative Complications / Q000517:prevention & control; D011237:Predictive Value of Tests; D011300:Preoperative Care; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome