FCBC with overt passage of intra-cystic material to the biliary tract is a serious complication, and the reported frequency is 3–37% in different case series[6, 12]. Intrabiliary rupture mainly results from compression of bile ducts from the gradually increasing cysts, causing bile stasis. The increased intraductal pressure induces fissure formation in the duct wall while local intracystic water pressure of up to 80 cm lead to the rupture of the cyst into biliary tract. Intrabiliary rupture mainly established in centrally localized cysts near to the hilum in liver segments III, Ⅳ, Ⅴ, Ⅵ, Ⅶ and there was also a correlation with the size especially those size over 10cm[9, 14, 15]. The main approach of surgery for hydatid cyst with intrabiliary rupture should be: cystic content evacuation, cavity management, clearance of cystic material from biliary tract with assurance of patent biliary channel and restoration of normal biliary flow. Although opinion on cavity management vary, but there is general consensus that meticulous CBD exploration with clearance of cystic material and maintenance of normal patency of biliary channel is mandatory.
For attaining proper cavity management with proper healing of communication between cavity and biliary system, the role of decompression of biliary tract is fundamental. Various technique including choledochoduodenostomy, T-tube drainage, and transduodenal sphincteroplasty have been recommended to decompress intrabiliary pressure[5, 11]. Placement of T-tube enables easier monitoring and seems to be traditional method after intrabiliary rupture of CE. But use of T-tube is not free of complications. The most frequently encountered morbidities were external biliary fistulas and suppuration of the residual cavity and postoperative biliary strictures. To prevent these late complications such as stricture, after PPC and T-tube decompression, we further perform extra T-tube in the cystobiliary orifice of bile duct in residual cavity. However, since it still remains controversial whether or not double T-tube decreases the risk of postoperative complications, long term follow-up is necessary to evaluate the outcomes of double T-tube decompression.
In current study, we evaluated the outcomes in 51 patients with FCBC who were treated by double or single T-tube drainages. However, nonnegligible drawbacks have been reported to affect the outcomes of PPC. The main immediate postoperative complications were biliary leakage and fistulas, along with septic complications of the residual cavity leading to prolonged hospital stays. Most of these complications may be ascribed to the pericyst lining the residual cavity. A pericyst left in situ, especially if thick and calcified, represents an obstacle to liver regeneration filling the residual cavity, thus leading to serum and blood accumulation or liver abscess formation[5, 6, 16]. Furthermore, the persistence of the pericyst hides possible biliary communication in the residual cavity, considered the main reason for biliary leakage. However, it should be stressed that even when biliary communications are identified, their closure within a stiff, calcified pericyst wall would not be easy or effective. Furthermore, infection, biliary fistula, and slow reduction of the cyst cavity may lead to more serious complications, such as obstruction of main hepatic ducts or the portal vein[1, 9, 11]. And, for this reason, we recommend a long-term follow-up for such situations, which was our another aim to report this study results a after 11 years observation. In these cases, reoperation is quite complex, with high mortality due to the technical difficulties related to distorted liver anatomy, deteriorated liver function, and poor general conditions. In our study, the overall stricture rate was 14.3% vs 0%, with late complications being more frequent in single vs. double T-tube drainage groups.
Although the longer follow-up period in double T-tube drainage group was necessary, no complications of stricture have been observed to date. It suggested that in most cases of FCBC, the cyst involved major bile duct or located near to hilum, and the residual cavity get shrinked and fibrosed gradually due to persistent leakages and recurrent infections. Progressive shrinkage and fibrosis lead to development of traction in underlying bile duct which gets stenosed and resultant stricture formation. So, introducing the sustaining T-tube in orifice of residual cavity, bile duct maintained the patency and was protected from postoperative strictures in double T-tube drainage group. We believed that after PPC and T-tube decompression, a further T-tube insertion into orifice of residual cavity bile duct was essential for the prevention of postoperative residual cavity infections and strictures especially when the location of the cyst is near to the hilum.
Based on our single center experience and current study, we demonstrate that specific indications may comply there instructions: (1) performing double T-tube drainage should be individualized, not just depend no FCBC size or location; (2) when the FCBC site is lobular or segmental bile ducts and near to hepatic hilum, or the duct was interrupted due to the rupture, a double T-tube drainage should be considered first; (3) when there is ulceration due to inflammation at the FCBC site, suturing may be difficult and double T-tube is recommended; (4) if corresponding upper level biliary tree is just a single or small-in-size liver segment, if there is liver atrophy at relevant liver parenchyma, if there is severe liver damage so it would not be saved properly, then a hepatectomy should be accompanied; (5) usually, > 5 mm diameter bile duct needs double T-tube drainage more than < 5 mm ones; (6) above items should be thought in an integrative way to achieve best practice and best patient outcome.
Shortcomings of this study is that it was a retrospective study based on relatively mall sample size, and higher quality randomized case control studies would be very helpful to achieve better evidence-based results. In addition, removal timepoint should be optimized due to late leakage could happen at original cysto-biliary communication site after withdrawal of decompression T-tube, in which occasion longer decompression was necessary.