Minimally invasive management of a difficult bile leak after deroofing of hydatid cyst: it’s all about pressures

Background and Aims

Surgery for hepatic hydatid cyst is often complicated by bile leak. In most cases, abolishing the gradient across the ampulla by a sphincterotomy or placing a stent heals the leak. Occasionally, surgical intervention may be required for repair. We share a case of a high-grade bile leak after hepatic hydatid deroofing in which surgical repair was prevented by applying basic principles of hydrostatics.

Methods

A 32-year-old man developed a high-grade bile leak after hydatid cyst surgery, with persistent bilious output from the surgical drain. We describe the basic principles, decision-making, and troubleshooting in this complex case that led to a successful outcome with minimally invasive techniques.

Results

The patient had an inadequate response to standard endoscopic biliary drainage techniques, including sphincterotomy, plastic stent placement, and external nasobiliary drainage. We created a pressure gradient to drive the bile away from the percutaneous drain by positioning the nasobiliary drain at a lower height. Complete resolution of bile leak was achieved.

Conclusions

Differential positioning of drains may be used to alter pressure gradients in patients with bile leak. This technique can be used for minimally invasive management of persistent and/or high-output bile leaks not responsive to standard endoscopic management.