A 7-year-old boy presented with sudden onset severe pain in the right hypochondrium, associated with multiple episodes of non-bilious copious vomiting. He was referred from a primary health care center as a suspected case of hepatic malignancy. There was no past history of similar episodes of pain.
On examination, the liver was enlarged and tender with liver dullness up to 6 cm below the right costal margin. Ultrasound revealed hepatomegaly along with a large cystic lesion of 10 × 9 × 9 cm involving segments VI, VII, and VIII of the liver and these findings were confirmed with a pre-operative contrast enhanced computed tomography (CECT) abdomen (Fig. 1a). Chest X-ray was done to rule out any associated lung cyst. The hydatid IgG serology was elevated (8.99 IU/ml). Liver function tests (LFT) showed elevated enzymes with normal bilirubin levels. The child was resuscitated with fluids and antibiotics to correct dehydration and dyselectrolytemia. A preoperative course of albendazole was given for 25 days in lieu of the large size of the cyst. On laparotomy with a right-side subcostal incision, under general anesthesia and anaphylactic prophylaxis, a large cyst measuring 10 × 9 × 9 cm was found replacing segments VI, VII, and VIII of the right lobe of the liver without any evidence of adjoining cystic lesions. After isolating the field with surgical sponges dipped in hypertonic saline (20% saline), the cyst cavity was opened up and about 1 l of hydatid fluid was aspirated, followed by filling up the cavity with scolicidal agent for 20 min (povidone iodine 10% solution). Daughter cysts were carefully evacuated along with floating membranes. Deroofing was done, followed by covering the cystic cavity with omentum to complete the capitonnage, after inspecting for any residual bile leak points with fresh white surgical sponges. An intracavitary wide bore tube drain was secured. On postoperative day four (POD 4), bile leak was noted which gradually increased to 150–300 ml/day and over the next 2 days mild icterus with passage of pale stools was also seen. There was mild elevation of the liver enzymes with serum bilirubin of 0.8/0.2 units (total and conjugated). In view of worsening cholangitis and abdominal distension, the child was taken up for re-exploration on POD 10 and no active bile leak sites could be identified in the cyst cavity. However, no per operative cholangiogram was performed. The cavity was bile tinged uniformly with tube drain in situ. The seepage sites were identified and repaired with prolene. Cyst cavity was packed with gel foam after omentoplasty. Post second surgery, due to persistent bilious drain output of 100–150 ml/day, a HIDA scan was done which suggested active bile leak from the proximal right hepatic duct and no evidence of bilio-enteric drainage (Fig. 2a, b).
Child was re-explored on postoperative day 11. Cyst cavity was opened and lavage given (Fig. 1b). Roux en Y limb 40 cm distal to DJ flexure mobilized through the transverse mesocolon up to the porta and jejunocystic anastomosis (cystojejunostomy) done with vicryl 4-0 (interrupted) (Fig. 1c). Wide bore infant feeding tube was secured into the cavity (transjejunal) as an anastomotic stent along with an abdominal drain in the sub-diaphragmatic space. Postoperatively, the child was kept on total parenteral nutrition and systemic octreotide. The drain output gradually decreased over next 10 days, and the child improved clinically with passage of normal colored stools. Oral feeds were gradually resumed. Repeat HIDA (Fig. 2c, d) scan suggested evidence of bile leak into the surgical cavity (cystojejunal cavity) with minimal drainage through the subdiaphragmatic drain. The child was discharged after removal of abdominal drain. The child is doing well under regular follow-up since last 2 years.
