Laparoscopic deroofing to treat an infected hepatic cyst because of fistula formation between the hepatic cyst and the duodenum ulcer

Abstract

We describe a rare case of laparoscopic deroofing to treat an infected hepatic cyst because of fistula formation between the hepatic cyst and the duodenum ulcer. A 71-year-old female was referred to our hospital for the evaluation of her abdominal pain. The laboratory workup revealed a high inflammatory reaction. Computed tomography (CT) visualized a large hepatic cyst in the left hepatic lobe, causing suspicion of a fistulous tract between the hepatic cyst and duodenum. A hepatic cyst infection was diagnosed, and both antibiotic treatment and percutaneous cyst drainage were performed. Although the acute inflammation improved after these treatments, chronic inflammation continued. We conducted laparoscopic deroofing of the infected cyst. The patient's post-operative course was uneventful, and CT revealed no recurrence 6 months post-procedure. For patients with non-parasitic hepatic cyst infection, physicians should consider not only conservative antibiotic treatment but also surgical treatment including laparoscopic cyst deroofing.

Keywords: duodenum ulcer; hepatic cyst infection; laparoscopy.

Figure 1

(a) Enhanced CT images findings obtained in the examination by the patient’s primary care physician. A 16-cm hepatic cyst in the left hepatic lobe area was observed. Dotted line: The hepatic cyst. (b, c) Plain CT images findings obtained at the patient’s hospitalization. (b) This axial section shows the large hepatic cyst in left hepatic lobe area, which was collapsed and contained air bubbles. There were no findings of free air or leakage into the peritoneal cavity. Arrowheads: The air bubbles of collapsed large hepatic cyst. (c) A low-density area between the hepatic cyst and the duodenum with a suspicion of a fistulous tract can be seen on this coronal section. Arrows: The low-density area between the hepatic cyst and the duodenum. (d) An abdominal X-ray finding after the percutaneous catheter aspiration of the hepatic cyst with a 7Fr pig-tail catheter (left arrow). Right arrow: The nasogastric tube.

Figure 2

The upper gastrointestinal contrast examination findings on day 13 of the patient’s hospital admission. (a) There was no obvious fistulous tract between the hepatic cyst and the duodenum. arrowheads: The stomach, arrowheads: The duodenum. arrow: The 7Fr pig-tail catheter. (b, c) Enhanced CT images findings on 20 day of admission. (b) Axial section. A shrunken hepatic cyst with a thickened cyst wall was observed. Dotted line: The large hepatic cyst. Arrowheads: The 7Fr pig-tail catheter. (c) Coronal section. A a low-density area was observed between the hepatic cyst and the duodenum, suspected of being a fistulous tract. Arrows: The low-density area between the hepatic cyst and the duodenum. Arrowheads: The 7Fr pig-tail catheter. (d) An upper gastrointestinal endoscopy on admission day 21 showed an ulcer scar at the anterior aspect of the duodenum bulb without obvious fistulous orifice. Arrowheads: The ulcer scar at the anterior aspect of the duodenum bulb.

Figure 3

(a–h) Operative findings during the patient’s laparoscopic surgery. (a) Inflammatory tissue adhesions were observed on the peritoneum, omentum, and hepatic cyst. (b) A large amount of purulent fluid was discharged from the opened hepatic cyst. (c, d) The hepatic cyst wall was resected at the junction of the hepatic cyst and the liver parenchyma using the LigaSure™ vessel sealing system (Medtronic, Dublin, Ireland). (e) The laparoscopic hepatic cyst deroofing was completed. (f) A depression in the lumen of the fenestrated cyst near the duodenal bulb was observed, which was thought to be the penetration site between the hepatic cyst and the duodenum. Arrowheads: The depression in the lumen of the fenestrated cyst near the duodenal bulb. (g) The depression was closed using a 3–0 Vicryl® suture (Ethicon, Cornelia, GA, USA). (h) After the peritoneal lavage, one closed drain was placed at the site of the fenestrated hepatic cyst.

Figure 4

Plain CT image 6 months after the patient’s surgery. There was no evidence of hepatic cyst recurrence.