Total closed pericystectomy using CUSA for hepatic hydatid cyst with preoperatively documented cystobiliary fistulae: a case report

Int J Surg Case Rep. 2026 Oct 23;138(11):5351-5357. doi: 10.1097/RC9.0000000000001212. eCollection 2026 Nov.

ABSTRACT

INTRODUCTION: Intrabiliary rupture is the most common serious complication of hepatic cystic echinococcosis (5-25%). When frank cystobiliary communication with obstructive jaundice is documented preoperatively, most surgeons opt for conservative procedures, perceiving radical surgery as hazardous. We report a case showing that total closed pericystectomy, enabled by the Cavitron Ultrasonic Surgical Aspirator (CUSA), can be achieved safely.

CASE PRESENTATION: A 62-year-old Tunisian male sheep-farmer presented with 6 months of right hypochondrial heaviness, followed by obstructive jaundice. CT confirmed a WHO CE3b hepatic hydatid cyst (segment V, 63 × 52 mm) with two preoperatively documented cystobiliary fistulae (8 and 9 mm) and intrabiliary hydatid migration. Total closed pericystectomy was performed using CUSA and bipolar forceps, along with fistula ligation, cholecystectomy, choledochotomy with biliary clearance, and choledochorrhaphy over a Kehr drain. Operative time was 145 minutes, with blood loss of 100 mL. The postoperative course was uneventful (Clavien-Dindo grade 0), and the patient was discharged on postoperative day 8, remaining recurrence-free at 1-year CT follow-up.

CLINICAL DISCUSSION: Facilitated by the CUSA’s selective disruption of parenchyma while sparing collagen-rich structures, radical surgery proved feasible despite large preoperatively documented fistulae, achieving complete parasitic eradication, eliminating the residual cavity, and minimizing fistulae, suppuration, and recurrence inherent in conservative procedures.

CONCLUSION: Total closed pericystectomy with CUSA offers three lessons: (1) Preoperatively documented cystobiliary fistulae are not an absolute contraindication to radical surgery; (2) The CUSA enables safe fistula identification and ligation; and (3) Pericystectomy with choledochotomy and Kehr drainage achieves complete parasitic and biliary clearance without bilioenteric anastomosis.

PMID:43005721 | PMC:PMC13747364 | DOI:10.1097/RC9.0000000000001212