Case Reports in Gastrointestinal Medicine 3 Table 2: International classiﬁcation of ultrasound images in cystic echinococcosis for application in clinical and ﬁeld epidemiological settings. Tybe of Cyst CL CE 1 CE 2 CE 3 CE 4 CE 5 Status Active Active Active Transitional Inactive Inactive Ultrasound features Signs no pathognomonic, unilocular, and no cyst wall Cyst wall, hydatid sand Multivesicular, c st wall, and “rosette-like” Detachment of laminated membrane, “water-lil sign,” less round-decreased intracystic pressure Heterogeneous hypo- or hyperechogenic degenerative contents, no daughter cysts Thick calciﬁed wall, calciﬁcation partial to complete, and not pathognomonic but highly suggestive of diagnosis Remarks Usually early stage, not fertile, and diﬀerential diagnosis necessary Usually fertile Usually fertile Starting to degenerate, may produce daughter cysts Usually no living protoscoleces, diﬀerential diagnosis necessary Usually no living protoscoleces Figure 5: Excision of cyst wall using a harmonic scalpel. Figure 6: Excision of cyst wall using endo-GIA stapler with 2.5 mm vascular loads. after surgical management [6]. ERCP, however, may cause complications and has a false negative rate of 17%–20% in identifying small cystobiliary communications due to elevated cyst pressure, minimal communication, or transient obstruction of the communication by daughter cysts [7]. Therefore, even if no cystobiliary communications are iden- tiﬁed preoperatively, cysts must still be carefully inspected intraoperatively, since small cystobiliary communications develop in 80%–90% of patients with hepatic echinococcal disease. Biliary obstruction only occurs in 5%–10% of patients due to biliary communications that are at least 5 mm in diameter. Communications of this size or larger are more signiﬁcant due to their ability to carry hydatid debris and daughter cysts into the common bile duct causing biliary obstruction in over 66.6% of cases. In patients without jaun- dice or cholangitis, ERCP ﬁndings are normal in 50% and demonstrate cystobiliary rupture, biloma, or bile duct com- pression in the other 50% [8, 9]. O¨ zaslan and Bayraktar [7] suggest that preoperative or postoperative ERCP should be used only for complicated cases and that for uncomplicated cases, routine use of ERCP should not be recommended except for surgery planning. Another recent study suggested that cyst diameter independently predicts risk for biliary-cyst communication in asymptomatic patients. The mean cyst size in patients with biliary leakage was 10.2 cm, compared to 6.1 cm in patients without biliary leakage, and they suggested that preoperative ERCP should only be used in asymptomatic patients large cysts [10]. Use of an intraoperative cholangiogram is also controver- sial. Ramachandran and Arora suggest that an intraoperative cholangiogram is unnecessary and increases morbidity [11]. They state that inspection of the cyst wall using the laparoscope will identify all major bile leaks. Ozmen and Coskun [12] also states biliary tract communications can be controlled by inspection of the cyst cavity and ligation of ruptured bile ducts less than 5 mm in diameter. If bile ducts greater than 5 mm in diameter are identiﬁed, intraoperative cholangiogram is done to assess the common bile duct (CBD) for debris, which requires CBD exploration with T- tube placement if present. 5 mm is used as a cutoﬀ as bile ducts smaller than this rarely transmit particulate matter to the CBD, while 65% of bile ducts 5 mm or larger allow passage of material into the CBD. All surgical treatments require complete cyst exposure, cyst decompression evacuation and sterilization, ligation of bile duct communications, and cavity management [13].