Hydatid hepatic cysts may fistulize into the biliary tree, leading to obstructive jaundice, cholangitis, and septic complications. ERCP plays a major therapeutic role in endemic regions, yet high-quality real-life data remain limited. This study aimed to evaluate endoscopic findings, therapeutic maneuvers, and outcomes in patients with hydatid cysts fistulized into the bile ducts.

This retrospective, descriptive and analytical study included all patients with hydatid hepatic cysts complicated by biliary fistula who underwent ERCP in a tertiary center. Clinical, radiological, endoscopic and biological data were extracted from standardized records. Technical success was defined as complete ductal clearance, and clinical success as full symptomatic and inflammatory resolution. Exploratory analytical comparisons were performed between preoperative vs postoperative ERCP and between patients with vs without acute cholangitis. Categorical variables were compared using Chi-square or Fisher’s exact test.

Eighteen patients were included, the mean age was 51.1 ± 15.4 years. All patients were presented with hydatid cysts fistulized into the biliary tree. Acute cholangitis was the presenting circumstance in 4 patients (22.2%), including one case of septic shock (5.6%), whereas the remaining patients presented with obstructive jaundice, biliary colic, abdominal pain or postoperative bile leaks. Intraductal hydatid membranes or daughter vesicles were found in 8 patients (44.4%), and purulent bile in 9 (50.0%). ERCP was performed in a preoperative setting in 8 cases (44.4%) and in a postoperative context in 5 cases (27.8%). Endoscopic sphincterotomy was carried out in 9 patients (50.0%), while balloon extraction was required in 17 cases (94.4%), and Dormia basket extraction in 1 case (5.6%). Plastic biliary stents were placed in 3 patients (16.7%), typically in the presence of large fistulas or  incomplete clearance of biliary duct. Technical success was achieved in all patients (100%), and clinical success in 17 patients (94.4%), with only one documented recurrence of hydatidobiliary obstruction after an initial favorable response.

In comparative analyses, intraductal hydatid membranes were significantly more frequent during preoperative ERCPs than during postoperative procedures (87.5% vs 20.0%, p = 0.032). The presence of pus showed a non-significant tendency to be higher in postoperative ERCPs (100% vs 50.0%, p = 0.105). Biliary stenting rates did not differ significantly between preoperative and postoperative groups (37.5% vs 0%, p = 0.231). Moreover, acute cholangitis was neither associated with the timing of ERCP nor with the need for stent placement (0% vs 18.8%, p>0.05).

In this real-life cohort, all hydatid cysts were complicated by biliary fistulization, confirming the major burden of hydatid biliary disease in our setting. ERCP proved highly effective, with universal technical success and near-complete clinical resolution, and the hydatid materials extraction (mainly with ballon) was  the cornerstone of therapy. The strong association between intraductal hydatid material, cholangitis and preoperative presentations highlights the need for early endoscopic management in hydatid biliary complications.