Percutaneous aspiration and alcohol sclerotherapy for symptomatic hepatic cysts. An alternative to surgical intervention

Long-term results of laparoscopic unroofing of symptomatic solitary nonparasitic hepatic cysts

The long-term results of laparoscopic unroofing for symptomatic solitary nonparasitic hepatic cysts have not been well demonstrated. During the last 8 years, five patients with symptomatic solitary nonparasitic hepatic cysts underwent laparoscopic unroofing. Their symptoms were right-upper-quadrant pain (in three patients) and epigastric pain (in two). Accompanying the hepatic cysts were acute cholecystitis in one case and adenomyomatosis of the gallbladder in another. Perioperative data, including operation time, estimated blood loss, complications, hospital stay, and mortality rate, were evaluated. There were no conversions to open laparotomy. Cysts were located in segments 4 and 5 in three patients, segment 3 in one, and segment 8 in another, and the mean size of the cysts was 10.4 cm in diameter (range: 7-18 cm). In four cases cholecystectomy was performed simultaneously. Mean operation time, estimated blood loss, and postoperative hospital stay were 182 minutes (range: 72-270), 168 mL (range: minimal to 800 mL), and 9.4 days (range: 7-12), respectively. There were no deaths or instances of major morbidity. During a mean follow-up period of 66 months (range: 35-102), one patient had a recurrent lesion requiring reoperation. Laparoscopic unroofing is a feasible and safe procedure for patients with symptomatic solitary nonparasitic hepatic cysts. Strict patient selection, accurate location of the cyst within the liver, and a sufficiently wide unroofing technique are needed for the outcome to be successful.

The management of simple hepatic cysts: sclerotherapy or laparoscopic fenestration

BACKGROUND

Prior to the era of laparoscopic surgery, open surgical deroofing was considered to be the most appropriate therapy for uncomplicated simple hepatic cysts. Recently, there have been a number of reports of successful laparoscopic fenestration of simple hepatic cysts. Simple aspiration of these cysts is associated with a high recurrence rate. Cyst sclerosis with alcohol and, more recently, minocycline hydrochloride have been found to be effective in their management. So far there have been no trials comparing laparoscopic deroofing with sclerotherapy. A lack of consensus in their management results in considerable confusion and difficulty in deciding the optimum form of therapy.

METHODS

A systematic review of articles on the subject appearing in journals in the English language was conducted using the Medline database and by cross-referencing.

RESULTS AND CONCLUSIONS

Both laparoscopic deroofing and cyst sclerosis have been found to be effective in partial or complete obliteration of the cyst and in the relief of symptoms produced by the cyst. It is essential to rule out cystadenoma, malignancy, biliary communication and infection prior to treating these cysts. Alcohol/minocycline based sclerotherapy has the advantage of being associated with a lower incidence of complications. Surgery is indicated if it is difficult to rule out the above mentioned conditions, in the presence of biliary communication, in those cysts where sclerosis has been ineffective and in cases of recurrence. The choice between open and laparoscopic surgery depends on the location of the cysts within the liver parenchyma.

Sclerotherapy of peritoneal inclusion cysts: preliminary results in seven patients

OBJECTIVE

To evaluate the technical feasibility and the clinical effectiveness of sclerotherapy for the treatment of peritoneal inclusion cysts (PICs).

MATERIALS AND METHODS

Between June 1996 and February 2001, eight PICs in seven female patients aged 28-43 (mean, 36) years were instilled with sclerosant (povidone-iodine in three, ethanol in three, both povidone-iodine and ethanol in one). All seven patients subsequently experienced less abdominal pain. After drainage via an 8.5-Fr pigtail catheter inserted in the PICs (transabdominally in six cases, transvaginally in one), sclerosant equivalent in volume to about one-third that of drained fluid was introduced daily until the drained volume was less than 5ml. Follow-up by means of clinical procedures and ultrasound was performed every three months, at which time the success rate, possible complications and recurrence were determined.

RESULTS

Sclerotherapy was technically successful in all seven patients, though immediately after the procedure, minor complications were noted in three patients (mild pain in two, mild fever in one). During the follow-up of 4-60 (mean, 24.7) months, sclerotherapy proved successful and without long-term complications in all seven patients: lower abdominal pain disappeared and the diameter of the cysts decreased more than 50%, with complete regression in four cases. During the follow-up period there was no recurrence.

CONCLUSION

Sclerotherapy following catheter insertion is technically feasible and effective for the treatment of PICs.

Treatment of hepatic cysts in the era of laparoscopic surgery

BACKGROUND

Liver cysts are not uncommon. Rarely, they become symptomatic and require intervention. Surgery is the usual form of treatment; laparoscopic cyst unroofing has recently been introduced.

METHODS

The current status of diagnosis and conventional therapy of hepatic cysts was summarized. The surgical literature was surveyed to collect all reported cases of minimally invasive treatment of these lesions, and the advantages and limitations of the methods were evaluated.

RESULTS AND CONCLUSION

The general application of the minimally invasive technique should await a thorough evaluation of the operative complications and the outcome in terms of cyst recurrence in larger series of patients. However, laparoscopic wide cyst unroofing and laparoscopic cyst excision will probably become the methods of choice for the treatment of symptomatic liver cysts in carefully selected patients.

Adult polycystic liver disease: is fenestration the most adequate operation for long-term management?

OBJECTIVE

The aim of this study was to evaluate the immediate and long-term results in a retrospective series of patients with highly symptomatic adult polycystic liver disease (APLD) treated by extensive fenestration techniques. A classification of APLD was developed as a stratification scheme to help surgeons conceptualize which operation to offer to patients with APLD.

SUMMARY BACKGROUND DATA

Treatment options for APLD remain controversial, with partisans of fenestration techniques or combined liver resection-fenestration.

METHODS

Clinical symptoms, performance status, liver volume measurement by computed tomography (CT), and morbidity were recorded before surgery and after surgery. Adult polycystic liver disease was classified according to the number, size, and location of liver cysts and the amount of remaining liver parenchyma. Follow-up was obtained by clinical and CT examinations in all patients.

RESULTS

Ten patients with highly symptomatic APLD were operated on using an extensive fenestration technique (by laparotomy in 8 patients and by laparoscopy in 2 patients, 1 of whom conversion to laparotomy was required). The mean preoperative liver volume was 7761 cm3. There was no mortality. Postoperative morbidity occurred in 50%, mainly from biliary complications, requiring reintervention in two cases. Massive intraoperative hemorrhage occurred in one patient. During a mean follow-up time of 71 months (range, 17 to 239 months), all patients were improved clinically according to their estimated performance status. The mean postoperative liver volume was 4596 cm3, which represents a mean liver volume reduction rate of 43%. However, in type III APLD, despite absence of clinical symptoms, a significant increase in liver volume was observed in 40% of the patients.

CONCLUSIONS

Extensive fenestration is effective in relieving symptoms in patients with APLD. Hemorrhage and biliary complications are possible consequences of such an aggressive attempt to reduce liver volume. The procedure can be performed laparoscopically in type I APLD. A longer follow-up period is mandatory in type II APLD, to confirm the usefulness of the fenestration procedure. In type III APLD, significant disease progression was observed in 40% of the patients during long-term follow-up. Fenestration may not be the most appropriate operation for long-term management of all types of APLD.

Laparoscopic treatment of nonparasitic liver cysts: adequate selection of patients and surgical technique

Results of laparoscopic fenestration in patients with a highly symptomatic solitary liver cyst (17 patients) or polycystic liver disease (PLD) (9 patients) were prospectively evaluated in a multicenter practice of general surgeons. Conversion to laparotomy was required in two patients because of inaccessible deep liver cyst in one and a diffuse form of PLD in the other. There was no mortality or major morbidity. Mean postoperative hospital stay was 4.6 days after successful laparoscopic procedures. During a mean follow-up of 9 months, 23% of the patients had recurrence of symptoms and 38% had radiographic reappearance of cysts. Factors predicting failure included previous surgical treatment, deepsited cysts, incomplete deroofing technique, location in the right posterior segments of the liver, and a diffuse form of PLD with small cysts. Adequate selection of patients and type of cystic liver disease and meticulous and aggressive surgical technique are recommended.

Giant splenic cyst with high serum concentration of CA 19-9. Failure of treatment with percutaneous transcatheter drainage and injection of tetracycline

BACKGROUND

Recently, several cases of nonparasitic true splenic cyst with high serum concentration of carbohydrate antigen (CA 19-9) have been reported.

CASE

We report a giant splenic cyst presenting with high serum concentration of CA 19-9 in a 21-year-old man without a history of previous trauma. Imaging techniques showed a huge monolocular cyst of the spleen, and laboratory data showed increased serum CA 19-9 levels (326 U/ml; normal, < 37 U/ml). Serologic test was negative for parasitic infection. These findings led us to the diagnosis of epithelial splenic cyst. Percutaneous transcatheter drainage and injection of tetracycline were performed for 2 weeks. The cyst shrank, and the serum CA 19-9 level decreased favorably. However, cystic fluid reaccumulated in a month.

CONCLUSIONS

The accumulation of cystic fluid in splenic epithelial cysts may be attributable not only to the secretion of the lining cells but also to influx from the splenic sinuses.

Hepatic cystic disease in an adult polycystic kidney disease transplant population

BACKGROUND

A study of the incidence of polycystic liver in a transplant population and an assessment of the impact of this disease on the group was undertaken. Clinical presentation, investigation and treatment of hepatic polycystic disease are explored.

METHODS

The study examined the morbidity incurred by polycystic liver disease in patients, patient and graft survival, incidence of hepatic cysts and presentation, investigation and management of morbid hepatic cystic disease. One hundred and eleven patients were studied.

RESULTS

It was found that hepatic cysts occurred in the majority of patients that underwent transplants for renal failure because of polycystic kidney disease at this institution. Symptomatic hepatic cystic disease was found to be primarily responsible for three deaths and affected between 15 and 20% of the group. Gall bladder disease was found to be associated with highly symptomatic hepatic cystic disease.

CONCLUSION

Hepatic cystic disease is common in patients that have had kidney transplants because of polycystic kidney disease. Morbidity is likely to increase as patients survive for longer periods. Cholecystectomy should be considered in patients with significant hepatic cystic disease.

Treatment of symptomatic congenital hepatic cysts with single-session percutaneous drainage and ethanol sclerosis: technique and outcome

PURPOSE

To evaluate the safety and efficacy of percutaneous aspiration and ethanol sclerotherapy as the sole treatment for symptomatic, nonneoplastic, congenital hepatic cysts.

PATIENTS AND METHODS

In a prospective study, 59 symptomatic, congenital hepatic cysts in 25 patients were treated with ultrasound-guided percutaneous aspiration and ethanol sclerotherapy. Eleven patients had a solitary cyst, and 14 patients had polycystic liver disease. Mean follow-up was 4 years.

RESULTS

Fifty-seven (97%) of 59 sclerotherapy procedures were technically successful, and there were no recurrences. Eight cysts in six patients disappeared totally. The mean diameter of the remaining 49 cysts decreased from 9 cm to 3 cm. At the last follow-up visit, 14 patients were asymptomatic, four had milder epigastric pain than before the treatment, and seven with polycystic liver disease had recurrent symptoms due to growth of nontreated cysts. No major complications occurred.

CONCLUSION

Percutaneous aspiration with ethanol sclerotherapy is a safe, effective, and minimally invasive treatment method for symptomatic congenital cysts. It is the initial treatment of choice for all patients with symptomatic congenital hepatic cysts.

Liver transplantation for adult polycystic liver disease

Patients with adult polycystic liver disease and massive cystic replacement of the liver may present with severe debilitation and impairment of functional performance or, rarely, with signs of portal hypertension or hepatic dysfunction. In those patients incapacitated by severe hepatomegaly secondary to massive cystic replacement with predominantly small cysts (2 cm) without areas of parenchymal sparing, liver transplantation is a therapeutic option. Five patients with incapacitating symptoms from polycystic liver disease underwent liver transplantation as a final therapeutic procedure. Two patients had previous fenestration procedures without significant relief. All patients had radiographic evidence of concomitant polycystic kidney disease; two of these patients were dialysis-dependent at the time of liver transplantation. One patient underwent combined liver-kidney transplantation, whereas another received a six-antigen matched kidney transplant 64 months after liver transplantation. Four of five patients are alive 84, 39, 20, and 8 months after successful liver transplantation. All four have returned to normal functional status with complete resolution of symptoms. Liver transplantation is a suitable option for the patient with bilobar small cystic liver disease without areas of parenchymal sparing. However, only patients with severely compromised functional status should be offered this therapy. Concomitant renal evaluation is mandatory, and a knowledge of the natural history of this disease will aid in the decision of whether a combined liver-kidney transplantation is indicated.

Management of symptomatic polycystic liver disease: laparoscopy adjuvant with alcohol sclerotherapy

An 81 year old woman with extensive polycystic liver disease received laparoscopic unroofing and fenestration, followed by 95% ethanol sclerotherapy, resulting in almost complete disappearance of the cysts. Such a procedure can avoid complications of both the multi-segmental liver resections and extensive fenestrations, and untoward reactions from a large amount of alcohol. In addition, it can achieve a satisfactory result. It is suggested that this procedure could be a safe and effective alternative to traditional open surgery in selective patients.

Surgery for adult polycystic liver disease

BACKGROUND

Occasionally patients with adult polycystic liver disease (APLD) have symptoms. For these patients surgery may represent a valuable therapeutic option to relieve symptoms.

METHODS

From September 1977 to August 1993 at our institution, 10 women with APLD were examined and surgically treated. They underwent a partial hepatic resection together with cyst fenestration. The surgical outcome and long-term follow-up were retrospectively analyzed.

RESULTS

Postoperative morbidity consisted of one case of pneumonia, and one case of acute pancreatitis with deep vein leg thrombosis. One patient died after acute Budd-Chiari syndrome developed as a result of liver collapse after fenestration of a posterior cyst. In the long term six of nine patients were symptom free. Late surgical complications included acute cholecystitis (one patient), small bowel obstruction (one), and incisional hernia (two).

CONCLUSIONS

A combined surgical approach of hepatic resection and cyst fenestration has proved feasible for patients with highly symptomatic APLD. Extensive fenestration of posterior cysts should be avoided; transverse hepatic resection (frontal hepatectomy) up to the costal margin is proposed. This therapy provides good results at long-term follow-up.

Treatment of symptomatic hepatic cysts by percutaneous instillation of minocycline hydrochloride

Nine patients with 16 symptomatic nonneoplastic congenital hepatic cysts were treated prospectively by ultrasonically guided percutaneous minocycline hydrochloride injection, and the usefulness of this treatment was evaluated. Seven of the patients had multiple hepatic cysts, and two solitary cysts. All the patients were women, ranging in age from 36 to 81 years. After cystic fluid had been aspirated with a 21-gauge PTC needle, minocycline hydrochloride was injected into all the cysts. The minocycline hydrochloride was dissolved in saline at a concentration of 200 mg in 9 ml, and mixed with 1 ml of 2% mepivacaine hydrochloride. The total quantity of minocycline hydrochloride injected varied from 100 mg to 1200 mg per hepatic cyst, depending on its size. Total or subtotal regression of the cysts was observed in all patients during follow-up periods ranging from 15 to 35 months. Seven patients became symptom-free, one showed symptom reduction, and one showed no change in symptoms. Minor side effects, eg, transient abdominal pain, slight right shoulder pain, and temperature elevation, were noted in three patients respectively. On the basis of these results, we conclude that ultrasonically guided percutaneous minocycline hydrochloride injection is useful for the treatment of symptomatic hepatic cysts.

Alcohol sclerotherapy of simple parenchymal liver cysts

Three symptomatic non-parasitic liver cysts in three patients were treated by the technique of percutaneous aspiration followed by sclerosis of the cyst lining by irrigation with absolute alcohol. In two patients the treatment was fully successful, with partial success in the third case. Two cysts underwent two separate treatments. The technique, which is reviewed, was shown to be a safe and effective alternative to conventional surgical management.

Percutaneous treatment of hepatic cysts by aspiration and sclerotherapy

We treated 35 patients who had hepatic cysts (30 congenital cysts, 5 hydatid cysts) with percutaneous puncture and sclerotherapy. After puncture and drainage of the cyst, a 95% alcohol solution was instilled as sclerosing agent into the cystic cavity. In all the patients, cyst puncture and drainage was successful. Follow-up in all cases was at least 12 months. In three uncooperative patients, cysts recurred due to incomplete sclerosis of the lining epithelium of the cyst wall. No major complications were encountered in all cases. All congenital cysts were treated on an outpatient basis. Patients with hydatid cyst were hospitalized for 48 h after puncture and aspiration. In our opinion, percutaneous drainage and sclerosis of congenital hepatic cysts can be considered an effective alternative to surgical treatment.

Recurrent respiratory obstruction from a mediastinal bronchogenic cyst

A large mediastinal bronchogenic cyst presented acutely with paroxysmal atrial fibrillation and severe airflow obstruction. The patient had experienced identical symptoms on two other occasions over the previous 24 years. These had been previously misdiagnosed as due to a mediastinal lymphoma. Percutaneous extrapleural aspiration successfully decompressed the cyst with substantial improvement in lung function. Recurrent swelling of the cyst occurred that could not be relieved surgically. After repeat aspiration percutaneous instillation of bleomycin and alcohol has been used to prevent further increase in the size of the cyst.

Clinical experience with adult polycystic liver disease

Adult polycystic liver disease is characterized by multiple diffuse cystic lesions of the liver, usually in association with polycystic kidney disease. Rarely, significant liver disease will produce enough symptoms to call for surgical attention. Symptoms range from simple compression to fatal liver failure. Treatment of seven patients (six women) with symptomatic polycystic liver disease over 18 months is reported. Rapidly progressing liver failure and sepsis from infected ascites following puncture developed in one patient and precluded surgery. Another presented with an acute abdomen and anaemia from liver cyst bleeding and was treated conservatively. Five patients with massive hepatomegaly and compression symptoms underwent fenestration and resection to debulk the cystic liver mass. No intra-abdominal drains were used after operation and there were no hospital deaths. One patient developed a bile leak which was managed by percutaneous drainage. Clinical approach, complications and treatment options in adult polycystic liver disease are reviewed.

Percutaneous ethanol injection for the treatment of symptomatic cystic metastases from ovarian carcinoma. Work in progress

Two patients with symptomatic cystic metastases from ovarian epithelial carcinoma underwent ultrasound (US)-guided percutaneous aspiration and temporary injection of 99% ethanol into the cyst. In the first case, the patient initially underwent surgical resection of the mass and received systemic chemotherapy, but the cyst recurred 2 months later. Percutaneous aspiration and ethanol sclerotherapy were performed twice in the second case; fluid reaccumulated 2 months after the initial procedure. No side effects occurred. During the follow-up period (8 months in the first case and 4 months in the second), no clinical recurrence of the initial symptoms was noted. At the end of that period, a recurrent but asymptomatic cystic lesion was revealed at US examination in the first case. In the second case, a minimal asymptomatic residual collection was depicted with computed tomography. The results indicate that this technique should be considered in patients with symptomatic cystic metastases from ovarian carcinoma and may have potential benefit in the palliative treatment of such lesions.

Surgical experience with nonparasitic cysts of the liver--the characteristics and constituents of cyst fluid

Fifteen patients with nonparasitic hepatic cysts underwent surgery to relieve abdominal complaints, at the First Surgical Department, Tokyo University Hospital between 1966 and 1989. Total removal of the cyst was carried out in 14 of the patients, while puncture and aspiration only were performed in the other patient in whom a cyst had ruptured spontaneously, after which hemoperitoneum was observed at emergency laparotomy. The size of the cysts varied from 7-19 cm with a mean of 12.4 cm. Histological study revealed a congenital cyst in 14 patients and a cystadenoma in one. The epithelium lining of the internal surface of the congenital cysts was highly atrophic and desolated and often disappeared. Examination of the cyst fluid revealed the same concentration of electrolytes as in the serum. Hepatic enzyme levels were usually lower than in the serum, but lactic dehydrogenase and aminotransferase levels were elevated in a few cases. Tumor marker levels of the cyst fluid were higher than those in the serum in four of five patients examined.

Adult polycystic disease of the liver

Adult polycystic liver disease (APLD) is a rare disorder of liver parenchyma occasionally requiring surgical treatment. Its association with adult polycystic kidney disease has meant that as renal dialysis has become widely available there is an increased number of patients surviving with cystic liver changes. Although usually asymptomatic, patients with APLD may present with abdominal pain or swelling. Liver function is not usually compromised and computed tomography or abdominal ultrasonography are the most useful investigations. The complications of cyst rupture, infection, cholangiocarcinoma and compression of surrounding structures are discussed. Surgical treatment remains controversial, and the options of cyst puncture, fenestration with or without hepatic resection, and liver transplantation are reviewed.