Treatment of hydatid cyst of the liver: where is the evidence?

Assessment of Echinococcus granulosus somatic protoscolex antigens for serological follow-up of young patients surgically treated for cystic echinococcosis

Echinococcus granulosus protoscolex soluble somatic antigens (PSSAs) were assessed for their prognostic value in the serological follow-up of young patients treated for cystic echinococcosis (CE), compared to conventional hydatid fluid (HF) antigen. Based on different clinical courses and outcome of infection, as well as imaging findings, patients were retrospectively classified into two different groups including either cured CE (CCE; i.e., absence of active cysts or presence of inactive cysts, respectively) and noncured CE (NCCE) patients still presenting active cysts at the end of an up to 5-year follow-up period. An immunoglobulin G (IgG)-PSSA enzyme-linked immunosorbent assay (ELISA) showed a gradual decrease in antibody levels in CCE cases, reaching seronegativity in 20% of the cases at least within 5 years postsurgery. In comparison, the conventional IgG-HF ELISA showed a significantly lower progressive decrease in antibody levels, serology becoming negative in only 15% of CCE patients at the endpoint of the follow-up period. Serological analysis of PSSA by immunoblotting yielded an interesting immunoreactive double band of 27 and 28 kDa that, in 15 (75%) of 20 CCE cases, exhibited a rapid decrease and subsequent disappearance of respective antibody reactivities within 3 years postsurgery. Conversely, anti-27- and -28-kDa antibody reactivity strongly persisted until the endpoint of the follow-up period in all of the five NCCE patients. Further analysis of the 27- and 28-kDa doublet by using affinity-purified antibodies showed that the double band was not detectable in HF. Furthermore, a predominantly IgG4 subclass-restricted humoral immune response against the 27- and 28-kDa antigens was demonstrated in seroreactive CE patients. Overall, an anti-27- and -28-kDa response appeared to correlate with cyst activity. In conclusion, PSSA represents a useful candidate to carry out a serologic follow-up of CE subsequent to treatment and deserves further respective evaluation for other age groups of CE patients.

Treatment of hydatid liver disease

BACKGROUND

Echinococcal disease is still a serious problem in certain parts of the world. The liver is the organ affected most frequently. Over recent decades, various reports have been published comparing standard surgical and more conservative modalities for the treatment of the disease. Proper selection among the strategies reported so far could be the most appropriate part of successful patient management.

METHODS

A thorough review of the most recent reports on the treatment of liver Echinococcus infection, including percutaneous drainage, medical management, and laparoscopic, endoscopic and open surgical approaches has been conducted, focusing on patient outcomes.

RESULTS

The standard surgical approach, namely partial capsectomy, drainage, and epiploplasty, remains the most frequent operative method. Previous problems such as disease recurrence and a residual cavity seem to be managed optimally with more radical operations such as total pericystectomy. Laparoscopic and endoscopic approaches (endoscopic retrograde cholangiopancreatography and sphincterotomy) appear to have a crucial role, especially when the location of the cyst or the patient's status does not permit more radical approaches. Percutaneous computed tomography- or ultrasound-guided drainage appears to be of great value in certain cases. Chemotherapeutic agents remain useful as an adjuvant treatment.

CONCLUSIONS

Appropriate patient selection and proper use of the various available treatments are of great importance. A tailor-made approach should be employed for each patient. The surgeon's experience constitutes a principal criterion. To achieve the best possible results, an interdisciplinary approach should be used in the majority of patients.

Predictive factors of deep abdominal complications after operation for hydatid cyst of the liver: 15 years of experience with 672 patients

BACKGROUND

Operations are the mainstay of liver hydatid cyst (LHC) treatment. Operations are still associated with high morbidity and mortality because of specific postoperative complications (bile leaks, bilomas, deep bleeding, and deep suppurations) and deep abdominal complications (DAC). The aim of this study was to identify the predictive factors of DAC after LHC operation.

STUDY DESIGN

We conducted a retrospective study of 672 patients with LHC treated at the Surgery Department "A" at Ibn Sina University Hospital, Rabat, Morocco. Specific morbidity (DAC) and 30 variables were assessed. Univariate and multivariate logistic regression were performed to identify predictive factors for DAC. An associated risk scoring system was developed.

RESULTS

Six hundred sixty-four patients underwent operations. Mortality rate was 0.8% (n = 5) and DAC rate was 18.4% (n = 121). Five independent predictive factors of DAC after LHC operation were retained, ie, presence of cyst preoperative complications (odds ratio [OR] = 3.10; 95% CI, 1.85 to 5.17), 3 or more cysts in the liver (OR = 2.55; 95% CI, 1.42 to 4.59), thick pericyst (OR = 2.59; 95% CI, 1.27 to 5.29), biliary fistula (OR = 2.27; 95% CI, 1.38 to 3.72), and capitonnage alone as residual cavity management (OR = 2.23; 95% CI, 1.12 to 4.44). Multivariate model showed a good fit. Discriminating ability of the model was fair. In theoretical risk, scores ranged from 0 to 5. When the score was 2 or more, sensitivity of the scoring model was 80.3%, specificity was 58.5%, positive predictive value was 30.3%, and negative predictive value was 93%.

CONCLUSIONS

Identification of these five factors will allow more appropriate therapeutic care after LHC operation.

Albendazole for the treatment of human echinococcosis: a review of comparative clinical trials

BACKGROUND

Albendazole has been used in various ways in the treatment of cystic echinococcosis (CE).

METHODS

We reviewed the available evidence regarding the role of albendazole for the treatment of patients with CE. The available comparative clinical trials (randomized or not) that examined the use of albendazole in CE were identified from the PubMed and the ISI Web of Science databases. Relevant data from the trials were extracted and evaluated.

RESULTS

Thirteen studies were included in the review. Albendazole is superior to placebo for inoperable, symptomatic patients (1 study). In addition, in 4 trials that tested albendazole as a preoperative adjuvant therapy, the drug resulted in degeneration of hydatid cysts at the time of surgery in a considerable proportion of patients. Furthermore, combined therapy with albendazole and PAIR (Puncture, Aspiration, Injection of scolicidal agent, and Re-aspiration) technique was found more effective than albendazole or PAIR treatment alone, in a randomized controlled trial examining this issue. Finally, although existing evidence shows some superiority for albendazole compared to mebendazole, there is no definite proof about this.

CONCLUSIONS

Although the available comparative trials provide considerable evidence for the role of albendazole in patients with CE, there are some important clinical questions that remained unanswered by the studies. One of them is whether the combination of albendazole with praziquantel is superior to albendazole alone when both effectiveness and drug toxicity are taken into account. Also, further studies should also compare the combination of albendazole/PAIR with albendazole/surgery focusing on both short and long term outcomes.

Posttraumatic free intraperitoneal rupture of liver cystic echinococcosis: a case series and review of literature

BACKGROUND

A serious complication of cystic echinococcus (CE) is the rupture of the cysts. Free intra-abdominal rupture occurs in approximately 3.2% of all cases. Posttraumatic rupture of liver CE is very rare.

METHODS

The objective of the current study was to evaluate the clinical and radiographic findings and surgical treatment of this complication.

RESULTS

Twenty patients with posttraumatic ruptured liver CE were treated. The incidence rate of hydatid rupture was 3.06%. The common presenting symptom was abdominal pain. All patients were operated on under emergency conditions. There were 26 cysts in 20 patients, and all of the cysts were treated surgically.

CONCLUSION

Hydatid cyst rupture must be kept in mind in the management of trauma patients with cystic mass in the liver in particular and free intra-abdominal fluid, especially in the endemic area. We preferred conservative (unroofing associated with various procedures for the management of the residual cavity) rather than radical procedures such as hepatic resection or pericystectomy for the surgical treatment.

Endoscopic management of a relapsing hepatic hydatid cyst with intrabiliary rupture: a case report and review of the literature

Hydatid disease, although endemic mostly in sheep-farming countries, remains a public health issue worldwide, involving mainly the liver. Intrabiliary rupture is the most frequent complication of the hepatic hydatid cyst. Endoscopy is advocated, preoperatively, to alleviate obstructive jaundice caused by intracystic materials after a frank rupture and is also a useful and well-established adjunct in locating postoperative biliary fistulas. Endoscopic retrograde cholangiography with sphincterotomy has been successful as the sole and definitive means of treatment of intrabiliary ruptured hydatid cysts. A case of an elderly woman with frank rupture is presented, where the rupture was definitively managed endoscopically in conjunction with sphincterotomy to remove the intrabiliary obstructive daughter cysts and to achieve decontamination of the biliary tree. Endoscopic retrograde cholangiography provided an excellent diagnostic and therapeutic modality in the present case and, thus, it should be considered as definitive treatment in similar cases especially if surgical risk is anticipated to be high.

Prevention and control of cystic echinococcosis

Human cystic echinococcosis (hydatid disease) continues to be a substantial cause of morbidity and mortality in many parts of the world. Elimination is difficult to obtain and it is estimated that, using current control options, achieving such a goal will take around 20 years of sustained efforts. Since the introduction of current (and past) hydatid control campaigns, there have been clear technological improvements made in the diagnosis and treatment of human and animal cystic echinococcosis, the diagnosis of canine echinococcosis, and the genetic characterisation of strains and vaccination against Echinococcus granulosus in animals. Incorporation of these new measures could increase the efficiency of hydatid control programmes, potentially reducing the time required to achieve effective prevention of disease transmission to as little as 5-10 years.

Cystic echinococcal liver disease: new insights into an old disease and an algorithm for therapy planning

Human cystic echinococcosis (CE) continues to be a major health problem in developing countries. A review of current literature discloses four alternatives for the management of active CE, consisting of surgery, percutaneous treatment (PT), chemotherapy, and follow-up without intervention, but no clear guidelines for directing patients to the different management options. Palliation of symptoms or prevention of complications is the main rationale for the treatment of CE. Surgery has long been considered as the gold standard treatment. However, a meta-analysis comparing the clinical outcomes of patients treated with PT with those of a control group treated with surgery found PT to be more effective, safer, and cheaper. Medical therapy is considered to be ineffective when the criterion of success is defined as the disappearance of the lesion. However, medical therapy seems to be effective when the goal of therapy is defined as the prevention of complications in asymptomatic patients. We propose an algorithm for therapy planning in CE where the first line of therapy for patients with active lesions is PT. Patients with lesions unsuitable for PT are directed to surgery if they are symptomatic, have complicated lesions or have lesions that are prone to rupture. Asymptomatic patients with uncomplicated lesions are directed to medical therapy. Medical therapy failures are redirected to surgery.

Effects of octenidine HCl on liver tissue: could it be an alternative scolicidal for Hidatid disease?

Octenidine HCl is new topical antiseptic solution for wounds and abdominal washing that has been found to be highly effective for inactivating scolices in an in vitro study. However, the effects of octenidine HCl on the liver are not yet known. The aim of this study was to determine if there are any histopathologic changes after injecting octenidine HCl into the liver. A group of 50 male Sprague-Dawley rats were included in the study and randomly divided into five groups of 10 rats each, as follows: sham group; 0.09% NaCl group; 20% NaCl group; undiluted octenidine HCl group; 1% octenidine HCl group. The scolicidal agents (0.3 ml) were directly injected into the left lobe of the liver (except in the sham group). At 3 and 7 days after the injection, the rats were sacrificed, and the left lobe of the liver was harvested. Liver tissue was scored for degree of necrosis and the diameter of the necrosis examined under light microscopy. The highest scores were found in the undiluted octenidine HCl group, although a similar effect was observed in the 20% NaCl group. There was no necrosis in the sham group, the 0.09% NaCl group, or the 1% octenidine HCl group. All of the injury was coagulation-type necrosis. No mortality was observed throughout the study. The 1% octenidine HCl solution could thus be used as a scolicidal agent in liver tissue, whereas the undiluted form of octenidine and 20% NaCl solutions were shown to cause necrosis when directly injected into liver tissue in our animal model.

Efficacy of preoperative albendazole use according to months in hydatid cyst of the liver

PURPOSE

Hydatid cyst is still a significant health and economical problem due to insufficient preventive measures. Infestation by hydatid disease in humans most commonly occurs in the liver and causes complications unless treated properly. Therefore, hepatic hydatid cyst should immediately be treated when diagnosed. Today, the treatment of hydatid cysts is principally surgical. To avoid recurrence, viable scoleces in the hydatid cyst should be eliminated before emptying surgically. Length of Albendazole therapy, a drug effective on scoleces in the cyst, is still controversial.

METHODS

In this study, there was a significant difference in the rate of viable scoleces when group III receiving albendazole for 3 months preoperatively was compared with group I, group II, and the control group. We do think 3-month preoperative abendazole treatment is effective in reducing the rate of recurrence and if still viable scoleces are observed in the surgery, albendazole treatment should be continued for 1 month postoperatively.

RESULTS

After the therapy, in group I 10 (47.6%), in group II 7 (33.3%), and in group III 2 (0.9%) patient's scoleces were alive. In the control group (group IV) 17 (80%) patients' scoleces were intact. When group III is compared with the control group, a significant difference was observed (P<0.05). Yet again, there was a significant difference between the groups when groups I and II were compared with group III.

CONCLUSIONS

We concluded that in treatment of hydatid cyst, albendazole should be continued at least for 3 months preoperatively and if still viable scoleces are identified, medical treatment should follow the surgical intervention at least for 1 month to decrease the possibility of residual cysts and recurrence.

Radio Frequency Ablation (RFA)-assisted Pericystectomy for Hepatic Echinococcosis

The aim of this study is to describe an alternative technique, using radio frequency energy to perform pericystectomy for hepatic echinococcosis. We present 3 patients with hepatic echinococcosis who were treated with radio frequency ablation (RFA)-assisted pericystectomy. A Radionics Cooltip Radio Frequency System (Tyco, Greece, Radionics) with a single shaft 15 cm long needle electrode and a 2 cm exposure tip, was used. The needle electrode was inserted in consecutive sites into the "healthy" hepatic parenchyma close to the cyst wall, so that a tissue zone around the cystic cavity was gradually ablated. The complete ablation of a site was followed by sharp division of the parenchyma. The operation completed successfully in all patients. Minor bleeding and/or bile leakage were successfully controlled with RFA coagulation. No other hemostatic method was used. The postoperative course was uneventful. No evidence of recurrent disease, or any other cause of morbidity, has been demonstrated at follow up (2 y). RFA-assisted pericystectomy for hepatic hydatid disease in experienced hands, might be useful to perform a "sterile" resection, eradicating single or multiple cysts and preventing local recurrence, with minimal morbidity.

Hydatid cysts in muscle: a modified percutaneous treatment approach

INTRODUCTION

Any organ in the human body may be affected by hydatid disease, but the liver and the lungs are most commonly affected. A rare localization of hydatid disease is within muscle tissue. Herein we present three patients with muscular hydatid disease who were successfully treated with a modified percutaneous approach.

METHODS

Patients with Gharbi type III cysts were treated on an outpatient basis. All procedures were performed under ultrasound guidance in the ultrasonography unit of our department. After local anesthesia, percutaneous puncture was performed in a one-step procedure. After free drainage stopped, absolute ethanol and polidocanol were injected into the cyst cavity. After the procedure, the patient was observed for at least six hours for any adverse reactions and sent home. Patients were followed-up with ultrasonography. A positive treatment effect was characterized by a reduction of the cyst's pseudo-tumor pattern and size, and by detachment of the germinal membrane.

RESULTS

The three patients in this report had a total of five hydatid cysts in muscle tissue and were all successfully treated with a modified percutaneous approach without recurrence.

CONCLUSION

Percutaneous drainage without re-aspiration is simple, easy to apply, low cost, repeatable, and does not require hospitalization. There have been no reported deaths associated with the procedure and morbidity is very low. When the technique is applied properly, relapses do not occur. With its low complication rate and its suitability for outpatient treatment, this method can be an alternative to surgery or puncture, aspiration, injection, and re-aspiration (PAIR) in selected patients.

Falciform Ligament in the Management of the Residual Cavity for Liver Hydatidosis: New Surgical Technique

INTRODUCTION

Hydatid disease is a common condition worldwide and continues to be a significant societal problem in many countries of all continents. Alhough other treatment options are also available, surgery remains the cornerstone of therapy for hepatic hydatid disease. Omentoplasty seems to be an efficient technique for managing the residual cavity, but it has some shortcomings and might be difficult in secondary cases. Therefore we describe a new technique using the falciform ligament as a flap instead of omentum for managing the residual cavity, as it is more anatomic and a better option for liver cysts.

METHODS

From April 2004 to October 2005, a total of 20 patients (11 women) with a median age of 43 years (range 23-66 years) underwent partial cystectomy-falciformoplasty for hydatid liver disease. The falciform ligament was prepared as a flap in all patients during the initial step of the operation and, after partial cystectomy and evacuation of the cystic components, the flap was inserted into the cystic cavity and fixed with sutures. A single drain was inserted into the subhepatic area.

RESULTS

Cysts were located in the right lobe of the liver in 14 patients and mean diameter of the cyst was 10 cm (range 7-25 cm). The mean duration of the operation was 40 minutes (range 35-69 minutes), and the mean postoperative hospital stay was 4 days (range 3-7 days). None of the patients had any major complications. Only two patients had persistent drainage for 7 days, which stopped spontaneously. The median follow-up was 9 months (range 2-19 months). Patients underwent duplex ultrasonography (US) to check the viability of the flap and the residual cavity at 1 week, 1 month, and 3 months postoperatively. US did not reveal any collection, the cavities were fully collapsed, and blood flow to the falciform ligaments was seen to be viable.

CONCLUSIONS

Using the falciform ligament as a flap for management of the residual cavity is an easy, safe, effective new technique with few complications. It might be a good choice in patients with hydatid liver disease.

Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts

BACKGROUND

Hepatic hydatid cyst is an important public health problem in parts of the world where dogs are used for cattle breeding. Management of uncomplicated hepatic hydatid cysts is currently surgical. However, the puncture, aspiration, injection, and re-aspiration (PAIR) method with or without benzimidazole coverage has appeared as an alternative to surgery over the past decade.

OBJECTIVES

To assess the benefits and harms of PAIR with or without benzimidazole coverage for patients with uncomplicated hepatic hydatid cyst in comparison with sham/no intervention, surgery, or medical treatment.

SEARCH STRATEGY

The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Controlled Trials Register in The Cochrane Library, MEDLINE, EMBASE, DARE, and ACP Journal Club and full text searches were combined (all searched October 2004). Reference lists of pertinent studies and other identified literature were scanned. Researchers in the field were contacted.

SELECTION CRITERIA

Only randomised clinical trials using the PAIR method with or without benzimidazole coverage as the experimental treatment of uncomplicated hepatic hydatid cyst (ie, hepatic hydatid cysts which are not infected and do not have any communication with the biliary tree or other viscera) versus no intervention, sham puncture (ie, performing all steps for puncture, pretending that PAIR is being performed, but actually not performing the procedure proper), surgery, or chemotherapy were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and methodological quality of each trial was assessed by the authors. Principal authors of the trials were contacted to retrieve missing data.

MAIN RESULTS

We found no randomised clinical trials comparing PAIR versus no or sham intervention. We identified only two randomised clinical trials, one comparing PAIR versus surgical treatment (n = 50) and the other comparing PAIR (with or without albendazole) versus albendazole alone (n = 30). Both trials were graded as 'adequate' for allocation concealment; however, generation of allocation sequence and blinding methods were 'unclear' in both of them. Compared to surgery, PAIR plus albendazole obtain similar cyst disappearance and mean cyst diameter with fewer adverse events (32% versus 84%, P < 0.001) and fewer days in hospital (mean + SD) ( 4.2 + 1.5 versus 12.7 + 6.5 days, P < 0.001). Compared to albendazole, PAIR with or without albendazole obtain significantly more often (P < 0.01) cyst reduction and symptomatic relief.

AUTHORS' CONCLUSIONS

PAIR seems promising, but there is insufficient evidence to support or refute PAIR with or without benzimidazole coverage for treating patients with uncomplicated hepatic hydatid cyst. Further well-designed randomised clinical trials are necessary to address the topic.

Results of surgical, laparoscopic, and percutaneous treatment for hydatid disease of the liver: 10 years experience with 355 patients

Selection of the most appropriate treatment to obtain the best results with the lowest rate of recurrence and minimal morbidity and mortality is mandatory for the management of hepatic hydatid disease. The surgical approach is the mainstay of treatment, and there has been a tendency toward laparoscopic surgery and, more recently, percutaneous treatment (PT), which has become increasingly popular with revolutions in techniques. We aimed to evaluate the results of current therapeutic methods in the context of a 10-year single-institution experience. Between 1992 and 2003, 355 patients with 510 hydatid cysts of the liver were treated by open operation, laparoscopic surgery, or PT. The series included 128 females and 227 males ranging in age from 10 years to 73 years. Preferred treatment modalities, perioperative complications, interventions, recurrences, and length of hospital stay were retrospectively analyzed. There were two postoperative deaths (1.08%) in the open surgery group. Biliary leakage was observed in 28 patients treated with open surgery, in 10 patients after PT, and in 2 after laparoscopic treatment. Recurrence rates were 16.2%, 3.3%, and 3.5% after open surgery, laparoscopic surgery, and percutaneous treatment, respectively. Characteristics of the cyst, presence of cystobiliary communications, and the availability of a multidisciplinary team are the factors that we believe directly affect the results. Radical surgery can be done safely for suitable cases; conventional procedures are associated with greater morbidity. Laparoscopic surgery seems effective and safe, with low morbidity and recurrence rates for type I-III cysts in accessible localizations. Our experience with PAIR (puncture, aspiration, injection, and reaspiration) and catheterization provides evidence that the procedure is an effective and safe option.

Hydatid disease of the abdomen and other locations

We present patients treated for hydatid disease in our hospital (in northeastern Greece) over the last 20 years. In the period from 1984 to 2003, a total of 135 patients (54 male, 81 female) were treated for echinococcal disease (age 15-85 years). In 111 (82.2%) patients only the liver was affected; 9 (6.7%) patients had concomitant hepatic and extrahepatic hydatid disease; and 15 (11.1%) patients had only extrahepatic disease. Clinical symptoms in patients with hepatic locations of the disease included abdominal pain localized in the epigastrium or right upper quadrant of the abdomen, tenderness, hepatomegaly with palpable abdominal mass, jaundice, fever, and anaphylactic reaction. All the patients were treated surgically. Surgical techniques included partial cystectomy and drainage, cystectomy and capitonage, cystectomy and omentoplasty, only drainage, left lateral hepatectomy, total pericystectomy, and laparoscopic pericystectomy. Rupture into the bile duct was managed by T-tube drainage or biliodigestive anastomosis. Symptoms and surgical treatment for extrahepatic cysts varied according to the location of the cyst. The median cyst diameter of all patients was 11 cm. The postoperative complication rate was 17.0%. Two patients died (1.5%). The median hospital stay was 18 days. The recurrence rate was 6.7%. The study suggests that treatment of this benign disease should be the less radical surgical technique combined with pre- and postoperative anthelmintic administration. The surgical treatment should be combined with careful use of scolicidal fluids and aspiration of the cyst to avoid contamination and minimize the risk of recurrence.

Medical treatment of echinococcosis under the guidance of Good Clinical Practice (GCP/ICH)

Chemotherapy is one of the main components for the treatment of alveolar and cystic echinococcosis. Benzimidazoles are on the market since 30 years, and are used widely according to the recommendations of the 1996 WHO guidelines for treatment of cystic and alveolar echinococcosis [Bull WHO 1996; 74: 231-242.]. However, none of the two drugs (Albendazole or Mebendazole) would satisfy today the requirements for an approval by the relevant authorities, such as the European Agency for the Evaluation of Medicinal Products (EMEA) or the Food and Drug Administration (FDA). New anthelmithic drugs are in the pipeline, and some of them have already undergone preclinical testing. In addition, recent advances have been made in the definition of outcomes for clinical trials in alveolar echinococcosis. Thus, phase III studies with new active ingredients are needed to assess short- and long-term safety as well as the therapeutic value. The basic requirements for comparative drug testing are provided in the Note for Guidance on Good Clinical Practice (GCP), and are based upon the rules and regulations by International Conference on Harmonization (ICH) and the Clinical Trial Directive (Directive 2001/20/EC) of the European Commission. The application of these standards to new drug testing for echinococcosis will help to upgrade the level of evidence.