Diaphragmatic or transdiaphragmatic thoracic involvement in hepatic hydatid disease: surgical trends and classification

Turkish HPB Surgery Association consensus report on hepatic cystic Echinococcosis (HCE)

OBJECTIVES

Cystic Echinococcosis (CE) is one of the important problems of the Eurasian region. We aimed to prepare a consensus report in order to update the treatment approaches of this disease. This study was conducted by Turkish HPB Surgery Association.

MATERIAL AND METHODS

This study was conducted with the modified Delphi model. For this purpose, we conducted a three-stage consensus-building approach.

RESULTS

Six topics, including diagnosis, medical treatment, percutaneous treatment, surgical treatment, management of complications and posttreatment follow-up and recurrences in HCE were discussed.

CONCLUSION

The expert panel made recommendations for every topic.

Liver and lung hydatid cysts with transdiaphragmatic rupture treated by radical surgery

Hydatidosis is a parasitic disease caused by Echinococcus granulosus, a tapeworm that is endemic in certain parts of the world. We present a case of hepatopulmonary hydatidosis with diaphragm involvement and close contact with the suprahepatic inferior vena cava treated with radical surgery. We discuss therapeutical surgical options (approach and type of surgery).

Wandering parasite: endoscopic management of hydatid cysts of abdomen encroaching thorax

BACKGROUND

Minimal access surgery has opened avenues of hybrid approach for abdominal hydatid cysts extending into thorax. This approach of combined laparoscopy and thoracoscopy should be evaluated for its feasibility and efficacy.

AIM

Present prospective study was designed to highlight the feasibility and utility of endoscopic approach in the management of complex hydatid cyst of the liver and spleen extending into the thorax.

MATERIAL AND METHODS

Patients undergoing combined Laparoscopy and thoracoscopy for abdominal hydatid cysts extending into thorax over a period of 4 years were included in the study. Their clinical features, investigations, imaging, treatment and duration of hospital stay were studied. Clinical outcomes were assessed with respect to morbidity and mortality using Calvien Dindo scale.

RESULTS

A total of 15 patients were studied. All patients had thoracic hydatid cysts with liver involvement in 12, splenic involvement in 2, and both liver and spleen in 1 patient. The most common symptom was pain in the abdomen in 11 patients (73.3%) followed by lump in the abdomen in 2 patients (13.33%), and dyspnoea in 2 patients (13.33%). Computed Tomography was diagnostic in all patients. Most common type was Gomez type 1 (7 patients) followed by Gomez type II (3 Patient) and Gomez type III (2 patient). The mean operative time was 120 min. Mean hospital stay was 10 days. Pleural effusion being the commonest postoperative sequelae.

CONCLUSION

This endoscopic approach for liver and splenic hydatid cyst extending into thorax is feasible and averts morbidities of thoracotomy.

Gigantic Mediastino-Abdominal Hydatic Cyst Through Esophageal Hiatus

Hydatid disease is one of the most widespread and endemic infections causing a substantial health and economic burden. The liver and lungs remain the most affected viscera. We report the case of a 41-year-old man with an atypical presentation: a hydatid cyst of the liver with a massive extension to the mediastinum through the esophagus hiatus. This patient underwent a single-stage surgical session to treat the mediastinal and abdominal parts of the cyst through a unique thoracic route.

Thoracic hydatid disease: A radiologic review of unusual cases

Hydatid disease or echinococcosis is a zoonotic parasitic disease. The lung is the second most commonly affected organ after the liver. Intra-thoracic and extra-pulmonary hydatid disease is uncommon and may involve the pleura, mediastinum, heart, diaphragm, and chest wall. Unusual locations or complications of thoracic hydatid disease may pose a diagnostic challenge. We present imaging findings of cases with unusual location and presentations of thoracic hydatid disease with emphasis on their clinical implications.

Complications of hepatic echinococcosis: multimodality imaging approach

Hydatid disease is a worldwide zoonosis endemic in many countries. Liver echinococcosis accounts for 60-75% of cases and may be responsible for a wide spectrum of complications in about one third of patients. Some of these complications are potentially life-threatening and require prompt diagnosis and urgent intervention. In this article, we present our experience with common and uncommon complications of hepatic hydatid cysts which include rupture, bacterial superinfection, and mass effect-related complications. Specifically, the aim of this review is to provide key imaging features and diagnostic clues to guide the imaging diagnosis using a multimodality imaging approach, including ultrasound (US), computed tomography (CT), magnetic resonance (MR), and endoscopic retrograde cholangiopancreatography (ERCP).

Hepatic Echinococcosis with Thoracic Involvement. Clinical Characteristics of a Prospective Series of Cases

INTRODUCTION

Thoracic involvement (TIHE) is one of the evolutionary complications of hepatic echinococcosis (HE).

AIM

The aim of this study was to describe the clinical characteristics and postoperative morbidity (POM) of a series of patients with TIHE treated surgically.

MATERIAL AND METHODS

Series of cases of patients treated for TIHE between 2000 and 2014 in the Hospital Regional and Clínica Mayor in Temuco, Chile, with a minimum 12-month follow-up. The outcome variable was "development of POM". Descriptive statistics were used.

RESULTS

The series was composed of 37 patients with a mean age of 53.2 ± 47.4 years (51.4% female). Mean cyst diameter was 19.4 ± 15.5 cm, and 75.7% of the lesions were located in the right hepatic lobe. The most frequent surgical technique used for the cyst was subtotal pericystectomy (56.8%); the residual cavity was treated by capitonnage (27.0%) or omentoplasty (21.6%), and a phrenoplasty with or without prosthetic material was performed for the TIHE. Mean hospital stay was 6.0 ± 5.7 days and follow-up was 61.4 ± 79.9 months; a mortality rate of 2.7% (one patient) and a POM of 24.3% (9 patients) were verified.

CONCLUSION

TIHE is an uncommon evolutionary complication of HE associated with significant POM rate.

Hepatic hydatid disease complications: review of imaging findings and clinical implications

Hydatid disease is a zoonotic parasitic disease. The liver is the most commonly affected organ, and hepatic hydatid disease complications are not uncommon. Hydatid cyst superinfection, intrabiliary rupture, and direct rupture into the thoracic or abdominal cavities are the frequently encountered complications. Other exceedingly rare complications include rupture of the cyst into hollow viscera, abdominal wall invasion, and hepatic vasculature-related complications such as portal vein thrombosis and Budd-Chiari syndrome. These complications have variable clinical presentations and imaging findings and require different medical and surgical managements. We aim to provide a spectrum of imaging findings of different common and uncommon complications of hepatic hydatid disease with emphasis on their clinical implications.

Anesthetic challenges in the simultaneous management of pulmonary and hepatic hydatid cyst

Hydatidosis is a parasitic infection caused by the encysted larvae of Echinococcus granulosus, commonly called as hydatid cyst. Almost all organs can be involved, but most commonly it affects liver (55%-70%) followed by the lungs (18%-35%). The surgery and anesthetic management become very challenging if these cysts are in or near the vicinity of vital organs, such as heart. Pulmonary hydatid cysts may rupture into the bronchial tree or pleural cavity and produce cough, chest pain, or hemoptysis and there are chances of injury to heart if the cyst is in close proximity to it. We are describing the successful management of such a case of pulmonary and hepatic hydatid cyst in a young female patient.

Bilateral staged thoracotomy for multiple lung hydatidosis

BACKGROUND

Hydatid cyst disease is still a problem in many countries. Surgical removal is currently the generally accepted choice of treatment for lung hydatidosis. However, operating on bilateral widespread lung hydatidosis is still controversial. The aim of this retrospective study was to evaluate the results of surgical treatment in bilateral multiple hydatid disease of the lung.

METHODS

In this study, we reviewed our experience in the surgical treatment of 17 (3.7%) patients with bilateral, and at least three, lung hydatid cysts. These 17 patients (8 male, 9 female), with an average age of 34.6 years (range 12-58 years), underwent bilateral staged thoracotomy.

RESULTS

In total 105 lung cysts were removed from 17 patients who underwent staged thoracotomies. The mean count of cysts was 6.7 (range 3-20 cysts). Most of the cysts (38.2%) were located in the right lower lobe. The mean interval between thoracotomies was 4.2 (range 3-5) days. Two patients (11.7%) had cysts associated with hepatic hydatidosis and one (5.8%) had cysts associated with the spleen; they were treated via phrenotomy during thoracotomies. All cysts were removed without lung resection. We observed some complications such as prolonged air leaks (n = 2), atelectasis (n = 3) and empyema (n = 2). No further surgery was required for management of complications. The mean hospital stay was 9.3 days. (range 7-23 days). Oral albendazole was started on the 2nd post operative day after the first thoracotomy in the dose of 10-20 mg/kg and was continued for 3 months with a gap of 1 week after each 21 days. No recurrences or deaths occured during the follow-up period.

CONCLUSIONS

Although staged thoracotomy applied in 3-5 days after the initial thoracotomy increases the total hospital stay, it decreases the chance of possible complications can occur in cysts in the other lung when long intervals are preferred between the first and the second thoracotomy. In our experience, bilateral staged thoracotomy is an appropriate surgical option because morbidity rates are minimal and the hospital stay is acceptable for the treatment of bilateral widespread lung hydatidosis, even in patients who had a total of 20 hydatid cysts.

Complications of Hydatid Cysts of the Liver: Spiral Computed Tomography Findings

Background

The purpose of this retrospective study is to evaluate the role of Spiral Computed Tomography (CT) in the detection of the complications of hepatic hydatid cysts.

Methods

During a period of 8 years and after establishing the diagnosis of numerous hydatid cysts, 7 patients with complications of hydatid cysts were found. These 7 patients (5 females, 2 males, mean age 74.2 years, range 63 - 92 years) were studied. Four of them had a known medical history of hydatid disease, while all of them presented to our department as emergency cases.

Results

They underwent Spiral CT which revealed the following complications of hydatid cysts: intrabiliary rupture in 2 patients, rupture into the peritoneal cavity resulting to peritonitis in 1 patient, contained rupture and secondary transdiaphragmatic thoracic rupture in 1 patient, rupture into both biliary tract and hepatic subcapsular space in 1 patient, rupture into the subcapsular hepatic space in 1 patient and secondary bacterial infection of the cyst resulting to abscess formation in 1 patient. All of these CT findings were surgically confirmed.

Conclusions

CT provided a rapid and accurate diagnosis in all of these cases and proved to be a very useful preoperative imaging method.

Biliobronchial fistula after liver surgery for giant hydatid cyst

Background. Biliobronchial fistula (BBF) is a rare complication in the natural history of liver hydatid disease by Echinococcus granulosus. We present a case of BBF after resection of a giant liver hydatid cyst in a 72-year-old woman. Case Report. A total cystpericystectomy was done, leaving the left lateral section of the liver that was fixed to the diaphragm. Postoperatively, the patient developed obstructive jaundice. An ERCP showed an obstruction at the junction of the left biliary duct and the main biliary duct and contrast leak. At reoperation, the main duct was ischemic, likely due to torsion along its longitudinal axis. A hepatotomy was done at the hilar plate, and the biliary duct was dissected and anastomosed to a Roux-en-Y jejunal loop. She was discharged without complications. Five months later, the patient developed cholangitis and was successfully treated with antibiotics. However, she suffered repeated respiratory infections, and four months later she was admitted to the hospital with fever, cough, bilioptysis, and right lower lobe pneumonia. The diagnosis of BBF was confirmed with ^99mTc Mebrofenin scintigraphy. At transhepatic cholangiography, bile duct dilation was seen, with a biliothoracic leak. She underwent dilatation of cholangiojejunostomy stricture with placement of an external-internal catheter. The catheter was removed 3.5 months later, and two years later the patient remains in very good condition. Conclusion. An indirect treatment of the BBF by percutaneous transhepatic dilation of the biliary stenosis avoided a more invasive treatment, with satisfactory outcome.

Bronchobiliary fistula: a rare complication of hepatic endometriosis

OBJECTIVE

To report the case and surgical therapy of a patient with bilioptysis after vaginal delivery, caused by bronchobiliary fistula. Histologic analysis revealed endometrial glands embedded in the decidual stroma neighboring the liver and the lung.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 39-year-old patient, 7 days after vaginal delivery, without endometrial history.

INTERVENTION(S)

Synchronous liver and lung resection of a bronchobiliary fistula by laparotomy and a transdiaphragmatic approach.

MAIN OUTCOME MEASURE(S)

For complicated brochobiliary fistula caused by endometriosis, radical surgical treatment is mandatory.

RESULT(S)

Histopathologic analyses confirmed the presence of clusters of endometrial glands embedded in the decidual stroma that were neighboring the liver, and perifistulous lung tissue was shown to contain biliary pigment absorbed by macrophages and their derivatives.

CONCLUSION(S)

Hepatic and perihepatic endometriosis can cause a bronchobiliary fistula. Exacerbation of the symptoms can be triggered by high estrogen levels, physiologically dominating the last trimester. For such a rare case, surgery is mandatory.

[Outcomes after thoracotomy for intra-abdominal hydatid cysts ruptured into the thorax (a 160 case series)]

INTRODUCTION

The purpose of this study was to assess the results of the surgical treatment of abdominal hydatid cysts ruptured in the thorax.

PATIENTS AND METHODS

We collected data from 160 patients who experienced the intra-thoracic rupture of an abdominal hydatid cyst during the period 1997 - 2008: 158 located in the liver, one in the spleen and one in the kidney, which had been treated surgically in a single centre. Diagnosis was based on a history of surgery for abdominal hydatid cysts, specific symptoms including biliptysis (40% of the cases) and expectoration of hydatid cysts, as well as radiological findings (chest x-ray; abdominal ultrasound and CT-scan). All patients were operated on through a thoracotomy.

RESULTS

In-hospital mortality was 7.5%. Postoperative complications occurred in 16% and mainly consisted of pleural and pulmonary disorders.

CONCLUSION

Thoracotomy offers simultaneous and adequate access to address thoracic and abdominal injuries with a reasonable mortality and morbidity in patients with this condition.

Biliobronchial fistula due to hydatidosis of the liver and choledocholithiasis

INTRODUCTION Biliobronchial fistula (BBF) is an abnormal communication between the biliary system and bronchial tree due to trauma, hemiheptectomy benign biliary stricture with cholangitis and necrotic hepatic infections such as hydatid disease. Intratoracic rupture of a hydatis cyst of the liver is a rare but severe complication with an incidence about 1% and mortality rate about 10%. CASE REPORT A 50-year-old male patient presented with cough, episodes of biliary expectoration and haemoptysis followed with fever, fatigue and dyspnea. The diagnosis was set by echosonography, Chest x-ray finding, CT scan, bronchoscope aspirates while bronchography did not show results. The surgery was done through right subcostal laparotomy. A hydatid cyst was found in the right liver lobe its diameter being 10 cm, fixed with diaphragm. Intraoperative cholangiography revealed choledocholithiasis (two calculi), dilatation of bile ducts and communication of right hepatic duct with the irregular liver cavity as well as with the bronchi of the right lower pulmonary lobe. Cholecystectomy, choledocholitotomy with drainage lavage of bile ducts pericystectomy and cyst evacuation was performed, followed by diaphragm necrosectomy. The postoperative period and control cholangiography through T drain were normal. DISCUSSION The surgical treatment has five goals: to treat the liver cyst, secure free biliary drainage, perform hepatodiaphragmatic disconection, solve intratoracic lesion and restore ti diaphragm. We believe these goals could be achieved through abdominal approach except for irreversible bronchiectasis, intratoracal collection and chronic pulmonary sepsis. CONCLUSION In any case, a surgery still remains the treatment of choice in cases of echinococcosis. Most cases can be solved by laparo-tomy.

Bronchobiliary fistula in a cirrhotic patient: a case report and review of the literature

Bronchobiliary fistula is defined as the passage of bile in the bronchi. The presence of bronchobiliary fistula in patient with cirrhosis is extremely rare. Management of these fistulas is often very difficult and can be associated with high morbidity and mortality. We are presenting a patient with ethanol related cirrhosis and biliptysis in whom a diagnosis of bronchobiliary fistula was made. A review of the literature including diagnosis and management is performed.

Migrating and herniating hydatid cysts

OBJECTIVE

To present the prevalence and imaging findings of patients with hydatid disease (HD) showing features of migration or herniation of the hydatid cysts (HCs) and underline the clinical significance of this condition.

MATERIALS AND METHODS

Between May 2003 and June 2006, 212 patients with HD were diagnosed by abdomen and/or thorax CT, searched for migrating or herniating HC. Imaging findings of 7 patients (5 women, 2 men with an age range of 19-63 years; mean+/-S.D., 44+/-19 years) with HD showing transdiaphragmatic migration (6 subjects) or femoral herniation (1 subject) were evaluated. Diagnosis of all the patients were established by pathologic examination and migration or herniation was confirmed by surgery in all patients.

RESULTS

Liver HD were identified in 169 (79.7%) of 212 patients with HD. Transdiaphragmatic migration of HCs were identified in 6 (3.5%) of the 169 patients with liver HD. In one patient, femoral herniation of the retroperitoneal HC into the proximal anterior thigh was identified. All of these seven patients exhibiting migration or herniation of HCs had active HCs including 'daughter cysts'. Two patients had previous surgery because of liver HD and any supradiaphragmatic lesion was not noted before operation. Findings of migration or herniation were confirmed by surgery.

CONCLUSION

Active HCs may show migration or herniation due to pressure difference between the anatomic cavities, and in some of the patients, by contribution of gravity. Previous surgery may be a complementary factor for migration as seen in two of our patients. The possibility of migration or herniation in patients with HD should be considered before surgery.

Hydatid cyst presenting as an eosinophilic pleural effusion

A 61-year-old woman presented with an eosinophilic pleural effusion, secondary to transdiaphragmatic intrapleural spread of an hepatic hydatid cyst. Right posterolateral thoracotomy and frenotomy revealed a loculated pleural effusion associated with a 10 x 8 cm hydatid cyst in the posterior segment of the liver. Hydatid disease should be included in the differential diagnosis of eosinophilic pleural effusions in endemic regions.

Successful treatment of intractable bronchobiliary fistula using long-term biliary stenting

A bronchobiliary fistula (BBF) is an uncommon entity with bilioptysis being a pathognomonic sign. We describe the case of a 41-year-old man who had recurrent BBF, 6 months after resection of the anterior segment of the right lower pulmonary lobe and repair of a BBF due to hepatic hydatid disease. Magnetic resonance cholangiography revealed a communication between the biliary tree and the lower lobe of the right lung. Endoscopic biliary sphincterotomy and repeated insertion of large size biliary plastic stents led to a successful resolution of the symptoms and closure of the fistula.

Hydatid hepatic cysts rupture into the biliary tract, the peritoneal cavity, the thoracic cavity and the hepatic subcapsular space: specific computed tomography findings

BACKGROUND

This study attempts to demonstrate the role of computed tomography in the diagnosis of hepatic hydatid cyst rupture based on specific imaging findings and to propose combinations of the imaging findings diagnostic for specific types of rupture.

METHODS

Eleven patients were studied with computed tomography of the abdomen, with 4-8 mm slice thickness, after the oral administration of contrast material and intravenous contrast material in 6 cases.

RESULTS

Based on a combination of imaging findings the types of hepatic hydatid cyst rupture were: intrabiliary rupture in 7 patients, intraperitoneal rupture in 1 patient, intrathoracic rupture in 1 patient, hepatic subcapsular rupture in 2 patients. Structural deformity of the cyst was present in all cases, combined with: dilatation of the intrahepatic bile ducts (intrabiliary rupture); intraperitoneal fluid collections with diffuse haziness and stranding of the mesenteric fat (intraperitoneal rupture); an inhomogeneous lesion in the thorax with ipsilateral pleural effusion (intrathoracic rupture); a hydatid cyst located peripherally, with discontinuity of its adjacent to the hepatic capsule wall and subcapsular fluid collection (subcapsular rupture). The imaging findings were surgically and pathologically confirmed.

CONCLUSIONS

Using combinations of specific imaging findings we correctly diagnosed the type of hepatic hydatid cyst rupture in all cases.

Treatment of hydatid bronchobiliary fistulas: 30 years of experience

BACKGROUND

Bronchobiliary fistula (BBF) is an uncommon but severe complication of hydatid disease of the liver. Operation is considered the treatment of choice but the most appropriate operation is uncertain. The aim of this study was to evaluate the early and long-term outcomes following different surgical procedures.

METHODS

A retrospective evaluation of 31 patients with BBF was performed. Surgical access consisted of laparotomy, thoracotomy or a thoracoabdominal (TA) incision. Surgical procedures for the treatment of the cyst were classified as conservative or radical.

RESULTS

Radical treatment including lung resection and pericystectomy was performed in all patients in whom the surgical exposure was obtained by either thoracotomy or TA. Of the patients treated by laparotomy, two had a pericystectomy, and four had drainage of the cyst. There were two deaths among the seven thoracotomy patients and one among the 18 TA patients. Pleural effusion was observed in six of the TA, two of the thoracotomy, and three of the laparotomy patients. Biliary fistula occurred in two of the five thoracotomy patients surviving operation and in two laparotomy patients (2/6). Progression of the lung disease was observed in four laparotomy patients and in one thoracotomy patient.

CONCLUSIONS

The better outcome achieved in TA patients is the result of the simultaneous radical treatment of all the pathological aspects of BBF.

CT appearances of hydatid disease at various locations

Hydatid disease has characteristic imaging features on CT, which allow accurate preoperative diagnosis in most cases. However, when it occurs at unusual locations the diagnosis is often difficult, especially as the imaging appearance varies at different sites. In this article we have presented a pictorial review of the CT features of disease due to Echinococcus granulosus at various sites in the human body.

Classification of hydatid liver cysts

A number of investigations advocate various classification systems for liver hydatid cysts. However, none permits predicting the treatment outcome or making clinical decisions regarding medical treatment; open surgery; punction, aspiration, injection, reaspiration (PAIR); or laparoscopy. An international hydatid disease registry employing an uniform nomenclature and consistent reporting methods would allow more rational comparison of different management strategies. TN(R)C (topography, nature, recurrent, complication) classification is a comprehensive system based on four criteria: location (T), natural history (N), recurrence (R) and complications (C) of the cyst. This pictorial review illustrates the classification and puts accent of its clinical usefulness. The TN(R)C classification provides a standardized description formula of every liver hydatid cyst, permitting multiple comparisons and analyses.

Massive rupture of a hepatic hydatid cyst associated with mechanical ventilation

An 80-yr-old woman with a complicated Echinococcus cyst of the liver underwent endotracheal intubation with a simple endotracheal tube and conventional mechanical ventilation that led to massive rupture of the cyst into the bronchi followed by fatal anaphylactic shock. We believe that the currently recommended use of a double-lumen endotracheal tube during surgery in the pulmonary hydatid cysts should be extended to hydatid cysts of the liver with thoracic involvement.

IMPLICATIONS

We present a case of massive rupture of hepatic Echinococcus cyst associated with mechanical ventilation. We believe that the use of a double-lumen endotracheal tube could be crucial in the management of the hydatid cysts of the liver with thoracic involvement.

Thoracic rupture of hepatic hydatidosis (123 cases)

BACKGROUND

Hydatid disease is frequently endemic in countries with poor environmental sanitation and in geographic areas where interaction between humans and animals is common. Pulmonary complications result from the proximity of hydatid cysts in the liver and the diaphragm.

METHODS

The medical records of 123 patients, with established hydatid disease manifesting abnormal chest roentgenograms, were retrospectively analyzed for the period January 1990 to December 1999.

RESULTS

Chest roentgenogram and abdominal ultrasound provided a correct preoperative diagnosis in 108 patients (87.8%). Expectoration of bile, demonstration of fistula by ultrasound, expectoration of cyst contents, and additional ultrasound or imaging findings were the criteria used to establish the preoperative diagnosis. The remaining 15 cases were confirmed at operation. Men outnumbered women nearly 3:1. Mean age was 36.2 years. Pulmonary resection was performed in 67 cases. Sixty-eight patients presented with a bronchobiliary fistula (55.3%). Morbidity rate was 14.6% and mortality rate was 8.9%.

CONCLUSIONS

Thoracotomy offers adequate simultaneous access to both the chest and hepatic lesions with acceptable morbidity and mortality. Endoscopic sphincterotomy undertaken preoperatively is useful in reducing biliary complications.

Hydatid disease: radiologic and pathologic features and complications

Hydatid disease primarily affects the liver and typically demonstrates characteristic imaging findings. However, there are many potential local complications (eg, intrahepatic complications, exophytic growth, transdiaphragmatic thoracic involvement, perforation into hollow viscera, peritoneal seeding, biliary communication, portal vein involvement, abdominal wall invasion). Furthermore, secondary involvement due to hematogenous dissemination may be seen in almost any anatomic location (eg, lung, kidney, spleen, bone, brain). Ultrasonography (US) is particularly useful for the detection of cystic membranes, septa, and hydatid sand. Computed tomography (CT) best demonstrates cyst wall calcification and cyst infection. CT and magnetic resonance (MR) imaging may demonstrate cyst wall defects as well as the passage of contents through a defect. Chest radiography, US, CT, and MR imaging are all useful in depicting transdiaphragmatic migration of hydatid disease. CT is the modality of choice in peritoneal seeding. US and CT demonstrate rupture in most cases that involve wide communication. Indirect signs of biliary communication include increased echogenicity at US and fluid levels and signal intensity changes at MR imaging. CT allows precise assessment of osseous lesions, whereas MR imaging is superior in demonstrating neural involvement. Familiarity with atypical manifestations of hydatid disease may be helpful in making a prompt, accurate diagnosis.

Pulmonary hydatidosis: surgical treatment and follow-up of 240 cases

OBJECTIVE

We review a series of 240 patients treated surgically for pulmonary hydatid cyst in our center between 1966 and 1988, assessing the results with our surgical technique, which involves a novel needle aspiration device designed by Professor D. Figuera, and postoperative treatment protocol.

PATIENTS AND METHODS

The majority (60.4%) of the patients were from areas endemic for hydatid disease. The mean age of the patients at the time of the surgical procedure was 31.5 +/- 7.2 years (range: 4-70 years). A trocar-suction device was used for the needle aspiration of 276 (92%) of the 300 cysts encountered in the 240 patients. The remaining 24 cysts were removed integrally by means of different surgical techniques such as cyst enucleation, lobectomy, segmentectomy and atypical pulmonary resection. The residual cavity was treated by pericystectomy and eversion to the pleural surface in 238 cases (86.2%) and by capitonnage in 38 (13.7%). High vacuum suction (-30 cm H2O) was employed in every case. Depending on when the procedure was performed, the patients were treated with mebendazole or albendazole according to the protocol designed by Bekhti.

RESULTS

Clinical assessment of the symptoms and plain chest X-ray led to the correct diagnosis in 228 cases (95%). In six (2.5%), imaging studies such as ultrasonography, computed tomography and nuclear magnetic resonance were required, and in the remaining six cases (2.5%), the diagnosis was established intraoperatively or in the subsequent histopathological study. One hundred and seventy patients (70.8%) presented a solitary lung cyst, while the remaining 70 (29.2%) were found to have multiple cysts in one or more lobes of one or both lungs. In addition, 45 patients (18.7%) presented hepatic cysts and 25 (10.4%) had cysts in other locations. After 18 years of follow-up, the survival rate was 94.6%. Of the surviving patients, 98.3% were free of pulmonary hydatid disease and 95.1% were free of hydatid disease.

CONCLUSIONS

The trocar-suction device employed here for needle aspiration of hydatid cysts has demonstrated its efficacy in preventing the rupture of the cyst and its possible dissemination. With its use, the parasite is eradicated and the residual cavity can be excised.

FÍSTULA BÍLIO-BRÔNQUICA: RELATO DE CASO E REVISÃO DE LITERATURA

No presente trabalho é relatado um caso de paciente portadora de fístula bílio-brônquica (FBB) secundária a coledocolitíase tratada no Hospital da Universidade de Mogi das Cruzes e é feita uma revisão da literatura pertinente ao assunto. Tratava-se de uma paciente, 35 anos, feminino, parda, cujo quadro clínico inicial era dor em hipocôndrio direito, de caráter contínuo, acompanhada de icterícia do tipo obstrutivo e bilioptise que atingia até um litro em 24 horas. O diagnóstico foi confirmado por radiografia simples de abdome e ultra-sonografia abdominal. O tratamento consistiu em laparotomia, colecistectomia, coledocotomia com retirada de dois cálculos, drenagem de vias biliares, colangiografia intra-operatória e liberação da cápsula hepática da cúpula frênica direita. A evolução pós-operatória foi satisfatória, com regressão da bilioptise no pós-operatório imediato. Houve regressão progressiva da icterícia em torno do sétimo dia do pós-operatório. A paciente foi estudada com broncografia após 24 meses que mostrou não haver alterações anatômicas dos brônquios basilares direitos pela inundação biliar. A paciente encontra-se no sétimo ano de seguimento sem evidência da doença.

Surgical treatment of echinococcosis by a transthoracic approach: a review of 85 cases

OBJECTIVE

Human echinococcosis remains a serious health problem for the Mediterranean countries, among them Greece. As there is no effective medical therapy, surgery is still the treatment of choice.

MATERIAL AND METHODS

We present our experience in the surgical management of hydatidosis by a transthoracic approach, based on 85 patients (49 male, 36 female, aged 4-86 years) treated during 1986-1996.

RESULTS

Twenty-one patients (26.3%) appeared with complications as: hydatidemesis (n = 5), hydropneumothorax (n = 3), cyst infection (n = 3), empyema thoracis (n = 8), cholebronchial (n = 3) and cholebronchopleural fistula (n = 1). The location of the cysts was: 61 in the lungs (right, 29; left, 24; bilateral, eight), 31 on the liver dome, six in the pleural cavity, two in the mediastinum, and one in each of pericardium, chest wall, and right pararenal space. Surgical approach involved a thoracotomy or median sternotomy in all cases. Pulmonary endocystectomy and capitonnage was the procedure of choice in the surgical management. Hepatic cysts were approached through a right thoracophrenotomy and were managed with evacuation of the main and daughter cysts, suture of the diaphragm to the margins of the cyst, and drainage of the cystic and pleural cavities. There was no in-hospital mortality. Major postoperative complications were: empyema thoracis (n = 3), biliary fistula (n = 2), and bronchopleural fistula (n = 1). Five patients presented later with seven recurrences of the disease.

CONCLUSION

Transthoracic approach is a good and safe choice in surgical treatment of both the intrathoracic and the (concomitant or not) hydatid cysts on the upper surface of the liver.