Laparoscopic treatment of nonparasitic hepatic cysts

Clinical response after laparoscopic fenestration of symptomatic hepatic cysts: a systematic review and meta-analysis

BACKGROUND

Laparoscopic fenestration is one of the treatment options for symptomatic hepatic cysts, either solitary or in context of polycystic liver disease (PLD), but indications, efficacy and surgical techniques are under debate.

METHODS

A systematic literature search (1950-2017) of PubMed, Embase, Web of Science and the Cochrane Library was performed (CRD42017071305). Studies assessing symptomatic relief or symptomatic recurrence after laparoscopic fenestration in patients with symptomatic, non-parasitic, hepatic cysts were included. Complications were scored according to Clavien-Dindo. Methodological quality was assessed by Newcastle-Ottawa scale (NOS) for cohort studies. Pooled estimates were calculated using a random effects model for meta-analysis.

RESULTS

Out of 5277 citations, 62 studies with a total of 1314 patients were included. Median NOS-score was 6 out of 9. Median follow-up duration was 30 months. Symptomatic relief after laparoscopic fenestration was 90.2% (95% CI 84.3-94.9). Symptomatic recurrence was 9.6% (95% CI 6.9-12.8) and reintervention rate was 7.1% (95% CI 5.0-9.4). Post-operative complications occurred in 10.8% (95% CI 8.1-13.9) and major complications in 3.3% (95% CI 2.1-4.7) of patients. Procedure-related mortality was 1.0% (95% CI 0.5-1.6). In a subgroup analysis of PLD patients (n = 146), symptomatic recurrence and reintervention rates were significantly higher with respective rates of 33.7% (95% CI 18.7-50.4) and 26.4% (95% CI 12.6-43.0). Complications were more frequent in PLD patients, with a rate of 29.3% (95% CI 16.0-44.5).

CONCLUSIONS

Laparoscopic fenestration is an effective procedure for treatment of symptomatic hepatic cysts with a low symptomatic recurrence rate. The symptomatic recurrence rate and risk of complications are significantly higher in PLD patients.

Robot-assisted Laparoscopic Fenestration of Giant Hepatic Cysts

BACKGROUND

Traditionally, nonparasitic hepatic cysts are marsupialized using laparotomy. In the last 2 decades, laparoscopic fenestration has become the preferred treatment for hepatic cysts. However, this technique is limited by 2-dimensional view and the limited mobility of straight laparoscopic instruments. These limitations may be overcome by the use of a robotic system. We describe laparoscopic fenestration of giant hepatic cysts using the da Vinci Si robotic system with the use of the Endowrist One Vessel Sealer.

METHODS

Our first patient is a 32-year-old female with a solitary hepatic cyst. The second patient is a 51-year-old female with polycystic liver disease.

RESULTS

We performed robot-assisted laparoscopic cyst fenestration with good clinical outcome. No intraoperative complications occurred and patients recovered rapidly.

CONCLUSION

These data show that the da Vinci Si robotic system is eminently suited for the laparoscopic fenestration of large hepatic cysts and that this procedure is associated with rapid recovery.

Single-incision laparoscopic surgery versus standard laparoscopic surgery for unroofing of hepatic cysts

BACKGROUND AND OBJECTIVES

The aim of this report is to document the feasibility and safety of umbilical single-incision laparoscopic liver cyst unroofing in the treatment of simple hepatic cysts in a retrospective case-control study. We also introduce some operative skills for single-incision laparoscopic surgery.

METHODS

From May 2009 to July 2011, 15 patients underwent umbilical single-incision laparoscopic liver cyst unroofing. All the clinical data were retrospectively analyzed. Another 15 simple liver cyst patients who received standard laparoscopic liver cyst unroofing at our hospital during the same period--with a similar age, nature of the cyst, and position to the single-incision group--were selected to undergo a case-control study. The operative time, blood loss, recovery time of gastrointestinal function, volume of postoperative drainage, postoperative drainage time, postoperative hospitalization time, and postoperative recurrence rate were compared between the two groups.

RESULTS

There was no significant difference between the single-incision group and standard group in operative time (58.3 ± 7.43 minutes vs 58.7 ± 6.14 minutes), blood loss (17.0 ± 3.19 mL vs 14.7 ± 1.86 mL), recovery time of gastrointestinal function (2.5 ± 0.22 days vs 2.4 ± 0.22 days), volume of postoperative drainage (408.0 ± 119.5 mL vs 450.0 ± 89.5 mL), postoperative drainage time (2.6 ± 0.55 days vs 3.7 ± 0.59 days), or postoperative hospitalization time (4.8 ± 0.44 days vs 5.2 ± 0.56 days) (P > .05). The postoperative follow-up period was 1 to 24 months.

CONCLUSIONS

Compared with standard laparoscopic liver cyst unroofing, single-incision laparoscopic liver cyst unroofing shows no significant difference during the overall treatment process. In addition to the advantages of less trauma, more rapid recovery, and shorter hospital stay, single-incision laparoscopic surgery can reach the effect of "no scar" and can be safely and effectively carried out.

Laparoscopic deroofing for polycystic liver disease using laparoscopic fusion indocyanine green fluorescence imaging

BACKGROUND

Laparoscopic deroofing is widely used for the treatment of symptomatic polycystic liver disease (PCLD). However, bile leakage is a common complication of surgical management for PCLD. Until now, indocyanine green fluorescence imaging (IGFI) has played an active role in hepatobiliary surgery. Herein, we report the effective application of a laparoscopic fusion IGFI system, known as PINPOINT, for laparoscopic deroofing.

METHODS

In this study, we performed laparoscopic deroofing for PCLD using the laparoscopic fusion IGFI system. We conducted the procedure mainly under the normal view mode, occasionally switching to the fusion IGFI mode. First, we confirmed that the liver cysts did not contain bile using the fusion IGFI mode and then used a percutaneous puncture needle to remove the fluid from some of the giant cysts. Second, using the fusion IGFI mode, we were able to detect thin biliary branches and to adjust the division line of the cyst wall accordingly or, occasionally, to ligate the branches. Finally, we searched for and identified unexpected small bile leakage and then closed it using sutures.

RESULTS

The laparoscopic fusion IGFI system can simultaneously show fluorescent images, such as cholangiography and the liver parenchyma, on the normal color view. In the fusion IGFI mode, the intrahepatic bile duct and liver parenchyma can be easily discriminated in real time throughout the procedure. Accordingly, the laparoscopic fusion IGFI system is useful for the surgical treatment of PCLD, in which the boundary between the liver cysts and the liver parenchyma can otherwise be difficult to identify. This technique also enables the branches of Glisson's capsule to be identified without any other intervention.

CONCLUSION

The novel application of the laparoscopic fusion IGFI system allows reliable navigation for PCLD surgery.

Fenestration of liver cysts in polycystic liver disease to improve quality of life: a case report and literature review

Polycystic liver disease (PCLD) is characterized by a large number of liver cysts scattered throughout the liver parenchyma. We herein intend to present the beneficial effect of palliative fenestration treatment on quality of life in a patient with symptomatic PCLD. A 48-year-old female patient had been followed up for 5 years for both polycystic liver and kidney diseases at another institution. During follow-up for last 1 year, we recognized that she had barely maintained her ability of function in daily activities due to progressive worsening of fatigue and dyspnea on exertion. The patient finally underwent surgical fenestration treatment. Multiple cysts in the enlarged liver were opened and the cyst walls were excised with electrocautery. No surgical complication occurred and the patient was discharged 10 days after the open fenestration surgery. The total liver volume was 3,870 ml before surgery and 3,125 ml at 1 week after surgery, showing a volume reduction of 19.3%. After surgery, her performance status improved significantly. In the present case, significant improvement in quality of life and daily activity performance was achieved after open fenestration treatment over 18 months of follow-up without disease recurrence.

[Laparoscopic surgery of benign liver tumours]

273 patients underwent elective surgical treatment for benign liver lesions at the 1st Surgical Department of Semmelweis University, Budapest, Hungary between 2004 and 2014. Laparoscopic (LAP) interventions were performed in 83 cases. Cyst fenestration in 52, and hepatic resection in 31 cases. LAP liver resections were set against to open surgery of paired group of patients with comparable demographic and clinical parameters. Data revealed that the operative time in LAP group (113.7 min) was significantly longer than that in the open surgery group (89.5 min). The average postoperative length of hospital stay was shorter after LAP surgery (5.8 vs 9.1 days). There was no postoperative complication in the LAP group, two wound infections and one biliary collection were treated by ultrasonic drainage in the open group. Three patients were given blood transfusion in the LAP, four in the open group. Operative mortality was zero, and no reoperation required. The surgical technique which is described in detail in the text enables safe resection of segments 7-8 which are difficult to approach. Our data support the safety and feasibility of laparoscopic liver resection after adequate preoperative investigations.

Systematic review of laparoscopic versus open surgery in the treatment of non-parasitic liver cysts

We conducted a systematic review of the literature on the electronic databases Medline, Embase, Ovid and Cochrane to identify studies from 1990 to 2011 regarding the surgical management of non-parasitic liver cysts treated with laparoscopy (LT) and/or laparotomy (OT) to identify short-term and long-term outcomes of the relative treatments. Two reviewers independently extracted data regarding the following parameters: first author, year of publication, type of journal, study design, number of patients operated on, male/female ratio, mean age, mean size of the cysts treated, laparoscopic conversion rate, morbidity, mortality and recurrence in both groups (LT and OT). A qualitative analysis was carried out using the Pearson Chi square test and the Fischer's exact test where necessary. The data analysis was conducted by dividing the sample into three periods in relation to the development of laparoscopic surgery: period 1 (P1), 1990-1995 "pioneering" period of laparoscopy; period 2 (P2), 1996-2000 period of the "development of laparoscopy"; period 3 (P3), 2001-2011 period of "diffusion of laparoscopy." Thirty studies involving 948 patients comparing LT with OT were included in the final pooled analysis. Twenty-two studies were retrospective (73.3 %) and only 8 (26.7 %) were prospective. The number of publications increased during the three periods analysed. The correlation between the type of journal and the year of publication showed an increase (p = 0.048) in journals dedicated to LT during the three periods. In P1, the preferred approach was open surgery (66.3 %) with only 11 cases treated with LT. The conversion rate was 18.1 %. The overall complication rate was 33.3 % with a substantial equivalence between the two approaches (27.2 % for laparoscopic surgery and 36.6 % for laparotomic). The overall recurrence rate was 18.1 % with 36.3 % in the laparoscopic group and 9.2 % in the laparotomic group. In P2, the preferred approach was laparoscopic (56.7 %). The conversion rate was 2.3 %. The overall complication rate was 5.8 % but with some differences between the two approaches (10.3 % for the laparoscopic approach and 0 % for open surgery). The overall recurrence rate was 14.4 % with 17.4 % in the laparoscopic group and 10.4 % in the laparotomic group. In P3, the preferred approach was laparoscopic (69.9 %). The overall recurrence rate was 11.1 %; it was 6.1 % for the laparoscopic approach while it was 11.5 % for laparotomic. In all three periods analysed, the laparoscopic approach showed a statistically significant reduction in operative time (p = 0.009) and hospital stay (p = 0.001) and a significant (p < 0.05) reduction rate in symptomatic recurrences in patients with polycystic liver disease (25 %) as compared with simple liver cysts (7.5 %). The current data in the literature show that the laparoscopic approach may be the treatment of choice in patients with symptomatic non-parasitic cysts of the liver, providing the short-term advantages of minimally invasive surgery. Recurrence rates were acceptable and comparable to those of conventional surgery. Long-term outcomes should be verified by additional randomised controlled trials and long-term follow-ups.

Pathophysiology, epidemiology, classification and treatment options for polycystic liver diseases

Polycystic liver diseases (PLD) represent a group of genetic disorders in which cysts occur in the liver (autosomal dominant polycystic liver disease) or in combination with cysts in the kidneys (autosomal dominant polycystic kidney disease). Regardless of the genetic mutations, the natural history of these disorders is alike. The natural history of PLD is characterized by a continuous increase in the volume and the number of cysts. Both genders are affected; however, women have a higher prevalence. Most patients with PLD are asymptomatic and can be managed conservatively. Severe symptoms can affect 20% of patients who develop massive hepatomegaly with compression of the surrounding organs. Rrarely, patients with PLD suffer from acute complications caused by the torsion of hepatic cysts, intraluminal cystic hemorrhage and infections. The most common methods for the diagnosis of PLD are cross sectional imaging studies. Abdominal ultrasound and computerized tomography are the two most frequently used investigations. Magnetic resonance imaging is more sensitive and specific, and it is a valuable test for patients with intravenous contrast allergies or renal dysfunction. Different treatment modalities are available to physicians caring for these patients. Medical treatment has been ineffective. Percutaneous sclerotherapy, trans-arterial embolization, cyst fenestration, hepatic resection and liver transplantation are indicated to specific groups of patients and have to be tailored according to the extent of disease. This review outlines the current knowledge of the pathophysiology, clinical course, diagnosis and treatment strategies of PLD.

Surgical management of cystic lesions in the liver

BACKGROUND

Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear.

METHODS

A Pubmed and Medline literature review using key words non-parasitic hepatic cysts, polycystic liver disease, echinococcus, hydatid cysts parasitic cysts, Caroli's disease, cystadenoma; liver abscess, surgery, aspiration and treatment was undertaken and papers pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

RESULTS

Asymptomatic simple cysts in the liver require no treatment. Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. At present, insufficient evidence exists to recommend one over the other. Polycystic liver disease presents a unique management problem because of high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can effectively be treated by aspiration or drainage. With improved antimicrobial efficacy, prolonged treatment with antibiotics may also be considered.

CONCLUSION

All patients with cystic lesions in the liver require discussion at multi-disciplinary meetings to confirm and the diagnosis and determine the most appropriate method of treatment.

Technical report of a novel surgical technique: laparoscopic cyst fenestration and falciform ligament pedicle graft for treatment of symptomatic simple hepatic cysts

BACKGROUND

Simple hepatic cysts are common and infrequently develop into large symptomatic cysts that require surgical therapy. These benign cysts have been shown to be amenable to minimally invasive surgery; however, recurrences of symptoms have been reported. Our experience with over 200 simple hepatic cysts has lead to the development of a novel therapy to resolve symptoms associated with large simple hepatic cysts and reduce the rate of recurrent symptoms.

METHODS

An observational study demonstrating our experience with a novel minimally invasive technique for the management of symptomatic simple hepatic cyst.

RESULTS

A total of 6 cases were identified where laparoscopic mini-fenestration and placement of a falciform pedicle graft was used. There were no operative complications and 4 of 6 patients were discharged home the day of surgery. With mean follow-up of 9.6 months, there has not been any recurrence to date. One patient required an open hepatic resection for the treatment of a cystadenoma.

CONCLUSION

Laparoscopic mini-fenestration and placement of a falciform ligament pedicle graft shows promising early results as a treatment for the simple hepatic cyst. Long term follow-up data is required.

[Laparoscopic treatment of liver cysts]

OBJECTIVE

The authors present their experience with the laparoscopic management of non-parasitic liver cysts.

METHODS

During the period from May 2003 to August 2006, thirteen patients with non-parasitic liver cysts underwent laparoscopic fenestration. Eleven patients were female (84.6%) and two (15.4%) were male. The average age at diagnosis was 48.3 years (range 35-72). The majority of patients presented with pain, discomfort, dyspepsia, or early satiety at diagnosis. Computed tomography scans were performed in all cases. The cysts were solitary in eleven patients (84.6%) and polycystic liver disease in two patients (15.4%). The average size of the solitary cysts was 11.3 cm (range 9.5-17 cm), and the polycystic liver disease was 10.6 cm (range 9.2-12.1 cm). Operation was indicated due to symptoms in all patients. The technique performed was laparoscopic cyst fenestration.

RESULTS

Laparoscopic fenestration was completed in all patients. Mean operative time was 85 minutes (range 53-110). Intraoperative complications were not detected and there was no death. Postoperative complications were observed in two patients (15.4%). Bile leakage was present in one patient, and ascites in another patient. Both cases were treated conservatively. The average hospital stay was 3.5 days (range 2-9 days). Mean follow-up was 36 months. There was one asymptomatic recurrence (7.6%) in a patient with polycystic liver disease after two years of follow-up.

CONCLUSION

Laparoscopic fenestration is the preferred method of treatment for non-parasitic liver cyst. This operation causes low morbidity and the recurrence is uncommon. Adequate selection of patients and the laparoscopic technique are important for the treatment.

Spontaneous rupture of a large non-parasitic liver cyst: a case report

INTRODUCTION

Non-parasitic hepatic cysts are benign entities, occur rarely (5% of the population), and in the majority of cases, are asymptomatic. Cysts can cause symptoms when they become large and produce bile duct compression or portal hypertension, and also when complications such as rupture, infection or hemorrhage take place.

CASE PRESENTATION

We present the case of a 70-year-old Greek-Caucasian man with a large, asymptomatic and non-parasitic liver cyst that presented as an acute surgical abdominal emergency after spontaneous rupture into the peritoneal cavity.

CONCLUSIONS

We present an extremely rare complication of simple liver cyst, its rupture in the free abdominal cavity, and its presentation as an acute abdomen. Large simple liver cysts should be treated with intervention at early recognition as conservative management usually results in their recurrence.

Hepatic cyst misdiagnosed as a gastric submucosal tumor: A case report

We describe here a case of 51-year-old woman with a symptomatic hepatic cyst that was misdiagnosed as a gastric submucosal tumor (SMT) with endoscopic ultrasound (EUS) and CT scan. The patient presented with an epigastric pain for two months. On endoscopy, a submucosal tumor was found on the cardia of the stomach. Based on EUS and abdominal CT scan, the lesion was diagnosed as a gastric duplication cyst or a gastrointestinal stromal tumor (GIST). The operative plan was laparoscopic wedge resection for the GIST of the gastric cardia. A cystic mass arising from the left lateral segment of the liver was found at the laparoscopic examination. There was no abnormal finding at the gastric cardia. She was treated by laparoscopic hepatic wedge resection including the hepatic cyst using an endoscopic linear stapler.

Laparoscopic fenestration of liver cysts in polycystic liver disease results in a median volume reduction of 12.5%

INTRODUCTION

Patients with polycystic liver disease (PCLD) may develop symptoms due to increased liver volume. Laparoscopic fenestration is one of the options to reduce liver volume and to relieve symptoms. This study was performed to evaluate the safety and efficacy of laparoscopic liver cyst fenestration.

PATIENTS AND METHODS

Twelve patients (all female, median age 45 years, range 35-58) with symptomatic PCLD were included between August 2005 and April 2007. Surgical data were recorded, liver volumes were measured on pre- and postoperative computed tomography (CT) scans, and patients completed a validated symptom-based questionnaire pre- and postoperatively.

RESULTS

Median preoperative liver volume was 4,854 ml (range 1,606-8,201) and decreased to 4,153 ml postoperatively (range 1,556-8,232) resulting in median liver volume reduction of 12.5% (range +9.5 to -24.7%). Median procedural time was 123.5 min (range 50-318), and median hospitalization period was 3.5 days (range 1-8). Postoperative complications occurred in three patients including biliary leakage, obstruction of inferior vena cava and sepsis, all recovering with conservative management. Patients reported decreased symptoms of postprandial fullness and abdominal distension.

CONCLUSION

Laparoscopic fenestration in PCLD patients results in volume reduction of 12.5% and decrease of symptoms.

Percutaneous treatment of symptomatic non-parasitic benign liver cysts: single-session alcohol sclerotherapy versus prolonged catheter drainage with negative pressure

To evaluate whether prolonged catheter drainage with negative pressure yields better results than single-session alcohol sclerotherapy in the treatment of symptomatic non-parasitic benign liver cysts. Forty patients were randomly assigned to two groups in a 24-month prospective controlled trial. One group was treated with ultrasound-guided prolonged catheter drainage with negative pressure (20 patients with 24 cysts) and the other group with single-session alcohol sclerotherapy (20 patients with 23 cysts). Patient demographics, clinical characteristics, treatment outcome, and complications were analyzed. The median volumes and 95% CI (confidence interval) for the medians and interquartile ranges of all 47 cysts before treatment and on last follow-up were: 389 ml, 143-1,127 ml, 136-1,300 ml, and 0 ml, 0-10 ml, and 0-23 ml, respectively (P<0.0001). The average volume reduction was 92.4% (range, 74.9-100%), 94.2 % (range, 74.9-100%) in the drainage and 90.2% (range, 76.9-100%) in the sclerotherapy group. Twenty-seven cysts (57.4%) disappeared completely, 16 (66.7%) in the drainage and 11 (47.8%) in the sclerotherapy group. No differences in average volume reduction, final volume and disappearance of the cysts between the groups were noted. The hospital stay was 1 day for all patients. Percutaneous treatment is safe and effective for hepatic non-parasitic cysts. Prolonged catheter drainage with negative pressure and single-session alcohol sclerotherapy had similar results.