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Abbasi Dezfouli S, El Rafidi A, Aminizadeh E, Ramouz A, Al-Saeedi M, Khajeh E, Mieth M, Weber TF, Chang DH, Hoffmann K, Büchler MW, Mehrabi A. Risk factors and management of biliary leakage after Endocystectomy for hepatic cystic echinococcosis. PLoS Negl Trop Dis 2023; 17:e0011724. [PMID: 37906617 PMCID: PMC10637722 DOI: 10.1371/journal.pntd.0011724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/10/2023] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Endocystectomy is a conservative surgical approach to managing cystic echinococcosis. Bile leakage is the main complication of this technique. The aim of this study was to evaluate the factors associated with bile leakage and to assess the outcomes and cost efficiency of strategies used to treat bile leakage. METHODOLOGY/PRINCIPAL FINDINGS Patients who underwent endocystectomy between 2005 and 2020 were included. The preoperative characteristics, intra- and postoperative outcomes, hospital costs, and cost efficiency (the Diagnosis-Related Group reimbursement minus the overall cost) were evaluated prospectively. A total of eighty patients with 142 cysts were included. Postoperative complications occurred in 17 patients (21%), including 11 patients with bile leakage (type A: 1, type B: 6 and type C: 4 patients, total 13%). Bile leakage was more frequent in patients with preoperative MRI signs of cysto-biliary fistulas or intraoperative visible cysto-biliary fistulas (p = 0.03 and p = 0.04, respectively) and in patients with cysts larger than 8 cm (p = 0.03). Patients with bile leakage who underwent reoperation (type C) had significantly shorter hospital stays (9 vs. 16 days, p<0.01) and better cost efficiency than those who received radiologic or endocscopic interventions (€2,072 vs. -€2,097 p = 0.01). No mortality was observed, and recurrence was seen in two patients. CONCLUSIONS/SIGNIFICANCE Endocystectomy is a safe and efficient technique. Preoperative and intraoperative cysto-biliary fistulas and a cyst diameter larger than 8 cm are correlated to postoperative bile leakage. Early operative management of bile leakage reduces hospital stay and improves cost efficiency compared with radiologic or endoscopic treatments.
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Affiliation(s)
- Sepehr Abbasi Dezfouli
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ahmad El Rafidi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ehsan Aminizadeh
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany
| | - Tim Frederik Weber
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - De-Hua Chang
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kathrin Hoffmann
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany
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Huang L, Zheng B, Li X, Yao J. Association between radical versus conservative surgery and short-term outcomes of hepatic cystic echinococcosis in Nyingchi, China: a retrospective cohort study. BMC Surg 2023; 23:126. [PMID: 37173700 PMCID: PMC10182614 DOI: 10.1186/s12893-023-02000-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/10/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Radical or conservative surgical treatment for hepatic Cystic Echinococcosis (hepatic CE) is controversial. We aimed to measure the association between radical surgery (RS) versus conservative surgery (CS) and short-term outcomes in our cohort. METHODS Medical records of hepatic CE patients' demographic, clinical, radiological, operative and postoperative details who underwent surgical treatment between January 3, 2017 and January 3, 2018 at the Department of General Surgery, Nyingchi People's Hospital, Nyingchi, China, were retrieved and analyzed. The primary outcome was overall morbidity. The secondary outcomes included: (i) bile leakage; (ii) complications of lung, pleura, heart, liver, pancreas and biliary tract; (iii) incision infection and residual cavity abscess formation; (iv) anaphylactic reaction and shock; (v) tear of surrounding tissues; (vi) hospital and post-operative length of stay (LOS); (vii) length of surgery; (viii) blood loss during surgery. Multivariable logistic/linear regression models with various adjustment strategies for confounders were performed to evaluate the association. RESULTS A total of 128 hepatic CE patients were included with 82 (64.1%) and 46 (35.9%) receiving CS and RS, respectively. After fully adjusted, RS was associated with 60% lower risk of overall complication (aOR 0.4; 95%CI, 0.2-0.9) and 0.6-h shorter surgical time (aβ 0.4; 95%CI,-0.0-0.8) comparing to CS. However, RS was associated with more blood loss during surgery (aβ 179.3; 95%CI, 54.2-304.5). CONCLUSION To conclude, RS was associated with a 60% reduction in developing overall complication in the short term, but may result in more blood loss during surgery than CS.
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Affiliation(s)
- Liangping Huang
- Department of Drug and Medical Device Clinical Trial Office, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
- Department of Hematology and Oncology, Shenzhen Children's Hospital of China Medical University, Shenzhen, China
| | - Benrong Zheng
- Physical Examination Center, Nyingchi People's Hospital, Nyingchi, China
- Department of VIP Health Care Center, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xi Li
- Department of General Surgery, Nyingchi People's Hospital, Nyingchi, China.
- Department of Thyroid and Breast Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, No.600 Tianhe Road, Guangzhou, 510630, China.
| | - Jianchun Yao
- Department of Anesthesiology, Nyingchi People's Hospital, Nyingchi, China.
- Department of Anesthesiology, The First Affiliated Hospital of Shantou University Medical College, No. 57 Changping Road, Jinping District, Shantou, 515041, Guangdong Province, China.
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Vega EA, Salehi O, Conrad C. Central Pericystectomy for Hydatid Cyst Treatment. J Gastrointest Surg 2023:10.1007/s11605-023-05628-6. [PMID: 37069460 DOI: 10.1007/s11605-023-05628-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 01/28/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Compared to open resection for hepatic hydatid cysts, a laparoscopic approach may combine the benefit of reduced morbidity with complete cyst removal. Nonetheless, intraoperative cyst rupture during a laparoscopic approach due to reduced tactile feedback is a valid concern.1-3 Today, the laparoscopic experience remains limited even in high incidence regions.4 Here, a structured approach to laparoscopic pericystectomy is demonstrated. PATIENT A 37-year-old male from Uruguay presents with worsening abdominal pain, nausea, and vomiting. A 4-phase liver CT shows a large complex liver cyst (8.8 × 8.2 × 11.3 cm), encompassing the left hepatic lobe while abutting right hepatic vein (RHV), anterior fissure vein (AFV) and inferior vena cava (IVC). Further, the cyst causes mass effect on the hepatic vein vasculature. CT appearance is consistent with a large hydatid cyst with distorted hepatic anatomy resulting in compensatory hypertrophy of segments II, VI and VII. Appropriate institutional review board (IRB) and inform consent was obtained. TECHNIQUE Following neoadjuvant albendazole for 4 weeks to minimize any effects in case of inadvertent cyst spillage, the patient tested negative for echinococcal antibody. For surgical planning, the patient's anatomy was modeled to optimize the understanding of the complex spatial relationship between cyst, portal pedicle and hepatic veins. Further, port sites were preoperatively modelled to optimize port placement in the context of the altered anatomy from compensatory hepatic hypertrophy. During surgery, with the patient in a modified French position, the liver was completely mobilized. Then, a parenchymal transection plane was developed guided by RHV, AFV and IVC, while biliary radicals entering directly into the cyst were controlled individually. The complex transection plane resulted in preservation of the unaffected liver segments I, II, VI and VII. CONCLUSION The multimodal approach demonstrated here included pretreatment with albendazole followed by safe laparoscopic pericystectomy. In the preoperative setting, albendazole can reduce the risk of recurrence if spillage occurs during surgery. In inoperable patients, it has been previously shown to be an effective monotherapy for small (< 5 cm) CE1 and CE3a cysts.5 For preoperative planning, an automated image reconstruction software (Fujifilm Synapse 3D) is used. The software creates a 3D model of the liver segmentation and vessels from contrast-enhanced CT and MR images. In addition to modelling the liver, port placement in relation to the liver is being simulated prior to surgery to optimize port placement at the time of surgery. During the case, the parenchymal transection is guided by RHV, AFV and IVC. The common postoperative complication of persistent biliary leakage was avoided by controlling each biliary radicals entering the cyst from the liver parenchyma. Biliary leaks are a common complication and have been positively correlated with the cyst diameter (~ 79% of cysts with diameter of 7.5 cm or greater have cysto-biliary fistula).6 In this context, indocyanine green may help to identify relevant biliary radicals entering the cyst or aid in recognizing bile leaks. If the stepwise approach described here is followed, minimally invasive pericystectomy represents a safe alternative to open surgery, harnessing the advantages of minimal risk of recurrence due to complete cyst removal and low morbidity.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA.
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Laparoscopic Treatment Strategies for Liver Echinococcosis. Infect Dis Ther 2022; 11:1415-1426. [PMID: 35751754 PMCID: PMC9334471 DOI: 10.1007/s40121-022-00664-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 05/31/2022] [Indexed: 12/13/2022] Open
Abstract
Liver echinococcosis is clinically mainly composed of hepatic cystic echinococcosis (CE) and hepatic alveolar echinococcosis (AE). At present, laparoscopy has been comprehensively applied in the treatment of two types of liver echinococcosis. For hepatic CE treatment, both laparoscopic total pericystectomy and laparoscopic hepatectomy can achieve radical results, but the former is considered the first choice owing to its being more minimally invasive; laparoscopic subtotal pericystectomy and laparoscopic partial pericystectomy can be accepted as complementary options, considering the presence of complicated cysts and the level of laparoscopic technique in remote hospitals; laparoscopic cystectomy is simple, but it is not currently recommended for treatment of hepatic CE owing to poor efficacy and high risk of postoperative complications. For hepatic AE treatment, laparoscopy not only achieves the same radical effect as open surgery in selected patients, but also is more minimally invasive, so it has a better prospect.
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