Long-term results utilizing the unroofing technique in treating hydatid cysts of the liver

Clinical management of cystic echinococcosis: state of the art and perspectives

PURPOSE OF REVIEW

This review draws attention to patients with cystic echinococcosis migrating from highly endemic to non-endemic countries with limited experience in cystic echinococcosis management, to ultrasound-based cyst staging, and to the WHO cyst classification as a powerful, to date underused tool to triage patients into the four currently available treatment modalities.

RECENT FINDINGS

In non- and low-prevalence countries, cystic echinococcosis is often misclassified. Differential diagnoses, such as simple cysts and other benign and malignant space-occupying lesions, have similar appearances on imaging. Serology is confirmatory but often disappointing due to sensitivity and specificity problems. There is increasing confidence in assigning uncomplicated cystic echinococcosis cysts to the four treatment modalities [drug treatment (benzimidazoles), percutaneous methods, surgery, watch and wait] on the basis of cyst stage (WHO cyst classification), size and location. However, current best practice is still not widely implemented outside cystic echinococcosis treatment centres, and further consolidation is needed by well-designed clinical trials. Recently published long-term follow-up studies have shown that patients with inactive cyst stages CE4 and CE5 benefit, especially since they do not need any treatment at all if they have not received prior benzimidazole or percutaneous therapy. Instead, cysts that have reached cyst stages CE4 and CE5 through drug treatment do need careful follow-up as they often relapse. Surgical procedures in which the cysts are opened and percutaneous approaches require very careful control of cyst content spillage to the peritoneum, pleura and intravascularly to prevent dissemination - a still too often neglected issue with severe consequences for patients.

SUMMARY

Though a neglected disease with predominantly expert-opinion-based treatment strategies, cystic echinococcosis patients can greatly benefit from interdisciplinary management in cystic echinococcosis treatment centres and cyst-stage-based assignment of treatment modalities. Increased suspicion for cystic echinococcosis in migrants from endemic to non-endemic countries is urgently needed at the current level of global mobility.

Cysto-biliary communication in liver hydatidosis

BACKGROUND

Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree.

AIM

The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree.

RESULTS

Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm.

CONCLUSIONS

The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

Ambispective comparative study of two surgical strategies for liver hydatidosis

AIM

To investigate the morbidity, mortality, recurrence and technical aspects of two distinct surgical strategies that were implemented in successive periods.

METHODS

Ninty-two patients with 113 cysts underwent surgical procedures. The study was divided into 2 periods. Data from first period (P1) were compiled retrospectively. The surgical strategy was conservative surgery. The second period (P2) included a prospective study conducted according to a protocol following the criterion that radical procedures should be performed whenever it is technically feasible.

RESULTS

Patients of both periods showed no statistically significant differences in age, gender, cyst location or mortality. Among the P2 group, patients exhibited more preoperative jaundice, and cyst size was smaller (P < 0.05). Changes in surgical strategy increased the rate of radical surgery, decreases morbidity and in-hospital stay (P < 0.001). A negative result in P2 was the death of two old patients (4.8%) who had undergone conservative treatments. The rate of radical surgery in P2 was around 75%.

CONCLUSION

Radical surgery should be the technique of choice whenever it is feasible, because it diminishes morbidity and in-hospital stay. Conservative surgery must be employed only in selected cases.