1
|
Duijzer R, Bernts LHP, Geerts A, van Hoek B, Coenraad MJ, Rovers C, Alvaro D, Kuijper EJ, Nevens F, Halbritter J, Colmenero J, Kupcinskas J, Salih M, Hogan MC, Ronot M, Vilgrain V, Hanemaaijer NM, Kamath PS, Strnad P, Taubert R, Gansevoort RT, Torra R, Nadalin S, Suwabe T, Gevers TJG, Cardinale V, Drenth JPH, Lantinga MA. Clinical management of liver cyst infections: an international, modified Delphi-based clinical decision framework. Lancet Gastroenterol Hepatol 2024; 9:884-894. [PMID: 38878785 DOI: 10.1016/s2468-1253(24)00094-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/15/2024] [Accepted: 03/21/2024] [Indexed: 08/12/2024]
Abstract
Liver cyst infections often necessitate long-term hospital admission and are associated with considerable morbidity and mortality. We conducted a modified Delphi study to reach expert consensus for a clinical decision framework. The expert panel consisted of 24 medical specialists, including 12 hepatologists, from nine countries across Europe, North America, and Asia. The Delphi had three rounds. The first round (response rate 21/24 [88%]) was an online survey with questions constructed from literature review and expert opinion, in which experts were asked about their management preferences and rated possible management strategies for seven clinical scenarios. Experts also rated 14 clinical decision-making items for relevancy and defined treatment outcomes. During the second round (response rate 13/24 [54%]), items that did not reach consensus and newly suggested themes were discussed in an online panel meeting. In the third round (response rate 16/24 [67%]), experts voted on definitions and management strategies using an online survey based on previous answers. Consensus was predefined as a vote threshold of at least 75%. We identified five subclassifications of liver cyst infection according to cyst phenotypes and patient immune status and consensus on episode definitions (new, persistent, and recurrent) and criteria for treatment success or failure was reached. The experts agreed that fever and elevated C-reactive protein are pivotal decision-making items for initiating and evaluating the management of liver cyst infections. Consensus was reached on 26 management statements for patients with liver cyst infections across multiple clinical scenarios, including two treatment algorithms, which were merged into one after comments. We provide a clinical decision framework for physicians managing patients with liver cyst infections. This framework will facilitate uniformity in the management of liver cyst infections and can constitute the basis for the development of future guidelines.
Collapse
Affiliation(s)
- Renée Duijzer
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, Netherlands
| | - Lucas H P Bernts
- Department of Medical Microbiology, Radboudumc, Nijmegen, Netherlands
| | - Anja Geerts
- Department of Hepatology and Gastroenterology, Ghent University, Ghent, Belgium; European Reference Network RARE-LIVER, Hamburg, Germany
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Chantal Rovers
- Department of Internal Medicine, Radboudumc, Nijmegen, Netherlands
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ed J Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - Frederik Nevens
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology and Hepatology, UZ Leuven, Leuven, Belgium
| | - Jan Halbritter
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jordi Colmenero
- European Reference Network RARE-LIVER, Hamburg, Germany; Liver Unit, Hospital Clinic Barcelona, IDIBAPS-FRCB, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Juozas Kupcinskas
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mahdi Salih
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, Rotterdam, Netherlands
| | - Marie C Hogan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Maxime Ronot
- European Reference Network RARE-LIVER, Hamburg, Germany; Service de Radiologie, Hôpital Beaujon, APHP Nord, Clichy & Université Paris Cité, CRI, UMR 1149, Paris, France
| | - Valerie Vilgrain
- European Reference Network RARE-LIVER, Hamburg, Germany; Service de Radiologie, Hôpital Beaujon, APHP Nord, Clichy & Université Paris Cité, CRI, UMR 1149, Paris, France
| | | | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Pavel Strnad
- European Reference Network RARE-LIVER, Hamburg, Germany; Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Richard Taubert
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Roser Torra
- Inherited Kidney Disorders, Department of Nephrology, Fundació Puigvert, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Silvio Nadalin
- Department of General, Visceral, and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - Tatsuya Suwabe
- Nephrology Center, Okinaka Memorial Institute, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Tom J G Gevers
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Netherlands; NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Vincenzo Cardinale
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Joost P H Drenth
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marten A Lantinga
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands.
| |
Collapse
|
2
|
Ishikawa S, Kuroda S, Chosa K, Okada K, Tanimine N, Tahara H, Ohira M, Ide K, Kobayashi T, Ohdan H. Treatment of multiple huge liver cysts in a hybrid operating room: a case report. Surg Case Rep 2021; 7:232. [PMID: 34714449 PMCID: PMC8556466 DOI: 10.1186/s40792-021-01320-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/21/2021] [Indexed: 11/19/2022] Open
Abstract
Background Liver cysts are common, with most cases being asymptomatic. In symptomatic cases, the disease is amenable to treatment. However, huge or multiple liver cysts with vascular narrowing and associated systemic symptoms are extremely rare. Furthermore, the performance of a reliable and effective surgery in such cases remains a major problem. Here, we report a case of multiple giant liver cysts with impaired blood flow surgically treated in a hybrid operating room. Case presentation A 73-year-old male presented to a previous doctor with leg edema and dyspnea on exertion; computed tomography revealed that the cause complaint was right lung and heart compression and inferior vena cava (IVC) stenosis due to huge liver cysts in the caudal lobe. The patient was referred to our hospital because of disease recurrence despite percutaneous aspiration of the cyst. Multiple liver cysts were observed in addition to the drained cysts, two of which were located on both sides of the IVC and caused IVC stenosis. We performed open surgery for the liver cysts and used the hybrid operating room for intraoperative IVC angiography and measuring the hepatic vein and portal vein (PV) pressure. We performed unroofing of the hepatic cyst and cauterization of the cyst wall on the hepatic side. Angiography was performed before and after unroofing of the liver cysts, and IVC stenosis release was confirmed. IVC pressure measured at the peripheral side of the stenosis and PV pressures were continuously measured during surgery and were confirmed to have decreased during the opening of the liver cysts. The patient had a good postoperative course and was discharged on the 10th postoperative day. No recurrence was observed 6 months postoperatively. Conclusions Cyst unroofing surgery using angiography in a hybrid operating room is a useful treatment for deep hepatic lesions in that vascular stenosis improvement can be intraoperatively confirmed. Moreover, in cases wherein the cyst compresses the vasculature, intraoperative monitoring of IVC and PV pressures can be used to prove that the liver cyst is hemodynamically involved.
Collapse
Affiliation(s)
- Sho Ishikawa
- Department of Surgery, Kure City Medical Association Hospital, 15-24, Asahimachi, Kure-City, Hiroshima, 737-0056, Japan
| | - Shintaro Kuroda
- Department of Gastroenterological Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Keigo Chosa
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kenjiro Okada
- Department of Gastroenterological Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Naoki Tanimine
- Department of Gastroenterological Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Masahiro Ohira
- Department of Gastroenterological Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kentaro Ide
- Department of Gastroenterological Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hideki Ohdan
- Department of Gastroenterological Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| |
Collapse
|