Hepatectomy for patients with alveolar echinococcosis: Long-term follow-up observations of 144 cases

Characterization of research trends and prospects on hepatic echinococcosis over the past forty years: a bibliometric analysis

BACKGROUND

The distribution of hepatic echinococcosis (HE) is extensive, significantly impacting public health and economic development. Therefore, analyzing global collaboration networks and tracking developmental trends over the past four decades are crucial. This study aimed to demonstrate collaboration in the field of HE and explore key topics and future directions.

MATERIALS AND METHODS

Bibliometric analyses were conducted using CiteSpace, Bibliometrix package of R, and VOSviewer software on HE-related studies from the Web of Science Core Collection published before 1 August 2023.

RESULTS

This study identified 2605 records published in 196 journals by 9860 authors from 2607 institutes in 90 countries. Publications significantly notably increased in 2021. Developing countries like Turkey and China made notable contributions, while developed countries like the USA had higher average citation rates. The largest nodes in every cluster of the collaboration network were Hacettepe University, Tehran University, Xinjiang Medical University, Salford University, and the University of Pavia, and the top-producing authors were Wen H, Vuitton DA, Gottstein B, and Craig PS. Keyword co-occurrence analysis suggested that surgical techniques and novel drugs targeting combined immune checkpoints are the main therapeutic approaches in the future.

CONCLUSION

Although developing countries had significantly contributed to publications on HE, the citation rate for individual articles from developed countries was significantly higher. Additionally, advancements in surgical techniques and novel drugs targeting combined immune checkpoints may emerge as the next research focus and developmental direction.

Ubenimex combined with Albendazole for the treatment of Echinococcus multilocularis-induced alveolar echinococcosis in mice

Introduction

Alveolar echinococcosis (AE) is a parasitic disease caused by E. multilocularis metacestodes and it is highly prevalent in the northern hemisphere. We have previously found that vaccination with E. multilocularis-Leucine aminopeptidase (EM-LAP) could inhibit the growth and invasion of E. multilocularis in host liver, and Ubenimex, a broad-spectrum inhibitor of LAP, could also inhibit E. multilocularis invasion but had a limited effect on the growth and development of E. multilocularis.

Methods

In this study, the therapeutic effect of Ubenimex combined with Albendazole on AE was evaluated. Mice were intraperitoneally injected with protoscoleces and imaging examination was performed at week 8 and week 16 to detect cyst change. During this period, mice were intraperitoneally injected with Ubenimex and intragastrically administered with Albendazole suspension. At last, the therapeutic effect was evaluated by morphological and pathological examination and liver function.

Results

The results revealed that the combined treatment could inhibit the growth and infiltration of cysts in BALB/c mice infected with E. multilocularis protoscoleces. The weight, number, invasion and fibrosis of cysts were reduced in mice treated with Ubenimex in combination with Albendazole. The same effect was achieved by the single Ubenimex treatment because of its inhibitory effect on LAP activity, but it was less effective in inhibiting the growth of cysts. The levels of ALT, AST, TBIL, DBIL, ALP, and γ-GT were reduced after the combined treatment, indicating that treatment with both Ubenimex and Albendazole could alleviate liver damage.

Discussion

This study suggests that the combined treatment with Ubenimex and Albendazole could be a potential therapeutic strategy for E. multilocularis infections.

Single-center experience of Ex vivo liver resection and autotransplantation for complex hepatic alveolar echinoccosis

Objective

To summarize the single-centre experience of Ex vivo Liver Resection and Autotransplantation (ELRA) to treat end-stage hepatic alveolar echinococcosis (HAE).

Methods

Retrospective analysis of clinical data and follow-up data of 13 patients admitted to the Affiliated Hospital of Qinghai University from January 2015 to December 1, 2020, with the Ex vivo Liver Resection and Autotransplantation for hepatic alveolar echinococcosis.

Result

13 patients underwent successful total/ semi-ex-vivo liver resection combined with Ex vivo Liver Resection and Autotransplantation with no intra-operative deaths. the median standard liver volume was 1,118 ml (1,085-1,206.5 ml); the median residual liver volume was 634 ml (526.5-1,338 ml); The median weight of the autograft was 845.8 g (619.5-1,020.5 g), the median operation time was 14.5 h (11.5-16.15 h); the median anhepatic period time was 290 min (257-312.5 min). The median intraoperative blood loss was 1,900 ml (1,300-3,500 ml); the median number of erythrocyte suspensions entered was 7.5 u (6-9u). The median length of hospital stay was 32 days (24-40 days). Postoperative complications occurred in 9 patients during hospitalization,with 7 patients graded at grade III or higher by Clavien-Dindo; 4 patients died postoperatively. 1 patient had recurrent abdominal distension with massive thoracoabdominal fluid and coagulation dysfunction 8 months after surgery and was considered to have small liver syndrome. 1 patient developed HAE recurrence during the follow-up, which was considered intraoperative incisional implantation.

Conclusion

ELRA is one of the most valuable therapeutic measures for the treatment of end-stage complicated hepatic alveolar echinococcosis. Precise preoperative assessment of liver function, individualized intraoperative duct reconstruction, and precise management of the postoperative disease can achieve better treatment results.

[Extended Liver Resection with Complex Vascular Reconstruction in Locally Advanced Alveolar Echinococcosis]

BACKGROUND

Hepatic echinococcosis is rare in Germany. Liver resection is a potentially curative treatment, if a complete resection according to oncological standards can be achieved. Due to the infiltrating growth of E. multilocularis, liver resections can be challenging.

CASE

We present a case of hepatic echinococcosis with complete infiltration of left and middle hepatic vein and a partial infiltration of the right hepatic vein (RHV) and the vena cava (VCI). To better evaluate resectability, we performed a three-dimensional reconstruction based on the preoperative CT scan. Complete resection was achieved with an extended left hemihepatectomy (removal of segment 1-5 and partially segment 8) and tangential resection of the VCI and partial resection of the RHV. VCI was reconstructed with a bovine pericardial patch and the RHV was reconstructed end-to-end.

CONCLUSION

Liver resection may require complex vascular resections and reconstructions to achieve an R0 situation in the therapy of E. multilocularis. Three dimensional planning of the resection facilitated curative resection in the current case.

Laparoscopic resection of hepatic alveolar echinococcosis: A single-center experience

Introduction

Alveolar echinococcosis (AE) remains a very rare disease requiring complete radical resection for curative treatment. While open approaches are common, safety and efficacy of laparoscopic resections remain unknown.

Methods

This is a single-center, retrospective cohort study with patients undergoing liver resection for hepatic AE at the Department of Visceral Surgery and Medicine, Bern University Hospital from December 2002 to December 2020. Postoperative outcomes of patients following laparoscopic hepatectomy (LH) for hepatic AE were compared with those of patients undergoing open hepatectomy (OH).

Results

A total of 93 patients underwent liver resection for hepatic AE. Laparoscopic hepatectomy was performed in 23 patients and open hepatectomy in 70 patients. While there were no significant differences in terms of gender, age and diagnostic tools, the majority of patients of the LH cohort were PNM stage 1 (78%) in contrast to only 39% in the OH cohort (p = 0.002). Patients undergoing laparoscopic hepatectomy were treated by minor liver resections in 91% and in 9% by major liver resections in comparison to the open hepatectomy cohort with 61% major liver resections and 39% minor resections. Laparoscopic hepatectomy was associated with shorter mean operation time (127 minutes vs. 242 minutes, p <0.001), lower major complication rate (0% vs. 11%, p = 0.322) and shorter mean length of hospital stay (4 days vs. 13 days, p <0.001). Patients with LH had a distinct, but not significant lower recurrence rate (0% vs. 4%, p = 0.210) during a mean follow-up of 55 months compared with a follow-up of 76 months in the OH cohort. After subgroup analysis of PNM stage 1 patients, similar results are seen with persistent shorter mean operation time (120 minutes vs. 223 minutes, p <0.001), lower major complication rate (0% vs. 8%, p = 0.759) and shorter length of hospital stay (4 days vs. 12 days, p <0.001).

Conclusion

Laparoscopy appears as a feasible and safe approach for patients with PNM stage 1 alveolar echinococcosis without impact on early disease recurrence.

In this retrospective cohort study laparoscopic hepatectomy for hepatic alveolar echinococcosis had no negative impact on perioperative outcomes, disease recurrence or survival compared with open hepatectomy. The importance of this finding is that the laparoscopic approach is feasible and safe for selected patients with hepatic alveolar echinococcosis, especially those with PNM stage 1.

Comparative study of indocyanine green (ICG)-R15 and Albumin-Indocyanine Green Evaluation (ALICE) grading system in the prediction of posthepatectomy liver failure and postoperative mortality in patients with hepatic alveolar echinococcosis

BACKGROUND

A precise evaluation of liver reserve function in patients with hepatic alveolar echinococcosis (HAE) prior to hepatectomy could substantially increase the success rate of the operation and reduce the incidence of postoperative complications. The present study aimed to investigate the significance of the indocyanine green retention test at 15 min (ICG-R15) and the Albumin-Indocyanine Green Evaluation (ALICE) grading system in predicting severe posthepatectomy liver failure (PHLF) and postoperative mortality in HAE patients undergoing liver resection.

METHODS

A total of 105 HAE patients undergoing hepatectomy were enrolled in this study. The value of each variable in predicting severe PHLF was evaluated by univariate and multivariate logistic regression analyses. The area under the receiver operating characteristic (ROC) curves (AUC) were calculated to evaluate the predictive ability of the Child-Pugh grade, ICG-R15, and ALICE grading system. Also, patients were classified using the optimal cutoff value for ICG-R15 and different ALICE grades, and the incidence of severe PHLF and postoperative mortality were compared with the predicted values.

RESULTS

Out of the 105 HAE patients enrolled in this study, 34 patients (32.4%) developed severe PHLF. The ALICE grade and operative time were identified as independent predictors of severe PHLF. According to ROC analysis, the AUCs of the Child-Pugh grade, ICG-R15, and ALICE grade for predicting severe PHLF were 0.733 (95% confidence interval (CI), 0.637-0.814), 0.823 (95% CI, 0.737-0.891), 0.834 (95% CI, 0.749-0.900). The incidence of severe PHLF and postoperative 90-day mortality in patients with ICG-R15 > 7.2% were significantly higher than those with ICG-R15 ≤ 7.2% (P < 0.001; P = 0.008). Likewise, the incidence of severe PHLF and postoperative 90-day mortality in patients with ALICE grade 2 were higher than those with ALICE grade 1 within the Child-Pugh grade A (P < 0.001; P = 0.083).

CONCLUSION

ICG-R15 and ALICE grading system are powerful predictors of severe PHLF and postoperative mortality among HAE patients undergoing hepatectomy. Furthermore, a combination of the preoperative Child-Pugh grade and ALICE grading system may provide an even more precise and objective guidance and facilitate surgical decision-making for HAE patients.

Treatment of Complicated Hepatic Alveolar Echinococcosis Disease With Suspicious Lymph Node Remote Metastasis Near the Inferior Vena Cava-Abdominal Aorta: A Case Report and Literature Review

Echinococcosis is a human-animal parasitic disease caused by Echinococcosis tapeworm larvae in humans. From a global perspective, it is mainly prevalent in the mid-high latitudes of the Northern Hemisphere, and it is a widespread infectious disease. Its form, host and release areas are slightly different. In clinical practice, Echinococcus granulosus (hepatic cystic echinococcosis) is the most common. Its growth mode is swelling growth and its metastasis is more common in implanted metastasis; However, hepatic alveolar echinococcosis (HAE) is rare. It has been reported that HAE can metastasize through the blood or lymph nodes, and its invasive growth pattern is known as “carcinoma”. At this time, it may be accompanied by invasion of the portal vein and inferior vena cava(IVC)or metastasis to distant organs outside the liver (such as lung, brain, lymph nodes). Most patients are in the middle or late stages, making treatment complicated. World Health Organization guidelines recommend radical resection of HAE; However, there is no consensus on lymph node dissection. To date, there have been no reports of cases of HAE accompanied by inferior vena cava-para-abdominal aortic suspected lymph node metastasis and infection. This article reports a clinical case of a complex HAE treated by the surgical method of “middle liver resection + abdominal enlarged lymph node resection + inferior vena cava repair”, and histological examination was performed to illustrate the differences in microscopic pathology of alveolar echinococcosis invading the liver and lymph nodes at different magnifications. This article reviews the relevant literature on HAE and derives the latest treatment methods for HAE to provide a reference for future clinical cases of similar alveolar echinococcosis and maximize the benefits of patients.

Evaluation of Allicin Against Alveolar Echinococcosis In Vitro and in a Mouse Model

Purpose

At present, the chemotherapy for alveolar echinococcosis (AE) is mainly based on albendazole (ABZ). However, more than 20% of patients fail chemotherapy. Therefore, new and more effective treatments are urgently needed. Allicin has been reported to have antibacterial and antiparasitic effects. The objectives of the present study were to investigate the in vivo and in vitro efficacy of allicin against Echinococcus multilocularis (E. multilocularis).

Methods

The effects of allicin on protoscolex survival and structural changes were evaluated in vitro. The 4-week-old BALB/c male mice used for in vivo modelling underwent inoculation of E. multilocularis protoscoleces by intraperitoneal injection, followed by intragastric administration of allicin for 6 weeks. Then, the effects of allicin on lymphocyte subsets, metacestode growth and host tissue matrix metalloproteinase 2 (MMP2)/MMP9 expression around metacestodes in mice were evaluated. The toxicity of allicin was further evaluated in vivo and in vitro.

Results

Att 40 μg/mL, allicin showed a killing effect on protoscoleces in vitro and treatment resulted in the destruction of protoscolex structure. Molecular docking showed that allicin could form hydrogen bonds with E. multilocularis cysteine enzymes. After 6 weeks of in vivo allicin treatment, the spleen index of mice was increased and the weight of metacestodes was reduced. Allicin increased the proportion of CD4⁺ T cells and decreased the proportion of CD8⁺ T cells in the peripheral blood and spleen. Pathological analysis of the metacestodes showed structural disruption of the germinal and laminated layers after allicin treatment. In addition, allicin inhibited the expression of MMP2 and MMP9 in metacestode-surrounding host tissues. At 160 μg/mL, allicin had no significant toxicity to normal hepatocytes but could inhibit hepatoma cell proliferation. At 30 mg/kg, allicin had no significant hepatorenal toxicity in vivo.

Conclusion

These results suggest that allicin exerts anti-E. multilocularis effects in vitro and in vivo and can enhance immune function in mice, with the potential to be developed as a lead compound against echinococcosis.

Study on the Effect of Quasi-Radical Lesion Resection on the Quality of Life of Patients With Advanced Hepatic Alveolar Echinococcosis

Objective

To retrospectively analyze the effects of radical lesion resection and quasi radical lesion resection on the quality of life of patients with advanced hepatic alveolar echinococcosis.

Methods

Through the existing HIS system of Qinghai Provincial People's Hospital, 104 patients with hepatic alveolar echinococcosis who underwent surgical treatment in our hospital from January 2012 to December 2017 and completed the quality of life questionnaire were selected as the research objects. The above cases were divided into radical group (n = 51) and quasi-radical group (n = 53) according to different surgical methods (degree of radical cure). The quality of life of patients with hydatidosis was measured by interview or telephone follow-up. The preoperative indexes, intraoperative conditions and postoperative recovery indicators of the two groups were observed, such as Child-Puhg grade, PNM classification, scope of hepatectomy, intraoperative bleeding, Clavien grade, incidence of complications, 5-year recurrence rate and total score of quality of life and so on.

Results

There was no significant difference between the two groups in general data such as age, gender, hydatid size, Child-Puhg grade and preoperative liver function (P > 0.05). However, there was a statistically significant difference in PNM classification between the two groups (P < 0.05). There were significant differences in intraoperative bleeding, postoperative liver function recovery, Clavien grade of complication severity and 5-year recurrence rate between the two groups (P < 0.05). There was no significant difference in postoperative quality of life between the two groups (P > 0.05).

Conclusion

For patients with advanced hepatic alveolar echinococcosis whose objective cannot be achieved by conventional hepatectomy, quasi-radical resection of the lesion can not only reduce the risk and difficulty of surgery, but also the quality of life of the patients may be as good as that of radical resection.

Alveolar Echinococcosis-A Challenging Task for the Hepatobiliary Surgeon

(1) Background: Alveolar echinococcosis (AE) is an ultimately fatal disease, whose only curative treatment is surgery. Due to its late presentation extended liver resections are often necessary. The true benefit of extensive surgery has yet to be established; (2) Methods: We present a single center experience of 33 cases of Echinococcus multilocularis that have been treated at a high-volume hepatobiliary surgery center between 2004 and 2021. (3) Results: Of the 33 patients 24 patients underwent major liver resection (73%). In addition to the liver resection patients frequently underwent complex extrahepatic procedures such as lymphadenectomy (n = 21, 61%), vascular resections and reconstructions (n = 9, 27%) or resections and reconstruction of the extrahepatic bile duct (n = 11, 33%). Seven patients suffered from ≥ grade III complications (21%). Complete resection was achieved in 17 patients. Fourteen patients had R1 resections and two had macroscopic parasitic remnant (R2). Progressive disease was reported in three patients (The two R2 patients and one R1 resected patient). At a median follow-up of 54 months no mortality has occurred in our cohort; (4) Conclusions: Liver resection remains the gold standard for AE. Even in extensive disease the combination of complex resection and perioperative benzimidazoles can achieve favorable long-term outcomes.

Dramatic response to albendazole in transplantation candidates with unresectable hepatic alveolar hydatid disease

Long-term albendazole treatment should be given to all patients with unresectable hepatic alveolar echinococcosis as dramatic regression is possible in 15%-20%. It may be prudent to prepare a living donor for possible salvage transplant in case of a severe complication. Preemptive transplantation in mildly symptomatic patients should be discouraged.

Resection of retrohepatic inferior vena cava without reconstruction in ex vivo liver resection and autotransplantation: a retrospective study

Background

Retrohepatic inferior vena cava (RIVC) resection without reconstruction in ex vivo liver resection and autotransplantation (ERAT) for advanced alveolar echinococcosis (HAE) is unclear.

Methods

This is a retrospective study of consecutive patients referred to our hospital from 2014 to 2018. Depending on the presence of a rich collateral circulation and stable blood volume in ERAT, patients did not rebuild the RIVC. Then, patients were selected some appropriate revascularization techniques for the hepatic and renal veins. Finally, all ERAT procedures were completed, and short- and long-term outcomes were observed.

Results

Five advanced HAE patients underwent ERAT without RIVC reconstruction. One patient died of circulatory failure 1 day after surgery. Another four patients, with a median follow-up duration of 18 months (range, 10–25 months), demonstrated normal liver and kidney function, no thrombosis and no HAE recurrence.

Conclusions

Through the long-term results of ERAT, the pros and cons of not reconstructing the RIVC need to be re-examined. In cases with a rich collateral circulation, the RIVC cannot be reconstructed. However, in cases requiring the resection of multiple organs, RIVC without reconstruction was prudential.

Resection of retrohepatic inferior vena cava without reconstruction in ex vivo liver resection and autotransplantation: a retrospective study

BACKGROUND

Retrohepatic inferior vena cava (RIVC) resection without reconstruction in ex vivo liver resection and autotransplantation (ERAT) for advanced alveolar echinococcosis (HAE) is unclear.

METHODS

This is a retrospective study of consecutive patients referred to our hospital from 2014 to 2018. Depending on the presence of a rich collateral circulation and stable blood volume in ERAT, patients did not rebuild the RIVC. Then, patients were selected some appropriate revascularization techniques for the hepatic and renal veins. Finally, all ERAT procedures were completed, and short- and long-term outcomes were observed.

RESULTS

Five advanced HAE patients underwent ERAT without RIVC reconstruction. One patient died of circulatory failure 1 day after surgery. Another four patients, with a median follow-up duration of 18 months (range, 10-25 months), demonstrated normal liver and kidney function, no thrombosis and no HAE recurrence.

CONCLUSIONS

Through the long-term results of ERAT, the pros and cons of not reconstructing the RIVC need to be re-examined. In cases with a rich collateral circulation, the RIVC cannot be reconstructed. However, in cases requiring the resection of multiple organs, RIVC without reconstruction was prudential.

Outcomes of different surgical resection techniques for end-stage hepatic alveolar echinococcosis with inferior vena cava invasion

BACKGROUND

Hepatic alveolar echinococcosis (HAE) lesions with inferior vena cava (IVC) invasion require combined resection of the liver and IVC. The outcomes of different surgical treatments, including in situ, ante situm and ex vivo resection, remain unclear.

METHODS

A total of 71 consecutive HAE patients who underwent hepatectomy with retrohepatic IVC resection were included. The patients were divided into ex vivo liver resection and autotransplantation (ERAT) group (n = 45) and in vivo resection group (n = 26). These techniques were assessed for feasibility and short- and long-term outcomes.

RESULTS

There were no significant differences with respect to postoperative complications and mortality between the ERAT and in vivo resection groups. The causes of mortality were liver failure in 3 patients, hemorrhagic shock in 1 patient, intra-abdominal bleeding in 1 patient, and acute cerebral hemorrhage in 1 patient. During a median of 22 months followed-up time, 2 patients developed ascites because of venous outflow stenosis, and 1 patient developed biliary stenosis in the ERAT group. The distant metastasis, local recurrence, and mortality rates were 0%, 1.4%, and 8.5%, respectively.

CONCLUSION

Combined liver resection and reconstruction of the IVC can be safely performed in selected patients with in situ, ante situm, and ex vivo resection.

Surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients

Hepatic alveolar echinococcosis (HAE) is a potentially fatal disease caused by the larval growth of Echinococcus multilocularis. We analysed the clinical data of 178 consecutive HAE patients treated with definitive radical surgery at our institution. According to the surgical approach: group A patients underwent direct radical hepatic resection; group B patients first underwent percutaneous puncture external drainage, followed by radical hepatic resection 2 months later; group C patients underwent a two-step hepatic resection; and group D patients underwent liver transplantation. The baseline characteristics, mortality, postoperative complications and recurrence rates were evaluated. Symptoms were present in 79.8% (142/178) patients. Bi-lobar lesion was found in 34 (19.1%, 34/178) patients, 47.2% (84/178) of whom had ⩾2 lesions each. There were no intraoperative deaths. The postoperative mortality was 2.29% in group A, 8.62% in group D and 0% in groups B and C. The main cause of death was a serious postoperative complication (Clavien–Dindo grades III–V). Patients were followed-up systematically for a median of 35.8 months (8–72) without recurrence. Active HAE should be treated by radical liver resection, and the complicated alveolar echinococcosis of the liver has been managed whenever possible using principles of radical liver resection by experienced hepatic surgeons.

Elevated incidence of alveolar echinococcosis in immunocompromised patients

Introduction

Recent experimental data has revealed that the course of alveolar echinococcosis (AE) depends on adaptive immunity. For this study, we aimed to analyze the incidence and outcome of AE in immunocompromised humans.

Material and methods

Retrospective analysis of 131 patients with a median age of 54 years treated for AE between 1971 and 2017 at a Swiss tertiary referral Centre. Fifty-two percent were females and 65 patients (50%) were diagnosed incidentally. Fourteen patients (16%) were operated on laparoscopically. Overall, median follow-up was 48 months.

Results

New diagnoses have increased fourfold in immunocompetent and tenfold in immunocompromised patients in the past decade (p ≤ 0.005). Forty-one patients (31.3%) had co-existing or previous immunosuppressive conditions including 16 malignancies (36%), 11 auto-immune diseases or immunosuppressive therapies (31%), 5 infectious diseases (11%), 4 chronic asthma conditions (9%), 2 previous transplantations (4%) and 4 other immunocompromising conditions (9%). Serum levels of anti-Em18, −Em2 and -EgHF antibodies were neither associated with immunocompetence at diagnosis nor during follow-up, but significantly decreased after treatment with benzimidazole (n = 43) or surgery (n = 88) in all patients. Adjuvant therapy for ≥1 year (p = 0.007) with benzimidazole and resection status (R0) (p = 0.002) were both correlated with recurrence-free survival. Survival at 5 and 10 years after surgery was 97% and 94%, respectively, and after conservative treatment 91% and 73%, respectively. Curative surgery (p = 0.014) and immunocompetence (p = 0.048) correlated significantly with overall survival.

Conclusion

The incidence of human AE has increased over the last 2 decades with surgical interventions resulting in excellent outcomes. We have observed an association of immunosuppressive conditions with both incidence and survival of AE eventually justifying the implementation of a screening program for patients at risk in endemic regions.

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Alveolar echinococcosis incidence increased significantly in Switzerland.

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Immunosuppression may lead to an increased susceptibility for the disease.

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Coexisting immunosuppressive conditions lead to worse survival of AE.

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Adjuvant treatment with benzimidazole increases recurrence-free survival.

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Resections with sufficient safety margin improve recurrence-free survival.

Surgical treatment strategies for hepatic alveolar echinococcosis

Alveolar echinococcosis is a severe and rare helminthic disease with increasing incidence in endemic regions. Herein, available evidence on curative surgical and potential palliative approaches was reviewed. Such strategies have to be applied in the context of available resources in different health-care systems. Complete resection followed by adjuvant therapy remains the only curative treatment available. Curative surgery is performed by open or laparoscopic approach depending on the extent of the disease and the experience of the surgical team. Palliative resections are typically not indicated, because the availability of endoscopic treatments of biliary complications and long-term benzimidazoles represent efficient alternatives to surgery. Liver transplantation as an alternative to palliative surgery has not been shown to be superior to long-term conservative therapy. Immunosuppressive therapy might additionally contribute to fatal disease recurrence after transplantation.

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Alveolar echinococcosis is an aggressive zoonotic infection caused by the parasite Echinococcus multilocularis.

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Surgery remains the only curative treatment strategy for alveolar echinococcosis.

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In non-resectable patients, benzimidazole treatment is preferred over palliative surgery or liver transplantation.

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Follow-up is based on annual serological testing using Em18-Antigen and cross-sectional imaging.

Vascular infiltration-based surgical planning in treating end-stage hepatic alveolar echinococcosis with ex vivo liver resection and autotransplantation

BACKGROUND

For end-stage hepatic alveolar echinococcosis, insufficient guidance is available regarding surgical treatment, especially for ex vivo liver resection combined with autotransplantation. The indications for this complex surgery require further discussion.

METHOD

We reviewed 50 cases of patients who underwent ex vivo liver resection combined with autotransplantation from January 2014 to February 2018. A newly developed classification was used to describe vascular infiltration in all patients, who were divided into four groups based on anatomic lesion features and surgical patterns. The surgical planning for ex vivo liver resection combined with autotransplantation is then thoroughly discussed according to the gathered information.

RESULTS

In all patients, the length of the operation and the anhepatic phase were 735 minutes (range, 540-1,170 minutes) and 309 minutes (range, 122-480 minutes), respectively. The median remnant liver volume-to-standard liver volume ratio was 0.58 (range, 0.32-1.11). The rate of complications classified as Clavien-Dindo grade III or higher was 22% (11/50). A total of 3 postoperative deaths occurred. We identified 4 types with distinguished lesion anatomic features. Type I patients required more frequent unconventional reconstruction of the portal vein and bile duct than the other patients. Of the 6 type IV patients, 4 required modification of the surgical protocol according to intraoperative findings.

CONCLUSION

Vascular infiltration-based classification could improve the anatomic comprehension and, thus, facilitate surgical planning for ex vivo liver resection combined with autotransplantation. Through cautious evaluation of operability, liver function, and residual liver volume, together with delicate operative techniques and careful postoperative management, ex vivo liver resection combined with autotransplantation can achieve good results in the treatment of end-stage hepatic alveolar echinococcosis.

Novel techniques and preliminary results of ex vivo liver resection and autotransplantation for end-stage hepatic alveolar echinococcosis: A study of 31 cases

Ex vivo liver resection combined with autotransplantation is a recently introduced approach to cure end-stage hepatic alveolar echinococcosis (HAE), which is considered unresectable by conventional radical resection due to echinococcal dissemination into the crucial intrahepatic conduits and adjacent structures. This article aims discuss the manipulation details and propose reasonable indications for this promising technique. All patients successfully underwent liver autotransplantation with no intraoperative mortality. The median weight of the autografts was 636 g (360-1300 g), the median operation time was 12.5 hours (9.4-19.5 hours), and the median anhepatic phase was 309 minutes (180- 460 minutes). Intraoperative blood loss averaged 1800 mL (1200-6000 mL). Postoperative complications occurred in 13 patients during hospitalization; 5 patients experienced postoperative complications classified as Clavien-Dindo grade III or higher, and 2 patients died of intraabdominal bleeding and acute cerebral hemorrhage, respectively. Twenty-nine patients were followed for a median of 14.0 months (3-42 months), and no HAE recurrence was detected. The technique requires neither an organ donor nor any postoperative immunosuppressant, and the success of the treatment relies on meticulous preoperative assessments and precise surgical manipulation.

The choose of different surgical therapies of hepatic alveolar echinococcosis: A single-center retrospective case-control study

The aim of this study was to evaluate different surgical therapies for hepatic alveolar echinococcosis in different clinical stages.We analyze the clinical data of 115 patients who received surgical treatment in West China Hospital from January 2004 to June 2016. Among these patients, 77 cases underwent radical hepatic resection (group A, n = 77); 17 cases underwent palliative resection (group B, n = 17), and 21 cases underwent liver transplantation (group C, n = 21) with 12 cases of orthotopic liver transplantation and 9 cases of liver autotransplantation.The postoperative complication rate of radical hepatic resection group was 13.0% (10/77), which is statistically significant (P < .05) than the rate of palliative resection group 29.4% (5/17) or liver transplantation group 23.8% (5/21). The follow-up period ranged from 1 to 72 months. The overall median survival rate of radical resection was 72/77, higher than the rate of palliative group (12/17) or transplantation group (17/21), which was also statistically significant (P < .01).In our study, we believe in that all stages of hepatic alveolar echinococcosis should take active surgical interventions, and radical hepatic resection should be considered as the first-choice treatment for early stage of alveolar echinococcosis, while palliative surgery is still helpful to relieve symptoms and improve the life quality for advanced patients. Liver transplantation might also be an alternative option for the late-stage hepatic alveolar echinococcosis.