Surgical treatment of hydatid cysts of the liver in the era of percutaneous treatment

A Novel Technique for the Management of Persistent Biliary Fistulas Developing After Liver Hydatid Cyst Surgeries: Drain Clamping Technique

BACKGROUND

External biliary fistula, where the residual cyst is associated with the biliary tree, is one of the most common complications after liver hydatid cyst surgery. Surgical procedures become a consideration for patients in whom the biliary fistula persists despite all endoscopic procedures. However, reoperation for biliary fistula after hydatid cyst surgery leads to additional complications and increases morbidity and mortality.

AIM

This study aims to treat persistent biliary fistulas that develop after liver hydatid cyst surgery using a simple noninvasive technique.

MATERIALS AND METHODS

External drainage surgery was performed on 295 patients with liver hydatid cysts. Endoscopic treatment methods were used in patients who developed biliary fistula after surgery. Despite all endoscopic treatment methods, 14 patients developed persistent biliary fistulas. These patients were subsequently treated using the drain clamping technique.

FINDINGS

All persistent fistulas occluded in 11.86 days (with a range of 8-20 days). No complications were observed in the one-year follow-up visits.

CONCLUSION

Drain clamping, a novel approach to the treatment of persistent biliary fistulas developed despite all available endoscopic methods, can be safely used. This technique resulted in a complete recovery in patients without the need for surgical procedures.

Turkish HPB Surgery Association consensus report on hepatic cystic Echinococcosis (HCE)

OBJECTIVES

Cystic Echinococcosis (CE) is one of the important problems of the Eurasian region. We aimed to prepare a consensus report in order to update the treatment approaches of this disease. This study was conducted by Turkish HPB Surgery Association.

MATERIAL AND METHODS

This study was conducted with the modified Delphi model. For this purpose, we conducted a three-stage consensus-building approach.

RESULTS

Six topics, including diagnosis, medical treatment, percutaneous treatment, surgical treatment, management of complications and posttreatment follow-up and recurrences in HCE were discussed.

CONCLUSION

The expert panel made recommendations for every topic.

Treatment of Gharbi Type III Hepatic Hydatid Cysts: A Clinical Dilemma

This article aims to compare available treatment options for type III liver hydatid cysts, including surgery and percutaneous techniques. Hydatid disease is a helminthic infection caused by Echinococcus granulosus and is a serious public health problem in endemic regions of the world. Hydatid cyst of the liver is the most common clinical presentation of Echinococcus granulosus. According to Gharbi classification, hydatid cysts of the liver are classified into 5 types. Type III hydatid cysts are those with fluid collection and septa. Treatment of Gharbi type III hydatid cysts is still controversial. Some researchers think that Gharbi type III hydatid cysts are not suitable for percutaneous drainage, and surgery is the suitable treatment option. There are not enough prospective studies comparing percutaneous and surgical techniques for the treatment of type III hydatid disease of the liver. A proper meta-analysis does not seem to be possible with the available studies in current medical literature.

Daughter cyst sign in liver hydatid cyst

Daughter cyst sign is one of the most characteristic imaging findings of liver hydatid cysts. It is schematically divided into two types according to the daughter cyst localization in regard to the hydatid cyst wall: endogenous daughter cysts and exogenous daughter cysts. The endogenous daughter cyst is presented by a small cyst that protrudes into the lumen of the cystic mass. The exogenous daughter cysts are enclosed in the laminated layer then gradually pushed outwards giving the hydatid a bumpy appearance that distorts the classic circular radiological image. Imaging findings could detect these daughter cysts and dictate some additional precautions during surgical procedures. This surgery is associated with a high recurrence rate essentially in case of exogenous daughter cysts. However, if we detect many exogenous daughter cysts, a radical treatment should be favored otherwise the post-operative recurrence will be certain.

Current approaches in the surgical treatment of liver hydatid disease: single center experience

Background

Liver hydatid disease is a common benign condition in many countries. Compared to open surgery, laparoscopic treatment can play an important role in improving the post-operative recovery, reducing the morbidity and recurrence rate of these patients.The purpose of this study is to show that the laparoscopic method is effective and safe in the treatment of liver hydatid cysts compared to open surgery, even in large cysts.

Methods

All consecutive cases surgically managed for liver hydatid cyst from 7 January 2008 and 15 January 2010 in our institution were included in this study.The surgical approach (laparoscopic or open) and operative strategy, as well as operative and prognostic outcomes, were analyzed. Cyst size, type, location, presence of biliary tract communication, radiological findings, duration of hospitalization, recurrence and postoperative morbidity were analysed and compared retrospectively.

Results

A total of 60 patients were included in the study.A total of 23 patients underwent open surgery, and 37 patients underwent laparoscopic surgery.Operation types of laparoscopic surgery were as follows: partial pericystectomy (12patients), total cystectomy(2 patients), partial pericystectomy+total cystectomy(7patients) and cystectomy(16patients).The surgical procedures chosen for open treatment of the residual cavity were partial pericystectomy and omentoplasty(17cases), total pericystectomy(3cases) and partial and total pericystectomy(3cases).Cysto-biliary communication was found in 9 patients. A total of 10 patients underwent preoperative endoscopic retrograde cholangiography, and one patient underwent postoperative endoscopic retrograde cholangiography.There was a progression of hypernatremia in 1 patient, wound infections in 3 patients, and perioperative hemorrhage in 3 patients. There were no statistically significant differences concerning age(p = 0.344), gender(p = 0.318), ASA classification(p = 0.963), Gharbi classification(p = 0.649) whereas there were significant differences related to cyst location(p = 0.040) and size(p = 0.022) in patients undergoing laparoscopic and open surgery.

Postoperative temporary biliary fistulas were observed in 2 patients undergoing open surgery. Patients undergoing laparoscopic surgery had the advantages of shorter hospital stays and operation times, less blood loss, faster recovery, and lower wound infection rates. Recurrences were detected in 2.7% of patients undergoing laparoscopic surgery and 4.7% of those undergoing open procedures.

Conclusion

Compared to open surgery in the treatment of liver hydatid cysts, we have shown that laparoscopic method can be safely performed even in large cysts and/or cysto-biliary communication.

A Rare Case of Pancreatic Tail Hydatid Cyst with Incidental Adenocarcinoma of the Pancreatic Body

Pancreatic hydatid cyst is a rare disease found mostly in endemic regions. Having no specific clinical signs, it may present with tension related abdominal pain, dyspepsia, a palpable mass, and signs of external pressure on the surrounding organs in accordance with localization of the lesion. Pancreatic carcinoma as a neoplastic pathology with poor prognosis can have various clinical presentations changing with localization of the tumor which sometimes has cystic components. Due to the distinct nature of these pathologies, surgical approach can be fairly different. In this report, we present a case of a 70-year-old patient who had an isolated hydatid cyst in the tail of the pancreas with an incidental pancreatic carcinoma in the corpus of the pancreas. The patient was treated with a subtotal pancreatectomy, having no problems in the postoperative period leading to uncomplicated discharge.

Radical versus conservative surgical treatment of liver hydatid cysts: a meta-analysis

To date, the efficacy of radical surgery (RS) versus conservative surgery (CS) for liver hydatid cysts (LHC) remains controversial. This meta-analysis was conducted to compare the two interventions. PubMed, Embase, and Web of Science were searched from their inceptions until June 2016. Meta-analysis was performed using STATA 12.0 software. We identified 19 eligible studies from 10 countries by retrieval. In total, 1853 LHC patients who received RS were compared with 2274 patients treated by CS. The risk of postoperative overall complication, biliary fistula, and recurrence was significantly lower, and operation time was significantly longer in the RS group. However, no statistically significant differences were found in terms of mortality risk and the duration of hospital stay between RS and CS. No significant publication biases were observed in all the above analyses. In conclusion, RS reduces the rates of postoperative complications and recurrence, whereas no trend toward such a reduction in mortality was observed in LHC patients.

Radical Surgery for Liver Hydatid Cyst

Background and aims: Surgery is the basic treatment for liver hydatid cyst (LHC). Radical procedures (pericystectomy (PK) and hepatic resection (HR)) offers better results in selected cases cases than conservative approaches. Aims of this study were to evaluate the results of Radical surgery for LHC and and to determine witch of these two procedures is safe in experienced hepato-biliary surgical unit in endemic countries. Methods: A retrospective cohort study of 143 patients with liver hydatid cyst who underwent radical procedures at a single surgical department in an endemic country were reviewed. Mortality, morbidity and recurrence rates have been analyzed. Results: Thirty-two patients (22.4%) had a HR and 111 patients (77.6%) had a PK. Mortality rate was 1.4% (n=2) in HR group. Overall morbidity rate was 18.9% and vs 28.1% respectively in PK and HR group (p=.26). Postoperative bleeding occurred in 1.8% in PK group vs 3.1% in HR group (p=.535) and specific LHC operative complication occurred in 17.1% in PK group vs 28.1% in HR group (p=.167). Recurrence rate of LHC was 6.3% in PK group vs 6.6% in HR group (p=.999) after a median follow up of 108 months (54-144) vs 89 months (44-135) respectively. Conclusion: Radical surgery for LHC is safe. Each of PK and HR had a specific indication. A good screening of patient's guarantied a good outcome. Keywords: Liver, Hydatid Cyst, Morocco, Radical Surgery.

Hydatid Cyst of Liver Presented as Obstructive Jaundice in Pregnancy; Managed by PAIR

Incidence of Hydatid disease in pregnancy ranges from 1in 20,000 to 1 in 30,000. The most common site of hydatid cysts is the liver. The diagnosis of liver hydatid cysts is not difficult but the management during pregnancy is problematic. Both medical and surgical treatments are available but there is no consensus and each case has to be individualized. We present a case of liver hydatid cyst presented with obstructive jaundice during pregnancy which was managed by Puncture of the cyst under USG guidance; Aspiration of the cystic fluid, Injection of hypertonic saline, and Re-aspiration of solution without drainage (PAIR) and albendazole therapy. Very few cases of liver hydatosis were reported previously which had been managed by PAIR.

Surgical management of symptomatic hydatid liver disease: experience from a Western centre

BACKGROUND

Hydatid liver cysts are rare in North America. The objective of this study was to determine the optimal surgical management for hydatid liver cysts treated outside endemic areas.

METHODS

We reviewed the cases of consecutive patients who underwent management of hydatid liver cysts. Radical liver resections were compared with other types of procedures. Clinical presentation, investigations, perioperative outcomes and longterm follow-up were evaluated. We evaluated disease recurrence using the Kaplan- Meier method.

RESULTS

Forty patients underwent surgery for hydatid liver cysts. Most patients had single (68%) right-sided (46%) cysts with a median size of 10 cm. Most (83%) underwent liver resection with or without drainage/marsupialization. Radical liver resection was carried out in 60% (19 major, 5 minor). Additional procedures were required in 50% (biliary fistulization 30%, diaphragmatic fistulization 20% or paracaval location/ fusion 8%). Postoperative complications occurred in 48%. The median follow-up was 39 months. The 3-year recurrence-free survival was significantly different between patients who had radical resection and those who had other procedures (100% v. 71%, p = 0.002).

CONCLUSION

The surgical management of hydatid liver cysts in North America remains rare and challenging and is frequently associated with fistulizing complications. Excellent long-term outcomes are best achieved using principles of radical liver resection that are familiar to North American surgeons.

Radical versus conservative surgical treatment of liver hydatid cysts

BACKGROUND

The management of liver hydatid cysts is controversial. Surgery remains the basic treatment, and can be divided into radical and conservative approaches. The purpose of this study was to compare the results of radical and conservative surgery in the treatment of liver hydatid cysts.

METHODS

Data from all patients with liver hydatid cyst treated in a hepatobiliary surgical unit, between January 1990 and December 2010, were retrieved from a retrospective database. To minimize selection bias, propensity score matching was performed, based on 17 variables representing patient characteristics and operative risk factors. The primary outcome measure was hydatid cyst recurrence.

RESULTS

One hundred and seventy patients were matched successfully, representing 85 pairs who had either a radical or a conservative approach to surgery. At a median (i.q.r.) follow-up of 106 (59–135) and 87 (45–126) months in the radical and conservative groups respectively, the recurrence rate was 4 per cent in both groups (odds ratio (OR) 1.00, 95 per cent confidence interval 0.19 to 5.10). There were no statistically significant differences between conservative and radical surgery in terms of operative mortality (1 versus 0 per cent; P=0.497), deep abdominal complications (12 versus 16 per cent; OR 1.46, 0.46 to 3.49), overall postoperative complications (15 versus 19 per cent; OR 1.28, 0.57 to 2.86), reinterventions (0 versus 4 per cent; P=0.246) and median hospital stay (7 (i.q.r. 5–12) days in both groups; P=0.220).

CONCLUSION

This study could not demonstrate that radical surgery reduces recurrence and no trend towards such a reduction was observed.

Risk factors of postoperative morbidity in patients with uncomplicated liver hydatid cyst

PURPOSE

To determine postoperative morbidity (POM) in patients undergoing surgery for uncomplicated hepatic echinococcosis (HE) and determine associations with the variable POM looking for possible risk factors for POM.

METHODS

Nested case-control study. We included patients undergoing surgery for uncomplicated HE in two hospitals in Temuco between 2000 and 2012. The main outcome variable was development of POM. Other variables of interest were hospital stay, mortality and recurrence. Surgical techniques used were pericystectomy and liver resection. Descriptive statistics and analytical statistics were applied using T-test, ANOVA and Kruskal-Wallis test to compare continuous variables; Chi(2) and Fisher's exact test for categorical variables, and logistic regression models were used, estimating OR.

RESULTS

126 patients, median age 41 years, 61% female. The incidence of POM was 10.3%, with 76.9% Clavien grade I or II. The etiology was 6.5% and 4.1% of medical and surgical complications, respectively. There was no mortality and with a median follow-up of 83 months, recurrence incidence was 0.8%. Association was found between cases and controls and the variables age, alkaline phosphatase, cyst location and hospital stay. Applying regression models age (p = 0.002 and OR 1.07) and cyst location (p = 0.003 and OR 3.94) were found to be risk factors.

CONCLUSIONS

Observed POM is lower and of less severity than those previously published. Risk factors were determined.

Efficacy of Berberis vulgaris aqueous extract on viability of Echinococcus granulosus protoscolices

BACKGROUND

Surgery is one of the best choices for the treatment of hydatidosis. To prevent the secondary infection, it is essential to use effective scolicidal agents during surgery for hydatid cyst. Up to now, no effective and safe agent has been identified for this purpose. Berberis vulgaris called "Zereshk" in Persian has been traditionally used as a herbal remedy for the treatment of different complaints. Many studies have shown that Berberis vulgaris has antibacterial, antifungal, and antiparasitic effects.

METHODS

In our study, the scolicidal effect of barberry with different concentrations (0.5, 1, 2, and 4 mg/ml diluted form) and at different exposure times (5, 15, and 30 min) was evaluated. For this purpose, we obtained sheep liver hydatid cysts from a slaughterhouse. Viability of protoscolices was assessed by 0.1% Eosin staining. Normal saline and hypertonic saline were used as negative and positive controls, respectively.

RESULTS

All the different concentrations of Berberis vulgaris aqueous extracts had scolicidal effect. The strongest effect was observed to be in 4 mg/ml concentration, which acted as positive control. Scolicidal activity of 2 mg/ml dilution was close to 4 mg/ml and the least scolicidal effect was observed in 0.5 mg/ml. Scolicidal activity of extracts had significant differentiation between 5th and 30th min of exposure.

CONCLUSION

The scolicidal activity was very effective in low concentration (4 mg/ml) and short exposure time (5 min). Therefore, after being examined in vivo and additional experiments, it may be used as a suitable and effective scolicidal in surgery.

Is hepatic resection the best treatment for hydatid cyst?

BACKGROUND

Hydatid disease is a serious public health problem in endemic areas, and the management is controversial. Operative treatment is generally accepted especially in patients presenting complications. Our policy is to perform radical surgery and, whenever possible, anatomic hepatic resection. The purpose is to report our experience and results in the management of liver hydatid disease.

METHODS

Between January 1991 and December 2010, 97 patients were referred to our department for surgical treatment of hepatic hydatid cyst. Data were retrospectively reviewed. Patients were divided into three treatment groups: conservative surgery (CS), total pericystectomy (PC), and hepatic resection (HR). The main outcome measures were the mortality, morbidity, and recurrence rate.

RESULTS

Median patient age was 45 years (range, 30-56 years). A total of 105 hydatid cysts were treated. Radical surgery was performed in 85 patients: major HR in 43 patients, minor HR in 9, and total PC in 33. CS was performed in 12 cases. There were no postoperative deaths, and the overall morbidity was 20 %. Postoperative morbidity in the HR group was 20 %. Minor (Grade I/II) and major (Grade III/IV) complications were comparable between groups (p = ns). No statistical difference in duration of hospitalization was observed between the CS and the HR group. One patient in the HR group developed a recurrence.

CONCLUSIONS

The findings of this study suggest that surgical resection is not associated with much more postoperative and cyst cavity-related complications than the other groups. In addition, there was no mortality and a low recurrence rate.

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.

Comparison of endoscopic therapeutic modalities for postoperative biliary fistula of liver hydatid cyst: a retrospective multicentric study

BACKGROUND

Hydatid disease most commonly affects the liver, and rupture into the bile ducts is a frequent complication occurring in 5% to 25% of patients. Biliary endoscopic procedures have become the treatment of choice for the management of biliary fistulae. Objective parameters for the endoscopic management of biliary fistulas are still necessary.

METHODS

In this multicentric retrospective study, a total of 109 patients who underwent surgery for a hydatid cyst localized to the liver and presented with persistent drainage of bile from a lodge drain after surgical intervention were included in this study. All patients were treated by an endoscopic retrograde cholangiopancreatography. Patients were divided into 3 groups according to the therapeutic endoscopic procedure: group 1 (n: 70) included patients who underwent only endoscopic sphincterotomy; group 2 (n: 22) included patients who had a 10 F biliary stent inserted; and group 3 (n: 17) included patients who had a 7 F biliary stent inserted. Recorded data were reviewed and the groups were compared.

RESULTS

The mean daily fistula output was 247 mL (range: 100 to 600 mL) in group 1, 534 mL (range: 200 to 1000 mL) in group 2, and 372 mL (range: 120 to 780 mL) in group 3, respectively. There were significant differences between the sphincterotomy group and the stenting groups (P<0.001). The closure time of the external biliary fistula was 23.7 days (range: 6 to 60 d) in group 1, 12.6 days (range: 7 to 23 d) in group 2, and 20 days (range: 6 to 33 d) in group 3, respectively. When compared with the sphincterotomy group, the fistula closure time was shorter in group 2 than in group 1 (P<0.001). There were no differences in this respect between the groups 1 and 3 (P=0.214). Group 2 also had a shorter fistula closure time than group 3 (P<0.001). There was no mortality in any of the study groups. Mild bleeding was observed in 3 cases in group 1 and in 1 in group 3. CONCULUSIONS: Endoscopic retrograde cholangiopancreatography and related therapeutic procedures are safe and valuable in the postoperative management of external biliary fistulae in the hepatic hydatid disease. In high-output fistulae (>300 mL/d), indicating a major cystobiliary communication, stent placement may be preferred. The diameter of the stent should preferably be 10 F. This 10 F stent is superior to other endoscopic approaches in the treatment of biliary fistulas.

Surgical treatment of hydatid disease of the liver: 25 years of experience

BACKGROUND

The aim of this study was to evaluate the results of conservative and radical treatment of liver hydatid disease.

METHODS

Records of patients who underwent surgery for liver hydatid disease between 1980 and 2005 were reviewed. Outcomes measured were operative morbidity and mortality, hospital stay, and recurrence.

RESULTS

Two hundred fourteen patients underwent conservative treatment (external drainage, marsupialization, omentoplasty), and 240 had radical surgery (hepatic resection, cystopericystectomy). Operative morbidity was 79.9% and 16.2% for conservative and radical procedures, respectively (P < .001). Operative mortality was 6.5% for conservative procedures and 9.2% for radical procedures (P = .3). The recurrence rate was 30.4% in patients having conservative surgery and 1.2% in patients undergoing radical surgery (P < .001). No recurrences occurred in patients with clear cysts after conservative surgery.

CONCLUSIONS

Cystopericystectomy was a safe and effective procedure that achieved excellent immediate and long-term results. Hepatic resection should be considered only in exceptional cases, because it involves the unnecessary sacrifice of healthy hepatic parenchyma. Conservative surgery and alternative procedures should be restricted to the treatment of clear cysts and to patients who cannot undergo radical surgery.

Complex Hydatid Cysts of the Liver: A Single Center's Evolving Approach to Surgical Treatment

In our study, we arbitrarily define complex hydatid cysts of the liver as either cysts with a diameter ≥ 10 cm, or as multiple and recurrent cysts. These types of cysts were then divided into two subgroups: giant cyst identified as a cyst with a diameter ≥ 10 cm, and complicated cyst as multiple, recurrent, abscessed cysts, or those resistant to conservative treatment. The aim of this study was to retrospectively analyze a series of 38 consecutive patients who underwent surgery for complex hydatid cysts over a period of 9 years at the same institute to determine the evolution of the surgical treatment and the risk factors for recurrence. Fourteen (36.8%) of these patients were women and 24 (63.2%) men (median age 48.1; range 16-71 years). The mean postoperative follow-up was 24 ± 10.8 months. All patients were treated prophylactically with albendazole (10 mg/Kg/day) for 15 days preoperatively and for 2 months postoperatively. Partial cystectomy was performed in two cases (5.26%) and radical pericystectomy in 20 cases (52.63%). In 15 cases the patients underwent liver resection (39.47%): left hepatectomy was performed in eight cases (21.05%), and right hepatectomy in seven cases (18.42%). In one case, both wedge resection and pericystectomy were performed. There were no deaths and only one patient (2.63%) showed signs of recurrence at follow-up. Radical surgery is the most effective treatment for complex hydatid cysts. In our experience, partial or total pericystectomy virtually eliminated, over time, the need for hepatic resection.

Does primary surgical management of liver hydatid cyst influence recurrence?

BACKGROUND AND AIMS

Hydatid disease is still a major health problem in sheep-raising areas. Surgery remains the basic treatment for liver hydatid cyst (LHC). However, recurrences can occur after all therapies. Surgery for recurrence of LHC becomes technically more difficult with higher rate of morbidity and mortality. The aim of this study was to determine perfective factors associated to hepatic recurrence after LHC surgery and to propose and discuss postoperative follow-up schedules.

METHODS

It is a retrospective cohort study of 672 patients with LHC treated at the surgery department "A" at Ibn Sina University Hospital, Rabat, Morocco, from January 1990 to December 2004. Recurrence rates have been analyzed by the Kaplan-Meier method for patients undergoing surgery.

RESULTS

Fifty-six patients (8.5%) had LHC recurrence after surgery. There were 34 females (60.7%) and 22 males (39.3%). Median duration of recurrence's diagnosis was 24 months (interquartile range: 10-48 months). Recurrence's risk was 2.3% +/- 0.6% at 1 year and 9.1% +/- 1.3% at the 10th year. The history of LHC (hazard ratio, 2; 95% confidential interval, 1.13-3.59) and three cysts or more (hazard ratio, 3.8; 95% confidential interval, 2.07-6.98) was an independent risk factor for recurrence.

CONCLUSION

We think that the surgeon's practice and experience are the most important to success the surgical treatment. It prevents complications and recurrences.

More than 25 years of surgical treatment of hydatid cysts in a nonendemic area using the "frozen seal" method

Background

Hydatid disease of the liver remains endemic in the world and is an imported disease in The Netherlands. The aim of this study was to evaluate the treatment and outcome of surgically treated patients for hydatid disease in a single center in The Netherlands.

Methods

This retrospective study included 112 consecutive patients surgically treated for hydatid disease between 1981 and 2007. The primary outcome was relapse of the disease. Secondary outcomes were infections, complications, reoperations, length of hospital stay, and mortality.

Results

In all cases, echinococcosis was diagnosed by computed tomography or ultrasonography (US). Serology (enzyme-linked immunosorbent assay, immunofluorescence) confirmed the diagnosis in 92.9%. Most of the cysts were seen only in the liver (73.5%). All cysts were operated on with the frozen seal technique. Relapse of disease was seen in 9 (8.0%) cases. Five (4.5%) required surgical treatment at a later stage. Twenty (17.9%) complications were recorded. Four (3.6%) needed radiological drainage and three (2.7%) a reoperation. Follow-up was performed with US and/or serology at a mean of 24 months (range 0.5–300 months). All but one complication were seen in the liver-operated group, this proved not to be of statistical significance (P = 0.477). Patients with complications stayed significantly longer in hospital than did the patients without complications (P < 0.001). No mortality was observed in this study.

Conclusions

The present study suggests that the frozen seal method of surgery for hydatid disease is safe and effective. Future studies are needed to prove its position in the treatment of hydatid disease as new developments show promising results.

Predictive model of biliocystic communication in liver hydatid cysts using classification and regression tree analysis

Background

Incidence of liver hydatid cyst (LHC) rupture ranged 15%-40% of all cases and most of them concern the bile duct tree. Patients with biliocystic communication (BCC) had specific clinic and therapeutic aspect. The purpose of this study was to determine witch patients with LHC may develop BCC using classification and regression tree (CART) analysis

Methods

A retrospective study of 672 patients with liver hydatid cyst treated at the surgery department "A" at Ibn Sina University Hospital, Rabat Morocco. Four-teen risk factors for BCC occurrence were entered into CART analysis to build an algorithm that can predict at the best way the occurrence of BCC.

Results

Incidence of BCC was 24.5%. Subgroups with high risk were patients with jaundice and thick pericyst risk at 73.2% and patients with thick pericyst, with no jaundice 36.5 years and younger with no past history of LHC risk at 40.5%. Our developed CART model has sensitivity at 39.6%, specificity at 93.3%, positive predictive value at 65.6%, a negative predictive value at 82.6% and accuracy of good classification at 80.1%. Discriminating ability of the model was good 82%.

Conclusion

we developed a simple classification tool to identify LHC patients with high risk BCC during a routine clinic visit (only on clinical history and examination followed by an ultrasonography). Predictive factors were based on pericyst aspect, jaundice, age, past history of liver hydatidosis and morphological Gharbi cyst aspect. We think that this classification can be useful with efficacy to direct patients at appropriated medical struct's.

Efficacy of chlorhexidine gluconate during surgery for hydatid cyst

BACKGROUND

Dissemination of protoscolices-rich fluid during surgery for hydatid cyst disease is a major cause of recurrence. Instillation of a scolicidal agent into a hepatic hydatid cyst before opening is the most commonly employed measure to prevent this serious complication. In this clinical study, the efficacy of 0.04% chlorhexidine gluconate (Chx-Glu) during hydatid cyst surgery was tested, and early-term results were evaluated.

METHODS

A total of 30 consecutive patients with 45 liver cysts were studied. Only type I and type II cysts were included. Cysts were punctured, and fluid was aspirated. The viability of protoscolices in this fluid was determined. Chx-Glu 0.04% was instilled into the cyst cavity. After 5 minutes of exposure, the cyst fluid was reaspirated and evaluated for the viability of protoscolices. Imprints of the germinative membranes were determined for protoscolices viability.

RESULTS

All protoscolices in 45 cysts evaluated were killed by 5 minutes of exposure to 0.04% Chx-Glu. The whole of the germinative membrane imprints contained dead protoscolices. Chx-Glu 0.04% did not cause any adverse effect on biliary tracts in communication with cysts. There was no recurrence during the 2-year follow-up period. There were also no mortality and no cavity-related complications.

CONCLUSIONS

This study shows that intracystic injection of 0.04% Chx-Glu is an effective measure against the dissemination of viable protoscolices. In addition, Chx-Glu is the most convenient scolicidal agent as per the criteria defined by the World Health Organization. Therefore, it can be used safely during hydatid cyst surgery. However, there remains the need to perform advanced comparative clinical studies on the efficacy of Chx-Glu and other scolicidal agents.

Use of albendazole sulfoxide, albendazole sulfone, and combined solutions as scolicidal agents on hydatid cysts (in vitro study)

AIM: To establish which scolicidal agents are superior and more suitable for regular use.

METHODS: Echinococcus granulosus protoscoleces were obtained from 25 patients with liver hydatid cysts. Various concentrations of albendazole sulfone, albendazole sulfoxide, and albendazole sulfone and albendazole sulfoxide mixed together in concentrations of 50 &mgr;g/mL, and H₂O₂ in a concentration of 4%, NaCl 20%, and 1.5% cetrimide-0.15% chlorhexidine (10% Savlon-Turkey) were used to determine the scolicidal effects. Albendazole (ABZ) derivatives and other scolicidal agents were applied to a minimum of 100 scoleces for 5 and 10 min. The degree of viability was calculated according to the number of living scolices per field from a total of 100 scolices observed under the microscope.

RESULTS: After 5 min, ABZ sulfone was 97.3% effective, ABZ sulfoxide was 98.4% effective, and the combined solution was 98.6% effective. When sulfone, sulfoxide and the combined solutions were compared, the combined solution seemed more effective than sulfone. However, there was no difference when the combined solution was compared with sulfoxide. After 10 min, hypertonic salt water, sulfone, sulfoxide, and the combined solution compared to other solutions looked more effective and this was statistically significant on an advanced level. When sulfone, sulfoxide, and the combined solutions were compared with each other, the combined solution appeared more effective than sulfone. When the combined solution was compared with sulfoxide, there was no difference.

CONCLUSION: Despite being active, ABZ metabolites did not provide a marked advantage over 20% hypertonic saline. According to these results, we think creating a newly improved and more active preparation is necessary for hydatid cyst treatment.

Long-term results of percutaneous treatment of hydatid liver cysts: a single center 17 years experience

BACKGROUND

Liver cystic echinococcosis is considered a relatively benign disease, nevertheless, treatment is mandatory in symptomatic cysts and recommended in active cysts because of the risk of severe complications. Surgery is still considered the gold standard treatment. In the last two decades percutaneous injection of scolicidal agents has been developed with excellent results in terms of disappearance of the cyst, very low side effects and low mortality rate.

MATERIALS AND METHODS

One hundred sixty eight patients with 225 liver cysts were studied. A total of 108 patients with 151 viable hydatid liver cysts underwent Double Percutaneous Aspiration and Injection of alcohol of the cyst without re-aspiration of the ethanol, which remained in situ.

RESULTS

The mortality rate was 0.9% (1 patient), the overall morbidity was 8.6% with only 2.5% of major side effects. The mean hospital stay was very short (2.9 days). Follow-up ranged from 14 to 204 months (median 48 months). Ultrasonography showed complete disappearance of the cyst with reconstitution of liver parenchyma in 109 out of 225 (48.4%) cysts; in the remaining cysts a solid or a liquid findings were observed in 104 (46.2%) and 12 (5.3%), respectively, with a decreased volume of 50-80%.

CONCLUSION

These data show that Double Percutaneous Aspiration and Injection of alcohol for hydatid liver cysts can achieve comparable results to open surgery. The low incidence of side effects shows that this technique is safe and cost effective, compared to radical or conservative surgery.

Predictive factors of deep abdominal complications after operation for hydatid cyst of the liver: 15 years of experience with 672 patients

BACKGROUND

Operations are the mainstay of liver hydatid cyst (LHC) treatment. Operations are still associated with high morbidity and mortality because of specific postoperative complications (bile leaks, bilomas, deep bleeding, and deep suppurations) and deep abdominal complications (DAC). The aim of this study was to identify the predictive factors of DAC after LHC operation.

STUDY DESIGN

We conducted a retrospective study of 672 patients with LHC treated at the Surgery Department "A" at Ibn Sina University Hospital, Rabat, Morocco. Specific morbidity (DAC) and 30 variables were assessed. Univariate and multivariate logistic regression were performed to identify predictive factors for DAC. An associated risk scoring system was developed.

RESULTS

Six hundred sixty-four patients underwent operations. Mortality rate was 0.8% (n = 5) and DAC rate was 18.4% (n = 121). Five independent predictive factors of DAC after LHC operation were retained, ie, presence of cyst preoperative complications (odds ratio [OR] = 3.10; 95% CI, 1.85 to 5.17), 3 or more cysts in the liver (OR = 2.55; 95% CI, 1.42 to 4.59), thick pericyst (OR = 2.59; 95% CI, 1.27 to 5.29), biliary fistula (OR = 2.27; 95% CI, 1.38 to 3.72), and capitonnage alone as residual cavity management (OR = 2.23; 95% CI, 1.12 to 4.44). Multivariate model showed a good fit. Discriminating ability of the model was fair. In theoretical risk, scores ranged from 0 to 5. When the score was 2 or more, sensitivity of the scoring model was 80.3%, specificity was 58.5%, positive predictive value was 30.3%, and negative predictive value was 93%.

CONCLUSIONS

Identification of these five factors will allow more appropriate therapeutic care after LHC operation.

Albendazole for the treatment of human echinococcosis: a review of comparative clinical trials

BACKGROUND

Albendazole has been used in various ways in the treatment of cystic echinococcosis (CE).

METHODS

We reviewed the available evidence regarding the role of albendazole for the treatment of patients with CE. The available comparative clinical trials (randomized or not) that examined the use of albendazole in CE were identified from the PubMed and the ISI Web of Science databases. Relevant data from the trials were extracted and evaluated.

RESULTS

Thirteen studies were included in the review. Albendazole is superior to placebo for inoperable, symptomatic patients (1 study). In addition, in 4 trials that tested albendazole as a preoperative adjuvant therapy, the drug resulted in degeneration of hydatid cysts at the time of surgery in a considerable proportion of patients. Furthermore, combined therapy with albendazole and PAIR (Puncture, Aspiration, Injection of scolicidal agent, and Re-aspiration) technique was found more effective than albendazole or PAIR treatment alone, in a randomized controlled trial examining this issue. Finally, although existing evidence shows some superiority for albendazole compared to mebendazole, there is no definite proof about this.

CONCLUSIONS

Although the available comparative trials provide considerable evidence for the role of albendazole in patients with CE, there are some important clinical questions that remained unanswered by the studies. One of them is whether the combination of albendazole with praziquantel is superior to albendazole alone when both effectiveness and drug toxicity are taken into account. Also, further studies should also compare the combination of albendazole/PAIR with albendazole/surgery focusing on both short and long term outcomes.

Satellite cysts and biliary fistulas in hydatid liver disease. A retrospective study of 17 liver resections

In Switzerland, the preferred mode of treatment for hydatid liver disease caused by Echinococcus granulosus is surgery, giving us the opportunity for a retrospective histopathologic study of 17 consecutive liver resections. We focused on the occurrence of satellite cysts and of biliary fistulas and their effects on bile ducts. Of 17 patients, 6 (35%) had one or more satellite cysts, to be distinguished from internal daughter cysts. Small areas of fibrinoid necrosis within the fibrous pericyst, a surprisingly constant histologic finding, offer a simple explanation for the occurrence of such satellite cysts as well as for the development of biliary fistulas. Large fistulas with gross drainage of cyst contents into bile ducts were present in 5 patients (30%). The accompanying cholangitis was distinctly granulomatous in 2 of them, an observation rarely mentioned in the literature. All 5 patients with large fistulas also had chronic sclerosing cholangitis and dilatation of smaller bile ducts, in all probability the result of chronic cyst fluid leakage through preexisting, clinically silent smaller fistulas. Dilatation of small bile ducts is rightly considered a precursor sign for large fistulas. Awareness of the histopathology of these complications facilitates the interpretation of ultrasound and radiologic imaging, sheds light on their pathogenesis, and may influence the choice of treatment.

Falciform Ligament in the Management of the Residual Cavity for Liver Hydatidosis: New Surgical Technique

INTRODUCTION

Hydatid disease is a common condition worldwide and continues to be a significant societal problem in many countries of all continents. Alhough other treatment options are also available, surgery remains the cornerstone of therapy for hepatic hydatid disease. Omentoplasty seems to be an efficient technique for managing the residual cavity, but it has some shortcomings and might be difficult in secondary cases. Therefore we describe a new technique using the falciform ligament as a flap instead of omentum for managing the residual cavity, as it is more anatomic and a better option for liver cysts.

METHODS

From April 2004 to October 2005, a total of 20 patients (11 women) with a median age of 43 years (range 23-66 years) underwent partial cystectomy-falciformoplasty for hydatid liver disease. The falciform ligament was prepared as a flap in all patients during the initial step of the operation and, after partial cystectomy and evacuation of the cystic components, the flap was inserted into the cystic cavity and fixed with sutures. A single drain was inserted into the subhepatic area.

RESULTS

Cysts were located in the right lobe of the liver in 14 patients and mean diameter of the cyst was 10 cm (range 7-25 cm). The mean duration of the operation was 40 minutes (range 35-69 minutes), and the mean postoperative hospital stay was 4 days (range 3-7 days). None of the patients had any major complications. Only two patients had persistent drainage for 7 days, which stopped spontaneously. The median follow-up was 9 months (range 2-19 months). Patients underwent duplex ultrasonography (US) to check the viability of the flap and the residual cavity at 1 week, 1 month, and 3 months postoperatively. US did not reveal any collection, the cavities were fully collapsed, and blood flow to the falciform ligaments was seen to be viable.

CONCLUSIONS

Using the falciform ligament as a flap for management of the residual cavity is an easy, safe, effective new technique with few complications. It might be a good choice in patients with hydatid liver disease.

Endoscopic stenting for selected cases of biliary fistula after hepatic hydatid surgery

BACKGROUND

Biliary fistula develops in 4%-28% of patients after hepatic hydatid disease (HHD) surgery. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) are helpful in the treatment of this complication, persistent fistulas may occur. We therefore conducted a study to evaluate the efficacy of endoscopic biliary stenting in the treatment of biliary fistulas after HHD.

METHODS

In this study, 84 patients who underwent ERCP for postoperative biliary fistula due to HHD were evaluated. Group I included 70 patients treated with only ES, and group II included 14 patients who underwent biliary stenting as their initial treatment. Demographic data, complications, the results of treatment and the reasons for the failure were compared between two groups.

RESULTS

Ninety-five ERCPs were performed. In 63 patients, biliary fistulas were successfully treated with only ERCP and ES. However, 7 patients underwent repeat ERCP and stent placement because of persistent fistula. Biliary stenting was initially performed in 14 patients. The average time for closure of the fistula was 14 +/- 10 days and 7 +/- 3 days in group I (7 patients with repeat ERCP were excluded) and group II, respectively (p = 0.007). There was no statistically significant difference in the complication rates between the groups.

CONCLUSIONS

Although ES is effective in the treatment of biliary fistula after HHD surgery, endoscopic biliary stenting may be considered as the initial procedure in patients with biliary stricture, incomplete clearance of hydatid material in the bile duct, and persisting biliary fistulas after treatment with ERCP and ES.

Giant Hepatic Hydatid Cyst as a Cause of Small Bowel Obstruction

Today, giant hydatid cysts are fairly rare even in endemic areas. We describe a case of an extremely large hydatid cyst of the liver that was causing massive compression of the neighboring organs, giving rise to a subocclusive syndrome of the intestine. After considering the various approaches available for the treatment of this disease, it was decided that radical surgery was still the best therapeutic choice, especially when extremely large cysts are involved. In particular, in clinical situations where it is difficult to perform radical surgical procedures, less aggressive surgery followed by drug treatment should be the treatment of choice.

Global socioeconomic impact of cystic echinococcosis

Because the human and economic losses of cystic echinococcosis are substantial, global prevention and control measures should be increased.

Cystic echinococcosis (CE) is an emerging zoonotic parasitic disease throughout the world. Human incidence and livestock prevalence data of CE were gathered from published literature and the Office International des Epizooties databases. Disability-adjusted life years (DALYs) and monetary losses, resulting from human and livestock CE, were calculated from recorded human and livestock cases. Alternative values, assuming substantial underreporting, are also reported. When no underreporting is assumed, the estimated human burden of disease is 285,407 (95% confidence interval [CI], 218,515–366,133) DALYs or an annual loss of US $193,529,740 (95% CI, $171,567,331–$217,773,513). When underreporting is accounted for, this amount rises to 1,009,662 (95% CI, 862,119–1,175,654) DALYs or US $763,980,979 (95% CI, $676,048,731–$857,982,275). An annual livestock production loss of at least US $141,605,195 (95% CI, $101,011,553–$183,422,465) and possibly up to US $2,190,132,464 (95% CI, $1,572,373,055–$2,951,409,989) is also estimated. This initial valuation demonstrates the necessity for increased monitoring and global control of CE.

Results of surgical, laparoscopic, and percutaneous treatment for hydatid disease of the liver: 10 years experience with 355 patients

Selection of the most appropriate treatment to obtain the best results with the lowest rate of recurrence and minimal morbidity and mortality is mandatory for the management of hepatic hydatid disease. The surgical approach is the mainstay of treatment, and there has been a tendency toward laparoscopic surgery and, more recently, percutaneous treatment (PT), which has become increasingly popular with revolutions in techniques. We aimed to evaluate the results of current therapeutic methods in the context of a 10-year single-institution experience. Between 1992 and 2003, 355 patients with 510 hydatid cysts of the liver were treated by open operation, laparoscopic surgery, or PT. The series included 128 females and 227 males ranging in age from 10 years to 73 years. Preferred treatment modalities, perioperative complications, interventions, recurrences, and length of hospital stay were retrospectively analyzed. There were two postoperative deaths (1.08%) in the open surgery group. Biliary leakage was observed in 28 patients treated with open surgery, in 10 patients after PT, and in 2 after laparoscopic treatment. Recurrence rates were 16.2%, 3.3%, and 3.5% after open surgery, laparoscopic surgery, and percutaneous treatment, respectively. Characteristics of the cyst, presence of cystobiliary communications, and the availability of a multidisciplinary team are the factors that we believe directly affect the results. Radical surgery can be done safely for suitable cases; conventional procedures are associated with greater morbidity. Laparoscopic surgery seems effective and safe, with low morbidity and recurrence rates for type I-III cysts in accessible localizations. Our experience with PAIR (puncture, aspiration, injection, and reaspiration) and catheterization provides evidence that the procedure is an effective and safe option.

Surgical treatment of liver hydatid cysts

BACKGROUND

The surgical treatment technique for liver hydatic cyst (LHC) cannot be standardized, and the surgical technique should be tailored according to the extent of the cyst and any adjunct complications of hydatid disease.

PATIENTS AND METHODS

All patients were treated with albendazole (10 mg/kg/day) for 15 days preoperatively. Total pericystectomy was performed in three patients (7%). Partial cystectomy and its modifications were performed in the remaining 41 patients (93%).

RESULTS

A total of 44 patients were operated on for LHC between December 1998 and October 2004 in our center. Patients were evaluated with ultrasonography and computed tomography scan to determine the extent of the disease and preoperative staging. Twenty-four (53%) of these patients were women and 20 were men (median age, 52.5 years; range, 19-81 years). The majority of patients (n=27) had 1 cyst, and the remaining 17 patients had multiple cysts. In four patients (9.1%), daughter cysts were found in the biliary system, and abscesses were present in three patients (7%). Biliary fistula was the most frequent complication (n=5). Three patients had wound infections. Follow-up was complete for 33 patients (75%). The mean postoperative follow-up was 11.9+/-10.8 months; there were four recurrences during this time.

DISCUSSION

The aim should be to provide complete drainage and obliteration of the cavity. Bile leak and biliary obstruction may complicate the postoperative course if bile leakage into the peritoneal cavity and obstruction in the biliary system are missed.

Factors associated with morbitity in liver hydatid surgery

BACKGROUND

The purpose of the present paper was to determine the association between clinical evolutionary and laboratory variables with postoperative morbidity in patients surgically treated for liver hydatidosis (LH).

METHODS

A case-control nested cohort study was undertaken. Patients were studied and surgically treated in Hospital Regional of Temuco between 1994 and 2001. The morbidity variable registered with a minimum 12-month follow-up period was considered in a dichotomous way. The association with clinical, laboratory, evolutionary, and surgical variables was studied. Descriptive statistics, bivariate analysis using chi(2) and Fisher's exact test for categorical variables; t-test, anova, and Kruskal-Wallis for continuous variables; odds ratio calculations, and ordinal and multivariate logistic regression models were applied.

RESULTS

The cohort was composed of 202 patients surgically treated for LH, 112 women (55.5%) and 90 men (44.5%), with an average age of 45.2 years. Average morbidity of the series, with a median follow-up period of 53 months, was 16.4%. Six variables were significantly associated in the bivariate analysis (age, haematocrit, total leucocyte count, alkaline phosphatase, history of previous surgery for LH and existence of biliary communications), but only two achieved statistical significance in the multivariate model (age and history of previous surgery for LH; P = 0.017 and 0.018; and odds ratio of 1.0 and 4.1, respectively).

CONCLUSIONS

In surgical decision making for patients with LH, the history of previous surgery for LH must be considered as a risk factor for postoperative morbidity.

Antiparasitic therapy in children

Treatment of parasitic infections in children presents many challenges for the clinician. Although parasitic infections are ubiquitous on a worldwide basis, with an estimated 1 billion persons infected with intestinal helminthes alone, physicians in the United States and other developed countries are often unfamiliar with the management of these diseases. Children are traveling internationally in larger numbers than ever before, however, and emigration from developing countries to the United States and other Western countries is increasing, so clinicians in these countries are confronted more frequently with parasitic diseases from the tropics. This article describes current approaches to antiparasitic therapy. Drugs used in the treatment of more than one type of parasite are presented once in detail, with reference to the detailed description in subsequent sections.

Dual treatment of albendazole in hepatic hydatidosis: New therapeutic modality in 52 cases

BACKGROUND

Hepatic hydatidosis still remains as a serious problem in general surgery. Recurrence and/or secondary hydatidosis rates are up to 25% in the cases treated with surgery alone. Albendazole is the most commonly used drug in the medical treatment of echinococcosis. The aim of the present study was to evaluate the effect of albendazole using the intraoperative and perioperative periods as dual therapy.

METHODS

Fifty-two cases of hepatic hydatidosis were evaluated and treated by dual treatment of albendazole together with surgery. Perioperative albendazole treatment was given in a dose of 12-15 mg/kg per day in four divided doses. The treatment started 2-28 days before the surgery when the diagnosis was established and continued for 2-24 months (4.76 +/- 3.25) postoperatively in a cyclic monthly form. A total of 1.7 microg/mL albendazole solution was used as a protoscolicidal agent in the cystic cavity intraoperatively. In the postoperative period serology, ultrasonography and computed tomography evaluations were done. The follow-up period was 5-92 months (mean: 62.48 months).

RESULTS

There was no recurrence in the present study. One patient died in the 6th postoperative week due to cerebral hydatidosis and multiple organ failure. Early and late morbidity rates were 7.69 and 9.61%, respectively.

CONCLUSIONS

Dual albendazole treatment is effective in the prevention of recurrences and/or secondary hydatidosis.

Effect of Different Pharmacologic and Chemical Agents on the Integrity of Hydatid Cyst Membranes

OBJECTIVE

We performed an in vitro investigation of the effects of widely used scolicidal and sclerosing agents, as well as some pharmacologic products, on the integrity of the membrane of hydatid cysts.

MATERIALS AND METHODS

Two milliliters each of 22 agents, 2 mL of clear fluid, and one piece of hydatid cyst membrane were put into bottles. The hydatid cyst membranes were evaluated by visual observation and manual palpation. Visual examination of the bottles was performed daily for 7 days, and observations of membrane changes, including translucency, destruction, swelling, and melting, were recorded. Manual evaluation was done on the seventh day by finger examination, and membrane fragility was scored.

RESULTS

The hydatid cyst membrane was completely melted in a few minutes in a 2.5% solution of sodium hypochlorite and in 1 hr by a 0.1% sodium hypochlorite solution. The integrity of the hydatid cyst membrane was preserved in alcohol, acetone, glutaraldehyde, albendazole, acetylsalicylic acid, formaldehyde, lidocaine, hydrochloric acid, ammonia, pancreatin, Betadine, methylene blue, and isotonic saline samples. The membranes in the metronidazole and hypertonic saline solutions were not damaged but showed significantly increased fragility. The membranes in levamisole and piperazine hexahydrate became translucent and showed moderate fragility.

CONCLUSION

None of the agents that are used in clinical practice had important effects on the dissolution of hydatid cyst membranes. However, sodium hypochlorite solutions completely melted the hydatid cyst membranes. Because the use of this agent on living tissue is limited, further study is needed to investigate its clinical use.

Controversies in the laparoscopic treatment of hepatic hydatid disease

BACKGROUND

Laparoscopic treatment of hydatid disease of the liver can be performed safely in selected patients.

METHODS

Six hundred and fifty patients were treated for hydatid disease of the liver between 1980 and 2003 at the Hepatopancreatobiliary Surgery Unit of Istanbul Medical Faculty, Istanbul University. Of these, 60 were treated laparoscopically between 1992 and 2000. A special aspirator-grinder apparatus was used for the evacuation of cyst contents. Ninety-two percent of the cysts were at stages I, II or III according to the ultrasonographic classification of Gharbi.

RESULTS

Conversion to open surgery was necessary in eight patients due to intra-abdominal adhesions or cysts in difficult locations. There was no disease- or procedure-related mortality. Most of the complications were related to cavity infections (13.5%) and external biliary fistulas (11.5%) resulting from communications between the cysts and the biliary tree. There were two recurrences in a follow-up period ranging between 3.5 and 11 years.

DISCUSSION

Laparoscopic treatment of hydatid disease of the liver is an alternative to open surgery in well-selected patients. Important steps are the evacuation of the cyst contents without spillage, sterilization of the cyst cavity with scolicidal agents and cavity management using classical surgical techniques. Our specially designed aspirator-grinder apparatus was safely used to evacuate the cyst contents without causing any spillage. Knowledge of the relationship of the cyst with the biliary tree is essential in choosing the appropriate patients for the laparoscopic technique. In our experience of 650 cases, the biliary communication rate was as high as 18%; half of these can be detected preoperatively. In the remaining, biliary communications are usually detected during or after surgery. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are helpful to overcome this problem. As hydatid disease of the liver is a benign and potentially recurrent disease, we advocate the use of conservative techniques in both laparoscopic and open operations.

Epidemiology, clinical manifestations and diagnosis of zoonotic cestode infections: an update

This paper reviews the literature on zoonotic cestode infections with specific reference to the years 1999-2003. The sources and prevalence of various zoonotic tapeworm infections caused by adult and larval stages of the genera Taenia, Echinococcus, Diphyllobothrium, Hymenolepis and Dipylidium continue to be an important cause of morbidity and mortality, not only in most underdeveloped countries but also in industrialized countries, particularly in rural areas or among immigrant groups from endemic areas. The review gives a detailed report on recent molecular epidemiological studies on the taxonomy and phylogenetic variations in Echinococcus granulosus, immunological tests and imaging techniques used in epidemiological surveys and clinical investigations of important adult and larval tapeworm infections of animals and humans. Larval stages or metacestodes of Taenia solium, Echinococcus spp. and pseudophyllidean tapeworms (Spirometra syn. Diphyllobothrium spp.) may reside in various tissues of their intermediate hosts, including humans. In particular, Cysticercus cellulosae (T. solium) and the larvae of E. granulosus, and E. multilocularis, which are predominantly located in the liver, lungs and central nervous system forming various types of cysts, lead to a complex of systemic diseases such as cysticercosis, cystic echinococcosis and alveolar echinococcosis, respectively. Relatively rare clinical manifestations are seen in the muscles, subcutaneous tissue, spleen, kidneys, bones and body cavities.

Single-stage transthoracic approach for right lung and liver hydatid disease

OBJECTIVE

Human echinococcosis remains a serious health problem for the Mediterranean countries. Synchronous pulmonary and hepatic hydatid disease may occur in 4% to 25% of cases. Our experience on simultaneous surgical treatment of right lung and liver hydatid disease in patients was reviewed.

METHODS

Between 1990 and 2000, 48 patients (33 female patients and 15 male patients) with synchronous right lung and liver dome hydatid cysts were operated with a 1-stage procedure.

RESULTS

Six patients had previous surgical treatment of hepatic (n = 2) or pulmonary (n = 4) hydatid cyst. The pulmonary cysts were diagnosed with radiography in 18 patients and thoracic computed tomography scan in 30. The pulmonary cysts of 9 patients were bilateral. Seventy-five pulmonary cysts were seen in radiological examinations. The diagnosis of hepatic cysts was established with ultrasonography in 18 patients and upper abdominal computed tomography in 30. The total number of hepatic cysts was 48. In cases with pulmonary cysts, cystotomy and capitonnage were performed in 32 patients, only cystotomy was done in 14 patients, and wedge resection was performed in 2. Liver cysts were approached to transdiaphragmatically after the lung cysts had been dealt with and were managed with evacuation of the cysts. In the remaining cases, marsupialization (n = 2), pericystectomy (n = 1), and enucleation (n = 1) were performed. Major postoperative complications were hemorrhage (n = 1) and biliocutaneous fistula (n = 1). Hepatic recurrence was seen in 3 patients (6.2%) and pulmonary recurrence in 1 (2.1%).

CONCLUSION

Transthoracic approach is a useful and a safe surgical management of both pulmonary and upper surface of hepatic hydatid cysts.

Echinococcus granulosus infection: the challenge of surgical treatment

BACKGROUND

Cystic echinococcosis (CE) is a worldwide zoonosis caused by larval stages of the cestode Echinococcus granulosus. Surgery, chemotherapy, and interventional procedures are the therapeutic options. Surgery can cure the patient if the parasite is removed entirely. However, the technical procedures are inconsistent and comprise partial liver resection or opening of the parasitic cyst and removal of the parasite. Laparotomy is the most common approach. In selected cases laparoscopic methods are successful. Retrospective studies outweigh prospective ones by far. However, proper management gives favorable results.

METHODS

We critically review the literature and present a brief summary of current surgical strategy and focus on issues relevant for surgeons: diagnosis, indication for medical treatment, indication for surgical treatment, surgical procedures, scolicidal agents, morbidity, mortality, recurrence, perioperative medication, standards.

RESULTS

All surgical procedures aim at the complete removal of the parasite. Liver resection and pericystectomy are procedures that resect the closed cysts with a fairly wide safety margin. A meta-analysis shows the best results regarding lethality (1.2%), morbidity (11.7%), and recurrence rates (2%) for resective operations. However, most surgeons consider these methods as too radical for a benign disease. Procedures that remove the parasite and keep the pericyst (=cystectomy) are easier to carry out than resective ones. The meta-analysis presented revealed a lethality of 2%, morbidity of 23%, and recurrence rate of 10.4% for these operations. Omentoplasty is the option of choice for the management of the remaining cyst cavity. Despite alternative procedures surgery is the treatment of choice. Supportive measures comprise the use of scolicidal agents and postoperative benzimidazole administration. However, a critical review of the literature disclosed a lack of scientific confirmation of established treatment modalities and procedures. The results of ultrasound imaging were classified and correlated to the developmental phases of CE.

CONCLUSIONS

Cystectomy and omentoplasty for CE should be the standard surgical procedure because it is safe, simple, and effective and meets all criteria of surgical treatment for hydatid disease: entire elimination of the parasite, no intraoperative spillage especially by using a cone, and saving healthy tissue. Pericystectomy should be used for peripherally located liver cysts that are surrounded by parenchyma only partially. Ultrasonic classification of the parasitic lesion should be used as a guideline for therapeutic measures.