Distribution of hydatid cysts into the liver with reference to cystobiliary communications and cavity-related complications

Biliary fistula and late recurrence of liver hydatid cyst: Role of cysto-biliary communication: A prospective multicenter study

BACKGROUND

Hydatid cyst disease (HCD) is common in certain locations. Surgery is associated with postoperative biliary fistula (POBF) and recurrence. The primary aim of this study was to identify whether occult cysto-biliary communication (CBC) can predict recurrent HCD. The secondary aim was to assess the role of cystic fluid bilirubin and alkaline phosphatase (ALP) levels in predicting POBF and recurrent HCD.

AIM

To identify whether occult CBC can predict recurrent HCD. The secondary aim was to assess the role of cystic fluid bilirubin and ALP levels in predicting POBF and recurrent HCD.

METHODS

From September 2010 to September 2016, a prospective multicenter study was undertaken involving 244 patients with solitary primary superficial stage cystic echinococcosis 2 and cystic echinococcosis 3b HCD who underwent laparoscopic partial cystectomy with omentoplasty. Univariable logistic regression analysis assessed independent factors determining biliary complications and recurrence.

RESULTS

There was a highly statistically significant association (P ≤ 0.001) between cystic fluid biochemical indices and the development of biliary complications (of 16 patients with POBF, 15 patients had high cyst fluid bilirubin and ALP levels), where patients with high bilirubin-ALP levels were 3405 times more likely to have biliary complications. There was a highly statistically significant association (P ≤ 0.001) between biliary complications, biochemical indices, and the occurrence of recurrent HCD (of 30 patients with recurrent HCD, 15 patients had high cyst fluid bilirubin and ALP; all 16 patients who had POBF later developed recurrent HCD), where patients who developed biliary complications and high bilirubin-ALP were 244.6 and 214 times more likely to have recurrent hydatid cysts, respectively.

CONCLUSION

Occult CBC can predict recurrent HCD. Elevated cyst fluid bilirubin and ALP levels predicted POBF and recurrent HCD.

Surgical treatment of liver hydatic cyst and evaluation of cystobiliary fistula: experience of two centers

Objective: Intrabiliary rupture or cystobiliary fistula is the most common complication of hepatic hydatid cyst. In this article, our objective is to evaluate the clinical, laboratory, imaging, surgical treatment and results of cystobiliary fistulas, which is the most common complication of hydatid cysts. Material and Method: In our study, patients who underwent open surgery and were followed up and treated for hydatid cyst in the gastroenterology and general surgery outpatient clinic and service between years 2015-2021 were included. The clinical, laboratory, radiological and surgical results of 171 patients with hydatid cysts were retrospectively analyzed. Results: The mean age of 171 patients who underwent surgery for hydatid cyst was 44.8 (18-71), 68 of whom were men and 103 were women. Bile leakage was present in 50 patients (50 (29.23%)). There were 24 (48%) men and 26 (52%) women with bile leakage. The cyst diameter was 74.2 (36-170) mm and the number of cysts was 1.2 (1-2). The cysts were located in the right lobe of the liver in 116 (79%) patients, in the left lobe in 30 (15%) patients, and in both lobes in 25 (6%) patients. Cystobiliary fistula developed more frequently, especially in cysts located in the right lobe(36 (72%)). Cystobiliary fistula was most common in CE3 (Gharbi type 2) type (30 (60%)). Cystectomy+drainage was performed in 137 (80%) patients in all groups. Cystectomy and drainage were the most common surgical procedures. The cyst diameter was 10 cm in the group with cystobiliary fistula and was significant compared to the group without fistula (p<0.001). Aminotransferase (AST and ALT) levels were high in patients with cystobiliary fistula (p=0.012, p=0.054). However, there was no significant difference between the two groups in alkaline phosphatase, total bilirubin, and gamma glutamyl transferase (p=0.231, p=0.097, p=0.544). Conclusion: Liver hydatid cyst is endemic in our country as well as in many other countries in the world. Complicated hepatic hydatid cysts require timely and appropriate treatment because of their life-threatening complications. Cytobiliary fistula is the most common complication. In the surgical treatment of hydatid cyst disease, the earlier the diagnosis of occult cystobiliary fistulas is made (especially in the preoperative or peroperative period), the easier the treatment is, and the risk of bile leakage and consequently the morbidity and mortality decreases. Our results and experience showed that treatment and complications are related to the location and size of the cyst, occult/large cystobiliary fistula, detectability of occult fistulas, experienced center and surgeon.

Radical versus conservative surgical treatment of liver hydatid cysts: A paired comparison analysis

BACKGROUND

The management of liver hydatid cysts (LHC) is complex and includes surgery, percutaneous drainage, chemotherapy and observation. Broadly, there are two types of surgical treatment for LHC - conservative surgery (CS) and radical surgery (RS). The purpose of this study was to compare the outcome of RS and CS.

METHODS

Data from all patients with LHC treated in Sahloul Hospital, between January 2000 and December 2019, were retrieved. To minimize selection bias, paired comparison analysis (PCA) was performed.

RESULTS

A total of 914 patients were included in this study. RS and CS were performed in 284 and 630 patients, respectively. After PCA, 206 patients were included in each group. The incidence of intraoperative bleeding was significantly higher in the RS group. The overall morbidity was significantly lower in the RS group. Thity-four patients developed recurrence with significantly higher recurrence in CS group.

CONCLUSION

RS is associated with fewer postoperative complications and lower recurrence rate compared to CS. RS may be the preferred procedure for LHC if the expertise is available.

Closed Cyst Resection for Liver Hydatid Disease: a New Standard

BACKGROUND

Although radical resections are recommended for the surgical management of liver hydatid disease (LHD), whether closed (CCR) or opened (OCR) cyst resections should be performed remains unclear. The aim of this study was to compare the postoperative and long-term outcomes of CCR and OCR for primary and recurrent LHD.

MATERIALS AND METHODS

Medical charts of patients who underwent surgery at a single centre were retrospectively reviewed and compared with respect to major postoperative complications and recurrence rates.

RESULTS

Seventy-nine CCRs and 37 OCRs were included. The major morbidity rates were 19% and 5% in the OCR and CCR groups, respectively (P = 0.036). In multivariate analysis, OCR (P = 0.030, OR = 5.37) and the operative time (P < 0.001, OR = 18.88) were the only independent predictors of major complications. The 5-year and 10-year recurrence rates were both 0% in the CCR group compared to 18% and 27%, respectively, in the OCR group (P < 0.001). The mean time to recurrence was 10.5 (± 8) years.

DISCUSSION

Closed cyst resection for LHD is a safe and effective approach with a low risk of recurrence. Considering that recurrence could appear more than 10 years after surgery, follow-up of patients should be adapted.

Bile leakage test in emergency hydatid liver cyst surgery

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It is not always possible to reveal the existing occult CBC during the operation.

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Bile leakage test has been shown to reduce postoperative biliary complications.

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Bile leakage test has been performed by cannulated the common bile duct via 22G catheter.

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Normal saline and parenteral lipid solution has been given to demonstrate the CBCs.

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This test can be applied even in emergency conditions.

Introduction and importance

In liver cyst hydatid surgery, presence of cysto-biliary communication (CBC) is important for the prevention of postoperative morbidity. If cysto-biliary connections are not obvious, diagnosis is not easy. Intraoperative bile leakage test has been shown to reduce postoperative biliary complications by revealing occult CBCs. However, bile leakage testing in emergency conditions such as hydatid cyst perforation has not been experienced so far.

Case presentation

Here, a bile leakage test performed in a 23-year-old male patient undergoing emergency surgery due to the perforation of the hydatid liver cyst was presented. Following the treatment of perforated hydatid liver cyst and biliary peritonitis, a bile leakage test was performed. The common bile duct was cannulated with a 22G catheter, normal saline and parenteral lipid solution were given to demonstrate the CBCs, and leakage areas were suture ligated. The patient was discharged postoperatively without any problem.

Conclusion

We recommend detection and treatment of the CBCs even in emergency hydatid liver cyst surgery for prevention of postoperative biliary complications.

Double versus single T-tube drainage for frank cysto-biliary communication in patients with hepatic cystic echinococcosis: a retrospective cohort study with median 11 years follow-up

BACKGROUND

Partial peri-cystectomy (PPC) is one of the major surgical approaches for hepatic cystic echinococcosis (CE) and has been practiced in most centers worldwide. Cysto-biliary communication (fistula, leakage, rupture) is a problematic issue in CE patients. T-tube is a useful technique in situations where an exploration and decompression are needed for common bile duct (CBD). However, postoperative biliary complications for cystic cavity still remains to be studied in depth.

METHODS

A retrospective cohort analysis of CE cases in our single center database from 2007 March to 2012 December was performed. Patients (n = 51) were divided into two cohorts: double T-tube drainage (one at CBD for decompression and one at the fistula for sustaining in cystic cavity, n = 23) group and single T-tube drainage cohort (only one at CBD for decompression, n = 28). Short-/long-term postoperative complications focusing on biliary system was recorded in detail and they were followed-up for median 11 years.

RESULTS

Overall biliary complication rates for double and single T-tube drainages were 17.4% vs. 39.3% (P > 0.05). Short-term complications ranged from minor to major leakages, cavity infection and abscess formation, and prevalence was 17.4% vs. 21.4% (P > 0.05) respectively for double and single T-tube groups; most importantly, double T-tube drainage group had obvious advantages regarding long-term complications (P < 0.05), which was biliary stricture needing surgery and it was observed only in single T-tube drainage group.

CONCLUSIONS

Double T-tube drainage had better outcomes without procedure-specific postoperative biliary complications than single T-tube drainage. Meanwhile, we recommend long-term follow-up when comparing residual cavity related biliary complications in CE patients as it could happen lately.

Surgical management of hepatic hydatid cysts - conservative versus radical surgery

BACKGROUND

Surgical management is considered one of the effective treatment modality for liver hydatid. However the choice of surgery is debatable. This study aims to compare the outcome of radical surgery (RS) and conservative surgery (CS) in liver hydatid disease.

METHODS

This is retrospective analysis of prospectively maintained institutional data of surgically treated liver hydatid from January 2012 to January 2019. The basis of diagnosis was typical imaging, confirmatory Hydatid serology and/or Intraoperative details. The clinical presentation, radiological data, operative detail, post-operative outcome, post-operative recurrence data was analysed.

RESULTS

Sixty-four patients underwent surgery during the study period and were included. RS was done in 27 (42.2%) patients and CS in 37 (57.8%) patients. The mean age was 35.6 (13-72) years. The mean size of the cyst was 10.3 ± 2.9 cm. The cyst location was peripheral in 81.5% and 56.8% in RS and CS groups respectively. Intraoperative Cyst biliary communication was detected in 48.1% of RS & 35.1% in CS group of patients. The post-operative bile leak was significantly less in RS group (7.4% vs 27.0%, p = 0.047). Postoperative endoscopic stenting for persistent biliary fistula was necessitated in five of CS and only one patient from RS group. None of RS patients had recurrence while 3 patients of CS developed recurrence.

CONCLUSION

Radical surgery reduces post-operative bile leak and prevents recurrence and may be preferable to conservative surgery.

Nomogram Analysis and Internal Validation to Predict the Risk of Cystobiliary Communication in Patients Undergoing Hydatid Liver Cyst Surgery

Purpose

Biliary leakage caused by cystobiliary communication (CBC) is a common clinical concern. This study sought to identify predictors of CBC in hepatic cystic echinococcosis (HCE) patients undergoing hydatid liver cyst surgery and establish nomograms to predict CBC.

Methods

A predictive model was established in a training cohort of 310 HCE patients diagnosed between January 2013 and May 2017. Upon revision of the records of clinical parameters and imaging features of these patients, the lasso regression model was used to optimize feature selection for the CBC risk model. Combined with feature selection, a CBC nomogram was developed with multivariable logistic regression. C-index and calibration plots were used to analyze and evaluate the discrimination and calibration. The net benefit and predictive accuracy of the nomogram were performed via decision curve analysis (DCA) and receiver operating characteristic (ROC) curve. An independent validation cohort of 132 patients recruited from June 2017 to May 2019 was used to evaluate the practicability of the nomogram.

Results

Predictors contained four features, namely alkaline phosphatase (ALP), glutamyl transpeptidase (GGT), cyst size and cyst location. The C-index of the nomogram is 0.791 (95% CI, 0.736–0.845), while the C-index verified by bootstrap is 0.746, indicating high prediction accuracy. The area under the curve (AUC) of the CBC in training was 0.766. ROC curve analysis demonstrated high sensitivity and specificity. Decision curve analysis confirmed the CBC nomogram was clinically useful when the intervention was determined at the non-adherence possibility threshold of 8%.

Conclusion

The nomogram developed using the ALP, GGT, cyst size and cyst location could be used to facilitate the CBC risk prediction in HCE patients.

Subcutaneous Hydatid Cyst in Laboratory Mice: Is it a Suitable Method for Evaluating Therapeutic Agents against Hydatid Cyst?

Hydatid disease is an economic and public health concern in many countries. Currently, surgery is the main treatment option for hydatid disease. In the surgical treatment of hydatidosis, the use of scolicidal agents is very important due to inactivating live protoscoleces and preventing the recurrence of infection. Therefore, it is necessary to investigate newscolicidal agents and novel medications with higher safety and efficacy. In the previous in vitro studies, the scolicidal effects of the methanolic extracts and aromatic water of Zataria multiflora (Z. multiflora) have been demonstrated. Consequently, in this study, the impact of the nanoemulsion of Z. multiflora essential oil on subcutaneous hydatid cysts was compared with albendazole (ABZ). Fifty laboratory male mice were inoculated with 300 viable protoscoleces subcutaneously on the two sides of the abdomen. Following five months of infection, the remaining infected mice (n=42) were allocated into two treatment and one control (without treatment) groups containing fourteen animals each. Group A received ABZ at the dose of 50 mg/kg for 60 days, group B received the nanoemulsions of Z. multiflora at the dose of 50 mg/kg in drinking water for 60 days, and group C was considered as the control group. All the infected mice were euthanized and necropsied two months post-intervention. Afterwards, the cysts were cautiously collected and their number, size, and weight were compared between the mice of different groups. The mean number of hydatid cysts indicated that the nanoemulsion of Z. multiflora essence had a relative superiority to ABZ. On the other hand, the therapeutic effect of ABZ was higher than the nanoemulsion of Z. multiflora essential oil in terms of the mean weight and mean size of hydatid cysts. However, no significant difference was observed between the groups (P&amp;gt;0.5). Overall, the number, weight, and size of cysts were not significantly different between the groups in this investigation. The lack of satisfactory therapeutic results in this study might be due to the location of hydatid cysts in the subcutaneous space.

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.

The Role of Prophylactic Endoscopic Sphincterotomy for Prevention of Postoperative Bile Leak in Hydatid Liver Disease: A Randomized Controlled Study

BACKGROUND

Bile leak is the main cause of morbidity and mortality after surgery for hydatid liver cysts. Aim was to assess the role of prophylactic endoscopic sphincterotomy (ES) in reducing postoperative bile leak in patients undergoing partial cystectomy.

METHODS

Fifty-four patients with hepatic hydatid cyst met inclusion criteria, 27 were excluded or declined to participate. Twenty-six women and 28 men (mean age 44.6 ± 10.1, range: 22-61 years) were randomly assigned to either group I with ES (n = 27) or group II without ES (n = 27).

RESULTS

Demographics and clinical, laboratory, and radiological characteristics of cysts were not statistically different between two groups. Group I had a significant decrease in bile leak rate compared with group II (11.1% versus 40.7%, P = .013), with significantly shorter duration of hospital stay (P < .0001). Biliary fistula in group I had significantly lower daily output (100 mL/day versus 350 mL/day) with gradual reduction till stoppage of leak in 3-4 days without intervention. Biliary fistula in group II had a significantly higher need for biliary intervention through postoperative endoscopic retrograde cholangiopancreatography with ES compared with biliary fistula in group I (^FEP = .002), with significantly longer mean time of fistula closure (P = .011) and longer time to drain removal (P < .0001). Nonbiliary complications were comparable between two groups.

CONCLUSION

Prophylactic ES provides significant reduction in postoperative bile leak rate with shorter hospital stay after partial cystectomy of hydatid cyst. Biliary fistula in patients with ES has significantly lower daily output with shorter time of drain removal and shorter time to closure than patients without ES.

Fat-Containing Liver Lesions on Imaging: Detection and Differential Diagnosis

OBJECTIVE

The purpose of this article is to review how fat is detected on imaging and to discuss the differential diagnosis of fat-containing liver lesions.

CONCLUSION

Fat is a highly useful feature in characterizing liver lesions on imaging. Although a variety of liver lesions can show fat on cross-sectional imaging, the presence of fat usually indicates that the lesion is of hepatocellular origin. Less commonly, nonhepatocellular fatty lesions may be distinguished by ancillary clinical and imaging features.

Incidence and risk factors of biliary fistulation from a hepatic hydatid cyst in clinically asymptomatic patients

Biliary fistulation from a hepatic hydatid cyst is its most frequent complication. If unrecognised, this may cause difficulties during and after surgical intervention. Our study looked into its incidence and also the possible risk factors in a retrospective investigation of 60 patients (34 women) who had undergone surgery or percutaneous treatment. Demographics and anatomical characteristics, such as cyst type, location, number, diameter and laboratory findings were examined. A full 50% had biliary fistulation, with increased risk if the cyst diameter was ≥8.8 cm.

Risk Factors for Development of Biliary Complications after Surgery for Solitary Liver Hydatid Cyst

Biliary leakage (BL) is the most common cause of postoperative morbidity after conservative liver hydatid cyst surgery. The objective of this study was to determine incidence of BL and related risk factors in patients with solitary liver hydatid cyst who underwent conservative surgery. A total of 186 patients were included in this study. Age, gender, cyst recurrence, diameter, and localization, World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) classification, cavity management techniques, cyst content, and alkaline phosphatase (ALP) levels were evaluated with univariate and multivariate analyses. Of these patients 104 were female and 82 were male. The mean age was 43.5 ± 14.7 years. Postoperative BL was detected in 36 (19.4%) patients. Cyst diameter (P = 0.019), cyst localization (P = 0.007), WHO-IWGE classification (P = 0.017), and ALP level (P = 0.001) were the most significant risk factors for BL. Independent risk factors for BL were perihilar localization, large cyst diameter, high ALP level, and advanced age according to WHO-IWGE classification.

Spontaneously ruptured hepatic cyst treated with laparoscopic deroofing and cystobiliary communication closure: A case report

The rupture of a nonparasitic hepatic cyst with biliary communication is rare. We report the case of a patient with a hepatic cyst with biliary communication that spontaneously ruptured and was successfully treated by laparoscopic deroofing and closure of the communication. A 61-year-old woman presented at our hospital with a chief complaint of right upper abdominal pain. Enhanced abdominal CT showed a collapsed hepatic cyst and fluid collection. Drip infusion CT cholangiography showed contrast medium pooling in the collapsed cyst. Therefore, hepatic cyst rupture with biliary communication was diagnosed, and laparoscopic deroofing and closure of the communication were performed. The postoperative course was uneventful, and the patient was discharged on postoperative day 6. In cases of hepatic cyst rupture, even in the presence of biliary communication, laparoscopic deroofing and closure of the communication should be recommended as the first-choice treatment.

Value of cyst localization to predict cystobiliary communication in patients undergoing conservative surgery with hydatid cyst

OBJECTIVE

The objectives of this study were to investigate the relationship between the segmental localization of liver hydatid cyst by computed tomography (CT) and the presence of cystobiliary communication (CBC) and to identify the risk factors for CBC.

PATIENTS AND METHODS

One hundred and eleven of 163 patients who underwent liver hydatid surgery between January 2011 and September 2014 were included in this study and analyzed retrospectively. The size, number, stage, and segmental and lobar localization of the cysts were investigated by CT. The presence of CBC and preoperative laboratory findings were recorded from operation notes.

RESULTS

CBC was more frequent in single large cysts. CBC was most commonly detected in segment 1 (50%), 8 (48.3%), 7 (41.2%), and 4 (40%). CBC was more frequent in the right lobe (40.4%) and Gharbi stage 3 (41.8%) and 4 (55.6%) lesions. There were no differences in CBC according to distance from the hilus. In addition, preoperative total bilirubin, direct bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT) elevations were associated with higher CBC frequency (P<0.05). Cyst diameter, number of cysts, and ALP and GGT elevations were independent predictors of CBC presence.

CONCLUSION

The evaluation of hydatid cyst diameter, morphological stage, and segmental and lobar localization by abdominal CT and measurement of preoperative cyst diameter, number of cysts, and ALP and GGT values may predict the presence of CBC.

A New Preoperative Categorization and Potential Preoperative Indicator for Cysto-Biliary Fistula in Hydatid Hepatic Disease

The objective of this study was to determine the risk for cysto-biliary fistula (CBF) and preoperative predictive factors in patients with hepatic hydatid disease (HHD) with high levels of hepatobiliary enzymes (HLE) alone. The risk of CBF and predictive factors in patients with HHD whose only sign of fistula was HLE is unknown. A total of 116 patients without clinical and radiologic signs who were operated for HHD were categorized into 2 groups: patients with and without HLE. The patients with HLE were defined as “usual suspicious.” The potential preoperatively predictive factors for CBF were retrospectively analyzed in this group. Our data included 18.1% of patients (n = 21) with CBF and 69.2% of patients (n = 81) with HLE. The usual suspicious group contained 24.7% of patients (n = 20) with CBF. The risk of CBF was 11-fold higher in the usual suspicious group (95% confidence interval, 1.4–86.7). The red cell distribution width (RDW) was higher in patients with CBF than in patients without CBF in the usual suspicious group (P = 0.006). The performance of the RDW, with a cutoff value of 13.75%, was found to be suboptimal for predicting CBF for patients in the usual suspicious group (area under the curve, 0.661; 95% confidence interval, 0.525–0.798). We defined a new preoperatively high-risk group with HLE alone; this definition can help to identify patients at risk for preoperatively undetectable CBF. The RDW was not found to be sufficient for the discrimination of usual suspicious group with CBF.

Surgical management of liver hydatid disease: subadventitial cystectomy versus resection of the protruding dome

BACKGROUND

The aim of this study was to compare postoperative outcome and long-term results after management of liver hydatid cysts (LHC) by subadventitial cystectomy (SC) and resection of the protruding dome (RPD) in two tertiary liver surgery centers.

METHODS

Medical records of 52 patients who underwent SC in one center, and 27 patients who underwent RPD in another center between 1991 and 2011 were reviewed. Patients underwent long-term follow-up, including serology tests and morphological examinations.

RESULTS

Postoperative mortality was nil. The rate of severe morbidity was 7.7 and 22% (p = 0.082), while the rate of serological clearing-up was 20 and 13.3% after SC and RPD, respectively (p = 1.000). After a mean follow-up of 41 months (1-197), four patients developed a long-term cavity-related complication (LTCRC) after RPD (including one recurrence) and none after SC (p = 0.012). All LTCRCs occurred in patients with hydatid cysts located at the liver dome; three required an invasive procedure by either puncture aspiration injection re-aspiration (N = 1) or repeat surgery (N = 2).

CONCLUSIONS

RPD exposes to specific LTCRC, especially when hydatid cysts are located at the liver dome, while SC allows ad integrum restoration of the operated liver. Therefore, SC should be considered as the standard surgical treatment for LHC in experienced hepato-pancreato-biliary centers.

Endoscopic retrograde cholangiopancreatography in ruptured liver hydatid cyst

One of the most common and serious complications of hepatic hydatid cyst disease is communication between the cyst and the biliary tree. Surgical management of biliary fistula is associated with high morbidity and mortality. We retrospectively reviewed the effectiveness of endoscopic treatment of ruptured hydatid cyst into intrahepatic bile ducts. Diagnosis of intrabiliary rupture of hydatid cyst was mostly suspected by acute cholangitis, jaundice, pain, and/or persistent external biliary fistula after surgery. The diagnosis was confirmed by radiology and endoscopic retrograde cholangiopancreatography (ERCP) findings. We retrospectively reviewed clinical, laboratory, imagery, and ERCP findings for all patients. The therapeutic methods performed were endoscopic sphincterotomy, extraction by balloon or Dormia basket, stenting, or nasobiliary drainage. Sixteen patients with ruptured hepatic hydatid cyst into bile ducts were seen in 9 years. Nine of 16 patients had a surgical history of hepatic hydatid cyst and three patients had a percutanous treatment history. We carried out ERCP with sphincterotomy and extraction of hydatid materials (extraction balloon n = 11; Dormia basket n = 5) or biliary drainage (nasobiliary drainage n = 1; biliary stenting n = 1). The fistula healed in 80 % of patients with a median time of 6 weeks [range, 1-12] after endoscopic treatment. ERCP was an effective method of treatment for hepatic hydatid cyst with biliary fistula.

Role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease

Most cases of hepatic hydatid disease exhibit uncomplicated clinical course and management. However, the diagnosis and management of complicated hepatic hydatid disease is a special issue. One of the most common and serious complications of hepatic hydatid disease is the rupture of the cyst into intrahepatic bile ducts. The clinical appearance of intrabiliary rupture can range from asymptomatic to jaundice, cholecystitis, cholangitis, liver abscess, pancreatitis and septicemia. Current treatments for major ruptures can result in high morbidity and mortality rates. Furthermore, ruptures that cannot be diagnosed preoperatively can induce complications such as biliary fistulae, biloma, cavitary infection and obstructive jaundice. In the past, these complications were diagnosed and treated by surgical methods. Currently, complications in both the pre- and postoperative periods are diagnosed and treated by non-invasive or minimally invasive methods. In clinical practice, endoscopic retrograde cholangiopancreatography (ERCP) is indicated for patients with preoperative frank intrabiliary rupture in which hydatid elements are clearly seen in the bile ducts, or for biliary adverse events after surgery, including persistent biliary fistulae and jaundice. However, controversy concerning routine preoperative ERCP and prophylactic endoscopic sphincterotomy in patients suspected of having minor cystobiliary communications still remains. In this article, the role of ERCP in the diagnosis and management of hepatic hydatid disease during the pre- and postoperative periods is reviewed.

Surgical treatment of giant liver hydatid cysts: comparison of cystojejunostomy and partial cystectomy

PURPOSE

The aim of this study was to compare partial cystectomy and internal drainage of the cyst cavity with cystojejunostomy for the surgical treatment of giant hepatic hydatid cysts.

METHODS

Patients who underwent any type of surgical treatment between March 2009 and May 2013 for giant hepatic hydatid cysts were retrospectively evaluated. The data collected included demographic variables, diagnostic methods, surgical procedures, morbidity and mortality rates.

RESULTS

Twenty-eight patients who underwent surgery for giant hepatic hydatid cysts were included. There were 16 (57 %) female patients, with a mean age of 32.8 years. The diagnostic methods primarily included abdominal ultrasonography and computed tomography, which were performed in 62 % of the patients. The patients were divided into two groups with respect to the treatment modality: Group A (n = 13) treated with cystojejunostomy and Group B (n = 15) treated with partial cystectomy. The overall rate of cavity-related complications was 25 % in Group B, whereas none of the patients in Group A had a cavity-related complication during the follow-up period (p < 0.05).

CONCLUSION

Cystojejunostomy is an effective and safe surgical approach for the treatment of giant hepatic hydatid cysts, with a lower rate of morbidity than partial cystectomy, and thus may be the surgical treatment of choice for giant hepatic hydatid cysts.

Surgical management of non-parasitic hepatic cyst with biliary communication: a case report

Non-parasitic hepatic cysts with biliary communication are rare. The clinical symptoms involved are not specific to this condition, thereby making diagnosis difficult and treatment controversial. Here, we report a case of 70-year-old woman complaining of abdominal satiety, combined with non-specific pain in the right upper quadrant. The abdominal contrast-enhanced MRI-scan revealed a large and thick-walled septus cystic lesion in the liver. During operation, the biliary fistula was confirmed in the cyst cavity. A silica gel tube was inserted via the cystic duct for cholangiography, which demonstrated communication between the cyst and biliary tract. We performed wide-scale cyst wall resection; the biliary fistula was completely repaired by the closure of communicated bile ducts. The postoperative course was uneventful, and the patient was discharged with no sign of cholangitis or any other symptoms. The novel surgical management via wide resection of the cyst wall and closure of biliary communication proved to be an adequate and effective procedure for treating nonparasitic hepatic cysts with biliary communication.

Frank intrabiliary rupture in liver hydatidosis located in the hilar plate: a surgical challenge

BACKGROUND

Frank intrabiliary rupture (FIR) is a severe complication that occurs in around 30% of patients with liver hydatidosis. When FIR is present, the contents of the cyst may pass into the common bile duct and cause a variety of complications. If the FIR is located in the hilar confluence, surgical repair is a challenge. Currently there are no data regarding its optimum treatment.

MATERIAL AND METHODS

Between May 2007 and December 2012, we treated 59 patients with liver hydatidosis. Four patients, all women, with a mean age of 51.7 years, had hydatid cysts located between segments IVb and V and FIR affecting the hilar plate. In 3 cases, the initial clinical condition was obstructive jaundice. The fourth patient presented recurrence after having undergone two operations as a child.

RESULTS

In each patient a major hepatectomy was performed with hilar plate reconstruction (3 left and 1 right). Morbidity included mild biliary fistula (1 patient) and abdominal collection resolved by percutaneous drainage (1 patient). There was no mortality. During follow-up (47 months), no recurrences of the disease or biliary strictures were recorded.

CONCLUSIONS

FIR is a severe complication of liver hydatidosis. When it is located in the hilar confluence, liver resection may be the best surgical option for definitive resolution of the problem.

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.

Cysto-biliary communication in liver hydatidosis

BACKGROUND

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

AIM

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

RESULTS

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

CONCLUSIONS

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

Can occult cystobiliary fistulas in hepatic hydatid disease be predicted before surgery?

BACKGROUND

Biliary fistulas because of the cystobiliary communication is the most frequent and undesirable postoperative complication of hepatic hydatid surgery. We aimed to identify the predicting factors of the occult cystobiliary communication in this study.

METHODS

The patients who underwent surgical treatment for hepatic hydatid disease between 2003 and 2008 were reviewed retrospectively. The patients who had jaundice history, preoperative high total bilirubin and direct bilirubin levels, dilated bile duct in preoperative radiologic imagings were not included the study. Patients were divided into two groups: group A; without postoperative biliary fistula, group B; with biliary fistula. The two groups were compared according to preoperative descriptive findings, cystic specialties, and laboratory findings.

RESULTS

There were 53 patients and 15 patients in groupA and groupB, respectively. The 20 (37.7%) of 53 patients were male in group A and the 10 (66.7%) patients were male in group B (p<0.05). The age, number of cysts, Garbi scores of cysts, the rate of recurrent cysts, the level of preoperative bilirubin, alkalene phosphatase, and transaminases were similar in both groups (p>0.05). GGT was significantly different between two groups (p<0.05). The cystotomy + drainage, cystotomy + omentopexy, and intracystic biliary suture rates were similar in both groups. Postoperative non biliary complications were determined in 4 (7.5%) patients in group A and 7 patients (46.7%) in group B (p<0.05). Hospital stay was longer in group B significantly (p<0.05).

CONCLUSIONS

In conclusion, GGT as a laboratory [corrected] test for predicting occult CBC preoperatively have been shown to be useful in the clinical practice. However, larger prospective studies are needed on this subject. Occult cysto-biliary fistulas can only be exposed during surgery when suspected by a surgeon. If occult CBC is found, the opening in the biliary system should be sutured with absorbable material, with or without cystic duct drainage. If no biliary opening is found, cystic duct drainage may be performed if preoperative factors predict the presence of CBC. As the development of external biliary fistulas increases the morbidity and the hospitalization period, novel surgical methods to prevent the development of bile fistulas are required in such patients.

Leakage tests reduce the frequency of biliary fistulas following hydatid liver cyst surgery

BACKGROUND AND AIM

Biliary fistulas are the most common morbidity (8.2-26%) following hydatid liver surgery. The aim of our study was to reduce the incidence of postoperative biliary fistulas after the suturing of cystobiliary communications by applying a bile leakage test.

PATIENTS AND METHODS

A total of 133 hydatid liver cysts from 93 patients were divided into two groups, according to whether the test was performed. Tests were performed on 56 cysts from 34 patients, and the remaining 77 cysts from 59 patients were treated without the test. In both groups, all visible biliary orifices in the cysts were suture ligated, and drains were placed in all cysts. The visibility of the biliary orifices and postoperative biliary drainage through the drains were recorded. Patients in both groups were also compared with respect to the number of days living with the drains, the length of the hospital stay, and secondary interventions related to biliary complications.

RESULTS

Biliary orifices were more visible in the tested cysts (13% vs. 48%; P <0.001). Fewer biliary complications occurred in the tested patients (8.8% vs. 27.7%, P = 0.033). The mean drain removal time (4.1 ± 3.3 days vs. 6.8 ± 8.9 days, P < 0.05) and the length of the hospital stay (6.7 ± 2.7 days vs. 9.7 ± 6.3 days, P,0.01) were shorter for the tested patients. None of the patients in the test group required postoperative Endoscopic retrograde cholangiopancreaticography (ERCP) or nasobiliary drainage (0.0% vs. 8.4%, P = 0.09). There were no long-term biliary complications for either group after three years of follow-up.

CONCLUSIONS

Identification of biliary orifices with a bile leakage test and the suturing of cystobiliary communications significantly reduced postoperative biliary complications following hydatid liver surgery.

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.

Asymptomatic occult cysto-biliary communication without bile into cavity of the liver hydatid cyst: a pitfall in conservative surgery

BACKGROUND

An occult cysto-biliary communication in liver hydatid disease is still a major problem in surgical practice. Radiologic and intraoperative findings may not be helpful to detect cysto-biliary communications in some asymptomatic patients with liver hydatid disease. Biliary leakage is a troubling complication that arises after conservative surgery in patients who have occult "insidious" cysto-biliary communications. We aimed to identify the factors which are associated with the risk of occult insidious cysto-biliary communications in patients preoperatively who developed biliary leakage after surgery.

PATIENTS AND METHODS

We investigated the records of 183 asymptomatic patients treated for liver hydatid cyst and analyzed potential predictors of occult insidious cysto-biliary communication, retrospectively.

RESULTS

There were 115 female and 68 male patients; the mean age was 42.3 years. Occult insidious cysto-biliary communications which presented as postoperative biliary leakage found in 24 (13.1%). Independent clinical predictors were alkaline phosphatase >133 U/L, total bilirubin levels >1.2 mg/dL, white blood cell count >10,000/mm(3) and cyst diameter >10 cm on multivariate analysis. Seventeen of 24 were low output biliary fistula which resolved spontaneously within 9.2 days. The remaining 7 were high output biliary fistula for which endoscopic sphincterotomy was performed in all patients, fistulas resolved within 22.6 days. Average interval between endoscopic sphincterotomy and fistula closure was 10.3 days. Mean hospital stay was longer in patients with biliary leakage than in those without (9.8 vs. 4.2 day p<0.001). There was no hospital mortality.

CONCLUSION

The predictors demonstrated in this study should allow the likelihood of occult insidious cysto-biliary communication to be determined and, thus, indicate the need for additional procedures during operations to prevent the complications of biliary leakage.

Efficacy of radical surgery in preventing early local recurrence and cavity-related complications in hydatic liver disease

BACKGROUND

Hydatic disease of the liver remains to be a complex worldwide problem especially in rural areas. Early local recurrence and cavity-related complications are still a matter of conflict in the management of hydatic liver disease. The aim of this study is to investigate efficacy of the type of surgical treatment in preventing early local recurrence and cavity-related complications of this disease. Here, we present the preliminary results of our study.

METHODS

This study was performed prospectively including 32 patients who were operated for hydatic liver disease between January 2001 and January 2005. Patients were randomized into radical and conservative surgery groups. Recurrences at the primary surgical site in the first 2 years were considered as early local recurrence and biliary leakage, biliary fistula, cavity abscess, etc. were considered as cavity-related complications.

RESULTS

Early local recurrences were observed only after conservative surgical procedures (p=0.045). Recurrent cysts were found to be due to satellite cysts or pericystic disease. Cavity-related complications were seen in six patients in the conservative surgery group (p=0.011).

CONCLUSIONS

In suitable patients, radical surgical resection provides an effective surgical management option in preventing early local recurrence and cavity-related complications when compared to conservative surgical approaches.

[Hydatid cysts of the spigelian lobe (segment I) of the liver: clinical and therapeutic particularities]

OBJECTIVE

Hydatid cysts of the spigelian lobe, that is, segment I of the liver, are rare. We analyzed their clinical and therapeutic particularities.

METHODS

We conducted a retrospective search for the hydatid cysts of the liver treated surgically in our department from January 1, 1994, through December 31, 2005. Cases were identified and confirmed with the following investigatory techniques: routine abdominal ultrasonography, abdominal computed tomography recommended by the ultrasound operator when a cyst was discovered in segment I, routine intraoperative cholangiography, and three separate serological techniques: electrosyneresis, hemaglutination and ELISA (enzyme-linked-immunosorbent assay)(the latter two being quantitative). The cystic cavity was treated with hypertonic serum. Several surgeons performed different combinations of the following techniques: deroofing, sometimes with omentoplasty, simple drainage, and subtotal pericystectomy.

RESULTS

We treated 44 hydatid cysts of segment I surgically in 10 men and 34 women, with a mean age of 40.6 years. Ten patients (22.7%) had a history of hydatid cysts. Symptoms or complications were noted at admission in 45% of cases. Only five cases (11.4%) required emergency surgery. Surgical examination confirmed vascular compression in 17 cases (38.6%) and a biliary fistula in 17 cases (38.6%). Surgical treatment consisted of deroofing in 37 cases (84,1%), with omentoplasty in 23 (54%), subtotal pericystectomy in 3 and simple drainage in 4. Large biliary fistulas (> 5 mm) were treated with bipolar drainage in 2 cases and internal transfistulary drainage in 3. Some hemorrhaging occurred during surgery in 5 cases, and one cyst ruptured in the peritoneal cavity. Albendazole was prescribed postoperatively for nine patients. There was one intraoperative death, secondary to hemorrhage resulting from erosion of the inferior vena cava. Morbidity was 25%. After a mean follow-up of 32 months, five patients had recurrences in the liver but outside segment I.

CONCLUSION

Segment I of the liver is a rare site for hydatid disease, and a site where vascular and biliary complications are frequent. Its management requires a good knowledge of the vascular anatomy of the liver and wide experience of hydatid cyst surgery and especially of simple surgical procedures.

Endoscopic retrograde cholangiography for intrabiliary rupture of hydatid cyst

BACKGROUND

Hydatid disease affects most commonly the liver, and rupture into the bile ducts is a frequent complication, occurring in 5% to 25% of cases. These complications can cause major clinical problems either preoperatively or postoperatively with post-resectional abscess or prolonged biliary fistula. We reviewed our experience with preoperative endoscopic retrograde cholangiography (ERC) and the diagnosis of major cyst-biliary fistula.

METHODS

During a 7-year period, 78 patients underwent surgery for hepatic hydatid disease. Ten patients, in whom a major intrabiliary rupture of the cyst was suspected on the basis of clinical and radiological criteria, underwent preoperative ERC, with clearing of the biliary tree. Endoscopic sphincterotomy was performed in 7 cases when the fluid contained daughter cysts or pus. Three patients, in whom the biliary content was fluid only, did not undergo sphincterotomy. One patient in whom a preoperative ERC was not feasible underwent operative transduodenal sphincterotomy. In all 11 patients the cyst was resected. Two patients underwent preoperative ERC, but no fistula was detected . They were compared with the remaining group of 67 patients who underwent resectional surgery during the same period, for apparently uncomplicated echinococcal cysts, and with an historical group of 569 patients operated on from January 1966 to January 1995.

RESULTS

According to the clinical and radiological preoperative criteria, there were 2 false positives. Preoperative ERC allowed visualization of the fistula, clearing of the biliary tree, and sphincterotomy in selected cases. The incidence of postoperative fistula was significantly decreased after the introduction of selective preoperative ERC, on the basis of preoperative clinical and radiological criteria.

CONCLUSIONS

Preoperative ERC is very helpful in patients with cyst-biliary fistula, allowing visualization of the fistula and drainage of the biliary tree, and reducing the incidence of postoperative complications from 11.1% to 7.6%. In selected cases it can solve the problem, without further surgical therapy.

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.

Intrabiliary rupture: An algorithm in the treatment of controversial complication of hepatic hydatidosis

AIM: Intrabiliary rupture (IBR) is a common and serious compli-cation of hepatic hydatid cyst. The incidence varies from 1% to 25%. The treatment of IBR is still controversial. We aimed to design an algorithm for the treatment of hepatic hydatidosis with IBR by reviewing our cases.

METHODS: Eight cases of IBR were analyzed retrospectively. Patients were evaluated according to age, sex, clinical findings, cyst number and stage, abdominal ultrasonography and CT-scan, surgical methods, complica-tions, results and coincidental diseases.

RESULTS: Female/male ratio was 1/7. Mean age was 52.12±18.26 years (range 24-69 years). Right upper quadrant pain, flatulence, palpable hepatic mass were symptoms common in all patients. Cholestatic jaundice was found in four cases. In all patients, cyst evacuation and omento-plasty were performed, followed by either choledochod-uodenostomy, T-tube drainage, intracavitary suturing of the orifice, two cases in each. Whereas in two patients diagnosed post-operatively percutaneous drainage of biliary collection or ERCP and sphincteroplasty were added. Morbidity and hospital stay were higher in these cases.

CONCLUSION: When the diagnosis of IBR can be done pre-or intra-operatively, morbidity decreases. If a biliary fistula is seen post-operatively, endoscopic procedures such as ERCP, sphincteroplasty or nasobiliary drainage can be applied.

Classification of hydatid liver cysts

A number of investigations advocate various classification systems for liver hydatid cysts. However, none permits predicting the treatment outcome or making clinical decisions regarding medical treatment; open surgery; punction, aspiration, injection, reaspiration (PAIR); or laparoscopy. An international hydatid disease registry employing an uniform nomenclature and consistent reporting methods would allow more rational comparison of different management strategies. TN(R)C (topography, nature, recurrent, complication) classification is a comprehensive system based on four criteria: location (T), natural history (N), recurrence (R) and complications (C) of the cyst. This pictorial review illustrates the classification and puts accent of its clinical usefulness. The TN(R)C classification provides a standardized description formula of every liver hydatid cyst, permitting multiple comparisons and analyses.

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.