Treatment of symptomatic congenital hepatic cysts with single-session percutaneous drainage and ethanol sclerosis: technique and outcome

Complete and Incomplete Alcohol Sclerotherapy for Treatment of Symptomatic Hepatic Cysts: Comparison of Volume Reduction and Clinical Outcomes

Background: The purpose of this study was to compare the efficacy of incomplete alcohol sclerotherapy with complete treatment for hepatic cysts. Methods: From 2005 to 2021, a total of 80 patients (19 males, 61 females; median age 65 years; age range, 42-86 years) who underwent alcohol sclerotherapy for symptomatic benign hepatic cysts were enrolled and retrospectively reviewed. Complete treatment was defined as injecting 25-33% of the aspirated cyst volume with alcohol in 2-3 cycles, with a maximum of 100 mL per cycle. The overall volume reduction rate was compared between the complete and incomplete treatment groups. The response, based on cystic volume reduction, was classified as a complete regression (CR), near-complete regression (NCR), partial regression (PR), or no response (NR). CR and NCR were considered objective responses. Among 80 patients with 85 hepatic cysts, 26 patients with 29 hepatic cysts received incomplete treatment. Results: The overall volume reduction rate was not significantly different between the complete and incomplete treatment groups (94.39% vs. 95.47%, respectively, p = 0.623). The CR and NCR groups showed a significantly higher rate of symptom improvement than the PR and NR groups (p = 0.043). Conclusions: In conclusion, the efficacy of incomplete alcohol sclerotherapy was not inferior to that of complete treatment.

Ultrasound-guided polidocanol foam sclerotherapy for symptomatic giant hepatic cyst: A single-center experience

AIM

Simple hepatic cysts are typically benign; however, when they are large and symptomatic, therapeutic intervention is required. We previously reported our initial experience with ultrasound (US)-guided polidocanol foam sclerotherapy in three patients with symptomatic giant hepatic cysts. In the present study, we examined the efficacy and safety of polidocanol foam sclerotherapy in a larger number of patients with long-term follow-up.

METHODS

Between May 2016 and April 2021, 15 patients with symptomatic giant hepatic cysts were referred to our hospital. All patients were prospectively included in the study and underwent US-guided polidocanol foam sclerotherapy.

RESULTS

The mean maximum diameter and estimated cyst volume were 128.4 mm (77-223 mm) and 922.3 ml (123.2-2797 ml), respectively. Polidocanol foam was successfully administered through an 8.5-Fr pigtail catheter in all patients. The percentages of cyst diameter/volume after 1-3 months, 3-6 months, 6 months-1 year, 1-2 years, and 2-4 years of sclerotherapy were 66.8%/36.5%, 48.1%/14.8%, 34.1%/6.9%, 28.2%/3.7%, and 26.2%/3.1%, respectively. During the follow-up period, there were no cases of symptom recurrence or need for additional treatment due to cyst re-growth. Six patients (40%) had fever, one had nausea, and one had right-sided chest pain, but none of these adverse events required prolonged hospitalization or readmission.

CONCLUSIONS

US-guided polidocanol foam sclerotherapy may be an effective and safe method for the treatment of symptomatic giant hepatic cysts.

Giant hepatic cyst as a cause of gastric outlet obstruction

We describe the case of a 58-year-old female who presented to her primary care provider with lifelong anorexia, 6-week history of liquid only diet and new onset epigastric abdominal pain radiating to the back accompanied by nausea and abdominal distension. An initial computed tomography scan with contrast demonstrated a massive simple hepatic cyst with mass effect compression of the duodenal sweep. Repetitive treatment with aspiration sclerotherapy using hypertonic saline provided initial resolution of symptoms and led to substantial reduction of cyst diameter. Repeat imaging demonstrated complete drainage of the cyst and decompression of the duodenum. Ultimately, the patient's symptoms returned 6 weeks later at which time she opted for surgical deroofing of the cyst. Surgery provided for complete resolution. This case appears to be the first to document the compression of second portion of the duodenum by a massive simple hepatic cyst causing anorexia and mimicking gastric outlet obstruction.

Symptom relief and not cyst reduction determines treatment success in aspiration sclerotherapy of hepatic cysts

OBJECTIVE

To assess whether quantitative assessment of symptom reduction is a better outcome parameter than cyst volume reduction for treatment success in patients treated by aspiration sclerotherapy.

METHODS

We included patients with symptomatic, large (> 5 cm), hepatic cysts from a randomized controlled trial (NCT02048319). At baseline and 6 months after treatment, symptoms were assessed with the polycystic liver disease questionnaire (PLD-Q) and we measured cyst volume using ultrasonography. Patient-reported change in health was assessed on a 5-point Likert scale (much worse to much better) after 6 months. We tested whether PLD-Q scores and cyst volumes changed after aspiration sclerotherapy (responsiveness). Changes in PLD-Q scores and cyst volume were compared with change in health as a measure of treatment success (discriminative ability). As secondary analysis, we compared baseline characteristics between responders (improved) and non-responders (not improved).

RESULTS

We included 32 patients. Six months after treatment, 23 patients (72%) improved. Both PLD-Q score and cyst volume significantly decreased (median 38 to 18 points, p < 0.001, and 479 to 68 mL, p < 0.001). Larger improvement in PLD-Q score was associated with a positive change in health (p = 0.001), while larger proportional reduction in cyst volume was not significantly associated with health improvement after treatment (p = 0.136). Responders had larger baseline cyst volumes compared to non-responders (median 624 mL [IQR 343-1023] vs. 322 mL [IQR 157-423] p = 0.008).

CONCLUSION

Cyst diameter reduction does not reflect treatment success in aspiration sclerotherapy from patients' perspective, while symptoms measured with the PLD-Q can be used as a reliable outcome measure.

KEY POINTS

• Cyst diameter reduction poorly reflects treatment success in aspiration sclerotherapy. • Symptoms measured by the polycystic liver disease questionnaire (PLD-Q) is a better outcome measure than cyst volume reduction for treatment success after aspiration sclerotherapy. • Particularly patients with larger cysts (≥ 529 mL) benefit from aspiration sclerotherapy.

Ultrasound-guided microfoam sclerotherapy with polidocanol for symptomatic giant hepatic cyst: Initial experience

AIM

In cases of symptomatic giant hepatic cysts, appropriate treatment is required to relieve symptoms. Ethanol, minocycline hydrochloride, and ethanolamine oleate have been conventionally used for ultrasound (US)-guided sclerotherapy. However, liquid sclerosing agents could mix with the residual fluid in the cyst and reduce their sclerotic effects. We carried out US-guided microfoam sclerotherapy using polidocanol for three patients and evaluated its efficacy and safety.

METHODS

Between May 2016 and March 2017, three female patients with symptomatic giant hepatic cysts were referred to our hospital. All of them were prospectively included in this study.

RESULTS

The maximum diameters of the hepatic cysts in the three patients were 92 × 89 × 86 mm, 155 × 119 × 140 mm, and 223 × 195 × 123 mm, respectively. Polidocanol microfoam was successfully administered through an 8.5-Fr pigtail catheter for all patients. One, two, and three microfoam sclerotherapy sessions were undertaken according to the initial cyst volume for cases 1, 2, and 3, respectively. The mean reduction rates of the cyst volume were 90.1% (85.5-98.9%) at 3 months, 96.3% (91.9-99.9%) at 6 months, and 99.5% (99.1-99.9%) at 9 months after treatment. No significant treatment-induced adverse effects were observed.

CONCLUSION

Ultrasound-guided microfoam sclerotherapy using polidocanol could be an effective and safe method for the treatment of symptomatic giant liver cysts.

Ethanol sclerotherapy or polidocanol sclerotherapy for symptomatic hepatic cysts

BACKGROUND

Over the past decades, multiple approaches to aspiration sclerotherapy of large symptomatic hepatic cysts have been investigated. However, comparative data are scarce.

OBJECTIVE

The objective of this article is to compare cyst reduction, symptomatic relief, and adverse events between ethanol sclerotherapy and polidocanol sclerotherapy.

METHODS

This retrospective study included adults having a symptomatic hepatic cyst treated at a European tertiary referral center with ethanol sclerotherapy (Center 1) or polidocanol-sclerotherapy (Center 2). We compared cyst diameter reduction (%) and symptom improvement (yes/no) within 12 months' post-treatment between centers using multivariate regression analyses adjusted for confounding factors. Finally, we compared adverse events using Fisher's exact test.

RESULTS

We included 71 patients from Center 1 and 66 patients from Center 2 (median age 57 years; 126/137 (92%) female). Cyst reduction was comparable between Centers 1 and 2: 37.5% (IQR 15.7-61.0%) versus 44.2% (IQR 24.6-60.5%), respectively (p = 0.35). Correspondingly, symptomatic relief was comparable: 30/53 (56.6%) versus 43/66 (65.2%), respectively (p = 0.88). Center 1 reported significantly more (11 versus 3; p = 0.047) adverse events than Center 2.

CONCLUSION

We found comparable cyst reduction and symptomatic relief rates between ethanol- and polidocanol sclerotherapy, while adverse events occurred more often in the ethanol group. Prospective studies focused on clinical response are needed to further explore differences between approaches.

Pasireotide does not improve efficacy of aspiration sclerotherapy in patients with large hepatic cysts, a randomized controlled trial

OBJECTIVES

We tested whether complementary use of the somatostatin analogue pasireotide would augment efficacy of aspiration sclerotherapy of hepatic cysts.

METHODS

We conducted a double-blind, placebo-controlled trial in patients who underwent aspiration sclerotherapy of a large (>5 cm) symptomatic hepatic cyst. Patients were randomized to either intramuscular injections of pasireotide 60 mg long-acting release (n = 17) or placebo (sodium chloride 0.9 %, n = 17). Injections were administered 2 weeks before and 2 weeks after aspiration sclerotherapy. The primary endpoint was proportional cyst diameter reduction (%) from baseline to 6 weeks. Secondary outcomes included long-term cyst reduction at 26 weeks, patient-reported outcomes including the polycystic liver disease-questionnaire (PLD-Q) and safety.

RESULTS

Thirty-four patients (32 females; 53.6 ± 7.8 years) were randomized between pasireotide or placebo. Pasireotide did not improve efficacy of aspiration sclerotherapy at 6 weeks compared to controls (23.6 % [IQR 12.6-30.0] vs. 21.8 % [9.6-31.8]; p = 0.96). Long-term cyst diameter reduction was similar in both groups (49.1 % [27.0-73.6] and 45.6 % [29.6-59.6]; p = 0.90). Mean PLD-Q scores improved significantly in both groups (p < 0.01) without differences between arms (p = 0.92).

CONCLUSIONS

In patients with large symptomatic hepatic cysts, complementary pasireotide to aspiration sclerotherapy did not improve cyst reduction or clinical response.

KEY POINTS

• Complementary pasireotide treatment does not improve efficacy of aspiration sclerotherapy. • Cyst fluid reaccumulation after aspiration sclerotherapy is a transient phenomenon. • Aspiration sclerotherapy strongly reduces symptoms and normalizes quality of life.

An update on the pathophysiology and management of polycystic liver disease

Polycystic liver disease (PLD) is characterized by the presence of multiple cholangiocyte-derived hepatic cysts that progressively replace liver tissue. They are classified as an inherited ciliopathy /cholangiopathy as pathology exists at the level of the primary cilia of cholangiocytes. Aberrant expression of the proteins in primary cilia can impair their structures and functions, thereby promoting cystogenesis. Areas covered: This review begins by looking at the epidemiology of PLD and its natural history. It then describes the pathophysiology and corresponding potential treatment strategies for PLD. Expert commentary: Traditionally, therapies for symptomatic PLD have been limited to symptomatic management and surgical interventions. Such techniques are not completely effective, do not alter the natural history of the disease, and are linked with high rate of re-accumulation of cysts. As a result, there has been a push for drugs targeted at abnormal cellular signaling cascades to address deregulated proliferation, cell dedifferentiation, apoptosis and fluid secretion. Currently, the only available drug treatments that halt disease progression and improve quality of life in PLD patients are somatostatin analogues. Numerous preclinical studies suggest that targeting components of the signaling pathways that influence cyst development can ameliorate growth of hepatic cysts.

Predictors of treatment response following aspiration sclerotherapy of hepatic cysts: an international pooled analysis of individual patient data

OBJECTIVES

To identify predictive variables of treatment response following aspiration sclerotherapy of large symptomatic hepatic cysts.

METHODS

We collected individual patient data from two tertiary referral centres and included all patients treated with aspiration sclerotherapy of a large (>5 cm), symptomatic hepatic cyst. At six months, clinical response was defined as complete or incomplete. Secondary, suboptimal technical response was defined as lower quartile of cyst reduction. Predictive variables of clinical and technical response were analyzed by logistic regression analysis.

RESULTS

We included 86 patients (58 ± 10 years; female 90 %). Complete clinical response rate was 55 %. Median cyst diameter and volume reduction were 71 % (IQR 50-87 %) and 98 % (IRQ 88-100 %), respectively. Patients with complete clinical response had a significantly higher cyst reduction compared to incomplete responders (OR 1.02, 95 % CI 1.00-1.04). Aspiration of haemorrhagic cyst fluid (OR 4.39, 95 % CI 1.34-14.39) or a lower cyst reduction at one month (OR 1.06, 95 % CI 1.02-1.10) was associated with a suboptimal technical response at six months.

CONCLUSION

Complete clinical response is associated with effective cyst reduction. Aspiration of haemorrhagic cyst fluid or a restricted diameter reduction at one month predicts a suboptimal technical treatment response, however, these variables did not predict symptom disappearance.

KEY POINTS

• Aspiration sclerotherapy of hepatic cysts shows excellent clinical and technical efficacy. • Optimal clinical responders have a markedly higher cyst reduction. • Haemorrhagic aspirate and a strong fluid reaccumulation predict suboptimal cyst reduction.

Efficacy and Safety of Aspiration Sclerotherapy of Simple Hepatic Cysts: A Systematic Review

OBJECTIVE

Aspiration sclerotherapy is a percutaneous procedure indicated for treatment of symptomatic simple hepatic cysts. The efficacy and safety of this procedure have been sources of debate and disagreement for years. The purpose of this study was to assess the long-term efficacy and safety of aspiration sclerotherapy in a systematic review of the literature.

MATERIALS AND METHODS

A systematic search was conducted of the electronic databases PubMed MEDLINE, Embase, Web of Science, and the Cochrane Library (until August 2015). Studies of proportional volume or diameter reduction after aspiration sclerotherapy of simple hepatic cysts were included for full-text evaluation. Case reports and case series were excluded. Risk of bias was assessed by use of the Newcastle-Ottawa scale.

RESULTS

From 9357 citations, 100 were selected for full-text assessment. We included 16 studies, which included 526 patients with a total of 588 treated cysts. Overall, risk of bias was high, with 12 of 16 studies having a score of poor. Proportional cyst volume reduction ranged between 76% and 100% after a median follow-up period of 1-54 months. Change in symptoms was evaluated in 10 studies: 72-100% of patients reported symptom reduction, and 56-100% reported disappearance. Postprocedural pain occurred most frequently, at a rate of 5-90% among studies. Ethanol intoxication occurred in up to 93% of cases and was reported more frequently in studies with either high ethanol volumes (133.7-138.3 mL) or long sclerotherapy duration (120-180 minutes).

CONCLUSION

We found excellent results with respect to long-term efficacy and safety after aspiration sclerotherapy of hepatic cysts. Nevertheless, because of the high risk of bias in the included studies, definite conclusions regarding efficacy cannot be drawn.

Long-term follow-up of large symptomatic hepatic cysts treated by percutaneous ethanol sclerotherapy

BACKGROUND

As a minimally invasive treatment, ethanol sclerotherapy has been used for large symptomatic hepatic cysts, but there are not many long-term reports on treatment outcomes and safety.

PURPOSE

To evaluate the long-term outcomes of percutaneous ethanol sclerotherapy in patients with large symptomatic hepatic cysts.

MATERIAL AND METHODS

This study included 43 symptomatic, enlarging hepatic cysts in 42 patients who had undergone ethanol sclerotherapy from 2003 to 2013 and were followed up for >1 year. The treatment outcomes were evaluated in terms of the reduction of cyst size and resolution of symptoms. The patients were followed up for a mean period of 33 months with either ultrasound or computed tomography examination.

RESULTS

Thirty-nine hepatic cysts (91%) were successfully treated with ethanol sclerotherapy, showing resolution of symptoms and remarkable reduction in cyst volume. Eight hepatic cysts (19%) disappeared completely, and 31 hepatic cysts (72%) decreased in size during the follow-up period. The mean diameter of the cysts decreased from 12.5 ± 4.4 cm to 3.8 ± 3.4 cm during follow-up. There were no immediate serious complications related to the procedure. There were four cases (9%) of treatment failure requiring subsequent surgical procedures.

CONCLUSION

Percutaneous ethanol sclerotherapy can be considered as an effective first-line treatment for large symptomatic hepatic cysts.

Single-session alcohol sclerotherapy of symptomatic liver cysts using 10-20 min of ethanol exposure: no recurrence at 2-16 years of follow-up

PURPOSE

To assess long-term results after single-session alcohol sclerotherapy of symptomatic benign liver cysts performed with maximum 20 min of exposure to alcohol.

METHODS

We included 47 patients aged 32-88 years (42 women, 5 men) with 51 benign non-parasitic liver cysts that were exposed to ethanol for 7-20 min in a single sclerotherapy session and were followed for at least 24 months. Each cyst was emptied before injecting ethanol (10% of cyst volume, but maximum 100 mL) into it. The patient rotated from side to side to facilitate contact between ethanol and the whole cyst wall. Pre-treatment cyst volume was defined as the volume of aspirated cyst fluid after complete emptying of the cyst. Follow-up cyst volume was estimated based on computed tomography images.

RESULTS

Cyst volumes were 30-4900 (median 520) mL at pre-treatment and 0-230 (median 1) mL at 24-193 (median 56) months follow-up, a reduction of 83-100% (median 99.7%). No cyst required repeated treatment during the follow-up. Median volume reduction was 99.7% at median 49 months of follow-up for 35 cysts exposed to ethanol for 7-10 min vs. 99.6% at median 75 months of follow-up for 16 cysts exposed for 20 min (p = 0.83, Mann-Whitney test). Ethanol intoxication occurred in one patient. There were no other complications except for pain.

CONCLUSION

Long-term results of single-session alcohol sclerotherapy performed with maximum 20 min of exposure to ethanol were satisfactory with no sign of recurrence of cyst fluid.

Ultrasound-guided percutaneous ethanol ablation for primary non-parasitic splenic cysts in 15 patients

PURPOSE

This study aimed to evaluate the feasibility, safety, and efficacy of ultrasound (US)-guided percutaneous ethanol ablation (PEA) for primary non-parasitic splenic cysts.

MATERIALS AND METHODS

Between February 2006 and February 2015, 15 patients (4 men and 11 women; mean age, 33 ± 15.3 years; age range, 17-65 years) with primary non-parasitic splenic cysts were treated with US-guided PEA. 99.5% absolute ethanol in an amount of approximately 50%-100% of the aspirated volume was injected into each cyst and no more than 240 mL. Standard laboratory tests (hemogram, coagulation, serum, and biochemical tumor marker levels) were performed before and after PEA.

RESULTS

The median follow-up time was 18.7 months (range 2.8-59.2 months). During follow-up, seven cysts after treatment had disappeared completely, while the other eight cysts had decreased significantly in size. The 3-, 6-, 12-, and 24-month volume reduction rates were 49.7%, 87.6%, 94.3%, and 96.7%. Serum tumor marker CA19-9 levels significantly decreased. Mild adverse reactions included moderate pain in four (26.7%), unbearable pain in one (6.67%), fever in two (13.3%) and slight intracystic bleeding in one (6.67%). There were no serious complications.

CONCLUSION

US-guided PEA appears to be a safe and effective minimally invasive technique for management of primary non-parasitic splenic cysts.

Technical challenges in treating recurrent non-parasitic hepatic cysts

PURPOSE

Simple non-parasitic hepatic cysts (NPHC) are relatively frequent and often asymptomatic. When symptomatic, surgery is recommended. Most patients can be treated with laparoscopic deroofing. However, recurrence rate varies greatly, and there is no consensus on the optimal approach for symptomatic recurrences.

MATERIALS AND METHODS

A retrospective study on 33 patients surgically treated for symptomatic simple NPHC was performed. Recurrence was considered only when symptomatic.

RESULTS

Most patients were initially submitted to laparoscopic deroofing. Symptomatic recurrence was found in five patients treated with laparoscopic deroofing. Specific location of the cysts was a common characteristic. In three cases, recurrence was unsuccessfully treated with open deroofing, and patients were submitted to resection. Open deroofing does not offer any advantage in terms of recurrence in comparison with laparoscopic deroofing.

CONCLUSION

Laparoscopic deroofing can be proposed for symptomatic recurrent cysts, except for cysts located in S4, S7 and S8, where recurrence rates are higher and complete resection should be undertaken.

Rerupture of nonparasitic liver cyst treated with cyst fenestration: a case report

We herein describe a case involving spontaneous rerupture of a nonparasitic liver cyst successfully treated with cyst fenestration and an omental flap. A 59-year-old Japanese woman was transferred to our hospital for evaluation of acute abdominal pain. She had a history of conservative treatment with antibiotics for spontaneous rupture of a liver cyst 1 month previously. On arrival, she exhibited abdominal tenderness and muscular defense. Enhanced computed tomography showed ascites and a large ruptured hepatic cyst (diameter of 10 cm). We diagnosed rerupture of a liver cyst and performed laparotomy for cyst fenestration and intraperitoneal drainage. During the operation, we found the perforation site on the ventral side of the cyst and brown, muddled ascitic fluid. Cholangiography showed no bile leakage on the inner wall. Pathological investigation revealed no evidence of malignancy. The patient recovered without any adverse events and was discharged on postoperative day 8. No recurrences or complications occurred for 2 years.

Solitary Septated Simple Liver Cyst in a Newborn Infant

Simple liver cysts (SLC) are generally rare and are typically symptomatic when detected in infancy. We present a case of a newborn infant in whom fetal ultrasound and MRI revealed a cystic structure. Postnatal imaging revealed a septated, single cystic structure causing mass effect on the common bile duct and partially obstructing the inferior vena cava. Treatment of a solitary septated SLC was successful by laparoscopic total excision. The infant had an uncomplicated postsurgical course and has done well.

A stepwise approach for effective management of chronic pain in autosomal-dominant polycystic kidney disease

Chronic pain, defined as pain existing for >4-6 weeks, affects >60% of patients with autosomal-dominant polycystic disease (ADPKD). It can have various causes, indirectly or directly related to the increase in kidney and liver volume in these patients. Chronic pain in ADPKD patients is often severe, impacting physical activity and social relationships, and frequently difficult to manage. This review provides an overview of pathophysiological mechanisms that can lead to pain and discusses the sensory innervation of the kidneys and the upper abdominal organs, including the liver. In addition, the results of a systematic literature search of ADPKD-specific treatment options are presented. Based on pathophysiological knowledge and evidence derived from the literature an argumentative stepwise approach for effective management of chronic pain in ADPKD is proposed.

Effectiveness of CT-guided sclerotherapy with estimated ethanol concentration for treatment of symptomatic simple hepatic cysts

BACKGROUND AND OBJECTIVE

The mean Hounsfield value of 99.9% ethanol did get down to -190 Hounsfield units (HU), there was a linear correlation between ethanol concentration and Hounsfield values. We aimed to evaluate whether sclerotherapy with estimated ethanol concentration was helpful in improving the success rate for treatment of symptomatic simple hepatic cysts.

METHODS

Forty-five patients with 52 symptomatic simple hepatic cysts were enrolled in this study. Twenty-one patients (24 cysts, group A) were treated by sclerotherapy without estimated ethanol concentration and 24 patients (28 cysts, group B) with estimated ethanol concentration. The Chi-square test and Mann-Whitney U test were used to compare the difference in characteristics and treatment outcomes of the subjects between these two groups.

RESULTS

The mean cyst size before and after treatment were 8.4cm and 2.3cm, respectively, in group A, and 8.2cm and 0.8cm, respectively, in group B. There was no significant difference in the initial size of hepatic cysts between the groups. However, the final size was significantly smaller in group B (P=0.022). The mean ethanol exposure time was 18.3minutes in group B, which was less than that in group A (P<0.001). The success rate was significantly higher in group B (96.4%) than in group A (70.8%) (P=0.03). There were no major complications in either group.

CONCLUSION

CT-guided sclerotherapy with estimated ethanol concentration yields better results than those without estimated ethanol concentration in the treatment of symptomatic simple hepatic cysts.

Hepatic cysts treated with percutaneous ethanol sclerotherapy: time to extend the indications to haemorrhagic cysts and polycystic liver disease

OBJECTIVES

To describe the long-term clinical and morphological outcome of symptomatic hepatic cysts treated with percutaneous ethanol sclerotherapy (PES).

METHODS

From December 2003 to September 2011, all patients with hepatic cysts undergoing PES with a follow-up after 12 months were included. Evolution of the volume of the cysts and clinical and biological data were recorded. Features of the cyst were evaluated in each patient: simple, haemorrhagic or developed on underlying polycystic liver disease (PCLD).

RESULTS

Fifty-eight cysts (median volume 666 mL) were treated in 57 patients (52 women, mean age 58 years (18-80)). Twenty-two patients (39 %) had simple hepatic cysts, 19 (33 %) had dominant cysts on PCLD and 20 had haemorrhagic cysts (34.5 %), including 4 with PCLD. After a mean 27.3 months of follow-up, the final median cystic volume was 13.5 mL (p < 0.0001), and the median reduction in cyst volume was 94 % (58-100 %). Treatment was satisfactory in 95 % of the patients (54/57) (symptoms disappeared in 45/57 (79 %), decreased in 9/57 (16 %)). There was no clinical or morphological difference between patients with PCLD, haemorrhagic cysts or simple cysts.

CONCLUSION

The clinical and morphological efficacy of a single session of PES is very high, regardless of the presence of intracystic haemorrhage or underlying PCLD.

KEY POINTS

• The clinical efficacy of percutaneous ethanol sclerotherapy is very high. • Haemorrhagic content should not be a contraindication for percutaneous sclerotherapy. • Dominant cysts on polycystic liver disease should be treated with PES. • Imaging follow-up should not be performed shortly after the procedure.

Image-guided percutaneous splenic biopsy and drainage

Percutaneous splenic biopsy and drainage are relatively safe and accurate procedures. The risk of major complication (1.3%) following percutaneous splenic biopsy does not exceed that of other solid intra-abdominal organ biopsies, and it has less morbidity and mortality than splenectomy. Both computed tomography and ultrasound can be used to provide image guidance for biopsy and drainage. The safety profile of fine-needle aspiration cytology is better than core needle biopsy, but core biopsy has superior diagnostic accuracy.

Percutaneous sclerotherapy of cystic lesions

With modern cross-sectional imaging techniques, cystic lesions are very common and usually incidental findings, especially if small. However, when cysts enlarge, become infected, bleed, or undergo torsion, they can be symptomatic, and percutaneous drainage can be effective in the management. When cysts recur after aspiration, which is often the case for hepatic and renal cysts, cyst sclerosis or surgical unroofing may be required. This article describes the indications for and technical aspects of percutaneous sclerotherapy of cystic lesions of multiple organ systems.

Rare cystic liver lesions: A diagnostic and managing challenge

Cystic formations within the liver are a frequent finding among populations. Besides the common cystic lesions, like simple liver cysts, rare cystic liver lesions like cystadenocarcinoma should also be considered in the differential diagnosis. Thorough knowledge of each entity’s nature and course are key elements to successful treatment. Detailed search in PubMed, Cochrane Database, and international published literature regarding rare cystic liver lesions was carried out. In our research are included not only primary rare lesions like cystadenoma, hydatid cyst, and polycystic liver disease, but also secondary ones like metastasis from gastrointestinal stromal tumors lesions. Up-to date knowledge regarding diagnosis and management of rare cystic liver lesions is provided. A diagnostic and therapeutic algorithm is also proposed. The need for a multidisciplinary approach by a team including radiologists and surgeons familiar with liver cystic entities, diagnostic tools, and treatment modalities is stressed. Patients with cystic liver lesions must be carefully evaluated by a multidisciplinary team, in order to receive the most appropriate treatment, since many cystic liver lesions have a malignant potential and evolution.

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.

Isolated polycystic liver disease

Isolated polycystic liver disease (PCLD) is an autosomal dominant disease with genetic and clinical heterogeneity. Apart from liver cysts, it exhibits few extrahepatic manifestations, and the majority of patients with this condition are asymptomatic or subclinical. However, a small fraction of these patients develop acute liver cyst-related complications and/or massive cystic liver enlargement, causing morbidity and mortality. Currently, the management for symptomatic PCLD is centered on palliating symptoms and treating complications.

Treatment of polycystic liver disease with resection-fenestration and a new classification

AIM: To evaluate outcomes in patients with autosomal dominant polycyst liver disease (APLD) treated by combined hepatic resection and fenestration. A new classification was recommended to presume postoperative complications and long outcome of patients.

METHODS: Twenty-one patients with APLD were treated by a combined hepatic resection and fenestration technique. All patients were reviewed retrospectively, and clinical symptoms, performance status and morbidity were recorded. A new classification of APLD is recommended here.

RESULTS: All patients were discharged when free of symptoms. The mean follow-up time was 55.7 mo and three patients had a recurrence of symptoms at 81, 68 and 43 mo after operation, respectively. The overall morbidity rate was 76.2%. Two patients with Type B-IIand Type B-I developed biliary leakage. Four patients had severe ascites, including three with Type B-III and one with Type B-II. Nine patients had pleural effusion, including one with Type A-I; one with Type B-I; five with Type B-II; one with Type A-III and one with Type B-III. Three patients with Type B had recurrence of symptoms, while none with Type A had severe complications.

CONCLUSION: Combined hepatic resection and fenestration is an acceptable procedure for treatment of APLD. According to our classification, postoperative complications and long outcome can be predicted before surgery.

Advances in management of polycystic liver disease

The focus of this review is polycystic liver disease, a genetic disorder characterized by multiple macroscopic liver cysts that initially bud from biliary epithelium but subsequently lack communication with the biliary tree. There are two main clinical presentations: polycystic liver associated with autosomal dominant polycystic kidney disease and isolated polycystic liver disease. Both of these forms of polycystic liver disease exhibit an autosomal dominant pattern of inheritance. Clinical manifestations of polycystic liver disease are related to either mass effect of the volume of hepatic cysts or to complications arising within the cysts. Polycystic liver disease rarely progresses to hepatic failure or clinical complications of portal hypertension. Management is directed at counseling patients and families, treating complications and reducing cyst load by surgical techniques: cyst fenestration, hepatic resection or, rarely, hepatic transplantation. Recent research suggests that blockade of cyst secretion or inhibition of epithelial cells might be useful in halting progression of disease--these observations are discussed in this review.

Obstructive jaundice in polycystic liver disease related to coexisting cholangiocarcinoma

Although jaundice rarely complicates polycystic liver disease (PLD), secondary benign or malignant causes cannot be excluded. In a 72-year-old female who presented with increased abdominal girth, dyspnea, weight loss and jaundice, ultrasound and computed tomography confirmed the diagnosis of PLD by demonstrating large liver cysts causing extrahepatic bile duct compression. Percutaneous cyst aspiration failed to relief jaundice due to distal bile duct cholangiocarcinoma, suspected by magnetic resonance cholangiopancreatography (MRCP) and confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Coexistence of PLD with distal common bile duct cholangiocarcinoma has not been reported so far.

Management of polycystic liver disease

The adult forms of polycystic liver disease are characterized by autosomal dominant inheritance and numerous hepatic cysts, with or without renal involvement. Mutations in two distinct genes predispose to renal and liver cysts (PKD1 and PKD2), and mutations in two different genes yield isolated liver cysts (PRKCSH and SEC63). Mutations at certain loci of PKD1 may predispose to more severe renal cystic disease or cerebral aneurysms. Risk factors for severe hepatic cystic disease include aging, female sex, pregnancy, use of exogenous female steroid hormones, degree of renal cystic disease, or severity of renal dysfunction (in patients with mutations in PKD1 or PKD2). Although liver failure or complications of advanced liver disease is rare, some patients develop massive hepatic cystic disease and become clinically symptomatic. There is no effective medical therapy. Treatment options include cyst aspiration and sclerosis, open or laparoscopic cyst fenestration, hepatic resection, and liver transplantation.

Percutaneous treatment of symptomatic non-parasitic benign liver cysts: single-session alcohol sclerotherapy versus prolonged catheter drainage with negative pressure

To evaluate whether prolonged catheter drainage with negative pressure yields better results than single-session alcohol sclerotherapy in the treatment of symptomatic non-parasitic benign liver cysts. Forty patients were randomly assigned to two groups in a 24-month prospective controlled trial. One group was treated with ultrasound-guided prolonged catheter drainage with negative pressure (20 patients with 24 cysts) and the other group with single-session alcohol sclerotherapy (20 patients with 23 cysts). Patient demographics, clinical characteristics, treatment outcome, and complications were analyzed. The median volumes and 95% CI (confidence interval) for the medians and interquartile ranges of all 47 cysts before treatment and on last follow-up were: 389 ml, 143-1,127 ml, 136-1,300 ml, and 0 ml, 0-10 ml, and 0-23 ml, respectively (P<0.0001). The average volume reduction was 92.4% (range, 74.9-100%), 94.2 % (range, 74.9-100%) in the drainage and 90.2% (range, 76.9-100%) in the sclerotherapy group. Twenty-seven cysts (57.4%) disappeared completely, 16 (66.7%) in the drainage and 11 (47.8%) in the sclerotherapy group. No differences in average volume reduction, final volume and disappearance of the cysts between the groups were noted. The hospital stay was 1 day for all patients. Percutaneous treatment is safe and effective for hepatic non-parasitic cysts. Prolonged catheter drainage with negative pressure and single-session alcohol sclerotherapy had similar results.

Aspiration-sclerotherapy results in effective control of liver volume in patients with liver cysts

PURPOSE

To study the extent to which aspiration-sclerotherapy reduces liver volume and whether this therapy results in relief of symptoms.

RESULTS

Four patients, group I, with isolated large liver cysts, and 11 patients, group II, with polycystic livers, underwent aspiration-sclerotherapy. Average volume of aspirated cyst fluid was 1,044 ml (range 225-2,000 ml) in group I and 1,326 ml (range 40-4,200 ml) in group II. Mean liver volume before the procedure was 2,157 ml (range 1,706-2,841 ml) in group I and 4,086 ml (range 1,553-7,085 ml) in group II. This decreased after the procedure to 1,757 ml (range 1,479-2,187 ml) in group I. In group II there was a statistically significant decrease to 3,347 ml (range 1,249-6,930 ml, P = 0.008). Volume reduction was 17.1% (range -34.7% to -4.1%) and 19.2% (range -53.9% to +2.4%) in groups I and II, respectively. Clinical severity of all symptoms decreased, except for involuntary weight loss and pain in group II.

CONCLUSION

Aspiration-sclerotherapy is an effective means of achieving liver volume reduction and relief of symptoms.

Surgical management of polycystic liver disease

Adult polycystic liver disease (PCLD) is an autosomal dominant condition commonly associated with autosomal dominant polycystic kidney disease (ADPKD). However in the last decade, it has been recognized that there is a distinct form of autosomal dominant PCLD that arises without concomitant ADPKD. Early knowledge of the pathogenesis was gained from the study of hepatic cysts in patients with ADPKD. Bile duct overgrowth after embryogenesis results in cystic hepatic dilatations that are known as biliary microhamartomas or von Meyenburg complexes. Further dilatation arises from cellular proliferation and fluid secretion into these cysts. There is a variable, broad spectrum of manifestations of PCLD. Although PCLD is most often asymptomatic, massive hepatomegaly can lead to disabling symptoms of abdominal pain, early satiety, persistent nausea, dyspnea, ascites, biliary obstruction, and lower body edema. Complications of PCLD include cyst rupture and cyst infection. Also, there are associated medical problems, especially intracranial aneurysms and valvular heart disease, which clinicians need to be aware of and evaluate in patients with PCLD. In asymptomatic patients, no treatment is indicated for PCLD. In the symptomatic patient, surgical therapy is the mainstay of treatment tailored to the extent of disease for each patient. Management options include cyst aspiration and sclerosis, open or laparoscopic fenestration, liver resection with fenestration, and liver transplantation. The surgical literature discussing treatment of PCLD, including techniques, outcomes, and complication rates, are summarized in this review.

Catheter-based drainage and agitation for definitive cytological diagnosis of a ciliated hepatic foregut cyst in a child

Ciliated hepatic foregut cyst (CHFC) is an uncommon lesion, which rarely presents in the pediatric population. It is congenital in origin and manifests because of the migration of a bronchiolar bud of the foregut through the pleuroperitoneal canal. CHFC is accompanied by a broad list of differential diagnoses and is difficult to diagnose by means of radiologic evaluation. Therefore, fine-needle aspiration with cytology has been used in an attempt to diagnose this lesion. In previously reported cases, this approach has been moderately successful in the diagnosis of CHFC, while in others, no definitive diagnosis was achieved because of the retrieval of scattered, irregular cells insufficient for cytologic evaluation. We report a case of a 16-year-old girl who presented with a CHFC and discuss a promising alternative for obtaining large, intact cellular specimens to facilitate cytologic evaluation and definitive diagnosis.

Concentration-dependent ablation of pancreatic tissue by EUS-guided ethanol injection

BACKGROUND

Ethanol is a commonly available agent and has been used to successfully and safely ablate cystic lesions of various organs.

OBJECTIVE

The aim of this study was to determine the short-term effects of an EUS-guided injection of ethanol into the pancreas of pigs by using 2 mL ethanol, in increasing concentration of 0% to 100%.

DESIGN

Six pigs were sedated by general anesthesia, and ethanol was injected, under EUS-guidance, with a 22-gauge needle into the pancreatic tail.

MAIN OUTCOME MEASUREMENTS

End points of this study were gross and microscopic evidence of pancreatitis and clinical tolerance. During the 7-day observational period, the animals were monitored by serum levels of amylase and lipase and by a CT on day 4.

RESULTS

At euthanasia, there was no pancreatic lesion in the animals that received normal saline solution or 20% ethanol. The injection of 40% to 100% ethanol led to a visible necrotic area in the pancreatic tail. By histology, the average maximal diameter of the lesions was 20.8 +/- 4.3 mm. The cross-sectional area of necrosis was proportional to the concentration of ethanol (r = 0.961). CT demonstrated a localized site of nonenhancing pancreatic tissue, with an average diameter of 19.4 +/- 10.5 mm; 40% to 100% ethanol. Clinically, the animals appeared to tolerate the procedure without sequelae. Serum levels of amylase and lipase were normal.

CONCLUSIONS

The EUS-guided injection of ethanol into the pig pancreas resulted in a localized concentration-dependent tissue necrosis without complications.

Nine-year single-center experience with nonparastic liver cysts: diagnosis and management

This study presents the experience with laparoscopic deroofing of nonparasitic liver cysts at a single center over a 9-year period. A total of 25 patients, undergoing 32 operations, were identified. Median cyst diameter was 10 cm for de novo cysts and 9.5 cm for recurrent cysts. Six patients had multiple cysts consistent with polycystic liver disease. In total, there were 26 laparoscopic procedures and 2 open conversions. Four procedures were commenced as open, three of which were for recurrent cysts. Minor complications were bleeding from a port site (n=1), pneumothorax (n=2), and intra-abdominal collection (n=1). One major complication of bile leak and relaparotomy occurred following an open deroofing. No major complications were recorded for laparoscopic procedures. Symptomatic recurrence of cysts occurred in four patients with simple cysts (5%) and one patient with polycystic liver disease. We conclude that laparoscopic liver cyst deroofing is an effective method of dealing with symptomatic nonparasitic liver cysts.

Single-session prolonged alcohol-retention sclerotherapy for large hepatic cysts

OBJECTIVE

Our purpose was to evaluate the safety and therapeutic efficacy of single-session prolonged alcohol sclerotherapy in treating large hepatic cysts. A therapeutic comparison between 4-hour and 2-hour retention techniques was also studied.

MATERIALS AND METHODS

Twenty-seven patients with 31 hepatic cysts were enrolled in this study. Seventeen patients (18 cysts) were treated by alcohol retention for 4 hours (group 1) and 10 patients (13 cysts) for 2 hours (group 2). The mean diameter of the hepatic cysts was 12.4 cm (range, 8-23 cm) with a comparable size range in each group. The sclerosing agent used was 95% alcohol, and the maximum amount was limited to 200 mL. Patients changed position and vital signs were monitored every 10-15 minutes. The blood alcohol concentrations were checked hourly for 5 consecutive hours in the initial nine patients. The nonparametric Mann-Whitney U test was used to compare the difference in characteristics and treatment results of the subjects between these two groups. The level of statistical significance was set at a p value of less than 0.05.

RESULTS

All but one patient in group 2 tolerated the entire course of sclerotherapy. The mean aspirated volume and mean injected alcohol volume of the hepatic cysts were 730 mL and 138.3 mL, respectively, in group 1 patients, and 931 mL and 139 mL, respectively, in group 2 patients. The mean maximum blood alcohol concentration was 128.2 mg/dL (range, 60-199 mg/dL) at 3-4 hours after alcohol instillation. The mean posttherapy residual cystic diameter was 2.5 cm (range, 0-6 cm), with an average volume reduction rate of 98.3% and 97.7%, respectively, for patients in group 1 and group 2 after a mean follow-up period of 29.6 months (9-59 months). No statistical differences of the mean reduction rate between the two groups were noted.

CONCLUSION

Long retention of the alcohol in a single-injection technique is safe and effective. Two-hour alcohol retention has a comparable efficacy to that of 4-hour retention.

Outcome and quality of life in patients with polycystic liver disease after liver or combined liver-kidney transplantation

In advanced stages of polycystic liver disease, often associated with polycystic kidney disease, a curative therapy is liver or combined liver-kidney transplantation. However, little is known about long-term outcome and quality of life. Between 1990 and 2003, 36 patients (32 female, 4 male) with polycystic liver or combined liver-kidney disease underwent liver (n = 21) or liver-kidney (n = 15) transplantation at our center. Main indications for liver transplantation were cachexia, muscle atrophy, loss of weight, recurrent cyst infections, portal hypertension, and ascites. Apart from clinical parameters, 2 anonymous questionnaires (standard short form 36 and self-designed) addressing quality of life and social status were evaluated. Five patients (14 %) died due to sepsis or myocardial infarction with pneumonia, all within 61 days after transplantation. The follow-up time of the remaining 31 patients ranged from 5 to 156 months, with a mean of 62 months. Of the 23 (74%) answered the questionnaires, 91% of patients felt "much better" or "better," only 9% felt "worse" than before, and 52% of patients participated in sports regularly. Fatigue, physical fitness, loss of appetite, and vomiting improved significantly after transplantation. Physical attractiveness and interest in sex increased as well. Professional occupation did not change for 71% of patients. Family situation before and after transplantation changed in 1 case only. Finally, 78% of patients said they would opt for transplantation again, while 17% were undecided; 1 patient would not repeat transplantation. In conclusion, patients with advanced polycystic liver or polycystic liver-kidney disease have an excellent survival rate and an improved quality of life after liver or combined liver-kidney transplantation.

Successful aspiration and ethanol sclerosis of a large, symptomatic, simple liver cyst: Case presentation and review of the literature

Simple liver cysts are congenital with a prevalence of 2.5%-4.25%. Imaging, whether by US, CT or MRI, is accurate in distinguishing simple cysts from other etiologies, including parasitic, neoplastic, duct-related, and traumatic cysts. Symptomatic simple liver cysts are rare, and the true frequency of symptoms is not known. Symptomatic simple liver cysts are predominantly large (> 4 cm), right-sided, and more common in women and older patients. The vast majority of simple hepatic cysts require no treatment or follow-up, though large cysts (> 4 cm) may be followed initially with serial imaging to ensure stability. Attribution of symptoms to a large simple cyst should be undertaken with caution, after alternative diagnoses have been excluded. Aspiration may be performed to test whether symptoms are due to the cyst; however, cyst recurrence should be expected. Limited experience with both laparoscopic deroofing and aspiration, followed by instillation of a sclerosing agent has demonstrated promising results for the treatment of symptomatic cysts. Here, we describe a patient with a large, symptomatic, simple liver cyst who experienced complete resolution of symptoms following cyst drainage and alcohol ablation, and we present a comprehensive review of the literature.

Radiologic management of cysts in the abdomen and pelvis

OBJECTIVE

Few abdominal or pelvic cystic lesions come to the attention of the interventional radiologist, and those that do are symptomatic. Differentiation of cysts from cystic-appearing masses is not difficult when a multitechnique imaging approach is used. Our objective is to summarize the principles and specifics for management of symptomatic cysts through percutaneous catheter techniques.

CONCLUSION

Percutaneous aspiration of cysts can relieve symptoms without the need for surgery. A sound knowledge of the various types of cysts that may be found in the abdomen and pelvis enables the radiologist to select those patients who will benefit the most from percutaneous management.

The occurrence of asymptomatic and symptomatic simple hepatic cysts. A prospective, hospital-based study

AIM

To examine the prevalence of asymptomatic and symptomatic liver cysts in a university hospital patient population using modern US equipment.

METHODS

Abdominal US scans of 1541 cases referred during the period 21 January to 11 November 2000 were examined for hepatic cysts.

RESULTS

Of 1541 cases, 174 (11.3%) were found to have hepatic cysts, i.e. 109 female (12.5%) and 65 (9.7%) male patients (9.7%). In 413 individuals younger than 40 years, no cysts were found. Above the age of 40 years, prevalence increased with age.

CONCLUSION

By using modern US equipment, we found a higher prevalence of hepatic cysts than that reported in previous studies. Patient selection and the prevalence of liver cysts in the population from which the patients were referred may have influenced our results.

New advances in evaluation and management of patients with polycystic liver disease

Adult polycystic liver disease (APLD) is an autosomal dominant condition most commonly associated with polycystic kidney disease. However, over the last decade it has come to be recognized that APLD is a genetically heterogeneous disorder involving derangements on at least three different chromosomes. Mutations involving chromosomes 16 and 4 accounting for autosomal dominant polycystic kidney disease (ADPKD) type 1 and type 2 have been well described as have their gene products, polycystin-1 and polycystin-2. These have since been joined by a more recently recognized mutation in the short arm of chromosome 19 thought to be responsible for a much rarer form of autosomal dominant polycystic liver disease without any associated renal involvement. Despite the sometimes impressive physical and radiologic findings, only a minority of patients will progress to advanced liver disease or develop complications as a result of massive hepatomegaly. In these patients, medical management alone has proved ineffectual. Therefore, in the symptomatic APLD patient, surgical therapy remains the mainstay of therapy and includes cyst aspiration and sclerosis, fenestration with and without hepatic resection and orthotopic liver transplantation. The surgical literature on treatment of APLD, to include outcome measurements and complication rates are summarized. Additionally, we review other potential organ involvement and resultant complications.

Ethanol lavage of pancreatic cystic lesions: initial pilot study

BACKGROUND

Ethanol lavage has been used to successfully and safely ablate cystic lesions of the liver, the kidneys, and the thyroid.

METHODS

Asymptomatic patients who undergo EUS examination for a pancreatic cystic lesion were eligible. Patients underwent complete examination with a linear-array echoendoscope, and cyst characteristics were documented. After evacuation of the cyst with needle aspiration, the cyst cavity was lavaged with ethanol for 3 to 5 minutes. The concentration (5%-80%) of ethanol was gradually increased over the course of the study. Patients were monitored for complications during 2 hours after the procedure, and further follow-up was obtained at 72 hours and 1 year after lavage.

OBSERVATIONS

Twenty-five patients were enrolled, 80% were women, and the mean age of all patients was 64.5 years. Cysts had a mean diameter of 19.4 mm and were equally located in the head, the body, and the tail of the pancreas. Cyst-fluid characteristics included high viscosity in 13 (52%) and a mean carcinoembryonic antigen and amylase of 5916 ng/mL and 11,506 U/L, respectively. None of the patients reported any symptoms in short- and long-term follow-up. Of the 23/25 patients with complete follow-up, 8 patients (35%) had complete resolution of their cysts on follow-up imaging. Five patients underwent resection, and histologic evidence of epithelial ablation was seen.

CONCLUSIONS

Ethanol lavage of pancreatic cystic lesions is safe and feasible. A subset of patients undergoing ethanol lavage appears to have long-term resolution on follow-up imaging. Further prospective studies are required to determine if ethanol lavage is an effective treatment for pancreatic cystic lesions.

Posttransplant symptomatic lymphocele treatment with percutaneous drainage and ethanol sclerosis

PURPOSE

Lymphocele following kidney transplantation is a well-known complication. We present here the long-term results of percutaneous drainage and ethanol sclerosis in posttransplant lymphoceles.

PATIENTS AND METHODS

Between October 1988 and September 2003, 18 patients with symptomatic lymphoceles were treated with percutaneous transcatheter ethanol sclerosis among 300 renal transplants followed up. Catheters were positioned under ultrasonography (US) guidance. Cavity dimensions and extravasation were evaluated by pouch graph. The day after catheter insertion, sclerotherapy with ethanol was applied. Daily output and probable complications were followed up on periodic controls, and the alcohol was instilled when required.

RESULT

The mean initial size of the lymphoceles was 6 x 8 x 10 cm (range 3 x 4 x 6 to 7 x 12 x 21 cm), with a mean initial volume of 230 ml (range 40-1340 ml). Incomplete resolution was achieved in all patients after sclerotherapy in the first week (100%). The mean duration of therapy was 17 days (range 4-45 days). The mean therapy sitting was 12 (4-21), and the average alcohol volume in one sitting was 30 ml. One recurrence and one graft lost were seen in this series. Minor complications like discomfort and mild temperature elevation were determined in 10 patients. In one case, temporary double-J stent was required to alleviate the increased pressure in collecting system of transplanted kidney. No late complication was occurred.

CONCLUSION

As a less invasive method, percutaneous transcatheter ethanol sclerosis and drainage in the treatment of symptomatic lymphocele is a simple, safe and cost-effective method. Other treatment choices, like open or laparoscopic fenestration, can be used in case of failure.

Polycystic disease of the liver

Autosomal dominant polycystic disease is genetically heterogeneous with mutations in two distinct genes predisposing to the combination of renal and liver cysts (AD-PKD1 and AD-PKD2) and mutations in a third gene yielding isolated liver cysts (the polycystic liver disease gene). Transcription and translation of the PKD1 gene produces polycystin-1, an integral membrane protein that may serve as an extracellular receptor. Mutations occur throughout the PKD1 gene, but more severe disease is associated with N-terminal mutations. The PKD2 gene product, polycystin-2, is an integral membrane protein with molecular characteristics of a calcium-permeant cation channel. Mutations occur throughout the PKD2 gene, and severity of disease may vary with site of mutation in PKD2 and the functional consequence on the resultant polycystin-2 protein. Polycystic liver disease is genetically linked to protein kinase C substrate 80K-H (PRKCSH). The PRKCSH gene encodes hepatocystin, a protein that moderates glycosylation and fibroblast growth factor receptor signaling. More prominent in women, hepatic cysts emerge after the onset of puberty and dramatically increase in number and size through the child-bearing years of early and middle adult life. Although liver failure or complications of advanced liver disease are rare, some patients develop massive hepatic cystic disease and become clinically symptomatic. There is no effective medical therapy. Interventional and surgical options include cyst aspiration and sclerosis, open or laparoscopic cyst fenestration, hepatic resection, and liver transplantation.

Polycystic disease of the liver

Autosomal dominant polycystic disease is genetically heterogeneous with mutations in two distinct genes predisposing to the combination of renal and liver cysts (AD-PKD1 and AD-PKD2) and mutations in a third gene yielding isolated liver cysts (the polycystic liver disease gene). Transcription and translation of the PKD1 gene produces polycystin-1, an integral membrane protein that may serve as an extracellular receptor. Mutations occur throughout the PKD1 gene, but more severe disease is associated with N-terminal mutations. The PKD2 gene product, polycystin-2, is an integral membrane protein with molecular characteristics of a calcium-permeant cation channel. Mutations occur throughout the PKD2 gene, and severity of disease may vary with site of mutation in PKD2 and the functional consequence on the resultant polycystin-2 protein. Polycystic liver disease is genetically linked to protein kinase C substrate 80K-H (PRKCSH). The PRKCSH gene encodes hepatocystin, a protein that moderates glycosylation and fibroblast growth factor receptor signaling. More prominent in women, hepatic cysts emerge after the onset of puberty and dramatically increase in number and size through the child-bearing years of early and middle adult life. Although liver failure or complications of advanced liver disease are rare, some patients develop massive hepatic cystic disease and become clinically symptomatic. There is no effective medical therapy. Interventional and surgical options include cyst aspiration and sclerosis, open or laparoscopic cyst fenestration, hepatic resection, and liver transplantation.