Laparoscopic treatment of symptomatic cysts of the liver

Endoscopic ultrasound guided hepatic interventions

Intervention for liver disease has predominantly been performed through the percutaneous approach. However, as endoscopic ultrasound (EUS) applications have expanded, there have emerged various EUS-guided interventions for liver disease, a space we call "Endo-Hepatology". EUS-guided liver biopsy can be considered the "forerunner" of Endo-Hepatology and has become a clinical option for patients requiring histologic diagnosis and staging of their liver disease. EUS also enables direct access to the portal vein. Subsequently, many procedures are being explored, such as angiography, measurement of the portosystemic pressure gradient, portal vein sampling to detect cancer cell or DNA, and EUS-guided transhepatic intrahepatic portosystemic shunt creation. Since the transducer is close to the liver, especially the left and caudate lobes, EUS can be used as a rescue when the percutaneous approach is not favorable and EUS-guided treatments of liver tumor, cyst and abscess have been reported. This review summarizes the available studies of EUS-guided intervention in the liver.

Clinical response after laparoscopic fenestration of symptomatic hepatic cysts: a systematic review and meta-analysis

BACKGROUND

Laparoscopic fenestration is one of the treatment options for symptomatic hepatic cysts, either solitary or in context of polycystic liver disease (PLD), but indications, efficacy and surgical techniques are under debate.

METHODS

A systematic literature search (1950-2017) of PubMed, Embase, Web of Science and the Cochrane Library was performed (CRD42017071305). Studies assessing symptomatic relief or symptomatic recurrence after laparoscopic fenestration in patients with symptomatic, non-parasitic, hepatic cysts were included. Complications were scored according to Clavien-Dindo. Methodological quality was assessed by Newcastle-Ottawa scale (NOS) for cohort studies. Pooled estimates were calculated using a random effects model for meta-analysis.

RESULTS

Out of 5277 citations, 62 studies with a total of 1314 patients were included. Median NOS-score was 6 out of 9. Median follow-up duration was 30 months. Symptomatic relief after laparoscopic fenestration was 90.2% (95% CI 84.3-94.9). Symptomatic recurrence was 9.6% (95% CI 6.9-12.8) and reintervention rate was 7.1% (95% CI 5.0-9.4). Post-operative complications occurred in 10.8% (95% CI 8.1-13.9) and major complications in 3.3% (95% CI 2.1-4.7) of patients. Procedure-related mortality was 1.0% (95% CI 0.5-1.6). In a subgroup analysis of PLD patients (n = 146), symptomatic recurrence and reintervention rates were significantly higher with respective rates of 33.7% (95% CI 18.7-50.4) and 26.4% (95% CI 12.6-43.0). Complications were more frequent in PLD patients, with a rate of 29.3% (95% CI 16.0-44.5).

CONCLUSIONS

Laparoscopic fenestration is an effective procedure for treatment of symptomatic hepatic cysts with a low symptomatic recurrence rate. The symptomatic recurrence rate and risk of complications are significantly higher in PLD patients.

Robot-assisted Laparoscopic Fenestration of Giant Hepatic Cysts

BACKGROUND

Traditionally, nonparasitic hepatic cysts are marsupialized using laparotomy. In the last 2 decades, laparoscopic fenestration has become the preferred treatment for hepatic cysts. However, this technique is limited by 2-dimensional view and the limited mobility of straight laparoscopic instruments. These limitations may be overcome by the use of a robotic system. We describe laparoscopic fenestration of giant hepatic cysts using the da Vinci Si robotic system with the use of the Endowrist One Vessel Sealer.

METHODS

Our first patient is a 32-year-old female with a solitary hepatic cyst. The second patient is a 51-year-old female with polycystic liver disease.

RESULTS

We performed robot-assisted laparoscopic cyst fenestration with good clinical outcome. No intraoperative complications occurred and patients recovered rapidly.

CONCLUSION

These data show that the da Vinci Si robotic system is eminently suited for the laparoscopic fenestration of large hepatic cysts and that this procedure is associated with rapid recovery.

Hepatic cyst with intracystic bleeding: contrast-enhanced sonographic findings

Intracystic bleeding is a relatively rare complication of hepatic cysts, which is very difficult to diagnose by conventional sonography (US). Hence, a new US technique has been sought for this purpose. We present the case of a hepatic cyst with intracystic bleeding in which contrast-enhanced US showed microbubbles oozing from the cyst wall into the cystic cavity. Contrast-enhanced US is now an important diagnostic tool for diagnosing liver tumors, but contrast-enhanced US findings relating to intracystic bleeding have not been reported. Our observations suggest that this technique may be a useful new diagnostic tool for this purpose.

Effective use of a vessel-sealing system for laparoscopic unroofing of liver cysts

INTRODUCTION

Liver cysts that present with symptoms such as jaundice, abdominal pain, and intra-cystic infection require treatment. In laparoscopic unroofing of liver cysts, appropriate treatment is needed in cases where the cystic walls contain vessels or bile ducts. A vessel-sealing system can seal not only vessels, but also bile ducts. We experienced four cases in which laparoscopic unroofing of liver cysts was performed with a vessel-sealing system.

MATERIALS AND SURGICAL TECHNIQUE

Case 1 was a woman in her 70s who presented at our hospital with abdominal pressure. Abdominal CT showed liver cysts with a maximum diameter of 13 cm. Laparoscopic unroofing was performed with LigaSure Impact. Case 2 was a woman in her 50s with abdominal discomfort. CT showed a cyst 15 cm in diameter situated in the right lobe. We performed SILS using a LigaSure Blunt Tip to unroof the cyst. Case 3 was a man in his 80s with abdominal pain. CT showed a huge cyst 25 cm in diameter in the right lobe. We performed hybrid SILS with a LigaSure Blunt Tip to unroof the cysts. Case 4 was a woman in her 70s with upper abdominal pain. CT showed multiple cysts with a maximum diameter of 15 cm in the bilateral lobes. We performed hybrid SILS to successfully unroof her cysts. None of the cases experienced postoperative complications, such as bleeding or bile leakage, and none experienced recurrence of cysts.

DISCUSSION

A laparoscopic unroofing using a vessel-sealing system can be a minimally invasive and safe treatment for liver cysts.

Rare benign tumors of the liver: still rare?

Background

Benign liver tumors are common. They do not spread to other areas of the body, and they usually do not pose a serious health risk. In fact, in most cases, benign liver tumors are not diagnosed because patients are asymptomatic. When they are detected, it’s usually because the person has had medical imaging tests, such as an ultrasound (US), computed tomography (CT) scan, or magnetic resonance imaging (MRI), for another condition.

Materials and methods

A search of the literature was made using cancer literature and the PubMed, Scopus, and Web of Science (WOS) database for the following keywords: “hepatic benign tumors”, “hepatic cystic tumors”, “polycystic liver disease”, “liver macroregenerative nodules”, “hepatic mesenchymal hamartoma”, “hepatic angiomyolipoma”, “biliary cystadenoma”, and “nodular regenerative hyperplasia”.

Discussion and conclusion

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in some areas of the world; there is an increasing incidence worldwide. Approximately 750,000 new cases are reported per year. More than 75 % of cases occur in the Asia-Pacific region, largely in association with chronic hepatitis B virus (HBV) infection. The incidence of HCC is increasing in the USA and Europe because of the increased incidence of hepatitis C virus (HCV) infection. Unlike the liver HCC, benign tumors are less frequent. However, they represent a chapter always more interesting of liver disease. In fact, a careful differential diagnosis with the forms of malignant tumor is often required in such a way so as to direct the patient to the correct therapy. In conclusion, many of these tumors present with typical features in various imaging studies. On occasions, biopsies are required, and/or surgical removal is needed. In the majority of cases of benign hepatic tumors, no treatment is indicated. The main indication for treatment is the presence of significant clinical symptoms or suspicion of malignancy or fear of malignant transformation.

Ethanol lavage of huge hepatic cysts by using EUS guidance and a percutaneous approach

BACKGROUND

EUS-guided and percutaneous lavage therapy for large hepatic cysts can replace surgical drainage. EUS-guided therapy can especially enable the alcohol lavage to be done with a 1-step approach.

OBJECTIVE

To evaluate the utility of EUS-guidance and percutaneous ethanol lavage therapy.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care referral teaching hospital.

PATIENTS

Adult patients with large liver cysts who underwent cyst drainage and alcohol ablation between 2009 and 2012.

INTERVENTIONS

Ethanol lavage via percutaneous and/or EUS-guided approaches.

MAIN OUTCOME MEASUREMENTS

Feasibility, efficacy, and safety of ethanol lavage.

RESULTS

Seventeen patients with 19 hepatic cysts were enrolled. The median cyst volume before therapy was 368.9 mL (interquartile range, 195.3-795.9 mL). Ten cysts were drained by the percutaneous approach with a pigtail catheter, and 8 cysts underwent EUS-guided aspiration and lavage treatment. In 1 case, both the percutaneous approach and EUS-guided puncture were used. During the median 11.5-month follow-up of the percutaneous approach group, the cysts showed 97.5% reduction. During the median 15-month follow-up of the EUS-guided group, the cysts showed nearly 100% reduction. Percutaneous catheter drainage ethanol lavage was more feasible for right-sided larger cysts, whereas the EUS-guided approach was useful for left-sided lobe cysts.

LIMITATIONS

Single-center retrospective study.

CONCLUSION

Excellent symptomatic and radiologic responses and long-term results were achieved with percutaneous catheter-guided and EUS-guided ethanol lavage. Ethanol lavage could be considered a primary method of treatment for hepatic cysts given its high degree of technical feasibility and safety.

Current diagnosis and management of simple hepatic cysts detected prenatally and postnatally

PURPOSE

The optimal management of simple hepatic cysts (SHCs) remains controversial. A retrospective review was carried out to evaluate the clinical presentation and surgical consideration of children with SHCs and outcome of management at our institution.

METHODS

We performed a retrospective review of all patients diagnosed with SHCs between January 1993 and May 2013. Patient variables included prenatal findings, age, gender, presenting symptoms, signs and diagnostic modality. Operative management and nonoperative follow-up were abstracted.

RESULTS

The 67 patients comprised 42 females and 25 males: 16 had prenatally detected, and 51 had postnatally detected hepatic cysts with a mean follow-up of 3.2 years (10 months-12 years). The average age was 5.9 years (0-17 years). Ten patients (six females and four males) were treated surgically. Fifty-seven asymptomatic patients were observed. Of those 57 patients, 9 (17%) had enlarged cysts, and 1 (2%) had clinical signs. The average enlargement time was 36 months (6-67 months). The cysts occurred in the right lobe in 47 patients, in the left lobe in 17 patients and in both lobes in 3 patients. The median cyst size for the asymptomatic cases was 2.1 cm (1.5-6 cm) and 13.7 cm (8-25 cm) for the surgery group. A statistically significant difference in cyst size was found between these two groups (p < 0.05). Prenatally detected cysts (n = 5) were subjected to surgery postnatally at an average age of 1.5 months (1 week-6 months). The main indication was the compressive effect of the cyst on the surrounding area. There was one case of hepatomegaly found to be causing pressure symptoms, two cases of respiratory distress, one case of hydroureteronephrosis, and one case of jaundice due to compression of the biliary system. Five patients underwent surgery in the postnatally detected group, and the main indication was a complication of the cyst or progressive enlargement. Symptoms included abdominal discomfort and pain in all five patients: one case exhibited a hemorrhage within the cyst, one case displayed a rupture with possible peritonitis, one case had a 25-cm cyst leading to secondary infection, and two cases were admitted with progressive enlargement with clinical symptoms.

CONCLUSION

Conservative management of SHCs is practical. Surgical excision is recommended in patients with larger cysts, causing pressure symptoms, or if the cyst size does not seem to involute with intractable abdominal pain or becomes complicated in the follow-up period.

Perioperative challenges and surgical treatment of large simple, and infectious liver cyst - a 12-year experience

BACKGROUND

Cystic lesions of the liver consist of a heterogeneous group of disorders that can present diagnostic and therapeutic challenges.

METHODS

A retrospective review of all medical records of adult patients diagnosed with large (>7 cm) cystic lesions of the liver between January 2000 and December 2011, at Kurume University Hospital. Cases with polycystic disease were excluded.

RESULTS

Twenty three patients were identified. The mean size was 13.9 cm (range, 7-22cm). The majority of simple cysts were found in women (females: males, 2: 21). In 19 patients, the cyst was removed surgically by wide deroofing (laparoscopically in 16 cases, combined with ethanol sclerotherapy in 13 cases). Infection of the liver cyst occurred in one patient, who later underwent central bi-segmentectomy.

CONCLUSION

Simple large cysts of the liver can be successfully treated by laparoscopic deroofing and alcohol sclerotherapy. Large hepatic cyst considered to need drainage should be removed surgically to avoid possible infection.

Management of giant hepatic cysts in the laparoscopic era

Purpose

We sought to evaluate the feasibility and outcomes of laparoscopic resection of giant hepatic cysts and surgical success, focusing on cyst recurrence.

Methods

From February 2004 to August 2011, 37 consecutive patients with symptomatic hepatic cysts were evaluated and treated at Dong-A University Hospital. Indications were simple cysts (n = 20), multiple cysts (n = 6), polycystic disease (n = 2), and cystadenoma (n = 9).

Results

The median patient age was 64 years, with a mean lesion diameter of 11.4 cm. The coincidence between preoperative imaging and final pathologic diagnosis was 54% and half (n = 19) of the cysts were located in segments VII and VIII. Twenty-two patients had American Society of Anesthesiologists (ASA) classification I and II, and nine had ASA classification III. Surgical treatment of hepatic cysts were open liver resection (n = 3), laparoscopic deroofing (n = 24), laparoscopic cyst excision (n = 4), laparoscopic left lateral sectionectomy (n = 2), hand assisted laparoscopic procedure (n = 2), and single port laparoscopic deroofing (n = 2). The mean fellow-up was 21 months, and six patients (16%) experienced radiographic-apparent recurrence. Reoperation due to recurrence was performed in two patients. Among the factors predicting recurrence, multivariate analysis revealed that interventional radiological procedures and pathologic diagnosis were statistically significant.

Conclusion

Laparoscopic resection of giant hepatic cysts is a simple and effective method to relieve symptoms with minimal surgical trauma. Moreover, the recurrence is dependent on the type of pathology involved, and the sclerotherapy undertaken.

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 was undertaken and articles pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

RESULTS

Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. Polycystic liver disease presents a unique management problem because of the 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 be effectively treated by aspiration or drainage.

CONCLUSION

All patients with cystic lesions in the liver require discussion at multidisciplinary meetings to confirm the diagnosis and determine the most appropriate method of treatment.

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.

Technical report of a novel surgical technique: laparoscopic cyst fenestration and falciform ligament pedicle graft for treatment of symptomatic simple hepatic cysts

BACKGROUND

Simple hepatic cysts are common and infrequently develop into large symptomatic cysts that require surgical therapy. These benign cysts have been shown to be amenable to minimally invasive surgery; however, recurrences of symptoms have been reported. Our experience with over 200 simple hepatic cysts has lead to the development of a novel therapy to resolve symptoms associated with large simple hepatic cysts and reduce the rate of recurrent symptoms.

METHODS

An observational study demonstrating our experience with a novel minimally invasive technique for the management of symptomatic simple hepatic cyst.

RESULTS

A total of 6 cases were identified where laparoscopic mini-fenestration and placement of a falciform pedicle graft was used. There were no operative complications and 4 of 6 patients were discharged home the day of surgery. With mean follow-up of 9.6 months, there has not been any recurrence to date. One patient required an open hepatic resection for the treatment of a cystadenoma.

CONCLUSION

Laparoscopic mini-fenestration and placement of a falciform ligament pedicle graft shows promising early results as a treatment for the simple hepatic cyst. Long term follow-up data is required.

Biliary obstruction due to a huge simple hepatic cyst treated with laparoscopic resection

Most hepatic cysts are asymptomatic, but complications occasionally occur. We describe a patient with biliary obstruction due to a huge simple hepatic cyst treated with laparoscopic resection. A 60-year-old Japanese woman was admitted to our hospital because of a nontender mass in the right upper quadrant of the abdomen. Laboratory tests revealed the following: serum total bilirubin, 0.6 mg/dL; serum aspartate aminotransferase, 100 IU/L; serum alanine aminotransferase, 78 IU/L; serum alkaline phosphatase, 521 IU/L; and serum gamma glutamic transpeptidase, 298 IU/L. Abdominal computed tomography, ultrasonography, and magnetic resonance cholangiopancreatography revealed a huge hepatic cyst, 13 cm in diameter, at the hepatic hilum, accompanied by dilatation of the intrahepatic bile duct and obstruction of the common bile duct. We diagnosed biliary obstruction due to a huge hepatic cyst at the hepatic hilum, and laparoscopic surgery was performed. A huge hepatic cyst was seen at the hepatic hilum. After needle puncture of the huge cyst, the anterior wall of the cyst was unroofed, and cholecystectomy was done. Intraoperative cholangiography through a cystic duct revealed stenosis of the duct. Subsequent decapsulation of the cyst was performed in front of the common bile duct. After this procedure, cholangiography revealed that the stenosis of the common bile duct had resolved. Histopathological examination of the surgical specimen confirmed the hepatic cyst was benign. The postoperative course was uneventful, and the results of liver function tests normalized. The patient was discharged 7 days after operation. Computed tomography 3 months after operation revealed disappearance of the hepatic cyst and no dilatation of the intrahepatic bile duct.

Liver cyst with biliary communication successfully treated with laparoscopic deroofing: a case report

A 56-year-old woman visited our hospital because of high fever and right hypochondralgia. Abdominal computed tomography showed a liver cyst 10 cm in diameter and dilatation of the intrahepatic bile duct. Percutaneous transhepatic drainage of the cyst guided by ultrasonography disclosed that the cyst contained a brown milky fluid, and cystography showed biliary communication. Thus, the cyst was diagnosed as an infectious hepatic cyst with biliary communication. Treatments for liver cysts include aspiration therapy, alcoholic sclerotherapy, laparoscopic fenestration, fenestration by laparotomy, cystojejunostomy, cystectomy, and hepatectomy. Because a simple liver cyst is benign, treatments should be low-risk and minimally invasive; thus, we performed laparoscopic fenestration. Fenestration should not be performed if the case is complicated by infection or biliary communication. Although cystography showed biliary communication, the cyst was not visualized with endoscopic retrograde cholangiography, and we concluded that the biliary communication was small. Operation time was 95 minutes, and blood loss was 10 g. Pathological findings of the liver cyst were consistent with a simple cyst. The postoperative course was good, and the patient left the hospital 10 days after the operation. Eighteen months have passed since the operation, and no recurrent cysts have been detected with computed tomography. This is the second report of liver cyst with biliary communication successfully treated with laparoscopic deroofing. Laparoscopic fenestration is a useful method for treating simple benign liver cysts because of its minimal invasiveness and may be useful in cases with small biliary communication.

Intracystic hemorrhage of a large simple hepatic cyst

Spontaneous intracystic hemorrhage rarely occurs in nonparasitic hepatic cysts. We describe a patient with spontaneous intracystic hemorrhage of a large simple hepatic cyst that mimicked a malignancy. A 59-year-old man presented with right abdominal discomfort. The patient's medical history included a simple hepatic cyst that had been detected 7 years earlier but was left untreated. Three weeks before presentation, right upper abdominal pain occurred but resolved spontaneously. The serum CA19-9 concentration was 48.3 U/mL (normal<37 U/mL). Ultrasonography revealed a large cystic mass, containing many hyperechoic structures and occupying nearly the entire right hepatic lobe. Computed tomography demonstrated a homogenous low-density area, 20 cm in diameter, in the right hepatic lobe. Magnetic resonance imaging revealed a heterogeneous hypointense lesion measuring 20 cm in diameter. The lesions showed linear hyperintense areas on T1-weighted sequences and mosaic heterogeneous hyperintensity on T2-weighted sequences. We suspected a hemorrhagic simple hepatic cyst, hydatid cyst, or hemorrhagic cystadenocarcinoma. Right hepatectomy was performed, and the enlarged right lobe was removed. The mass was soft, sponge-like, and contained fluid, but was not elevated. Pathologic examination of the surgical specimen confirmed the presence of a hemorrhagic benign hepatic cyst.

Laparoscopic resection of benign hepatic cysts: a new standard

BACKGROUND

We sought to evaluate the feasibility and outcomes of laparoscopic resection of symptomatic hepatic cysts.

STUDY DESIGN

Fifty-one patients underwent laparoscopic resections for symptomatic hepatic cysts. Resection was accomplished laparoscopically with an Endo-GIA vascular stapler. Data were collected in a prospective database.

RESULTS

Median patient age was 60 years, with a median lesion diameter of 13 cm. Indication for surgical treatment was pain in 92% of patients. Laparoscopic resection was successful in 100% of patients. A pure laparoscopic approach was used in 58% of patients, the remaining used a hand port. Median operating time was 178 minutes. Preoperative diagnosis was polycystic liver in 88% and simple cyst in 12% diagnosed by preoperative imaging. Histologic examination showed 90% to be simple cysts and 10% cystadenomas. There were nine minor perioperative complications. Median hospital stay was 2 days. Relief of symptoms was achieved in all patients operated on for pain, with a median followup of 13 months. Two patients required reoperation for recurrence of the same cyst. CT or MRI was used for yearly followup.

CONCLUSIONS

Laparoscopic resection of symptomatic liver cysts is a feasible and effective method to relieve symptoms with minimal surgical trauma. This series represents the largest report of laparoscopic management for benign hepatic cysts and provides evidence for a routine laparoscopic approach to benign symptomatic cysts. Traditional surgical methods should be reserved for when a malignancy is expected, laparoscopy is contraindicated, or for recurrence after an initial laparoscopic approach.

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.

Laparoscopic Resection of Type I Choledochal Cyst in an Adult and Roux-en-Y Hepaticojejunostomy: A Case Report and Literature Review

Choledochal cysts are rare cystic dilatations of the extrahepatic biliary tree, the intrahepatic bile ducts, or both and carry a substantial risk of malignant transformation. Type I choledochal cysts, which involve the entire common hepatic and common bile ducts, represent 80% to 90% of these lesions. We report laparoscopic excision of symptomatic type I choledochal cyst in a 37-year-old woman, and review the literature. Laparoscopic excision of the extrahepatic biliary tree from the hepatic confluence to the anomalous pancreatobiliary junction with en bloc cholecystectomy and reconstruction with a Roux-en-Y hepaticojejunostomy was accomplished. Postoperative recovery was uneventful with a hospital stay of 3 days. She remains well and asymptomatic at 6 months of follow-up. Laparoscopic excision of choledochal cysts may be safely accomplished with a prompt recovery. Further experience with this approach in larger number of patients is justified and long-term follow-up data are needed.

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.

Laparoscopic ultrasound navigation in liver surgery: technical aspects and accuracy

The functional-anatomic structure of the liver according to Couinaud classification based on the intrahepatical course of the vascular structures is the basis of all modern liver surgery. Consequently, the use of intraoperative ultrasound is an undisputed requirement for every liver resection. Exact following of the planned resection plane can be realized only with the application of permanent online navigation based on intraoperative ultrasound during the dissection of the hepatical tissue. Now that the authors have established ultrasound navigated resection in open liver surgery using a navigated parenchymal dissecting instrument, they intend to transfer this technique from open to laparoscopic liver surgery. A special adapter was developed to connect an ultrasound-based navigation system to laparoscopic instruments. The authors present the first results in terms of technical aspects and feasibility.

Laparoscopic treatment of nonparasitic hepatic cysts

BACKGROUND

We present our experience with laparoscopic deroofing of nonparasitic hepatic cysts.

METHODS

Laparoscopic deroofing was performed due to a solitary hepatic cyst in 21 patients and polycystic liver in four patients. Laparoscopy was indicated when a cyst was larger than 5 cm (the general size of cysts was 6.9 cm) and caused complaints and was in a superficial position. In eight patients in whom the cyst was larger than 10 cm, omentoplasty was performed.

RESULTS

Intraoperative complications were not detected. Two conversions were performed because of the deep position of the cyst. Postoperative bile leakage was detected in one case that was treated conservatively. The average hospital stay was 4.7 days. Relapse occurred in two patients (8%), but only one of them required a second operation.

CONCLUSIONS

We recommend laparoscopic deroofing for treatment of nonparasitic liver cysts. This operation causes only slight discomfort for the patients, the intra- and postoperative morbidity is low, and relapses are rare.

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.

Laparoscopic fenestration of symptomatic liver cysts

The purpose of this clinical study was to evaluate the usefulness of laparoscopic fenestration of symptomatic liver cysts. Between September 1996 and September 2001, 6 patients underwent laparoscopic fenestration for symptomatic hepatic cysts. All 6 patients were women. The mean age was 59.5 (range 40-74). Two patients had single and 4 had multiple cysts. The mean diameter of the lesions, measured by preoperative computed tomography (CT), was 16.8 cm (range 10-20). The indications for surgical treatment included abdominal fullness associated with pain or dyspepsia. The surgical procedure involved puncture and aspiration of the cyst and subsequent circular electroresection of the cystic wall. Laparoscopic fenestration was successfully done in all 6 patients. The operating time was 148 minutes (range 110-215). Mean blood loss was 93 mL (range 5-300). Histologic examination of the cyst wall showed 5 simple cysts and 1 papillary serous cystadenoma. There were no intraoperative or postoperative complications. The mean hospital stay after surgery was 4.3 days (range 3-5). Complete relief of symptoms was achieved in 5 patients during the postoperative follow-up (range 2-6 years, mean 4). Follow-up CT (1 month to 4 years) has shown regression of the cysts in all patients (mean 3.8 cm, range 2-8). Laparoscopic fenestration of symptomatic liver cysts is a simple and effective method to relieve symptoms with minimal surgical trauma.

Role of fenestration and resection for symptomatic solitary liver cysts

BACKGROUND

Symptomatic liver cysts can be managed surgically by fenestration or by hepatic resection. The present study was designed to investigate the current role of each surgical technique in the management of this benign condition.

METHODS

Forty consecutive patients with symptomatic liver cyst (non-parasitic and non-malignant) surgically treated by fenestration or resection were identified from a prospectively collected database. An analysis of primary outcome measures including operative parameters, morbidity and mortality rates, length of postoperative stay and recurrence rates in months was carried out.

RESULTS

The laparoscopic fenestration group had the best perioperative outcome. At median follow up of 20 months, there were no recurrences in the resection group but recurrence occurred in 6/27 (22%) in the fenestration group. Four of these recurrences were asymptomatic and were managed conservatively while two symptomatic recurrences required a resection.

CONCLUSION

Laparoscopic fenestration is the best treatment for symptomatic liver cysts as the primary operation. It is associated with the lowest blood loss, lowest morbidity and shortest hospital stay. Liver resection is best reserved for recurrent symptomatic cysts and cystic lesions suspicious of tumours where it can be safely performed and associated with a zero recurrence rate.

Minimally invasive management of dysontogenetic hepatic cysts

BACKGROUND

Liver cysts occur with a prevalence of 4%-7% in the general population. Laparoscopic surgery is effective for solitary cysts and in selected patients with polycystic liver disease (PLD). We present our experience in the laparoscopic management of dysontogenetic cysts.

PATIENTS AND METHODS

Between 1994 and 2002, 36 patients were referred to our centre for the management of dysontogenetic cystic liver disease. Management was laparoscopic in 16 cases. Indications were solitary giant cysts (n=9) and PLD (n=7).

RESULTS

Laparoscopic procedures were completed in 15 patients. Mean operating time was 90 min. There were no deaths. In one case there was an intraoperative complication: bleeding from a superficial hepatic vein necessitated conversion to an open procedure. There were two postoperative complications: one patient with biliary leakage, which was managed conservatively, and one patient with a pneumothorax caused by the cava catheter installed for anaesthesia. Median follow-up was 36 months. There was no symptomatic recurrence.

CONCLUSION

Laparoscopy can be recommended as the procedure of choice for symptomatic solitary giant cysts and PLD Gigot type I.

Long-term results of multiple minocycline hydrochloride injections for the treatment of symptomatic solitary hepatic cyst

BACKGROUND

The current study presents the long-term results of multiple minocycline hydrochloride (MINO) injections for the treatment of symptomatic solitary hepatic cyst.

METHODS

From 1989 to 1998, nine patients were referred for the treatment of a symptomatic solitary hepatic cyst, comprising two males and seven females aged between 41-72 years (mean 58.2 years). The chief complaint in all cases was upper abdominal discomfort or pain. Mean cyst diameter was 14.1 +/- 2.3 cm. After insertion of an 8 or 9-French catheter into the cyst, 200 mg of MINO in 10 mL saline was injected and the catheter was flushed with 10 mL saline, for a total of 20 mL saline. The catheter was then clamped for 30 min. MINO injection was performed daily for 7-8 days, after which time the catheter was removed.

RESULTS

One patient complained of moderate right subscapular pain immediately after the injection, and one patient complained of pain at the site of catheter insertion. Patients were followed for 42-153 months (mean 85 months). Cyst regression without recurrence was documented in all patients.

CONCLUSIONS

Multiple injections of MINO are safe, definitive treatments for symptomatic solitary hepatic cyst.

Laparoscopic Treatment of Large True Cysts of the Liver and Spleen is Ineffective

True epidermal cysts of the liver and spleen are uncommon and it has been recommended that laparoscopic management is appropriate. Often these cysts are large and centrally located by the time they reach clinical significance thereby making complete excision difficult without major liver resection or splenectomy. Definitive therapy consists of drainage and complete resection of the cyst wall. Three patients presented with upper abdominal pain. Workup revealed large nonparasitic true cysts of the liver (one) and spleen (two). All were initially treated with laparoscopic resection of their cysts with the primary objective being organ preservation. They were followed with periodic ultrasound/CT scanning. The pathology report in all three cases demonstrated benign congenital epithelial cysts and the patients did well postoperatively. Despite meticulous dissection and marsupialization of the cysts all three patients experienced recurrence that necessitated further therapy. We conclude that laparoscopic surgery is inadequate in the management of true cysts of the liver and spleen unless complete removal of all cyst wall can be assured.

Does laparoscopic fenestration provide long-term alleviation for symptomatic cystic disease of the liver?

BACKGROUND

The use of laparoscopic technique for management of symptomatic liver cysts is documented to be a feasible and safe procedure with good short-term symptomatic relief. However, it cannot be recommended as the standard of care as long-term results are scarce. The present study was initiated to review the long-term results of this approach in the management of symptomatic liver cysts.

METHODS

A retrospective review of all patients with symptomatic liver cysts that were treated by laparoscopic fenestration in our department over an 8-year period from 1993 to 2001. The clinical and radiographical data were analysed at follow-up to assess the -outcome.

RESULTS

Eleven patients were treated using a laparoscopic approach; 10 patients with solitary cysts and one with adult polycystic liver disease. All patients achieved short-term alleviation of symptoms and an uneventful postoperative course. The mean hospital stay was 3 days. Long-term follow up was available for 9 patients with a mean of 44 months. Histologically, one of the patients was diagnosed with a biliary cystadenoma and she had a symptomatic recurrence and a liver resection at 20 months. In the other seven patients, there was no clinical recurrence but a radiographical recurrence of 28.5%. The patient with adult polycystic liver disease had two symptomatic recurrences: at 26 months where he underwent a repeat laparoscopic fenestration and at 43 months where he underwent an open fenestration.

CONCLUSION

The present study confirms that with adequate patients election, long-term alleviation of symptoms can be achieved with the laparoscopic approach for solitary simple liver cysts but not for polycystic liver disease or cystic tumours of the liver.

Laparoscopic surgery of the liver and biliary tract

Laparoscopic treatment of liver and biliary tract disease is growing in popularity but requires extensive experience. Among the lesions now managed with minimally invasive methods are simple cysts, polycystic liver disease, hydatid cysts, biliary stones, and benign solid tumors. Patient selection, surgical techniques, and outcomes are described.

The surgical management of congenital liver cysts

BACKGROUND

Most series that report the results of surgical treatment for congenital liver cysts focus more on the technical aspects of the operation than on the late outcome of these patients. In this paper, we emphasize the importance of appropriate patient selection and adequate surgical technique for successful long-term outcome.

METHODS

Twenty-four consecutive patients with congenital liver cysts were selected for surgical treatment. According to our own classification, 13 patients had simple liver cysts, nine had multicystic liver disease, and two had type I polycystic liver disease. All of these patients were treated by the fenestration technique. An open approach was used for five patients (group 1) treated between 1984 and 1990. In 19 patients (group 2) treated since 1991, a laparoscopic approach was used. The incidence of complicated liver cysts was 40% in group 1 and 68% in group 2.

RESULTS

There were no treatment-related deaths in this series. The mean postoperative hospital stay was significantly shorter for patients who underwent successful laparoscopic fenestration (p < 0.05). In the open group (group 1), there were no postoperative complications, and all patients were alive and free of symptoms during a mean follow-up of 130 months, without any sign of cyst recurrence. In the laparoscopic group (group 2), four patients were converted to open surgery. One of these patients had an inaccessible posterior cyst; another had bile within the cystic cavity. A further two cases had complicated liver cysts with an uncertain diagnosis between congenital and neoplastic cysts. Four patients (21%) developed peri- or postoperative complications. During a mean follow-up time of 38.5 months, none of the patients with simple liver cysts incurred late symptoms or signs of cyst recurrence. In the six patients with multicystic liver disease, one developed disease-related cyst progression (17%) and required reoperation. One of the two patients with type I polycystic liver disease (50%) developed asymptomatic disease-related cyst progression.

CONCLUSIONS

When patients are carefully selected and a proper surgical technique is employed, excellent long-term results with a low morbidity rate can be achieved in patients with congenital liver cysts. Patients with multicystic liver disease or type I polycystic liver disease are more prone to late cyst recurrence. A tailored approach is thus indicated for patients with congenital liver cystic disease. However, the laparoscopic approach appears to be the gold standard for the treatment of highly symptomatic or complicated simple liver cysts.

Laparoscopic management of benign liver disease

Minimally invasive techniques may be used for treating a variety of benign hepatic lesions in selected patients. The size of the lesions is less important than the anatomic location in anterolateral regions. Laparoscopic unroofing of solitary liver cysts is the surgery of choice for this indication. The laparoscopic management of patients with PLD should be reserved for patients with a few, large, anteriorly located, symptomatic cysts. Active hydatid cysts present technical difficulties because of their complex biliovascular connections and the inherent nature of the parasite. The authors' results do not support the widespread use of laparoscopy in these cases. Uncomplicated benign liver tumors located in the left lobe or in the anterior segments of the right lobe can be resected safely using a four-hand technique. Open surgery is the treatment of choice when primary tumors are malignant, located posteriorly, or in proximity to major hepatic vasculature. Laparoscopic resection of liver metastases with a safety margin of 1 cm, when the total number is less than four, is not unreasonable and can be offered to patients without evidence of extrahepatic disease.