Percutaneous aspiration and alcohol sclerotherapy for symptomatic hepatic cysts. An alternative to surgical intervention

Endoscopic Ultrasound-Guided Ablation of Premalignant Pancreatic Cysts and Pancreatic Cancer

Pancreatic cancer is on the rise and expected to become the second leading cause of cancer-related death by 2030. Up to a one-fifth of pancreatic cancers may arise from mucinous pancreatic cysts, which are frequently present in the general population. Currently, surgical resection is the only curative approach for pancreatic cancer and its cystic precursors. However, only a dismal proportion of patients are eligible for surgery. Therefore, novel treatment approaches to treat pancreatic cancer and precancerous pancreatic cysts are needed. Endoscopic ultrasound (EUS)-guided ablation is an emerging minimally invasive method to treat pancreatic cancer and premalignant pancreatic cysts. Different ablative modalities have been used including alcohol, chemotherapy agents, and radiofrequency ablation. Cumulative data over the past two decades have shown that endoscopic ablation of mucinous pancreatic cysts can lead to cyst resolution in a significant proportion of the treated cysts. Furthermore, novel data are emerging about the ability to endoscopically ablate early and locally advanced pancreatic cancer. In this review, we aim to summarize the available data on the efficacy and safety of the different EUS-ablation modalities for the management of premalignant pancreatic cysts and pancreatic cancer.

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.

Polycystic Liver Disease: Pathophysiology, Diagnosis and Treatment

Polycystic liver disease (PLD) is a clinical condition characterized by the presence of more than 10 cysts in the liver. It is a rare disease Of genetic etiology that presents as an isolated disease or assoc\iated with polycystic kidney disease. Ductal plate malformation, ciliary dysfunction, and changes in cell signaling are the main factors involved in its pathogenesis. Most patients with PLD are asymptomatic, but in 2-5% of cases the disease has disabling symptoms and a significant reduction in quality of life. The diagnosis is based on family history of hepatic and/or renal polycystic disease, clinical manifestations, patient age, and polycystic liver phenotype shown on imaging examinations. PLD treatment has evolved considerably in the last decades. Somatostatin analogues hold promise in controlling disease progression, but liver transplantation remains a unique curative treatment modality.

Partial major hepatectomy with cyst fenestration for polycystic liver disease: Indications, short and long-term outcomes

BACKGROUND AND OBJECTIVE

Symptomatic polycystic liver disease (PLD) with massive hepatomegaly represents a challenging surgical issue. In this work, we focused on early and long term outcomes after partial hepatectomy with cyst fenestration (PHCF) in selected patients.

METHODS

All patients who had PHCF for treatment of PLD between January 2003 and December 2019 in our center were included in this study. PHCF was undertaken if at least one hepatic section was relatively spared from PLD, afferent and efferent hepatic vasculature was patent, and liver function was maintained.

RESULTS

Twenty nine patients (25 women) with a mean age of 54.6 ± 9 years underwent PHCF. Major hepatectomy was performed in all cases with 4.3 ± 0.8 resected segments. Overall perioperative morbidity (Clavien ≥ II) and mortality rates were 41.4.6% and 13.8% respectively. Significant postoperative liver volume reduction was 52.8% within the first year and 55.5% thereafter. From preoperative evaluation, performance status (PS) normalized or improved in 84% of patients. After a mean follow-up time of 70.8 ± 65 months, overall patient survival was 82.7%. In univariate analysis, PS, initial liver volume, operative time and transfusion were associated with post-operative complications and PS, preoperative cyst infection, portal hypertension, transfusion, postoperative sepsis and persistent ascites were associated with mortality.

CONCLUSIONS

Our study confirms that in spite of significant morbidity rate, PHCF allows a massive reduction of liver volume in selected patients with symptomatic PLD and is highly and durably effective for the reduction of liver volume and improvement of quality of life.

Alcohol-Mediated Renal Sympathetic Neurolysis for the Treatment of Hypertension: The Peregrine™ Infusion Catheter

Renal sympathetic denervation using conventional non-irrigated radiofrequency catheters has potential technical shortcomings, including limited penetration depth and incomplete circumferential nerve damage, potentially impacting therapeutic efficacy. Against this background, second generation multi-electrode, radiofrequency and ultrasound renal denervation systems have been developed to provide more consistent circumferential nerve ablation. Irrigated catheters may allow deeper penetration while minimizing arterial injury. In this context, catheter-based chemical denervation, with selective infusion of alcohol, a potent neurolytic agent, into the perivascular space, may minimize endothelial, intimal and medial injury while providing circumferential neurolysis. Animal studies demonstrate pronounced renal norepinephrine level reductions and consistent renal nerve injury after perivascular alcohol infusion using the Peregrine Catheter. Early clinical studies demonstrated significant blood pressure reductions and a reasonable safety profile. Randomized sham-controlled trials (NCT03503773, NCT02910414) are underway to examine whether the aforementioned theoretical advantages of alcohol-medicated denervation with the Peregrine System™ Kit translate into clinical benefits.

Laparoscopic Enucleation of Hepatic Cysts Reduces the Recurrence of Nonparasitic Hepatic Cysts

Background: Standard treatments for nonparasitic hepatic cysts (NPHCs) include laparoscopic deroofing (LD), percutaneous aspiration, and alcohol sclerotherapy. However, these treatments have limitations. LD and alcohol sclerotherapy, for example, fail to prevent NPHC recurrences, although alcohol sclerotherapy is satisfactorily effective in treating small cysts (diameter <5 cm), which do not usually need treatment. The present study introduces a novel surgical procedure, laparoscopic enucleation with intact cyst (LEIC), which may prevent postoperative cyst recurrence. Materials and Methods: In this study, we enrolled 14 patients, with NPHCs larger than 9 cm in diameter, who underwent LEIC. Dissection and coagulation were performed using the harmonic shear enucleation and bipolar coagulation techniques. We attempted to completely remove the cysts intact. Results: For all patients, symptoms disappeared after complete elimination of the cyst capsule. No complications (hemorrhage or bile leakage) were found during the perioperative period. The mean follow-up period was 19.3 months (range 10-38 months), during which no recurrences or complications were noted. Conclusions: LEIC is a novel surgical approach that shows satisfactory efficacy and safety in patients with large, surficial, and symptomatic NPHCs. LEIC's main advantage is that it can efficiently prevent cyst recurrence and decrease postoperative morbidity. However, its long-term efficacy and safety require further verification, especially with huge cysts.

Benign multicystic mesothelioma and peritoneal inclusion cysts: are they the same clinical and histopathological entities? A systematic review to find an evidence-based management

PURPOSE

Peritoneal mesothelial cysts (PMC) are a clinical dilemma because of their true pathogenic nature. Many definitions have been associated with PMC, including "benign multicystic mesothelioma", "cystic mesothelioma", "multilocular peritoneal inclusion cysts", ''inflammatory cysts of the peritoneum" or "postoperative peritoneal cyst".

METHODS

We herein performed a systematic review of the literature focusing on clinical and histopathological aspects of PMC, diagnosis, and therapies. Moreover, we described our experience with a case of PMC in a young female.

RESULTS

Since there is often a history of prior surgery or inflammatory disease, most authors consider PMC of reactive origin. However, in some cases they occur without any documentable signs of disease or injury. A variety of clinical findings can complicate the preoperative assessment and a multitude of histological pictures may potentially lead to a misdiagnosis. The absence of a uniform treatment strategy and lack of long-term follow-up often hinder the accurate definition leading to unnecessary or unnecessarily aggressive therapy.

CONCLUSIONS

PMC are more common than had previously been thought. Most authors consider them non-neoplastic; thus the designation of "peritoneal inclusion cyst" is preferable. The term "mesothelioma" should be used only in cases of histological evidences of atypia. The high rates of recurrence suggest that the goal of treatment should not be necessarily complete eradication, but symptomatic relief through individualized treatment. This is a topic of particular importance, especially in young female where recurrence rates could be lower than those reported in adults and where an improperly aggressive treatment could have repercussions on fertility.

Monoethanolamine Oleate Sclerotherapy for Polycystic Liver Disease

OBJECTIVE

The objective of treatment for polycystic liver disease is to reduce the liver volume and reduce or resolve compression symptoms such as abdominal fullness and abdominal pain due to hepatomegaly. Liver cysts are treated internally by puncture and aspiration of the cyst contents or hepatic artery embolization and surgically by cyst fenestration or hepatectomy, but no clear consensus has been reached concerning their selection. We introduced monoethanolamine oleate (EO) sclerotherapy therapy for liver cysts in 1999 and reported its effectiveness. In this study, cases were added, and the results including those of long-term follow-up were evaluated.

SUBJECTS

Twenty-two patients (5 males and 17 females, mean age 65.2) who underwent EO infusion therapy for liver cysts between January 1999 and June 2011 were evaluated.

METHODS

Liver cysts were punctured under ultrasound guidance, and a 7Fr pigtail catheter was inserted. After aspirating the cyst contents, EO was infused, and a clamp was applied for 24 h. Then, the catheter was declamped, cyst contents were aspirated again, and the catheter was removed. After the treatment, the cyst size was measured, and the patients were followed up.

RESULTS

Eight simple cysts in 8 patients (simple cyst group) and 21 cysts in 14 patients with multiple cysts (polycystic liver disease group) were treated and followed up over a median of 78 months (0-203 months). The mean volume reduction rate was 99% in the simple cyst group and 91% in the polycystic liver disease group (p = 0.04). One procedural accident resulting in liver abscess formation was observed in 1 patient 1 week after discharge, and it required drain placement and antibiotic administration. While mild abdominal pain was observed in a few patients, it was resolved spontaneously under observation.

CONCLUSION

EO infusion therapy achieves fairly high treatment response in the volume reduction (99%) and sustained shrinkage over long-term follow-up. Therefore, this is a breakthrough technique in the treatment of polycystic liver disease as well as simple cyst and should be a standard of care in the treatment of this disease.

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.

Symptomatic abdominal simple cysts: is percutaneous sclerotherapy with hypertonic saline and bleomycin a treatment option?

Aim. To evaluate the feasibility of percutaneous sclerotherapy of symptomatic simple abdominal cysts, using hypertonic saline and bleomycin, as an alternative to surgery. Materials and Methods. This study involved fourteen consecutive patients (ten women, four men, mean age: 59.2 y) with nineteen symptomatic simple cysts (liver n = 14, kidney n = 3, and adrenal n = 2) treated percutaneously using a modified method. Initially CT-guided drainage was performed; the next day the integrity of the cyst/exclusion of extravasation or communications was evaluated under fluoroscopy, followed by two injections/reabsorptions of the same quantity of hypertonic NaCl 15% solution and three-time repetition of the same procedure with the addition of bleomycin. The catheter was then removed; the patients were hospitalized for 12 hours and underwent follow-ups on 1st, 3rd, 6th, and 12th months. Cyst's volumes and the reduction rate (%) were calculated in each evaluation. Results. No pain or complications were noted. A significant cyst's volume reduction was documented over time (P < 0.001). On the 12th month 17 cysts disappeared and two displayed a 98.7% and 68.9% reduction, respectively. Conclusion. This percutaneous approach constitutes a very promising nonsurgical alternative for patients with symptomatic simple cyst, without complications under proper precautions, leading to eliminating the majority of 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.

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.

Pathophysiology, epidemiology, classification and treatment options for polycystic liver diseases

Polycystic liver diseases (PLD) represent a group of genetic disorders in which cysts occur in the liver (autosomal dominant polycystic liver disease) or in combination with cysts in the kidneys (autosomal dominant polycystic kidney disease). Regardless of the genetic mutations, the natural history of these disorders is alike. The natural history of PLD is characterized by a continuous increase in the volume and the number of cysts. Both genders are affected; however, women have a higher prevalence. Most patients with PLD are asymptomatic and can be managed conservatively. Severe symptoms can affect 20% of patients who develop massive hepatomegaly with compression of the surrounding organs. Rrarely, patients with PLD suffer from acute complications caused by the torsion of hepatic cysts, intraluminal cystic hemorrhage and infections. The most common methods for the diagnosis of PLD are cross sectional imaging studies. Abdominal ultrasound and computerized tomography are the two most frequently used investigations. Magnetic resonance imaging is more sensitive and specific, and it is a valuable test for patients with intravenous contrast allergies or renal dysfunction. Different treatment modalities are available to physicians caring for these patients. Medical treatment has been ineffective. Percutaneous sclerotherapy, trans-arterial embolization, cyst fenestration, hepatic resection and liver transplantation are indicated to specific groups of patients and have to be tailored according to the extent of disease. This review outlines the current knowledge of the pathophysiology, clinical course, diagnosis and treatment strategies of PLD.

Comparison of success rates of 'transvaginal aspiration and tetracycline sclerotherapy' versus 'only aspiration' in the management of non-neoplastic ovarian cysts

AIM

To investigate the value of tetracycline sclerotherapy for management of recurrent or persisting non-neoplastic ovarian cysts in comparison to the aspiration without sclerotherapy.

MATERIAL AND METHODS

Ninety-six patients with proven non-neoplastic ovarian cysts were randomized into two groups. Group 1 patients underwent cyst aspiration together with tetracycline sclerotherapy (n=48). Group 2 patients underwent only cyst aspiration without tetracycline sclerotherapy (n=48). Then, all patients were followed up monthly with ultrasonography for 12months. The procedure was considered to have failed if the recurring cyst, detected by ultrasound, was 4cm in size or greater.

RESULTS

There were no differences between the two groups regarding demographic data, initial cyst volume and tumor markers. Recurrence rates within 12months were 14.6% in group 1 and 50% in group 2 (P<0.001).

CONCLUSION

Based on the recurrence rates, we suggest transvaginal aspiration together with tetracycline sclerotherapy rather than only simple transvaginal aspiration in the management of non-neoplastic ovarian cysts.

Percutaneous aspiration and ethanolamine oleate sclerotherapy for sustained resolution of symptomatic polycystic liver disease: an initial experience

OBJECTIVE

Surgical therapy for symptomatic polycystic liver disease is effective but has substantial mortality and morbidity. Minimally invasive options such as percutaneous aspiration with or without ethanol sclerosis have had disappointing results. The purpose of this study was to evaluate percutaneous aspiration with ethanolamine oleate sclerosis in the management of symptomatic polycystic liver disease.

SUBJECTS AND METHODS

The study included 13 patients (11 with polycystic liver disease, two with simple cysts) with 17 cysts. All patients underwent percutaneous aspiration of the liver cyst under ultrasound guidance followed by insertion of a 7-French pigtail catheter, instillation of ethanolamine oleate (10% of cyst volume), and aspiration of the ethanolamine oleate. The catheter was kept in place for 24 hours of open drainage and then removed.

RESULTS

All but one of the cysts resolved with one instillation. The one cyst, in a patient with polycystic liver disease, required two instillations 3 months apart. The mean initial volume of cysts was 589.8 mL, and the mean reduction in volume was 88.8%. Both the simple cysts resolved completely. In the cases of polycystic disease, the volume of cysts larger than 10 cm in diameter was reduced by 92.8%. Cyst resolution was gradual, and clinically significant cyst reduction was achieved within 1 year of therapy. None of the patients needed surgery. The median follow-up period was 54 months (range, 1 week-95 months). There were no significant adverse effects, and all patients had relief of symptoms after therapy.

CONCLUSION

This initial experience with a single session of percutaneous aspiration and ethanolamine oleate sclerosis resulted in sustained resolution of symptomatic polycystic liver disease with minimal morbidity, avoidance of surgery, and improvement in quality of life.

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.

[Hepatic cysts: diagnosis and management]

Cystic lesions of the liver are common and usually benign. The most frequent lesion is simple hepatic cyst: typical imaging findings make their diagnosis easy and they require no treatment. Complicated hepatic cysts (i.e., compression, hemorrhage, infection) have more variable imaging findings making diagnosis more difficult; they may evoke other diagnoses. Asymptomatic hepatic cysts do not require any treatment or follow-up. Symptomatic cysts may benefit from simple follow-up or may be treated by laparoscopic fenestration or alcohol sclerotherapy. The differential diagnosis of complicated hepatic cysts includes cystadenoma, cystadenocarcinoma, hydatid cyst, or cystic metastasis; surgical resection is usually indicated for these lesions.

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.

Inferior vena cava stenting: a safe and effective treatment for intractable ascites in patients with polycystic liver disease

We performed a retrospective study of seven patients with polycystic liver disease who underwent stenting of the inferior vena cava for intractable ascites. All patients had symptomatic ascites and inferior vena cava stenosis demonstrable by venography. The mean pressure gradient across the inferior vena cava stenosis before stenting was 14.5 mm Hg (range 6-25 mm Hg) and significantly decreased to a mean pressure gradient of 2.8 mm Hg (range 0-6 mm Hg, p = 0.008) after stenting. Two patients also had stenting of hepatic venous stenoses after unsuccessful inferior vena cava stenting. After a mean follow-up of 12.2 months (range 0.5-39.1 months), five of the seven patients have had maintained clinical improvement, defined as decreased symptoms, diuretic requirements, and frequency of paracentesis. Four patients have required no further intervention. The other patient was lost in follow-up. Patients with clinical improvement had an overall larger mean pressure gradient before stenting (19.2 vs. 9.8 mm Hg) and a larger Delta pressure gradient (15.8 vs. 7.8 mm Hg) compared to those in whom stenting was unsuccessful. These results suggest inferior vena cava stenting is safe and effective and should be considered as a first-line intervention in the treatment of medically intractable ascites in select patients with polycystic liver disease.

Results of percutaneous sclerotherapy and surgical treatment in patients with symptomatic simple liver cysts and polycystic liver disease

AIM: To evaluate the results of the treatment of simple liver cysts (solitary and multiple) and polycystic liver disease (PLD) using percutaneous sclerotherapy and/or surgical procedures in a single tertiary referral centre.

METHODS: Retrospective analysis of 54 patients referred for evaluation and possible treatment of simple liver cysts (solitary and multiple) and PLD, from January 1997 to July 2006.

RESULTS: Simple liver cysts were treated in 41 pts (76%) with a mean size of 12.6 cm. The most common reason for referral was abdominal pain or discomfort (85%). Percutaneous sclerotherapy was performed as initial treatment in 30 pts, showing cyst recurrence in 6 pts (20%). Surgical treatment was initially performed in 11 pts with cyst recurrence in 3 pts (27%). PLD was treated in 13 pts (24%) with a mean size of the dominant cyst of 13 cm. Percutaneous sclerotherapy for PLD was performed in 9 pts with recurrence in 7 pts (77.8%). Surgical treatment for PLD was undertaken in 4 pts (30.8%) with recurrence in all. Eventually, 2 pts with PLD in the presence of polycystic kidney disease underwent liver- and kidney transplantation because of deterioration of liver and kidney function.

CONCLUSION: The majority of patients with simple liver cysts and PLD are referred for progressive abdominal pain. As initial treatment, percutaneous sclerotherapy is appropriate. Surgical deroofing is indicated in case of cyst recurrence after percutaneous sclerotherapy. However, the results of percutaneous sclerotherapy and surgical treatment for PLD are disappointing. Partial liver resection is indicated when there is suspicion of a pre-malignant lesion.

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.

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.

Laparoscopic treatment of biliary hepatic cysts: short- and medium-term results

BACKGROUND

The aim of this study was to evaluate the postoperative morbidity and, in the medium-term results, the incidence of relapses in the laparoscopic treatment of non-parasitic hepatic cysts (NPHC) and polycystic liver disease (PCLD).

PATIENTS AND METHODS

From 1999 to 2003, 12 patients with NPHC and 3 patients with PCLD with few large cysts in the anterior hepatic segments underwent laparoscopic fenestration and deroofing.

RESULTS

There were no conversions and no mortality; the mean operative time was 55 min for NPHC and 120 min for PCLD. Postoperative morbidity comprised two patients with bronchopneumonic infiltrations and in one patient with PCLD ascites resolved spontaneously. All the patients experienced resolution of the symptomatology. Follow-up was carried out from 3 to 38 months (mean 18 months). There was no relapse of the disease.

DISCUSSION

The preoperative selection of patients is fundamental to program the surgical treatment. Laparoscopy can be considered a safe and efficacious treatment for NPHC and PCLD.

Secretion and expression of epithelial markers supports the biliary origin of solitary nonparasitic cyst of the liver in infancy

Solitary nonparasitic cyst of the liver (SNPCL) is rare in children. Although there are several hypotheses regarding the pathogenesis, the true origin of SNPCL remains unknown. The authors present an infant with a huge SNPCL in whom the epithelial markers, CA19-9, DU-PAN-2, and SPan-1, were elevated in the serum and cystic fluid. The presence of CA19-9 and DU-PAN-2 was shown by immunohistochemistry in the cystic epithelia. These indicate that the classical idea of biliary origin of SNPCL is supported.

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.

Giant solitary non-parasitic cyst of the liver

BACKGROUND

Cystic diseases of the liver and intrahepatic biliary tree are uncommon. The majority of cases are detected only when patients become symptomatic, or as an incidental finding on radiological imaging.

METHODS

We discuss the case of a 25-yr-old female with a centrally located giant liver cyst causing obstructive jaundice, and briefly discuss the management options in the treatment of this uncommon problem.

RESULTS AND CONCLUSIONS

Intervention is recommended in patients with symptomatic simple cysts of the liver. Surgical cystectomy is the treatment of choice for large deep seated cysts.

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.

Highly symptomatic adult polycystic liver disease: options and results of surgical management

BACKGROUND

The majority of patients afflicted with adult polycystic liver disease (APLD) are asymptomatic. For those who are symptomatic, there are a variety of treatment procedures that have been proposed but these lack verification through long-term studies with respect to safety and long-term effectiveness. Choice of surgical procedure is related to the severity of APLD and morphology of the cysts within the liver. The aim of the present study was to analyse the immediate and long-term results of fenestration and combined resection-fenestration at Singapore General Hospital.

METHODS

A retrospective analysis of clinical, operative, imaging and follow-up data was carried out for 12 patients (10 women and two men) with symptomatic APLD who underwent surgery from January 1992 to December 2000. The primary outcome measures assessed were postoperative alleviation of symptoms, performance status, complications, mortality and long-term recurrence of symptoms.

RESULTS

Nine patients underwent 12 fenestration procedures and three patients had combined resection-fenestration. Fenestration was carried out for eight of nine patients with a dominant cyst morphology and combination resection-fenestration was carried out for those three patients with diffuse cyst morphology. There was no operative mortality and all patients were discharged from hospital free of their preoperative symptoms. Overall morbidity rate was 58%. The mean follow up for the present cohort was 29.3 months. Only two patients had recurrence of symptoms. One patient with dominant cyst morphology who underwent laparoscopic fenestration had recurrence at 26 and 43 months but this was successfully treated finally with open fenestration. The other patient had diffuse cyst morphology and was treated with fenestration for recurrent cyst infection that recurred 1 month postoperatively. This required subsequent intravenous antibiotics and percutaneous drainage for resolution of symptoms.

CONCLUSION

Treatment for symptomatic APLD should be based on the morphology of the liver cysts. Fenestration is a safe and acceptable procedure for patients with a dominant cyst pattern where liver size can be reduced after the cysts collapse. A combination of resection-fenestration is suitable for those with a diffuse cyst pattern where grossly affected segments are resected in combination with fenestration to allow for reduction in liver size.

Aspiration and alcohol sclerotherapy: a novel method for management of Bartholin’s cyst or abscess

OBJECTIVE

To investigate the efficiency and safety of alcohol sclerotherapy of Bartholin's cyst or abscess by comparing it with silver nitrate insertion.

STUDY DESIGN

Twenty-two patients with unilateral Bartholin's cyst or abscess were randomized into one of the treatment groups according to diameter of cyst or abscess. Group I consisted of 12 patients who were treated with alcohol sclerotherapy and Group II included 10 patients who were treated with silver nitrate insertion. In both groups, treatments were conducted under local anesthesia and in an outpatient setting. The patients were checked for morbidity of operations every 3 days until complete healing was observed and then followed up monthly for over 24 months.

RESULTS

The mean duration of procedure was 7+/-2 min in group I and 15+/-3 min in group II. Healing time was 4.8+/-1.3 days in group I and 9.2+/-2.5 days in group II. In group I although 10 patients showed complete healing without any early or late morbidity; two patients suffered from severe vulval pain, edema and echymosis, and then developed a total cyst necrosis. Healing in these patients completed with mild scar formation. Only one recurrence was documented during 24 months follow-up period. All patients in group II complained labial pain, four of them suffered from severe labial pain, edema, and echymosis. Healing in these patients was completed with moderate scar formation. Follow-up of 24 months revealed no recurrence in this group.

CONCLUSION

Alcohol sclerotherapy of Bartholin's cyst or abscess is as effective as silver nitrate application and is associated with less complication. It may be ideal, safe and attractive treatment modality for this gynecological disease.

Single-session alcohol sclerotherapy in symptomatic benign hepatic cysts performed with a time of exposure to alcohol of 10 min: initial results

The aim of this study was to evaluate the 1-year results of single-session sclerotherapy of symptomatic benign non-parasitic liver cysts performed with maximum 10 min time of ethanol exposure. During the period 1995-1999, 15 symptomatic liver cysts in nine patients--eight women and one man--were treated with 10 min time of exposure to ethanol. Ultrasound-guided puncture combined with fluoroscopy was used for catheter placement. Alcohol sclerotherapy was performed with a maximum volume of ethanol 96% of 10% of the cyst volume, never exceeding 100 ml. At follow-up the patients were examined with liver function tests, ultrasound or CT examination, clinical examination, and interview by a gastrointestinal surgeon. Ten cysts in seven patients (six women and one man; age range 44-61 years, median age 58 years), who had a follow-up of at least 1 year, were included. The original cyst volumes were 30-4110 ml (median 392 ml). After a follow-up period of 12-47 months (median 23 months), cyst volumes were 0-523 ml (median 21.5 ml) with a reduction of the median cyst volume by 95% ( p<0,005). All patients experienced relief of their clinical symptoms. Except for pain, no complications were observed. Sclerotherapy using only one session and maximum 10 min time of exposure to ethanol represents an effective treatment of symptomatic liver cysts.

Management of non-neoplastic ovarian cysts with sclerotherapy

OBJECTIVE

To evaluate sclerotherapy with alcohol and erythromycin in the management of simple ovarian cysts.

METHODS

Twenty-four simple ovarian cysts were subjected to sclerotherapy with alcohol and erythromycin. All procedures were performed under local anesthesia and in an outpatient setting. Cytological examination was carried out in all cases and two patients were excluded from the study because of suspicious cytological results. The patients were followed up monthly with color Doppler sonography for more than 12 months.

RESULTS

Cyst fluid was serous in 17 cases and dark-chocolate colored in seven cases. The volume of aspirated fluid ranged from 100 to 220 ml. The size of ovarian masses and cyst-wall thickness ranged from 5.5 to 8.5 cm and 1.5 to 5 mm, respectively. Cytological analysis of 15 cysts revealed acellular sediment, seven cysts were compatible with endometrioma, and two were reported as suspicious. During the 12-month follow-up, seven cyst recurrences were detected.

CONCLUSION

Aspiration and sclerotherapy with alcohol and erythromycin are followed by a relatively high recurrence rate when the aspirate is bloody. However, patients with a simple cyst that is painful or liable to torsion could benefit from sclerotherapy. Such patients, who are at low risk for malignancy, are relieved with sclerotherapy while avoiding surgery.