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

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.

Surgical management and longterm follow-up of non-parasitic hepatic cysts

BACKGROUND

Despite the increasing use of laparoscopic techniques, the optimal surgical approach for cystic liver disease has not been well defined. This study aims to determine the optimum operative approach for these patients.

METHODS

Data were identified from the Lothian Surgical Audit, case note review and general practitioner contact. Patients were contacted and asked to complete the SF-36 questionnaire on quality of life.

RESULTS

A total of 102 patients (67 with simple cysts, 31 with polycystic liver disease [PCLD], four with cystic tumours) underwent 62 laparoscopic deroofings, 15 open deroofings, 36 resections and one liver transplant between June 1985 and April 2006. The median follow-up was 77 months (range 3-250 months). Morbidity and recurrent symptom rates after laparoscopic surgery were greater in PCLD patients compared with simple cyst patients, at 31% (four patients) vs. 15% (seven patients) and 85% (11 patients) vs. 29% (24 patients), respectively. Four patients with simple cysts and eight with PCLD required further surgery. All patients with simple cysts had comparable quality of life after surgery. Patients with recurrent symptoms after surgery for PCLD had a significantly better quality of life following laparoscopic deroofing than after resection.

CONCLUSIONS

Most simple cysts can be managed laparoscopically, but there is a definite role for open resection in some patients. Open deroofing is the preferred approach for a dominant cyst pattern in PCLD, whereas resection is necessary for diffuse cystic disease.

Factors that influence outcome in non-invasive and invasive treatment in polycystic liver disease patients

AIM: To evaluate the factors that influence outcome of both non-invasive and invasive treatment of polycystic liver disease.

METHODS: Analysis of clinical files of patients with complete follow-up from July 1986 to June 2006.

RESULTS: Forty-one patients (male, 7; female, 34), 47.8 ± 11.9 years age, and 5.7 ± 6.7 years follow-up, were studied. Alkaline phosphatase (AP) elevation (15% of patients) was associated with the requirement of invasive treatment (IT, P = 0.005). IT rate was higher in symptomatic than non-symptomatic patients (65.4% vs 14.3%, P = 0.002), and in women taking hormonal replacement therapy (HRT) (P = 0.001). Cysts complications (CC) were more frequent (22%) in the symptomatic patients group (P = 0.023). Patients with body mass index (BMI) > 25 (59%) had a trend to complications after IT (P = 0.075). Abdominal pain was the most common symptom (56%) and indication for IT (78%). Nineteen patients (46%) required a first IT: 12 open fenestration (OF), 4 laparoscopic fenestration (LF) and 3 fenestration with hepatic resection (FHR). Three required a second IT, and one required a third procedure. Complications due to first IT were found in 32% (OF 16.7%, LF 25%, FHR 66.7%), and in the second IT in 66.7% (OF 100%). Follow-up mortality rate was 0.

CONCLUSION: Presence of symptoms, elevated AP, and CC are associated with IT requirement. HRT is associated with presence of symptoms and IT requirement. Patients with BMI > 25 have a trend be susceptible to IT complications. The proportions of complications are higher in FHR and second IT groups. RS is more frequent after OF.

Polycystic liver disease: multimodality imaging for complications and transplant evaluation

Polycystic liver disease (PLD) is usually associated with polycystic kidney disease but may also occur as an isolated finding in a rarer genetically distinct disease. In either case, the cyst burden will progress over time and, in rare cases, may affect liver function or become symptomatic due to massive hepatomegaly. The character, distribution, location, and size of hepatic cysts are important. Computed tomography, magnetic resonance imaging, or ultrasonography may provide the surgeon with valuable preoperative information, such as the location of infected or hemorrhagic cysts that may be responsible for symptoms. Less invasive cyst aspiration or fenestration may provide temporary relief from dominant or symptomatic cysts, but these cysts will recur in up to 75% of patients. Cyst fenestration with partial hepatic resection and liver transplantation are two therapies that provide more permanent resolution of symptoms in patients with extensive hepatic involvement. However, the higher risk of complications associated with more aggressive surgical therapy must be considered when determining the appropriate therapy for a given patient. Knowledge of the cyst patterns and available treatment options in patients with PLD will help the radiologist provide the referring clinician with important information for therapeutic decision making.

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

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