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

EASL Clinical Practice Guidelines on the management of cystic liver diseases

The advent of enhanced radiological imaging techniques has facilitated the diagnosis of cystic liver lesions. Concomitantly, the evidence base supporting the management of these diseases has matured over the last decades. As a result, comprehensive clinical guidance on the subject matter is warranted. These Clinical Practice Guidelines cover the diagnosis and management of hepatic cysts, mucinous cystic neoplasms of the liver, biliary hamartomas, polycystic liver disease, Caroli disease, Caroli syndrome, biliary hamartomas and peribiliary cysts. On the basis of in-depth review of the relevant literature we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with cystic liver disease.

Spontaneous rupture of hemorrhagic hepatic cyst: two case reports

Background

Spontaneous rupture of a hemorrhagic hepatic cyst is extremely rare. There is no standard treatment recommended for this condition. We report two cases of hemorrhagic hepatic cysts that spontaneously ruptured and were successfully treated with laparoscopic deroofing. We review the literature and discuss the characteristic features of spontaneous rupture of hemorrhagic hepatic cysts and their treatment.

Case presentation

The first patient was an 85-year-old man admitted for sudden-onset right hypochondralgia and fever. Computed tomography revealed a 13-cm hepatic cyst occupying the right lobe of the liver and spontaneous rupture of the cyst. Laparoscopic deroofing was performed and continuous oozing from the cystic wall was found. Histological examination revealed a simple hepatic cyst. The patient was discharged on postoperative day 6. In the second case, a 77-year-old woman who had been followed up for a simple hepatic cyst (13 cm) was admitted for sudden onset of right hypochondralgia. Computed tomography demonstrated a 9.9-cm hepatic cyst occupying segment 4 of the liver. Laparoscopic deroofing was performed and continuous oozing from the cystic wall was observed. Histological examination revealed a simple hepatic cyst. The patient was discharged on postoperative day 6.

Conclusion

Laparoscopic deroofing was performed in patients with spontaneous rupture of hemorrhagic nonparasitic hepatic cysts.

Traumatic rupture of a hemorrhagic hepatic cyst: a case presentation and literature review

Hemorrhagic hepatic cyst with or without rupture is rare cause of acute abdomen with less than 20 cases reported in the literature. A standardardized management algorithm is currently not present, but literature suggests surgical management is ideal for definitive treatment and successful patient outcome. We report a case of a 39-year-old female with a chief complaint of sudden onset abdominal pain, nausea and vomiting. Abdominal computed tomography scan showed a large, 12-cm cyst in the right hepatic lobe with a hemorrhagic component. Successful laparoscopic operative management was conducted without post-operative complications such as recurrent bleeding. When managing patients with an acute abdomen, ruptured hepatic hemorrhagic cysts should be considered in the differential diagnosis and prompt surgical management should be considered as primary management.

Traumatic rupture of a non-parasitic simple hepatic cyst presenting as an acute surgical abdomen: Case report

•

Traumatic rupture of a non-parasitic simple hepatic cyst is very unusual.

•

Open or laparoscopic cyst deroofing is a safe and effective treatment for non-parasitic simple hepatic cysts.

•

Rupture of a non-parasitic simple hepatic cyst could be included in the differential diagnosis of acute abdomen.

Introduction

Non-parasitic simple hepatic cyst is a very common type of benign liver disease, occurring in approximately 1–5% of the general population. These cysts are usually asymptomatic and are conservatively followed up without treatment. Some of these cysts, however, are associated with complications, including infection, hemorrhage, obstructive jaundice, portal hypertension, and rupture.

Presentation of case

A 74-year-old woman was transferred to our trauma center with epigastric pain after being knocked down by a cultivator. An abdominal computed tomography (CT) scan showed fluid collection and cystic lesion around the caudate lobe of the liver. Operative exploration showed that she had a ruptured hepatic cyst that originated from the caudate lobe of the liver. The cyst was deroofed to the margins of the liver parenchyma, and the internal surfaces of the cyst walls was subjected to electrocoagulator ablation.

Discussion

Open or laparoscopic cyst deroofing is a safe and effective treatment for non-parasitic simple hepatic cysts. Laparoscopic deroofing may also be difficult following rupture of non-parasitic simple hepatic cysts associated with infection or hemorrhage, as these cysts may collapse and the line of resection may be unclear. Laparoscopic ultrasound is a useful adjunct to delineate the boundaries of the cyst.

Conclusion

Traumatic rupture of a non-parasitic simple hepatic cyst is a very rare complication, but can lead to acute abdomen. In patients who are known to have non-parasitic simple hepatic cyst, rupture of cyst could be included in the differential diagnosis of acute abdomen.

Simple hepatic cyst rupture exacerbated by anticoagulation

Simple hepatic cysts are usually asymptomatic but can rarely result in life-threatening complications such as haemoperitoneum secondary to rupture. A 70-year-old woman with known simple hepatic cyst presented with acute chest pain and dyspnoea. The initial diagnosis was pulmonary embolism, and anticoagulation was commenced. However, she subsequently collapsed with haemodynamic instability. CT revealed a large hepatic cyst haematoma with rupture into the peritoneal cavity. The patient underwent emergency laparotomy, haemostasis and partial deroofing of the cyst. Retrospective review of CT scans suggested that the bleed had begun on presentation but was exacerbated by anticoagulation. To our knowledge, this is the first report of haemorrhagic hepatic cyst associated with acute anticoagulation. We discuss several important clinical lessons including cyst rupture as a possible cause of chest pain, the need for careful review of imaging and the choice of anticoagulation in patients with known simple hepatic cyst.

Laparoscopic deroofing of a ruptured hepatic cyst presenting as an acute abdomen

The rupture of a nonparasitic hepatic cyst is a rare complication for which there is no optimal treatment strategy yet. Laparoscopic deroofing is the standard approach for the elective treatment of symptomatic NHCs but it has seldom been described as an option for a ruptured hepatic cyst. The authors report a case of a male patient presenting to the emergency room with an acute abdomen caused by the rupture of a hepatic cyst. The patient was successfully treated by urgent laparoscopic deroofing of the cyst. Laparoscopic surgery can be a valid option for treating urgent cases presenting the same efficacy and less morbidity than open surgery.

Scarless surgery for a huge liver cyst: A case report

•

Fenestration is the definitive treatment for symptomatic/complicated liver cysts.

•

NOTES, which has been reported recently, enables surgery without scars.

•

Multiple clinical and technological barriers impede further progress with NOTES.

•

Our safe and unique method enables minimally invasive surgery with small incisions.

•

This “scarless surgery” is expected to yield some clinical benefits.

Introduction

Symptomatic or complicated liver cysts sometimes require surgical intervention and laparoscopic fenestration is the definitive treatment for these cysts. We performed minimally invasive surgery, hybrid natural orifice transluminal endoscopic surgery (NOTES) without scarring, for a huge liver cyst.

Presentation of case

An 82-year-old female presented with a month-long history of right upper abdominal pain. We diagnosed her condition as a huge liver cyst by morphological studies. She denied any history of abdominal trauma. Her serum CEA and CA19-9 were normal and a serum echinococcus serologic test was negative. Laparoscopic fenestration, using a hybrid NOTES procedure via a transvaginal approach, was performed for a huge liver cyst because we anticipated difficulty with an umbilical approach, such as single incision laparoscopic surgery (SILS). Her post-operative course was uneventful and she was discharged from our hospital three days after surgery. Pain killers were not required during and after hospitalization. No recurrence of the liver cyst or bulging was detected by clinical examination two years later.

Discussion

A recent trend of laparoscopic procedure has been towards minimizing the number of incisions to achieve less invasiveness. This hybrid NOTES, with a small incision for abdominal access, along with vaginal access, enabled painless operation for a huge liver cyst.

Conclusion

We report a huge liver cyst treated by hybrid NOTES. This approach is safe, less invasive, and may be the first choice for a huge liver cyst.

Elective laparoscopic deroofing to treat the spontaneous rupture of a large simple liver cyst: a case report

Background

The spontaneous rupture of nonparasitic liver cysts (NLC) is sometimes seen in clinical practice. However, there are no guidelines that describe the optimal treatment strategy and the surgical indications for an NLC rupture due to a small number of reports. Here, we present a case who underwent elective laparoscopic deroofing to treat a spontaneously ruptured NLC that had undergone conservative treatment.

Case presentation

A 67-year-old woman was referred to our hospital for the evaluation of acute abdominal pain after the conservative treatment of an NLC at another hospital. She had stable vital signs and no abdominal rigidity. We performed an elective laparoscopic deroofing following an examination of the cyst relative to the bile ducts and the patient’s general condition. Computed tomography (CT) and magnetic resonance imaging (MRI) showed that there was no solid mass in the cyst. During the laparoscopic surgery, the cyst wall was resected and the back wall of the cyst was incinerated using an inverse-opal-structure electrode. The patient’s postoperative course was stable without any complications.

Conclusions

We succeeded the conservative therapy and the elective laparoscopic surgery for ruptured of NLC. However, elective surgery in spontaneously ruptured NLC with intraabdominal infection or hemorrhage is still challenging.