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

A safe and effective endoscopic treatment method for simple hepatic cysts (with video)

Background and study aims Symptomatic simple hepatic cysts require treatment, with several guidelines recommending laparoscopic deroofing. However, cysts located in the posterosuperior segments are considered poor candidates for this procedure. Gastrointestinal endoscopes are more flexible and able to reach less accessible areas than laparoscopes. This study aimed to evaluate the utility of endoscopic transgastric hepatic cyst deroofing (ETGHCD) for treatment of simple hepatic cysts. Patients and methods Seven patients with simple hepatic cysts were evaluated between June 2021 and October 2023. The success rate, procedure time, post-procedure length of hospital stays, complications, pathologic diagnosis, and efficacy were recorded. Results Eleven cysts in seven patients (5 men; mean age 65.5 (standard deviation [SD] 8.5) years) were successfully treated without any complications. The mean procedure time was 65.6 minutes (SD 17.2). Mean post-procedure hospitalization was 4.4 days (SD 1.0). The pathologic diagnosis of 11 cysts showed simple hepatic cysts. The size of the cysts was significantly decreased from 337.0 cm 3 (SD 528.8) to 5.2 cm 3 (SD 6.3) 1 month after ETGHCD. During the median 12.7-month follow-up in seven patients, the cysts showed a 99.6% reduction with no recurrence. Conclusions ETGHCD provided a feasible, safe, effective, and minimal invasive alternative approach for the treatment of simple hepatic cysts.

Infected hepatic cyst complicating urinary sepsis

Congenital hepatic cysts are a common disorder. Usually they are asymptomatic and do not have to be treated. However, some serious complications can occur. We report here the case of an 86-year old patient who has been treated by a percutaneous drainage for an infected solitary hepatic cyst due to urinary sepsis. She was admitted to the Department of Internal Medicine for epigastric pain with fever and chills. The patient was treated for a urinary tract infection 3 weeks ago by her General Practitioner. On admission, blood tests showed 21 620 neutrophils per microliter with a C-reactive protein level at 443.7 mg/L, procalcitonin > 200 ng/mL, total bilirubin at 1.43 mg/dL, lactate dehydrogenase at 666 U/L and alanine aminotransferase at 227 U/L. Urinalysis and hemocultures highlighted the presence of Escherichia coli and Streptococcus constellatus. The abdominal tomodensitometry indicated the presence of a left hepatic biliary cyst with banal appearance. She was first treated with intravenous amoxicillin clavulanic acid. After a few days, another abdominal tomodensitometry with contrast pinpointed a large abscess of 11 centimeters in diameter extending to liver segments II and IV with a similar small lesion in segments IV and V. clindamycin per os was added to the treatment because of its good diffusion in tissues. Percutaneous drain was inserted under tomodensitometric control and stayed in place until the follow-up at three weeks. Bacteriologic culture on the fluid sample demonstrated the presence of Escherichia coli and Streptococcus constellatus. The abscess completely regressed after 6 weeks of treatment and the biologic abnormalities resolved at the same time.

Avoidance of bile duct injury during laparoscopic liver cyst fenestration using indocyanine green: A case report

By administering ICG test immediately before laparoscopic liver cyst fenestration, the biliary tract can be easily identified and intraoperative bile duct damage and postoperative bile fistula formation can be avoided, as demonstrated in this case.

Endoscopic ultrasound in chronic liver disease

Endoscopic ultrasound (EUS) is a minimally invasive diagnostic and therapeutic modality with a number of established as well as evolving uses in patients with chronic liver disease. Compared to other diagnostic tools such as cross-sectional imaging or conventional endoscopy, EUS has been shown to increase diagnostic sensitivity and therapeutic success for many clinical scenarios and applications with a low rate of adverse events. In this review, we discuss and focus on the current and growing role of EUS in the evaluation and/or treatment of hepatobiliary masses, hepatic parenchymal disease, portal hypertension, esophageal and other varices, and indeterminate biliary strictures.

Long-term safety and efficacy of ethanol retention therapy via percutaneous approach and/or EUS guidance for symptomatic large hepatic cysts (with video)

Background and Objectives

Ethanol retention therapy (ERT) under EUS guidance or a percutaneous approach is a safe treatment for large symptomatic hepatic cysts. However, reports on the long-term outcomes after ERT are very rare. Therefore, we aimed to evaluate the long-term outcomes of ERT in symptomatic large hepatic cysts.

Materials and Methods

A total of 47 consecutive patients with large symptomatic hepatic cysts treated at the Asan Medical Center from April 2009 to October 2017 were analyzed. Thirty patients with right hepatic cysts were treated with ERT through a percutaneous approach, and 14 patients with left hepatic cysts were treated with ERT under EUS guidance. Three patients were treated with ERT using both methods.

Results

Of the 47 patients, 43 (91%) showed complete regression and four (9%) showed partial regression on abdominal computed tomography. Recurrence of the cysts was not observed during the follow-up surveillance of a median of 66 months.

Conclusions

Percutaneous catheter drainage-guided ERT and EUS-guided ERT, based on their favorable long-term outcomes, may be considered as first-line treatments in patients with large symptomatic hepatic cysts.

Autosomal Dominant Polycystic Kidney Disease with Hepatic Cysts Complications in a Hemodialysis Patient: A Case Report

Background: Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disease in humans. It is a multisystemic disorder characterized by progressive cystic dilatation of both kidneys, with variable extrarenal manifestations in the gastrointestinal tract (hepatic cysts), cardiovascular system, reproductive organs and brain. An important issue of patients with hepatorenal cystic disease is the fact that complications can arise due to the growing of the cysts: local kidney complications (intracystic infection, intracystic hemorrhage) and local liver complications (portal hypertension as a result of portal vein compression by cysts, bile duct compression, ruptures and bleedings of the cysts, obstruction of the liver veins).

Objective: The main purpose of our case presentation is to emphasize the fact that ADPKD can be an aggressive disease with multiple complications, which requires an early diagnosis in order to properly avoid possible complications.

Material and Method: We present the case of a 61 years old male, known with polycystic hepatorenal disease, chronic kidney disease (CKD) in chronic hemodialysis since 2010, renal hypertension, hypertensive cardiomyopathy, renal anemia and stage 1 chronic lymphatic leukemia. The patient was diagnosed with hepatorenal polycystic disease 20 years ago and 9 years ago he started undergoing renal replacement therapy by hemodialysis. Three months ago, the patient presented a suddenly installed ascitic syndrome for which an MRI was performed. The imagistic investigation revealed multiple kidney and liver cysts, with secondary compression of the portal vein and a tumoral mass that may suggest an adenocarcinoma.

Results: The investigations performed confirm the diagnosis of portal hypertension secondary to compression due to cystic formations.

Conclusions: Hepatorenal polycystic disease has numerous clinical variations, so it needs to be followed in a multidisciplinary way with rapid therapeutic measures to prevent complications. Further investigations are needed when dealing with suspicious cystic formations with an uncertain substrate.

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.

Jaundice caused by protrusion of a hepatic cyst into common bile duct that was resolved by choledochoscopic needle-knife electrotomy: a case report

BACKGROUD

Hepatic cysts are the most frequent, innocuous, space-occupying lesions of the liver. The majority of solitary liver cysts are nonsymptomatic. When liver cysts reach a large size, there are some complications, including infection, rupture, spontaneous hemorrhage, obstructive jaundice, and neoplastic degeneration. Percutaneous aspiration, fenestration, hepatic resection, and liver transplantation have been proposed for symptomatic patients.

CASE PRESENTATION

In this case report, we describe a 41-year-old woman who presented with persistent liver dysfunction, indolent xanthochromia, and skin itching for 3 months. After a series of tests, she has a 5.0 × 5.3 cm hepatic cyst with many separations in the left medial liver lobe. The obstructive jaundice was caused by a large pedunculated lump protruding into the common bile duct from the left hepatic duct. She was treated with laparotomy and this lump was completely removed from the root by choledochoscopic needle-knife electrotomy with a good clinical response. Postoperative pathology of the lump suggested a hepatic cyst wall without heterocysts or tumor cells.

CONCLUSION

Hepatic cyst wall protruding into the common bile duct can form capsular lump and result in indolent jaundice. Choledochoscopic high-frequency needle-knife electrotomy could be considered as a simple, safe and effective complementary approach for benign mass on the bile duct wall.

Role of endoscopic ultrasound in liver disease: Where do we stand in 2017?

Endoscopic ultrasound (EUS) was first introduced into medical practice in 1980s as a diagnostic imaging modality for pancreatic pathology. EUS has the unique advantage of combining ultrasound and endoscopy to obtain detailed information of the gastrointestinal tract. Over the past decade, the use of EUS in liver diseases has been increasing. EUS, which was initially used as a diagnostic tool, is now having increasing therapeutic role as well. We provide a review of the application of EUS in the diagnostic and therapeutic aspects of liver disease. We also look at the evolving future research on the role of EUS in liver diseases.

Evaluation of the utility value of percutaneous drainage of symptomatic hepatic cysts combined with an obliteration attempt

Aim

The goal of the paper was to evaluate the procedure of percutaneous drainage of symptomatic hepatic cysts under the transabdominal ultrasound control combined with obliteration.

Material and method

Within the period from 2005 to 2015, 70 patients diagnosed with a simple hepatic cyst of symptomatic nature were subject to hospitalization and treated at the 2^nd General, Gastroenterological and Cancer Surgery of the Alimentary System Center and Clinics of the Medical University of Lublin. All the patients subject to evaluation were qualified to percutaneous drainage under an ultrasound control. The drainage utilized typical sets of drains with the diameter of at least 9 F, most often of pigtail type. The fluid aspirated form the cyst was dispatched for complex laboratory testing. Further, a 10% sodium chloride solution was administered to the cyst through the drain, in the volume depending on the previous size of the cyst and the patient's reaction.

Results

Patients reported for a re-visit within the period from 3 to 9 months following the procedure. Complete obliteration of the cyst was confirmed only in 8 patients (11%). Cyst recurrence was reported in cases when during the ultrasound evaluation, the diameter of the cyst following aspiration and obliteration enlarged to over 75% of the initial dimension. In this group, in 10 out of 12 examined (83%) there was a relapse of the previously observed ailments. Among patients, who has a cyst imaged within the period of observation, which had the diameter from 50% to 75% of the previous size, only in 6 cases (37.5%) the initial symptoms relapsed.

Conclusions

The utilization of a drainage and obliteration enables one to achieve the acceptable result of the therapy as well as significant decrease in the number of previously reported ailments and symptoms described.

Technical challenges in treating recurrent non-parasitic hepatic cysts

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

A Giant Simple Liver Cyst That Caused Increases in Serum CA 19-9 and CA 15-3 Levels

Simple cysts (SCs) of the liver are not associated with the biliary malformations in intrahepatic bile duct biliary. Seen in 0.1% to 7% of adult population, biliary malformations are more common in women. The levels of glycoprotein-like tumor markers (carbohydrate antigen (CA) 19-9) in the cysts and serum could be high. Although studies regarding CA 19-9 exist, sufficient data on cancer antigen (CA) 15-3 are not available. This case is about a 76-year-old woman who complained of painless intra-abdominal mass. The patient with a giant simple cyst extending from the gallbladder to the pelvis had preoparative CA 19-9 and CA 15-3 serum levels of 87.3 IU/L and 37 IU/L respectively. It was observed that CA 19-9 levels had decreased to 36 IU/L and CA 15-3 to 28.1 IU/L in blood samples taken in the third month after the surgery. There is a need for comprehensive studies to investigate the relationship between the size of the cyst and biomarkers (including markers such as CA 15-3) in the assesment of liver SC.