Percutaneous treatment of liver hydatid cysts: comparison of direct injection of albendazole and hypertonic saline solution

Comparison of ethanol and hypertonic saline as a single ıntracystic agent in the percutaneous treatment of liver hydatid cysts

PURPOSE

In this study, the effects of hypertonic saline and ethanol as a single intracystic agents in the percutaneous treatment of liver hydatid cysts were compared.

METHODS

The 50 patients were separated into two groups as those administered 30% hypertonic saline alone as the intracystic agent in percutaneous treatment (33 patients, 52 cysts), and those administered 96% ethanol alone (17 patients, 26 cysts). Both groups were compared in terms of percentage of cyst volume reduction, complications, and treatment success.

RESULTS

The follow-up period was median 17.0 months (11.0-20.0) in the ethanol group and 17.0 (14.0-22.0) in the hypertonic saline group (p = 0.269). Complications were observed in 5 (19.2%) cysts applied with ethanol as the intracystic agent and in 7 (13.5%) of the cysts where hypertonic saline was used (p = 0.521). Clinical success was evaluated as 100% in both groups. The percentage of cyst volume reduction according to the initial volume was determined as mean 75.6 ± 20.43 (28.19-98.13) in the ethanol group cysts and as 68.2 ± 16.45 (26.39-97.48) in the hypertonic saline group (p = 0.427).

CONCLUSION

The results of this study demonstrated similar efficacy of hypertonic saline and ethanol in the percutaneous treatment of CE1 and CE3A liver hydatid cysts. These results suggest that the use of hypertonic saline as a single intracystic agent in the percutaneous treatment of CE1 and CE3A liver hydatid cysts provides sufficient efficacy of treatment and cyst volume reduction. Nevertheless, there is a need for further prospective, randomized studies to support these findings.

Treatment of Hydatid Liver Cyst With Double Percutaneous Aspiration and Ethanol Injection Under Ultrasound Guidance: 6.5-Year Median Follow-up Analysis

PURPOSE

Although hydatid liver cyst (HLC) is a benign disease, treatment is recommended to avoid life-threatening complications. There are several treatment options for HLC: "wait-and-watch," medical or surgical or percutaneous treatment. The purpose of this study was to assess the long-term effectiveness of an alternative of the traditional percutaneous PAIR procedure, called double percutaneous aspiration and ethanol injection (D-PAI).

MATERIALS AND METHODS

This prospective, non-randomized study was conducted from 1988 to 2019 using DPAI procedure characterized by no reaspiration of the ethanol injected to replace the aspirated fluid and repetition of the procedure after 3-7 days.

RESULTS

Two hundred and three patients with 290 HLCs underwent D-PAI. Two hundred and two HLC (160 patients) were univesicular cysts and 88 (43 patient) were multivesicular. Seventeen patients underwent one D-PAI session, 15 patients two sessions, and 18 up to four sessions. The follow-up ranged 0.9-21 years (median 6.5 years). On ultrasound, 188 cysts (64.8%) disappeared; 57 cysts (19.7%) became solid (inactive) and 45 (15.5%) showed a small inactive residual component. Parasitologic cure was very high. The overall response to D-PAI was higher than 90% considering also the procedures carried out after the first D-PAI at the time of recurrence. One patient died for anaphylactic shock. The hospital stay ranged 1-3 days. Smaller cysts (< 5 cm) healed sooner than larger cysts (p < 0.001).

CONCLUSIONS

Long-term analysis showed that D-PAI is a safe and effective option in percutaneous treatment of viable HLC, except for CE2/CE3b in which the recurrences can be observed. This inexpensive and simple procedure can be applied everywhere and especially in developing countries.

Surgical treatment of liver hydatid cyst before autologous stem cell transplantation; presentation of two cases with literature review

Hydatid cyst, caused by Echinococcus granulosus, is a parasitic disease which is frequently seen in endemic areas. The disease can be seen as an isolated entity or simultaneously with other diseases. Treatment of hydatid cyst in patients with malignancy as well as in patients in need of transplantation is still unclear. Although there is information in the form of case reports, a large number of patient data are needed to create a consensus on the management of these patients. We reviewed two cases with the need of autologuous stem cell transplantation which underwent liver hydatic cystectomy before transplantation.

In vitro study of the scolicidal effects of Echinometra mathaei spine and shell extracts on hydatid cyst protoscolices

Hydatid cyst is a zoonotic parasitic infection caused by the tapeworm Echinococcus granulosus. Such infections are of considerable public health and economic concern, and new effective treatments are intensely sought. Sea urchin (Salmacis virgulata) shell extracts have potent antimicrobial and antioxidant activity, and spines of several species of echinoderms also show antimicrobial activity. In the present in vitro study, we investigated the scolicidal effect of spines and shells extractions from Echinometra mathaei obtained from the Persian Gulf. Spines and shells from the sea urchin, Echinometra mathaei were used in the tests. Spines and shells from 800 specimens were extracted with dibasic sodium phosphate buffer (pH 7.5). Procedures used protoscolices of E. granulosus were obtained aseptically from hydatid cyst in naturally infected sheep's liver and goats and viable protoscolices exposed with spine and shell extractions. The apoptosis was assessed by measuring the caspase 3 activity of the extract-treated protoscolices, using ELISA-based commercial kits to determine caspase activity. The scolicidal effects of shells were also showed, 20 μg/ml of shell extracts after 60 min exposure, the viability of protoscolices were 21.99 ± 0.01. The results showed that 20 μg/ml of spines gave maximum scolicidal activity (p < 0.05). This study represents the first attempt at combatting echinoid parasites by natural compounds with high efficiency, and may provide a base for future treatment of hydatid cysts.

Echinococcosis: Advances in the 21st Century

Echinococcosis is a zoonosis caused by cestodes of the genus Echinococcus (family Taeniidae). This serious and near-cosmopolitan disease continues to be a significant public health issue, with western China being the area of highest endemicity for both the cystic (CE) and alveolar (AE) forms of echinococcosis. Considerable advances have been made in the 21st century on the genetics, genomics, and molecular epidemiology of the causative parasites, on diagnostic tools, and on treatment techniques and control strategies, including the development and deployment of vaccines. In terms of surgery, new procedures have superseded traditional techniques, and total cystectomy in CE, ex vivo resection with autotransplantation in AE, and percutaneous and perendoscopic procedures in both diseases have improved treatment efficacy and the quality of life of patients. In this review, we summarize recent progress on the biology, epidemiology, diagnosis, management, control, and prevention of CE and AE. Currently there is no alternative drug to albendazole to treat echinococcosis, and new compounds are required urgently. Recently acquired genomic and proteomic information can provide a platform for improving diagnosis and for finding new drug and vaccine targets, with direct impact in the future on the control of echinococcosis, which continues to be a global challenge.

A systematic review and meta-analysis on the treatment of liver hydatid cyst using meta-MUMS tool: comparing PAIR and laparoscopic procedures

INTRODUCTION

There is an academic debate over surgical treatments of liver hydatid cyst disease. In this study, a systematic review and meta-analysis were carried out in order to evaluate the pros and cons of both PAIR (Puncture, Aspiration, Injection, Respiration) and laparoscopic techniques by considering the outcomes of liver hydatid cysts.

MATERIAL AND METHODS

We designed descriptive Boolean queries to search two databases, PubMed and Scopus, to derive the articles published in the period of January 2000 to December 2016 in order to evaluate the outcomes of these research articles. The outcomes of laparoscopic and PAIR procedures include the rates of cure, postoperative complications, recurrences, and mortality, which were extracted, assessed, and used as their corresponding effect sizes.

RESULTS

Fifty-seven studies including a total of 2832 patients (PAIR group n = 1650 and laparoscopic group = 1182) were analyzed. In this meta-analysis study, a random effect model of correlations of outcomes (postoperative complications, mortalities, recurrences, and cure rates) of PAIR and laparoscopy procedures was used. The meta-analysis and the forest plots of the two procedures show that the PAIR approach is superior in terms of cure, complication, and mortality rates compared with the laparoscopy technique. However, the recurrence rate is low in laparoscopic approaches. Moreover, Egger's tests for determining publication bias and heterogeneity tests were also performed.

CONCLUSIONS

This study shows promising trends toward an advantage of PAIR procedures in treatment of liver hydatid cyst in comparison with laparoscopic procedures. The PAIR procedure is superior to laparoscopy due to having a higher cure rate and lower complication and mortality rates; however, the latter has a lower recurrence rate.

A hydatic cyst of the appendix mimicking a uterine lateral mass: a case report

Background

Hydatic cyst is a zoonotic disease caused by Echinococcus granulosus. It is a public health problem in Tunisia and remains endemic. It occurs in intra-abdominal organs in 10–15% of the cases, particularly in the liver representing the most common affected organ. The aim of the case is to highlight the scarcity of this appendicle origin and to consider it among the differential diagnosis of any intra-abdominal cystic lesion.

Case presentation

A 45-year-old Tunisian woman, with no past medical history, was admitted for a pelvic cystic mass. The clinical manifestation as well as the imaging findings were toward a lateral uterine mass. Our patient underwent appendectomy and resection of the mass. The patient had no recurrence at 2 years of follow-up.

Conclusions

An extrahepatic hydatid cyst should be recognized among the differential diagnosis of any intra-abdominal cystic lesion. Treatment should be based on surgical excision. Due to the risk of recurrence, a close follow-up is mandatory.

Percutaneous treatment of hepatic cystic echinococcosis: the success of alcohol as a single endocavitary agent in PAIR, catheterization, and modified catheterization techniques

OBJECTIVES

This retrospective study aims at demonstrating the success rate, effectiveness, and advantages of alcohol as a scolicidal and sclerosing agent for the percutaneous treatment of liver hydatid cysts.

METHODS

A total of 554 liver hydatid cysts obtained from 347 patients admitted between January 2008 and February 2016 were retrospectively investigated. Of these, 435 (78.5%), 91 (16.4%), and 28 (5%) were classified as Gharbi type 1, 2, and 3, respectively. Type 1 and 2 cysts were treated using PAIR (puncture, aspiration, injection, respiration) and single puncture catheterization methods; type 3 lesions were treated using a modified catheterization technique. Alcohol was used as a scolicidal and sclerosing agent in all procedures.

RESULTS

After excluding three lesions (0.5%) because of lack of parenchymal support during catheterization, 274 (49.7%), 250 (45.3%), and 27 (4.9%) of 551 lesions were treated with PAIR, single puncture catheterization, and modified catheterization techniques, respectively. Therefore, a 99.5% of technical success rate was obtained. Major complications in 2 patients (0.5%) and minor complications were observed in 36 patients (10.3%). Mean hospital stay was 1.55±2.3 days (range: 0-23 days). Patients were followed-up for mean 19.6 months (range: 6-83 months), during which recurrences were detected in 19 patients (5.4%).

CONCLUSIONS

The use of alcohol as a scolicidal and sclerosing agent during the percutaneous treatment of liver hydatid cysts is associated with a high success rate and low rates of recurrence and complications, and should be considered an important alternative to surgical procedures.

A novel modified PAIR technique using a trocar catheter for percutaneous treatment of liver hydatid cysts: a six-year experience

PURPOSE

We aimed to demonstrate the success and reliability of a novel puncture, aspiration, injection, and reaspiration (PAIR) technique in liver hydatid cysts.

METHODS

Percutaneous treatment with ultrasonographic guidance was performed in 493 hepatic hydatid cysts in 374 patients. Patients were treated with a new PAIR technique by single puncture method using a 6F trocar catheter. The results of this novel technique were evaluated with regards to efficacy and safety of the procedure and complication rates.

RESULTS

Out of 493 cysts, 317 were Gharbi type I (WHO CE 1) and 176 were Gharbi type II (WHO CE 3A). Of all cysts, 13 were referred to surgery because of cystobiliary fistulization. Recurrence was observed in 11 cysts one month later. Therefore, the success rate of the PAIR technique was 97.7% (469/480). Minor complications (fever, urticaria-like reactions, biliary fistula) were seen in 44 treated patients (12%, 44/374); the only major complication was reversible anaphylactic shock which was observed in two patients (0.5%, 2/374).

CONCLUSION

This novel modified PAIR technique may be superior to catheterization by Seldinger technique due to its efficiency, easier application, lower severe complication rate, and lower cost. Further comparative studies are required to confirm our observations.

Current status of diagnosis and treatment of hepatic echinococcosis

Echinococcus granulosus (E. granulosus) and Echinococcus multilocularis (E. multilocularis) infections are the most common parasitic diseases that affect the liver. The disease course is typically slow and the patients tend to remain asymptomatic for many years. Often the diagnosis is incidental. Right upper quadrant abdominal pain, hepatitis, cholangitis, and anaphylaxis due to dissemination of the cyst are the main presenting symptoms. Ultrasonography is important in diagnosis. The World Health Organization classification, based on ultrasonographic findings, is used for staging of the disease and treatment selection. In addition to the imaging methods, immunological investigations are used to support the diagnosis. The available treatment options for E. granulosus infection include open surgery, percutaneous interventions, and pharmacotherapy. Aggressive surgery is the first-choice treatment for E. multilocularis infection, while pharmacotherapy is used as an adjunct to surgery. Due to a paucity of clinical studies, empirical evidence on the treatment of E. granulosus and E. multilocularis infections is largely lacking; there are no prominent and widely accepted clinical algorithms yet. In this article, we review the diagnosis and treatment of E. granulosus and E. multilocularis infections in the light of recent evidence.

The Comparison of 2 New Promising Weapons for the Treatment of Hydatid Cyst Disease: PAIR and Laparoscopic Therapy

BACKGROUND

To compare the effectiveness and safety for hydatid disease treatment, the 2 new minimally invasive therapies: laparoscopic and PAIR (puncture, aspiration, injection, and reaspiration) were compared by systematic meta-analysis.

METHODS

A comprehensive analysis of published cases from 1990 to 2014 was performed using PubMed database. A total of 231 publications on laparoscopic treatment of hydatid cysts and 298 publications on the PAIR treatment were identified. Thirty-eight studies involved 1230 laparoscope-treated subjects and 41 involved 2686 PAIR-treated subjects in this review. The effectiveness and safety of emphasis is placed on the recurrence, insufficient response, death, cure, and postoperative complications. Operation time and hospital stay are also discussed as new evaluation index. The stages of cyst are summarized to determine which stage is suitable for PAIR.

RESULTS

Clinical and parasitological cure occurred in 98.7% of patients undergoing laparoscopic intervention and in 97.5% of patients receiving PAIR plus chemotherapy (P<0.014). Recurrence occurred in 1.0% and 1.6%, respectively (P<0.087). Insufficient response occurred in 0.16% and 0.9%, respectively (P<0.009); 2 patients died in each group (P<0.594). Allergic reaction/urticarial/anaphylactic shock occurs in 0.14% and 4.24% of patients receiving laparoscopic intervention and PAIR plus chemotherapy, respectively (P<0.001). Infection/abscess (5.37% and 2.57%; P<0.001) and surgical-related complications (7.32% and 3.43%; P<0.001) were seen more frequently in laparoscopic intervention subjects than PAIR plus chemotherapy subjects.

CONCLUSIONS

Laparoscopic therapy and PAIR intervention are shown to be safe and effective alternative for open surgery with suitable indication such as cyst type and location. They have different postoperative complication features. The biliary fistula/bile leakage was more frequent in laparoscopic intervention (P<0.001) and fever occurred more in PAIR plus chemotherapy patients.

Hepatic Echinococcal Cysts: A Review

Cystic echinococcosis (CE) is a widely endemic helminthic disease caused by infection with metacestodes (larval stage) of the Echinococcus granulosus tapeworm. E. granulosus are common parasites in certain parts of the world, and are present on every continent with the exception of Antarctica. As a result, a large number of people are affected by CE. The increased emigration of populations from endemic areas where prevalence rates are as high as 5-10% and the relatively quiescent clinical course of CE pose challenges for accurate and timely diagnoses. Upon infection with CE, cyst formation mainly occurs in the liver (70%). Diagnosis involves serum serologic testing for antibodies against hydatid antigens, but preferably with imaging by ultrasound or CT/MRI. Treatment methods include chemotherapy with benzimidazole carbamates and/or surgical approaches, including percutaneous aspiration injection and reaspiration. The success of these methods is influenced by the stage and location of hepatic cysts. However, CE can be clinically silent, and has a high risk for recurrence. It is important to consider the echinococcal parasite in the differential diagnosis of liver cystic lesions, especially in patients of foreign origin, and to perform appropriate long-term follow-ups. The aim of this review is to highlight the epidemiology, natural history, diagnostic methods, and treatment of liver disease caused by E. granulosus.

Antihydatic and immunomodulatory effects of Punica granatum peel aqueous extract in a murine model of echinococcosis

OBJECTIVE

To investigate the effect of pomegranate peel aqueous extract (PGE) on the development of secondary experimental echinococcosis and on the viability of Echinococcus granulosus protoscoleces, and the immunomodulatory properties of PGE.

METHODS

Swiss mice were inoculated intraperitoneally with viable protoscoleces. Then, PGE was orally administered daily during cystic echinococcosis development. Cyst development and hepatic damage were macroscopically and histologically analyzed. The production of nitric oxide and TNF-α was assessed in plasma and the hepatic expression of iNOS, TNF-α, NF-κB and CD68 was examined. Moreover, protoscoleces were cultured and treated with different concentrations of PGE.

RESULTS

It was observed that in vitro treatment of protoscoleces caused a significant decrease in viability in a PGE-dose-dependent manner. In vivo, after treatment of cystic echinococcosis infected mice with PGE, a significant decrease in nitric oxide levels (P < 0.0001) and TNF-α levels (P < 0.001) was observed. This decline was strongly related to the inhibition of cyst development (rate of hydatid cyst growth inhibition = 63.08%) and a decrease in CD68 expression in both the pericystic layer of hepatic hydatid cysts and liver tissue (P < 0.0001). A significant diminution of iNOS, TNF-α and NF-κB expression was also observed in liver tissue of treated mice (P < 0.0001).

CONCLUSIONS

Our results indicate an antihydatic scolicidal effect and immunomodulatory properties of PGE, suggesting its potential therapeutic role against Echinococcus granulosus infection.

Optimization of fluoride-containing bioactive glasses as a novel scolicidal agent adjunct to hydatid surgery

We have presented a novel scolicidal agent made from fluoride-containing bioactive glass (FBG). The samples were characterized by XRD and the ion release behavior of the samples was evaluated at 37°C. The scolicidal activity, cellular response and antibacterial activity and biocompatibility of the different concentrations of the FBG (ranging from 0.5 to 2 mg ml(-1)) were evaluated in vitro and in vivo. The results showed an easy diffusion of the fluoride through the glass matrix in an F concentration-dependent manner. The FBG showed an intensive scolicidal property, so that toxicity effect begun from 5 min and the samples with 20, 10, 5 and 0% fluoride showed 98±2, 93±5.8, 76.2±6 and 5.8±1.7% scolicidal activity, respectively, after 8h exposing time. Our data revealed that scolicidal activity of the FBG increased with the increase of F ratio and concentrations of the bioactive glass. On the other hand, all the synthesized FBG samples found to be cyto-biocompatible when tested in vitro (MTT and LDH assays) and in vivo (no significant infiltration of inflammatory cells compared with control, p>0.05), and antibacterial against Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa. The results demonstrated that the synthesized FBG might have a potential application in prevention of post-surgery infections, especially hydatidosis.

Scolicidal effects of black cumin seed (Nigella sativa) essential oil on hydatid cysts

Surgery remains the preferred treatment for hydatid cyst (cystic echinococcosis, CE). Various scolicidal agents have been used for inactivation of protoscolices during surgery, but most of them are associated with adverse side effects. The present study aimed to evaluate the in vitro scolicidal effect of Nigella sativa (Ranunculaceae) essential oil and also its active principle, thymoquinone, against protoscolices of hydatid cysts. Protoscolices were aseptically aspirated from sheep livers having hydatid cysts. Various concentrations of the essential oil (0.01-10 mg/ml) and thymoquinone (0.125-1.0 mg/ml) were used for 5 to 60 min. Viability of protoscolices was confirmed by 0.1% eosin staining. Furthermore, the components of the N. sativa essential oil were identified by gas chromatography/mass spectroscopy (GC/MS). Our study revealed that the essential oil of N. sativa at the concentration of 10 mg/ml and its main component, thymoquinone, at the concentration of 1 mg/ml had potent scolicidal activities against protoscolices of Echinococcus granulosus after 10 min exposure. Moreover, thymoquinone (42.4%), p-cymene (14.1%), carvacrol (10.3%), and longifolene (6.1%) were found to be the major components of N. sativa essential oil by GC/MS analysis. The results of this study indicated the potential of N. sativa as a natural source for production of a new scolicidal agent for use in hydatid cyst surgery. However, further studies will be needed to confirm these results by checking the essential oil and its active component in in vivo models.

Medical treatment versus "Watch and Wait" in the clinical management of CE3b echinococcal cysts of the liver

Background

Available treatments for uncomplicated hepatic cystic echinococcosis (CE) include surgery, medical therapy with albendazole (ABZ), percutaneous interventions and the watch-and-wait (WW) approach. Current guidelines indicate that patients with hepatic CE should be assigned to each option based on cyst stage and size, and patient characteristics. However, treatment indications for transitional CE3b cysts are still uncertain. These cysts are the least responsive to non-surgical treatment and often present as indolent, asymptomatic lesions that may not warrant surgery unless complicated. Evidence supporting indications for treatment of this stage is lacking. In the attempt to fill this gap before the implementation of randomized clinical trials, we compared the clinical behavior of single hepatic CE3b cysts in 60 patients followed at the WHO Collaborating Centre for Cystic Echinococcosis of the University of Pavia.

Methods

We analyzed retrospectively data of 60 patients with hepatic CE3b cysts seen at our clinic over 27 years, who either received ABZ or were monitored with WW. Univariate and multivariate analysis were performed to investigate the effect on outcome (inactivation or relapse) of variables such as age, sex, origin, treatment, cyst size and presence of other echinococcal hepatic cysts using a multiple failure Cox proportional hazard model.

Results

ABZ treatment was positively associated with inactivation (p < 0.001), but this was not permanent, and no association was found between therapeutic approach and relapse (p = 0.091). No difference was found in the rate of complications between groups.

Conclusions

In conclusion, our study shows that ABZ treatment induces temporary inactivation of CE3b cysts, while during WW cysts remain stable over time. As the rate of adverse events during periods of ABZ treatment and WW did not differ significantly in the follow-up period considered in this study (median 43 months, IQR 10.7-141.5), expectant management might represent a valuable option for asymptomatic CE3b cysts when strict indication for surgery is absent and patients comply with regular long-term follow-up.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-492) contains supplementary material, which is available to authorized users.

Cystic echinococcosis of the liver: A primer for hepatologists

Cystic echinococcosis (CE) is a complex, chronic and neglected disease with a worldwide distribution. The liver is the most frequent location of parasitic cysts. In humans, its clinical spectrum ranges from asymptomatic infection to severe, potentially fatal disease. Four approaches exist in the clinical management of CE: surgery, percutaneous techniques and drug treatment for active cysts, and the ”watch and wait” approach for inactive cysts. Allocation of patients to these treatments should be based on cyst stage, size and location, available clinical expertise, and comorbidities. However, clinical decision algorithms, efficacy, relapse rates, and costs have never been properly evaluated. This paper reviews recent advances in classification and diagnosis and the currently available evidence for clinical decision-making in cystic echinococcosis of the liver.

Scolicidal effects of biogenic selenium nanoparticles against protoscolices of hydatid cysts

Cystic echinococcosis (hydatid cyst, CE) as a zoonotic parasitic infection caused by the larval stage of the dog tapeworm Echinococcus granulosus is still an important economic and public health concern in the world. One of the treatment options for CE is surgical removal of the cysts combined with chemotherapy using albendazole and/or mebendazole before and after surgery. Currently, many scolicidal agents, which have some complications, have been used for inactivation of the cyst contents. Therefore the development of new scolicidal agents with low side effects and more efficacies is an urgent need for surgeons. The present study was aimed to investigate the in vitro scolicidal effect of selenium nanoparticles biosynthesized by a newly isolated marine bacterial strain Bacillus sp. MSh-1 against protoscoleces of E. granulosus. Protoscolices were aseptically aspirated from sheep livers having hydatid cysts. Various concentrations (50-500 μg/ml) of Se NPs (in size range of about 80-220 nm) were used for 10-60 min. Viability of protoscoleces was confirmed by 0.1% eosin staining. The results indicated that biogenic Se NPs at all concentrations have potent scolicidal effects especially at concentrations 500 and 250 μg/ml after 10 and 20 min of application, respectively. In conclusion, the findings of present study proven that Se NPs have potent scolicidal effects, therefore may be used in CE surgery. However, the in vivo efficacy of these NPs remains to be explored.

Infections of the Liver

The portal vein carries blood from the gastrointestinal tract to the liver and in so doing carries microbes as well. The liver may therefore be involved in infections with a myriad number of microbial organisms. While some of these infections most commonly occur in the immunocompromised host, others affect the immune competence. Hepatic infections may be primary in nature or secondary, as part of systemic or contagious disease. The purpose of this chapter is to provide a brief overview of the various infections of the liver in the pediatric patient.

Hydatid cyst of paravertebral muscle mimicking disc herniation

STUDY DESIGN

Case report.

OBJECTIVE

To present a case of primary hydatid cyst in the lumbar subcutaneous tissue affecting posterior paravertebral muscle and mimicking disc herniation.

SUMMARY OF BACKGROUND DATA

Cystic hydatid disease is a rare but significant parasitic disease in endemic areas. Musculoskeletal or soft tissue hydatidosis accounts for about 0.5% to 5% of all echinococcal infections in endemic areas and is almost secondary to the hepatic or pulmonary disease. Primary lumbar subcutaneous hydatid cyst affecting paravertebral muscle and extending to neural foramina is a very rare condition even in endemic areas.

METHODS

A 25-year-old-female patient was admitted with swelling and pain in the right lumbar region for 3 months. The pain was reflecting in the right gluteal region and the right leg. Lumbar extension and right lateral flexion was painful and straight leg raising test was positive at right side. There was a mild hypoesthesia at L5 dermatome. According to the magnetic resonance image that the clinician obtained for initial diagnosis of lumbar disc herniation, we found multi-cystic masses located at the right paravertebral muscle at the level of L3-L5 which extended to L4-L5 neural foramina and at subcutaneous tissue at the right gluteal region.

RESULTS

The patient was operated for the purpose of removal of cysts. Postoperatively, diagnosis of hydatid cyst was confirmed by histopathology.

CONCLUSION

By this case, we emphasize that cystic hydatid disease should be taken into consideration in the differential diagnosis of low back pain and could mimic disc herniation.

LEVEL OF EVIDENCE

N/A.

A Hydatid Cyst of the Appendix which Mimicked a Tubo-ovarian Mass: A Case Report and Review of the Literature

Hydatid disease, an endemic in the cattle grazing areas, particularly in the Asian region, is a parasitic infection which is caused by the cestode tapeworm, Echinoccocus granulosus. There is involvement of the intra-abdominal organs apart from the liver, in 10-15% of the cases. We are reporting a case, wherein the appendix was involved with this parasitosis and we have discussed the review of the literature regarding the diagnostic, surgical and the newer percutaneous approaches for the management of this disease.

Effectiveness of puncture-aspiration-injection-reaspiration in the treatment of hepatic hydatid cysts

BACKGROUND

Hydatid disease of the liver is endemic in cattle rearing areas of the world. A variety of treatment options are available in its management. The common treatment options are medical therapy, surgery and puncture-aspiration-injection-reaspiration (PAIR) therapy.

OBJECTIVES

This study was performed to evaluate the effectiveness of PAIR therapy in the treatment of hepatic hydatid disease.

PATIENTS AND METHODS

This cross sectional study was carried out on 15 consecutive patients (Male: 2, Female: 13; Age group: 11-80 years) with hepatic hydatid disease and were treated by PAIR therapy and followed up for a period of 1 year. The cysts were punctured under local anesthesia with an 18G needle using sonographic guidance. Betadine (10% povidone iodine + 1% free iodine) was used as scolicidal agent and allowed to act for 30 min. Cysts larger than 5 cm (n = 5) were drained using an 8F pig tail catheter. The therapeutic response was studied by assessing the reduction in the cyst size, progressive solidification of the cyst, calcification of the wall and increase in the echogenicity of the cyst with pseudomass appearance on serial ultrasound examinations performed on the next day, after 1 month, at 3 months, 6 months and 1 year after the procedure.

RESULTS

Ten patients (66.7%) had Gharbi type I cysts, two (13.3%) had type II and three (20%) had type III cysts. All the patients (100%) showed reduction in cyst size over a 3-6 month period. Pseudomass appearance with solidification was seen in 73% of the patients and calcification was seen in 46.6%. None of the patients developed anaphylaxis, recurrence or peritoneal seedlings. Pain at the injection site was the most common complication observed.

CONCLUSION

PAIR therapy is an effective minimally invasive treatment for Gharbi type I-III hepatic hydatid cysts. It is a cost effective and safe procedure with significant reduction in the duration of hospital stay.

Surgical management of cystic lesions in the liver

BACKGROUND

Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear.

METHODS

A Pubmed and Medline literature review using key words non-parasitic hepatic cysts, polycystic liver disease, echinococcus, hydatid cysts parasitic cysts, Caroli's disease, cystadenoma; liver abscess, surgery, aspiration and treatment was undertaken and papers pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

RESULTS

Asymptomatic simple cysts in the liver require no treatment. Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. At present, insufficient evidence exists to recommend one over the other. Polycystic liver disease presents a unique management problem because of high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can effectively be treated by aspiration or drainage. With improved antimicrobial efficacy, prolonged treatment with antibiotics may also be considered.

CONCLUSION

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

The pattern of hydatid disease-a retrospective study from himachal pradesh, India

Hydatid disease is a common but little studied disease in Himachal Pradesh, India. This is a retrospective study from the Lady Willingdon Hospital, Manali. 115 patients presenting from April 1996 to March 2007 were included. Outcome measures were mortality and morbidity. 70 patients were female and 46 were male. (One female patient was operated on twice). 78% (n = 90) of the occurrences were hepatic. There were other varied sites. There were fourteen pulmonary hydatids. All patients underwent surgical cystectomy. An "AIR Technique" (Aspiration, Injection, Reaspiration) is described for scolicidal deactivation after March 2003 utilized in thirty two patients. There was no mortality. There were five documented recurrences in our series all of which occurred in cystectomy done without the AIR (Aspiration, Injection, Reaspiration) technique. Hydatid disease is a common disease in Himachal Pradesh warranting a high index of suspicion leading to an early diagnosis. A simple technique called the "AIR TECHNIQUE" (Aspiration, Injection, Reaspiration) is described.

In Vitro Study of Nitric Oxide Metabolites Effects on Human Hydatid of Echinococcus granulosus

Hydatidosis is characterized by the long-term coexistence of larva Echinococcus granulosus and its host without effective rejection. Previous studies demonstrated nitric oxide (NO) production (in vivo and in vitro) during hydatidosis. In this study, we investigated the direct in vitro effects of NO species: nitrite (NO₂⁻), nitrate (NO₃⁻) and peroxynitrite (ONOO⁻) on protoscolices (PSCs) viability and hydatid cyst layers integrity for 24 hours and 48 hours. Our results showed protoscolicidal activity of NO₂⁻ and ONOO⁻ 24 hours and 3 hours after treatment with 320 μM and 80 μM respectively. Degenerative effects were observed on germinal and laminated layers. The comparison of the in vitro effects of NO species on the PSCs viability indicated that ONOO⁻ is more cytotoxic than NO₂⁻. In contrast, NO₃⁻ has no effect. These results suggest possible involvement of NO₂⁻ and ONOO⁻ in antihydatic action and point the efficacy of these metabolites as scolicidal agents.

Cutaneous cysts of the head and neck

PURPOSE

A retrospective study on the features of cutaneous cysts of the head and neck as seen in a North Jordanian population.

PATIENTS AND METHODS

The records of the Department of Pathology at Jordan University of Science and Technology were reviewed for patients with cutaneous cysts of the head and neck during the 12-year period extending between 1991 and 2002. Applicable records were retrieved, reviewed, and analyzed. Primary analysis outcome measures included patient age, gender, location of the cyst, type, clinical presentation, and treatment. The records of 488 patients were available for analysis.

RESULTS

Epidermoid cyst was the most frequent lesion (49%) followed by pilar cysts (27%), and dermoid cysts (22%). The site affected most frequently was the scalp (34%), predominantly with pilar cysts (96%). Epidermoid cyst was the most frequent lesion in the neck (68%), cheeks (77%), periauricular area (70%), and the nasal area (55%). Dermoid cyst was the most frequent lesion in the periorbital area (52%). Females represented 51% of the patients and males accounted for 49%. The peak of age distribution for patients with dermoid cysts was at the first decade, and both of epidermoid and pilar cysts peaked at the third decade. Infection presented in 2.5% of cases. All cysts were enucleated surgically.

CONCLUSION

Maxillofacial surgeons often encounter cutaneous cysts of the head and neck, and they must be familiar with the clinicopathologic characteristics of these lesions.

Comparison of CT-guided sclerotherapy with using 95% ethanol and 20% hypertonic saline for managing simple renal cyst

OBJECTIVE

We wanted to compare the efficacies of 95% ethanol and 20% hypertonic saline (HS) sclerotherapies that were performed in a single session under CT guidance for the management of simple renal cysts.

MATERIALS AND METHODS

A prospective series of 74 consecutive patients (average age: 57.6 +/- 8.1 years) with simple renal cysts were enrolled in this study. They were randomized into two groups and 95% ethanol or 20% HS, respectively, corresponding to 25% of the aspiration volume, was injected. Treatment success was determined six months later with follow-up clinical evaluation and performing ultrasonography.

RESULTS

The sclerotherapy was accepted as technically successful without major complications in all except two patients who were excluded because of a communication between the simple renal cyst and the pelvicalyceal collecting system. Thirty-six patients in the ethanol group received sclerotherapy with 95% ethanol and 36 patients in the HS group underwent sclerotherapy with 20% HS. The complete regression ratio of the ethanol group was significantly higher (94% versus 72%, respectively) than that of the HS group. There was one patient with partial regression in each group. The failure ratio of the ethanol group was significantly lower (3% versus 25%, respectively) than that of the HS group.

CONCLUSION

Ethanol sclerotherapy under CT guidance is a successful and safe procedure and it can be used for the treatment of simple renal cysts. Sclerotherapy with 95% ethanol is more effective than 20% HS sclerotherapy. Sclerotherapy with HS may be an option for patients preferring to undergo a less painful treatment procedure.

Advances in liver echinococcosis: diagnosis and treatment

Echinococcosis or hydatid cyst disease is a zoonosis caused by the larval cestode Echinococcus granulosus. It consists of a parasitic tapeworm disease affecting mainly liver. Nevertheless, the disease might well spread to more unusual sites such as lungs and brain. The definitive diagnosis of liver echinococcosis requires a combination of imaging, serologic, and immunologic studies. Despite the fact that a number of scolecoidal agents have been developed against liver hydatid disease, the cornerstone of the definitive treatment remains surgery. Both the classic surgical techniques and the recently developed minimally invasive and laparoscopic methods target the eradication of the disease by simultaneously avoiding perioperative spillage and dissemination or recurrence of echinococcosis. The present article constitutes a review of the biology of the parasite as well as the epidemiology, diagnosis, and therapeutic options of the liver hydatid disease.