Hydatid liver cyst: an 11-year experience of treatment with percutaneous aspiration and ethanol injection

Primary Retroperitoneal Hydatid Cyst: A Diagnostic and Treatment Conundrum

Hydatid cysts are caused by accidental egg ingestion of the Echinococcus granulosus parasite. A 24-year-old female was admitted to our hospital for chronic left lumbar pain. Computed tomography (CT) and abdominal ultrasonography identified an 8/12 cm retroperitoneal cyst. The CT results coupled with enzyme-linked immunosorbent assay tests (positive IgG for Echinococcus granulosus) confirmed that the tumor was a hydatid cyst. Treatment consisted of preoperative chemotherapy with albendazole, intraoperative parasite inactivation, laparoscopic partial cystectomy, and drainage. The drain was removed after three days. Chemotherapy was maintained for two years after surgery. No relapse was observed at the six-month reevaluation. In this article, the diagnostic and therapeutic options and resources are discussed and compared with the published literature.

Unusual case of disappearing hepatic hydatid cyst: COVID-19 times

The larvae of the tapeworm Echinococcus granulosus cause echinococcosis or hydatid disease. Liver is the most commonly involved organ accounting for 60%–80%. Rupture into the biliary radicle through a cystobiliary communication is the most anticipated complication seen in 5%–17%, presenting with obstructive jaundice and cholangitis. We present a young patient who had presented with cholangitis and a tender hepatomegaly. Contrast-enhanced CT (CECT) had revealed a large hepatic hydatid cyst with multiple daughter cysts and significant dilatation of intrahepatic/extrahepatic biliary system. He had undergone an emergency Endoscopic Retrograde Cholangiopancreatography (ERCP) with extraction of the membranes and stenting of the common bile duct. A few cycles of albendazole were given to sterilise before elective laparoscopic surgery. However, a follow-up CECT showed complete resolution of the hepatic hydatid with calcification. In conclusion, medical treatment with a few cycles of albendazole and ERCP with stenting could be a good treatment option.

Treatment of Gharbi Type III Hepatic Hydatid Cysts: A Clinical Dilemma

This article aims to compare available treatment options for type III liver hydatid cysts, including surgery and percutaneous techniques. Hydatid disease is a helminthic infection caused by Echinococcus granulosus and is a serious public health problem in endemic regions of the world. Hydatid cyst of the liver is the most common clinical presentation of Echinococcus granulosus. According to Gharbi classification, hydatid cysts of the liver are classified into 5 types. Type III hydatid cysts are those with fluid collection and septa. Treatment of Gharbi type III hydatid cysts is still controversial. Some researchers think that Gharbi type III hydatid cysts are not suitable for percutaneous drainage, and surgery is the suitable treatment option. There are not enough prospective studies comparing percutaneous and surgical techniques for the treatment of type III hydatid disease of the liver. A proper meta-analysis does not seem to be possible with the available studies in current medical literature.

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.

Modern trends in surgical treatment of liver echinococcosis

The article presents literature review about surgical treatment of liver hydatidosis. Particular attention is paid to the development of percutaneous treatment. Also modern trend of surgical treatment are described. We presented results of percutaneous treatment of liver hydatidosis in our clinic. We analized them and made the conclusion that percutaneous treatment is effective and safe method for liver hydatidosis. To reduce the risk of recurrence we have to do it right and all patients must take anti-relapse chemotherapy.

Ultrasound and Cystic Echinococcosis

The introduction of imaging techniques in clinical practice 40 years ago changed the clinical management of many diseases, including cystic echinococcosis (CE). For the first time cysts were clearly seen before surgery. Among the available imaging techniques, ultrasound (US) has unique properties that can be used to study and manage cystic echinococcosis. It is harmless, can image almost all organs and systems, can be repeated as often as required, is portable, requires no patient preparation, is relatively inexpensive and guides diagnosis, treatment and follow-up without radiation exposure and harm to the patient. US is the only imaging technique which can be used in field settings to assess CE prevalence because it can be run even on solar power or a small generator in remote field locations. Thanks to US classifications, the concept of stage-specific treatments was introduced and because US is repeatable, the scientific community has gained a clearer understanding of the natural history of the disease. This paper reviews the scope of US in CE, describes its strengths and weaknesses compared to other imaging techniques and its relationship with serodiagnosis and discusses sonographic features that may be helpful in differential diagnosis.

Evaluation of the recombinant antigens B2t and 2B2t, compared with hydatid fluid, in IgG-ELISA and immunostrips for the diagnosis and follow up of CE patients

Cystic echinococcosis (CE) is one of the most widespread helminthic zoonoses and is caused by the tapeworm Echinococcus granulosus complex. CE diagnosis and monitoring primarily rely on imaging techniques, complemented by serology. This is usually approached by the detection of IgG antibodies against hydatid fluid (HF), but the use of this heterogeneous antigenic mixture results in a variable percentage of false positive and negative results, and has shown to be useless for follow-up due to the long persistence of anti-HF antibodies in cured patients. To improve test performances and standardization, a number of recombinant antigens mainly derived from HF have been described, among them the B2t and 2B2t antigens. The performance of these antigens in the diagnosis and follow up of patients with CE has been so far evaluated on a limited number of samples. Here, we evaluated the performances of tests based on B2t and 2B2t recombinant antigens compared to HF in IgG-ELISA and immunochromatography (IC) for the diagnosis and follow-up of patients with CE in a retrospective cohort study. A total of 721 serum samples were collected: 587 from 253 patients with CE diagnosed by ultrasonography (US), 42 from patients with alveolar echinococcosis and 92 from healthy donors from Salamanca (Spain). The highest overall sensitivity was obtained with HF in ELISA (85.5%), followed by IC containing HF and 2B2t-HF (83.0% and 78.2%, respectively). The lowest sensitivity was obtained with B2t and 2B2t in ELISA (51.8%). The highest specificity was obtained with IC containing 2B2t-HF (100%), and the lowest with HF-ELISA (78.0%). The lowest cross-reactivity with sera from patients with alveolar echinococcosis was detected with the recombinant antigens in ELISA (9.5% - 16.7%) and the highest with the HF-IC (64.3%). The results of B2t and 2B2t-ELISA were influenced by cyst stage, as classified by US according to the WHO-Informal Working Group on Echinococcosis (WHO-IWGE), with low sensitivity for inactive (CE4 and CE5) cysts, and by the drug treatment, with higher sensitivity in patients after drug treatment compared with patients not subjected to drug treatment. The two recombinant antigens in ELISA provided promising results for monitoring patients in follow-up, although their use is limited to patients with positive serology against them at the beginning of the follow-up. Potential biological reasons behind the low sensitivity of the recombinant antigens and possible strategies to enhance the performance of CE serology are discussed.

Cystic echinococcosis (CE) is a helminthic zoonosis caused by Echinococcus granulosus sensu lato. CE diagnosis and monitoring is of paramount importance for the clinical management of patients and primarily rely on imaging techniques, complemented by serology. CE serology is usually based on the detection of antibodies against hydatid fluid (HF), but the use of this heterogeneous antigenic mixture shows several drawbacks, including false positive and negative results, unsatisfied predictive values, and long persistence of detectable antibody levels in cured patients. As an alternative, to improve test performances and standardization, several recombinant antigens have been described, but these have been so far evaluated only on a limited number of samples. Here, two recombinant antigens derived from one of the immunodominant HF antigens (antigen B2) have been tested in enzyme-linked immunosorbent assay (ELISA) and in immunochromatographic strips (IC) against 721 serum samples. Although more specific than the HF, the recombinant antigens in ELISA showed low sensitivity for patients with inactive (CE4 and CE5) cysts and for patients not subjected to drug treatment. This limited their use for follow-up, although promising, to those patients with positive serology at the beginning of the follow-up period. These results will aid in the future development of a serological test with enhanced performance in the diagnosis and follow-up of patients with CE.

Intra-Abdominal Hydatid Cyst: Sociodemographics, Clinical Profiles, and Outcomes of Patients Operated on at a Tertiary Hospital in Addis Ababa, Ethiopia

Background

Hydatid cyst is caused by the tapeworm Echinococcus granulosus. The abdomen, specifically the liver, is the most common site affected.

Objective

Determine the presentation patterns, types of surgical management, and outcomes of patients operated for intra-abdominal hydatid cyst (IAHC).

Methodology

A retrospective descriptive study of patients admitted and operated for IAHC from September 1, 2011, to August 31, 2015.

Results

Forty-two patients whose age ranged from 10 to 65 (mean of 37 years) were operated on. Females comprised 27 (64.3%) of the patients. The commonest presenting complaint was abdominal pain (41, 97.6%). Abdominal mass was documented in 23 (54.7%) cases. Abdominal ultrasound (AUS) and CT were the main imaging studies done on 38 (90.5%) and 24 (57.1%) patients, respectively. Cysts measuring more than 10 cm in diameter were the most common finding in both studies. Liver was the primary site involved, 30 (71.4%) cases, the right lobe being the main side, 73%. Thirty-eight (90.5%) patients underwent deroofing, evacuation, marsupialization, and omentoplasty (DEMO). There was no perioperative death, but 4 (9.5%) of the patients had post-op complications.

Conclusion

Abdominal pain was the most common presenting complaint. AUS and CT remain the preferred imaging. DEMO was the most common surgery.

A comparison of imaging guided double percutaneous aspiration injection and surgery in the treatment of cystic echinococcosis of liver

OBJECTIVE

To compare the results and complications of treatment by double percutaneous aspiration injection (DPAI) in cystic echinococcosis (CE) of the liver with those of surgery. To the best of our knowledge, such a study has not been carried out till date.

METHODS

From November 2012 to November 2015, 43 patients were randomly allocated to DPAI group (n = 22) and surgery group (n = 21). After the intervention, patients were evaluated monthly for 3 months, then at the sixth month and 6 monthly thereafter.

RESULTS

Average hospital stay was 2.38 days in DPAI group and 8.23 days in the surgery group. Response to DPAI was categorized as successful in 95.3% (n = 20) patients and incomplete in 4.7% (n = 1) patients. Response to surgery was characterized as successful in 85.7% (n = 18) patients and incomplete in 4.7% (n = 1) patients, and recurrence was seen in 9.5% (n = 2) patients. Using a 10% margin for non-inferiority, treatment response in the DPAI group was non-inferior to that of the surgery group. In the DPAI group, 19 patients had no complications, minor complications were seen in 4.7% (n = 1) patients and a major complication was seen in 4.7% (n = 1) patients. In the surgery group, no complications were seen in 13 patients, major complications were seen in 28.57% (n = 6) patients and minor complications were seen in 9.5% (n = 2) patients.

CONCLUSION

Over a follow-up period of 3 years, DPAI is non-inferior to surgery in the treatment of CE of the liver, while there is a statistically significant difference in the hospital stay and occurrence of complications. Advances in knowledge: DPAI offers advantages such as a short hospital stay, minimal invasiveness and morbidity, while being non-inferior to surgery. Total Immunoglobulin G antibody titres have limited utility in follow-up of patients treated.

The Echinococcoses: Diagnosis, Clinical Management and Burden of Disease

The echinococcoses are chronic, parasitic diseases that are acquired after ingestion of infective taeniid tapeworm eggs from certain species of the genus Echinococcus. Cystic echinococcosis (CE) occurs worldwide, whereas, alveolar echinococcosis (AE) is restricted to the northern hemisphere, and neotropical echinococcosis (NE) has only been identified in Central and South America. Clinical manifestations and disease courses vary profoundly for the different species of Echinococcus. CE presents as small to large cysts, and has commonly been referred to as 'hydatid disease', or 'hydatidosis'. A structured stage-specific approach to CE management, based on the World Health Organization (WHO) ultrasound classification of liver cysts, is now recommended. Management options include percutaneous sterilization techniques, surgery, drug treatment, a 'watch-and-wait' approach or combinations thereof. In contrast, clinical manifestations associated with AE resemble those of a 'malignant', silently-progressing liver disease, with local tissue infiltration and metastases. Structured care is important for AE management and includes WHO staging, drug therapy and long-term follow-up for at least a decade. NE presents as polycystic or unicystic disease. Clinical characteristics resemble those of AE, and management needs to be structured accordingly. However, to date, only a few hundreds of cases have been reported in the literature. The echinococcoses are often expensive and complicated to treat, and prospective clinical studies are needed to better inform case management decisions.

ACG clinical guideline: the diagnosis and management of focal liver lesions

Focal liver lesions (FLL) have been a common reason for consultation faced by gastroenterologists and hepatologists. The increasing and widespread use of imaging studies has led to an increase in detection of incidental FLL. It is important to consider not only malignant liver lesions, but also benign solid and cystic liver lesions such as hemangioma, focal nodular hyperplasia, hepatocellular adenoma, and hepatic cysts, in the differential diagnosis. In this ACG practice guideline, the authors provide an evidence-based approach to the diagnosis and management of FLL.

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.

Cystic echinococcosis of the liver: experience from a Danish tertiary reference center (2002-2010)

BACKGROUND

Cystic echinococcosis (CE) of the liver can be treated with ultrasound-guided puncture, aspiration, injection, and re-aspiration (PAIR), with surgery and with benzimidazole derivatives. The aim of this study was to review available data concerning treatment modality and outcome for patients treated for CE of the liver in a Danish tertiary reference center.

METHODS

A search was made for patients treated for CE infection between January 1, 2002 and January 1, 2010. All relevant patient records and radiology exams were scrutinized and all cysts were re-classified according to the WHO-IWGE, blinded as to which treatment the patient had received. PAIR was performed as a first choice treatment and surgery was reserved for cases where PAIR was impossible. Inactive cyst stages received medical treatment only.

RESULTS

The search revealed 26 cases with confirmed CE of the liver. Nine patients underwent PAIR and nine patients surgery as a first choice treatment. Three patients were treated with PAIR secondary to surgery and one patient was treated with surgery secondary to PAIR. For all PAIR treatments, the success rate was 58% regardless of cyst stage and for surgery the success rate was 70%. The difference between the rates was not statistically significant (p = 0.67).

CONCLUSION

CE is a rare disease in Denmark and our study is the first describing clinical management of CE in our institution.

Hepatic hydatid: PAIR, drain or resect?

STUDY BACKGROUND

Hydatid disease of the liver is endemic in India and is a common health problem. Although various treatment options have been described ranging from pharmacotherapy to radiological interventions and surgical procedures (both conservative and radical), the best treatment option in an individual case continues to be debated.

METHODS

We did a retrospective analysis of patients with hydatid disease of the liver who were managed at our centre between January 2000 and December 2009. All cysts were classified as per the Gharbi's classification. The various treatment options used to treat hydatid cysts of the liver included percutaneous aspiration, injection and reaspiration (PAIR) or PAIR with drainage (PAIR-D) and surgery (both conservative and radical). The immediate and long-term outcomes following such management were analysed.

RESULTS

During the study period, 128 patients with hydatid cyst of the liver were managed with PAIR/PAIR-D (n = 52), radical/excisional surgery (n = 61) and conservative surgery (n = 33). In ten patients, the PAIR procedure was abandoned due to either bile or pultaceous material aspirated after the initial puncture and these patients subsequently underwent surgical management. The PAIR was unsuccessful in eight of the 42 patients in whom it was attempted and these subsequently underwent surgery. The mean intraoperative blood loss and the duration of surgery were comparable in patients who underwent either conservative or radical surgery (p = 0.35 and 0.19, respectively). Postoperative bile leaks and cavity abscesses were significantly higher in patients who underwent conservative surgery (p = 0.032 and p  = 0.001, respectively). Five patients (one following a radical operation and four following a conservative surgery, p = 0.05) developed recurrence in a mean follow-up period of 28 months and these were managed medically.

CONCLUSION

Several treatment options are available for the management of hydatid disease of the liver and the treatment modality chosen should be tailored to the individual patient. While percutaneous drainage (with PAIR/PAIR-D) is reserved for more favourable cases of type I and II cysts, the others are best managed surgically. Complete excision (cystopericstectomy or resection) of the hydatid cyst is the preferred approach and 61 of the 94 patients who were managed surgically were suitable for it. Although excisional surgery minimizes the risk of long-term recurrence and cavity-related complications, it may be hazardous in cysts located close to major biliovascular channels. In these cases (considering that it is benign disease), a drainage operation is preferable. Both conservative and radical surgery can be safely performed laparoscopically.

Percutaneous needle aspiration, injection, and re-aspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts

BACKGROUND

Hepatic hydatid cyst is an important public health problem in parts of the world where dogs are used for cattle breeding. Management of uncomplicated hepatic hydatid cysts is currently surgical. However, the puncture, aspiration, injection, and re-aspiration (PAIR) method with or without benzimidazole coverage has appeared as an alternative over the past decade.

OBJECTIVES

To assess the benefits and harms of PAIR with or without benzimidazole coverage for patients with uncomplicated hepatic hydatid cyst in comparison with sham/no intervention, surgery, or medical treatment.

SEARCH STRATEGY

The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, DARE, and ACP Journal Club and full text searches were combined (all searched October 2010). Reference lists of pertinent studies and other identified literature were scanned. Researchers in the field were contacted.

SELECTION CRITERIA

Only randomised clinical trials using the PAIR method with or without benzimidazole coverage as the experimental treatment of uncomplicated hepatic hydatid cyst (ie, hepatic hydatid cysts, which are not infected and do not have any communication with the biliary tree or other viscera) versus no intervention, sham puncture (ie, performing all steps for puncture, pretending PAIR being performed, but actually not performing the procedure), surgery, or chemotherapy were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, and the risk of bias in each trial was assessed by the authors. Principal authors of the trials were contacted to retrieve missing data.

MAIN RESULTS

We found no randomised clinical trials comparing PAIR versus no or sham intervention. We identified only two randomised clinical trials, one comparing PAIR versus surgical treatment (n = 50 participants) and the other comparing PAIR (with or without albendazole) versus albendazole alone (n = 30 participants). Both trials were graded as 'adequate' for allocation concealment; however, generation of allocation sequence and blinding methods were 'unclear' in both. Compared to surgery, PAIR plus albendazole obtained similar cyst disappearance and mean cyst diameter with fewer adverse events (32% versus 84%, P < 0.001) and fewer days in hospital (mean + SD) ( 4.2 + 1.5 versus 12.7 + 6.5 days, P < 0.001). Compared to albendazole, PAIR with or without albendazole obtained significantly more (P < 0.01) cyst reduction and symptomatic relief.

AUTHORS' CONCLUSIONS

PAIR seems promising, but there is insufficient evidence to support or refute PAIR with or without benzimidazole coverage for treating patients with uncomplicated hepatic hydatid cyst. Further well-designed randomised clinical trials are necessary to address the topic.

Human echinococcosis: a neglected disease

Echinococcosis is among the most neglected parasitic diseases. Development of new drugs and other treatment modalities receives very little attention, if any. In most developed countries, Cystic Echinococcosis (CE) is an imported disease of very low incidence and prevalence and is found almost exclusively in migrants from endemic regions. In endemic regions, predominantly settings with limited resources, patient numbers are high. Whole communities do not have access to appropriate treatment. The choice of treatment modalities is limited because of poor infrastructure and shortage of equipment and drugs. In this context, CE meets the criteria for a neglected disease. Furthermore, the terminology related to the designations around the parasite, its evolution and some therapeutic procedures is not uniform and sometimes inappropriate terms and wrong designations are used based on incorrect concepts. Although all of us know the different aspects of the disease it is pertinent to remember some important points and, above all, to clarify some aspects concerning the hydatid cyst's nomenclature in order to understand better the therapeutic options in the liver locations, particularly the different surgical approaches.

Clinical and sonographic management of viable hydatid liver cysts

AIM

The aim of this study was to review our 18-year experience in the treatment of viable hydatid liver cysts (HLCs) with double percutaneous aspiration and ethanol injection (D-PAI) and to provide indications for the clinical management of HLCs.

MATERIALS AND METHODS

From January 1989 to December 2007, 127 patients (100 males; 13-80 years) with 184 viable HLCs (137 univesicular, 47 multivesicular; 2.8-20 cm) underwent D-PAI.

RESULTS

Ultrasonography (US) showed complete disappearance of 125/184 (68%) cysts; in the remaining 59 cases, an inactive solid (37 cases, 20%) or liquid pattern (22 cases, 12%) was observed with volume decreases of 50-80%. The final US pattern was unmodified during the follow-up in 96.8%. Local recurrences were observed in 5 patients (3.9%): 4 patients with 8 multivesicular cysts and 1 patient with a bilocular cyst (with a solid pattern on US) that ruptured into the biliary tree 2 years after the procedure and disappeared after endoscopic sphincterectomy. The mortality rate was 0.8%, and the overall morbidity was 8.6%. The mean hospital stay was 2.9 days. The time of healing for smaller cysts (<5 cm) was shorter than that of large cysts (≥5 cm) (P < 0.001).

CONCLUSION

Our long-term results confirm the high effectiveness of D-PAI in the treatment of HLCs. These results suggest that multilocular cysts require closer follow-up than unilocular cysts.

Long-term results of percutaneous treatment of hydatid liver cysts: a single center 17 years experience

BACKGROUND

Liver cystic echinococcosis is considered a relatively benign disease, nevertheless, treatment is mandatory in symptomatic cysts and recommended in active cysts because of the risk of severe complications. Surgery is still considered the gold standard treatment. In the last two decades percutaneous injection of scolicidal agents has been developed with excellent results in terms of disappearance of the cyst, very low side effects and low mortality rate.

MATERIALS AND METHODS

One hundred sixty eight patients with 225 liver cysts were studied. A total of 108 patients with 151 viable hydatid liver cysts underwent Double Percutaneous Aspiration and Injection of alcohol of the cyst without re-aspiration of the ethanol, which remained in situ.

RESULTS

The mortality rate was 0.9% (1 patient), the overall morbidity was 8.6% with only 2.5% of major side effects. The mean hospital stay was very short (2.9 days). Follow-up ranged from 14 to 204 months (median 48 months). Ultrasonography showed complete disappearance of the cyst with reconstitution of liver parenchyma in 109 out of 225 (48.4%) cysts; in the remaining cysts a solid or a liquid findings were observed in 104 (46.2%) and 12 (5.3%), respectively, with a decreased volume of 50-80%.

CONCLUSION

These data show that Double Percutaneous Aspiration and Injection of alcohol for hydatid liver cysts can achieve comparable results to open surgery. The low incidence of side effects shows that this technique is safe and cost effective, compared to radical or conservative surgery.

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.

Management of hepatic and intracardiac echinococcal cysts: case report and review of the literature

BACKGROUND

Infection with Echinococcus granulosus affects the liver commonly, but disseminated involvement is rare. We describe a 63 year-old man with echinococcal infection producing both hepatic and cardiac involvement that was managed surgically after failed percutaneous hepatic treatment.

METHODS

This report is a case study of a unique surgical problem. Various treatment modalities are reviewed.

RESULTS

The patient was a 63 year-old man from Iraq who immigrated to the United States after becoming infected with Echinococcus granulosus. He had undergone percutaneous management and albendazole therapy prior to presentation for treatment of hepatic hydatid cysts. He continued to have abdominal pain and fever and was referred to our institution. Imaging revealed persistence of the hepatic hydatid cysts, as well as a new finding of an intracardiac hydatid cyst. The patient underwent successful treatment of his complicated hepatic hydatid cysts with pericystectomy and repair of a biliary fistula. The cardiac cyst was removed as well. The patient made an uneventful recovery, and his symptoms resolved.

CONCLUSION

Although rare, echinococcal infection may be encountered in the United States as travel increases to and from regions of the world where the disease is endemic. It is important for surgeons to be familiar with the multiple options for treatment of hydatid disease.

Percutaneous imaging-guided treatment of hydatid liver cysts: Do long-term results make it a first choice?

AIM

To evaluate the long-term results of percutaneous imaging-guided treatment of hydatid liver cysts.

MATERIALS AND METHODS

Sixty patients with 77 hydatid liver cysts underwent percutaneous treatment with ultrasonography (US) or computed tomography (CT) guidance. Absolute alcohol and hypertonic saline were used for sclerosing the cysts after aspiration. Prophylactic albendazole treatment was given before and after the procedures. Follow-up US and CT were obtained periodically, and changes in cyst morphology were recorded. Minimum follow-up period for the patients included in this study was 12 months. Serological correlation was also available for a group of patients. The outcome of the procedures were categorized into five groups based on morphological changes observed by imaging.

RESULTS

Procedures were regarded as successful in 80% and unsuccessful in 20% of patients. Failures most often occurred with type III cysts; less than half (39%) of the total type III cysts had a successful outcome. On the other hand, all type I cysts ended up with cure. Anaphylaxis, pneumotorax and severe pain interrupting the procedures were also among the reasons of failure.

CONCLUSION

Percutaneous aspiration, injection and reaspiration (PAIR) of types I and II hydatid liver cysts is effective and safe in the long-term. Surgery should no longer be regarded as the first choice treatment in all hydatid liver cysts but should be reserved for type III and certain active type IV cysts.

Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts

BACKGROUND

Hepatic hydatid cyst is an important public health problem in parts of the world where dogs are used for cattle breeding. Management of uncomplicated hepatic hydatid cysts is currently surgical. However, the puncture, aspiration, injection, and re-aspiration (PAIR) method with or without benzimidazole coverage has appeared as an alternative to surgery over the past decade.

OBJECTIVES

To assess the benefits and harms of PAIR with or without benzimidazole coverage for patients with uncomplicated hepatic hydatid cyst in comparison with sham/no intervention, surgery, or medical treatment.

SEARCH STRATEGY

The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Controlled Trials Register in The Cochrane Library, MEDLINE, EMBASE, DARE, and ACP Journal Club and full text searches were combined (all searched October 2004). Reference lists of pertinent studies and other identified literature were scanned. Researchers in the field were contacted.

SELECTION CRITERIA

Only randomised clinical trials using the PAIR method with or without benzimidazole coverage as the experimental treatment of uncomplicated hepatic hydatid cyst (ie, hepatic hydatid cysts which are not infected and do not have any communication with the biliary tree or other viscera) versus no intervention, sham puncture (ie, performing all steps for puncture, pretending that PAIR is being performed, but actually not performing the procedure proper), surgery, or chemotherapy were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and methodological quality of each trial was assessed by the authors. Principal authors of the trials were contacted to retrieve missing data.

MAIN RESULTS

We found no randomised clinical trials comparing PAIR versus no or sham intervention. We identified only two randomised clinical trials, one comparing PAIR versus surgical treatment (n = 50) and the other comparing PAIR (with or without albendazole) versus albendazole alone (n = 30). Both trials were graded as 'adequate' for allocation concealment; however, generation of allocation sequence and blinding methods were 'unclear' in both of them. Compared to surgery, PAIR plus albendazole obtain similar cyst disappearance and mean cyst diameter with fewer adverse events (32% versus 84%, P < 0.001) and fewer days in hospital (mean + SD) ( 4.2 + 1.5 versus 12.7 + 6.5 days, P < 0.001). Compared to albendazole, PAIR with or without albendazole obtain significantly more often (P < 0.01) cyst reduction and symptomatic relief.

AUTHORS' CONCLUSIONS

PAIR seems promising, but there is insufficient evidence to support or refute PAIR with or without benzimidazole coverage for treating patients with uncomplicated hepatic hydatid cyst. Further well-designed randomised clinical trials are necessary to address the topic.

Sedation for percutaneous treatment of hepatic hydatid cyst in a pregnant patient

BACKGROUND

A 15 cm hepatic hydatid cyst was diagnosed in a multigravida in 16 weeks of pregnancy and was managed percutaneously under sedation.

RESULTS

No complication occurred and she gave birth to a healthy male baby after 37 weeks gestation.

Results of alcohol and albendazole injections in hepatic hydatidosis: experimental study

BACKGROUND

Percutaneous drainage with alcohol injection for hydatid cysts has been commonly used in the last two decades. Albendazole is the drug of choice in the medical treatment of hydatidosis, and has also been used as an intraoperative scolicidal solution. The side-effects of its local application are not well known and have not been investigated. The purpose of the present study was to investigate the effects of the intracystic injections of alcohol and albendazole solutions on the hydatid cysts and hepatobiliary system of rabbits.

METHODS

There were three groups of eight rabbits: a control group, an alcohol group and an albendazole group. In all groups hepatic hydatidosis was obtained. The control group received no therapeutic procedure. Cyst liquid was aspirated, and alcohol or albendazole solutions were injected in the other two study groups. alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyl transferase (GGT) levels, echinococcus indirect hemagglutination (IHA) tests, and the size and volume of the residual cysts were investigated. Liver was histopathologically evaluated.

RESULTS

The ALT, AST, GGT, and alkaline phosphatase (ALP) levels were significantly higher in the alcohol group, whereas echinococcus IHA level was highest in the control group than in the study groups. Albendazole had similar effects but of a lesser degree (P < 0.01). After therapy, the cyst volume was greater in the control than in the albendazole group (P < 0.01). In histopathological evaluation hepatocellular necrosis, portal inflammation and fibrosis were most severe in the alcohol group (P < 0.01).

CONCLUSIONS

Alcohol and albendazole solutions are effective as scolicidal solutions. Higher scolicidal effect and lesser side-effects on hepatobiliary system are the advantages of albendazole solution.

Diagnosis and treatment of hepatic echinococcosis: an overview

BACKGROUND

Surgery has long been considered the first-choice treatment in patients with echinococcosis of the liver. The poorly predictable outcome of older studies using mebendazole or albendazole confirmed this belief. Since the introduction of a percutaneous technique (PAIR; puncture, aspiration, injection, reaspiration) treatment policy is changing. The actual question is which treatment is preferred in which patients.

METHODS

Review of recent literature.

RESULTS

Laparoscopic treatment of anteriorly located hepatic cysts is a new surgical technique with high success rates (77%-100%) and low complication (0%-17%) and recurrence rates (0%-9%). Albendazole is superior to mebendazole treatment. Degenerative changes were found in 82% of patients treated with albendazole and in 56% of those treated with mebendazole. The main problem is the high relapse rate: 25% mostly within 2 years. PAIR proved to be superior to albendazole treatment (88% versus 18%) and equally effective as surgery (86% versus 76%). A combined injection of alcohol with polidocanol is a simple alternative to PAIR. Percutaneous evacuation of cyst content (PEVAC) made percutaneous treatment accessible to patients with complicated cysts.

CONCLUSIONS

Albendazole is the first-choice treatment in patients with univesicular cysts. PAIR or combined injection of alcohol with polidocanol is indicated when pain is intractable or albendazole fails. In patients with multivesicular cysts, PEVAC is a better choice. Surgery is the first-choice treatment only when the expertise of percutaneous treatment is not available or when percutaneous treatment fails.

Dual treatment of albendazole in hepatic hydatidosis: New therapeutic modality in 52 cases

BACKGROUND

Hepatic hydatidosis still remains as a serious problem in general surgery. Recurrence and/or secondary hydatidosis rates are up to 25% in the cases treated with surgery alone. Albendazole is the most commonly used drug in the medical treatment of echinococcosis. The aim of the present study was to evaluate the effect of albendazole using the intraoperative and perioperative periods as dual therapy.

METHODS

Fifty-two cases of hepatic hydatidosis were evaluated and treated by dual treatment of albendazole together with surgery. Perioperative albendazole treatment was given in a dose of 12-15 mg/kg per day in four divided doses. The treatment started 2-28 days before the surgery when the diagnosis was established and continued for 2-24 months (4.76 +/- 3.25) postoperatively in a cyclic monthly form. A total of 1.7 microg/mL albendazole solution was used as a protoscolicidal agent in the cystic cavity intraoperatively. In the postoperative period serology, ultrasonography and computed tomography evaluations were done. The follow-up period was 5-92 months (mean: 62.48 months).

RESULTS

There was no recurrence in the present study. One patient died in the 6th postoperative week due to cerebral hydatidosis and multiple organ failure. Early and late morbidity rates were 7.69 and 9.61%, respectively.

CONCLUSIONS

Dual albendazole treatment is effective in the prevention of recurrences and/or secondary hydatidosis.

Complications after interventional sonography of focal liver lesions: a 22-year single-center experience

OBJECTIVE

To analyze the complications of diagnostic and therapeutic sonographically guided interventional procedures of focal liver lesions observed during a 22-year period in a single center.

METHODS

Complications of sonographically guided diagnostic and therapeutic procedures on focal liver lesions, observed during a 22-year period in a single center, were reviewed. From 1979 to 2001, 13,222 patients (age range, 7-89 years; mean, 59 years; 8,688 male and 4,534 female) with 13,777 focal liver lesions underwent 16,648 sonographically guided biopsies and 3,035 therapeutic procedures: pyogenic and amebic abscess aspiration, ethanol injection of hydatid liver cysts, and percutaneous ablative treatments (ethanol injection in either multiple or one-shot sessions, radio frequency ablation, and interstitial laser photocoagulation) of primary and secondary liver tumors.

RESULTS

The overall mortality was 0.06%. No death or major complication occurred after diagnostic procedures and liver abscess drainage. In the therapeutic group mortality was 0.6%: 1 patient died of anaphylactic shock during treatment of a hydatid cyst; 7 patients died after liver tumor ablation with ethanol injection (6 after one-shot treatments and 1 after multisession treatments). Major complications after liver tumor ablative procedures included 10 cases of acute liver failure, 2 cases of acute tubular necrosis, 2 cases of self-limiting hemoperitoneum, 2 cases of paralytic ileum, 2 abscesses, and 1 case of cholangitis. One case of a biliary cyst fistula and 1 case of intracystic hemorrhage occurred after treatment of hydatid liver cysts.

CONCLUSIONS

Sonographically guided diagnostic biopsy of focal liver lesions and liver abscess drainage are safe procedures. In contrast, liver tumor ablation procedures have a low but definite risk of mortality and major complications. Puncture of hydatid cysts must be performed only in institutions that can treat anaphylactic shock.