Surgical Treatment of Liver Echinococcosis — the Role of Laparoscopy

Background: The surgical approach to liver echinococcosis is still a controversial issue. This study shows our results of surgical treatment of liver hydatid cysts during a 5-year period.

Methods: A prospective study of 21 patients operated on in a 5-year period (1999–2003), in Dubrava University Hospital in Zagreb, Croatia, with hepatic hydatid cyst. All patients were pre-operatively treated with albendazole. In 12 patients, total pericystectomy without opening the cyst cavity was performed, 9 open and 3 laparoscopic. In the other 9 patients, partial pericystectomy was done, 6 open and 3 laparoscopic.

Results: There was no mortality after 5–65 months follow-up, but in 1 patient, in the open partial pericystectomy group, recurrence of the disease occurred after 3 years. When a laparoscopic procedure was done, there were no complications or recurrence. The median operative duration for open surgery was 100.0 min (range 60.0-210.0), and for laparoscopic surgery 67.5 min (range 60.0-120.0). The median length of hospitalisation for open surgery was 8.0 days (range 7.014.0), and for laparoscopic surgery 5.0 days (range 4.0-7.0).

Conclusion: Total pericystectomy without opening the cyst cavity, preceded by pre-operative albendazole therapy is the method of choice for hepatic hydatid cyst treatment. Despite the small group of patients, our first results show laparo-scopic total pericystectomy without opening the cyst cavity, in the treatment of hepatic hydatid cyst, as a good alternative to open surgery in selected patients.     

Laparoscopic management of echinococcal cysts of the liver

Even though echinococcal cysts have been cured by puncture and instillation of scolicidal medications, surgery is still the mainstay of the treatment of hydatid disease. The aim of the surgical treatment is the elimination of scolices, the removal of all viable parts of the cyst and the obliteration of the remaining cavity. This can be achieved by resective procedures, but also by a more conservative approach with drainage and obliteration of the cyst. The latter procedure can be done by open surgery or laparoscopically. The disadvantages of the laparoscopic approach are the increased danger of contamination of the abdominal cavity with scolices and difficulties to aspirate a highly viscous cyst content. Furthermore, cysts which are located deep in the parenchyma of the liver should not be approached laparoscopically because of the significant danger of hemorrhage. The advantage of the laparoscopic approach in selected cysts, i.e. those which are located superficially and having a liquid content, are a shorter hospital stay, lower incidence of wound infection and the ability of the surgeon to inspect the inside of the cyst more thoroughly and rule out daughter cysts and connections to the biliary tract. A review of the literature (n = 76) indicates that in most laparoscopically treated hydatid cysts of the liver a simple drainage (59%) or an unroofing (31%) is performed. The complication rate is 21%. Because there are no longterm observations after laparoscopic operations for hydatid disease the question of recurrence cannot yet be answered.     

Posttraumatic free intraperitoneal rupture of liver cystic echinococcosis: a case series and review of literature

BACKGROUND: A serious complication of cystic echinococcus (CE) is the rupture of the cysts. Free intra-abdominal rupture occurs in approximately 3.2% of all cases. Posttraumatic rupture of liver CE is very rare. METHODS: The objective of the current study was to evaluate the clinical and radiographic findings and surgical treatment of this complication. RESULTS: Twenty patients with posttraumatic ruptured liver CE were treated. The incidence rate of hydatid rupture was 3.06%. The common presenting symptom was abdominal pain. All patients were operated on under emergency conditions. There were 26 cysts in 20 patients, and all of the cysts were treated surgically. CONCLUSION: Hydatid cyst rupture must be kept in mind in the management of trauma patients with cystic mass in the liver in particular and free intra-abdominal fluid, especially in the endemic area. We preferred conservative (unroofing associated with various procedures for the management of the residual cavity) rather than radical procedures such as hepatic resection or pericystectomy for the surgical treatment.     

Predictive factors of deep abdominal complications after operation for hydatid cyst of the liver: 15 years of experience with 672 patients

BACKGROUND: Operations are the mainstay of liver hydatid cyst (LHC) treatment. Operations are still associated with high morbidity and mortality because of specific postoperative complications (bile leaks, bilomas, deep bleeding, and deep suppurations) and deep abdominal complications (DAC). The aim of this study was to identify the predictive factors of DAC after LHC operation. STUDY DESIGN: We conducted a retrospective study of 672 patients with LHC treated at the Surgery Department "A" at Ibn Sina University Hospital, Rabat, Morocco. Specific morbidity (DAC) and 30 variables were assessed. Univariate and multivariate logistic regression were performed to identify predictive factors for DAC. An associated risk scoring system was developed. RESULTS: Six hundred sixty-four patients underwent operations. Mortality rate was 0.8% (n = 5) and DAC rate was 18.4% (n = 121). Five independent predictive factors of DAC after LHC operation were retained, ie, presence of cyst preoperative complications (odds ratio [OR] = 3.10; 95% CI, 1.85 to 5.17), 3 or more cysts in the liver (OR = 2.55; 95% CI, 1.42 to 4.59), thick pericyst (OR = 2.59; 95% CI, 1.27 to 5.29), biliary fistula (OR = 2.27; 95% CI, 1.38 to 3.72), and capitonnage alone as residual cavity management (OR = 2.23; 95% CI, 1.12 to 4.44). Multivariate model showed a good fit. Discriminating ability of the model was fair. In theoretical risk, scores ranged from 0 to 5. When the score was 2 or more, sensitivity of the scoring model was 80.3%, specificity was 58.5%, positive predictive value was 30.3%, and negative predictive value was 93%. CONCLUSIONS: Identification of these five factors will allow more appropriate therapeutic care after LHC operation.     

肝包虫囊肿压迫下腔静脉的外科治疗

目的:探讨肝包虫囊肿压迫下腔静脉的外科治疗。方法:采用回顾性描述性研究方法。收集2013年5月至2018年5月石河子大学医学院第一附属医院收治的10例肝包虫囊肿压迫下腔静脉病人的临床资料;男7例,女3例;年龄为（46±5）岁,年龄范围为38~51岁。根据术中肝包虫囊肿与下腔静脉的贴合程度以及囊肿完整切除的难易程度,分别...     

Obstructive jaundice caused by hydatid cyst rupture in main bile duct

Hydatid hepatic cyst rupture into bile duct is a complication of hydatid disease. The rupture is more frequent in right or left epatic duct and occasionally in common bile duct (7-9%). A 50-year old man came to emergency room owing to jaundice, fever and abdominal pain. TC show an hydatid cyst with daughter's cyst of left liver and dilatation of biliary tree. Laboratory data of significance included an increased of liver function tests (Bilirubin, Alkaline ph., SGOT, SGPT), VES and leukocytosis. The patients was surgically treated, by total pericystectomy, colecystectomy and coledocotomy with lavage o common bile duct; finally we placed one Kehr drainage and two abdominal drainage. After 15 days of postoperative hospitalization patient was discharged. The best treatment of hydatid cyst is total pericystectomy (when possible). An alternative surgical treatment is possible for the presence of communication with biliary tree. ERCP is very important for a correct diagnosis and for a complete surgical treatment.     

Hydatic cyst of the liver. Considerations on 337 cases

Hydatid disease of the liver is still endemic in certain parts of the world. The modern treatment of hydatid cyst of the liver varies from surgical intervention to percutaneous drainage or medical therapy. Surgery is still the treatment of choice and can be performed by the conventional or laparoscopic approach. The aim of the study is to analyze the results of the surgical treatment in hydatid disease of the liver in First Surgical Clinic, Ia?i. The study concerned a period of 12.5 years (1992 - 31.07.2004) and it included 337 cases. There were performed radical procedures (ideal cystectomy - 17 cases - 5.04%, hepatic segmentectomy - 8 cases - 1.48%, atypical hepatectomy - 10 cases - 2.96%) or conservative procedures (de-roofing - 37 cases - 10.97%, subtotal pericystectomy - 34 cases -10.80%, total pericystectomy - 19 cases - 5.63%, partial pericystectomy - 212 cases -62.90%). In 35 cases (10.38%) the operation was started laparoscopically and 12 cases needed conversion. Postoperative course was complicated in 112 cases (33.32%) (external biliary fistula, cavity suppuration, residual cavity hydatid relapse). Radical methods constituted operations that had excellent results, but they are feasible in few cases. Conservative procedures, relatively simple and still accepted, have a higher rate of morbidity. The laparoscopic approach is more and more used, with good results.     

A rare complication of the hepatic hydatid cyst: intraperitoneal perforation without anaphylaxis

The hepatic hydatid cyst can lead to serious complications as a perforation into the biliary system or into the respiratory tract. The perforation into the peritoneal cavity can become dramatic, characterized by acute abdomen, usually with anaphylaxis. We recently treated a patient with a liver hydatid cyst perforated into the abdominal cavity. Computed tomography was a useful diagnostic tool, and the patient underwent emergency surgery. At laparotomy, 8 liters of hydatid liquid with floating daughter cysts and purulent material was found. The peritoneal cavity was washed with hypertonic solution, the hepatic cyst with daughter cysts. was removed, and a subtotal pericystectomy was performed. The critical clinical picture did not allow a cholecystectomy or a probe of the common hepatic duct to verify a biliary leakage. A biliary fistula appeared after 4 days and was successfully treated by endoscopic sphincterotomy. No anaphylactic phenomena were seen, probably because the great quantity of purulent material caused inactivity of the allergic component.     

Prevention of deep abdominal complications with omentoplasty on the raw surface after hepatic resection. The French Associations for Surgical Research

BACKGROUND: Several methods have been suggested to treat the hepatic raw surface after resection. Among these, omentoplasty (OP) has been employed occasionally but there are no clinical studies that clearly demonstrate its usefulness. METHODS: Of 172 randomized patients undergoing hepatic resection between January 1991 and December 1994, 5 were withdrawn for protocol violation, leaving 167 who were randomly allotted to undergo OP (n = 87) on the hepatic raw surface or not (NO; n = 80). This procedure was performed for malignant tumor in 125 cases, benign tumor in 33, and for other causes in 15. Six patients had more than two types of lesions, and 32 patients had associated cirrhosis. Sixty-five major and 102 minor hepatic resections were performed. The main outcome measures studied were the number of patients with deep abdominal complications (DAC; deep bleeding or hematoma, deep infection, with or without pus discharge through drains, bile leakage), as well as repeat operations and postoperative death. Patients were divided into two strata according to the site of the lesion with respect to the diaphragm: (1) in contact (posterosuperior segments II, VII and VIII) or (2) not in contact (anterior segments III, IV, V, and VI). RESULTS: Both groups were comparable as regards patient demographics, intraoperative procedures, intraoperative search for bile leaks and intraoperative transfusion requirements. Fewer patients had DAC in OP (n = 11) than in NO (n = 15) (difference not significant). Ten patients (6%) required repeat operations: 4 in OP without immediate mortality and 6 in NO, 3 followed by death. One further patient in OP required repeat operation after discharge and died. Four patients died in OP and 7 in NO, 1 and 4 of DAC, respectively (not significant). Deep abdominal complications were significantly associated with major hepatic resection (P <0.05) whereas postoperative death was significantly correlated with cirrhosis (P <0.05). CONCLUSIONS: OP on the raw surface after hepatic resection lowers the rate of all complications related to DAC (except biliary leaks) and their severity (repeat operations and death) but not significantly so. OP is not recommended as a routine measure to complete elective hepatic resections.     

RF-assisted cystectomy and pericystectomy: a new technique in the treatment of liver hydatid disease

BACKGROUND: Radiofrequency (RF) energy has been used for ablation and resection of liver tumors. Purpose: To present a new technique for the treatment of liver hydatid cyst disease. MATERIAL AND METHODS: Two patients with liver hydatid disease treated with RF energy cauterization and surgical resection are presented. Cystectomy was performed in a female patient aged 35 years and pericystectomy was carried out in another female patient aged 55 years using RF energy cauterization. Blood was not needed during the operation. RITA System (RITA Model 1500 RF Generator, RITA Medical Systems, Inc., USA) was used during the procedure. CONCLUSION: Cystectomy and pericystectomy in liver hydatid disease can be successfully performed with the assistance of RF energy.     

Hydatid Disease of the Abdomen and Other Locations

We present patients treated for hydatid disease in our hospital (in northeastern Greece) over the last 20 years. In the period from 1984 to 2003, a total of 135 patients (54 male, 81 female) were treated for echinococcal disease (age 15–85 years). In 111 (82.2%) patients only the liver was affected; 9 (6.7%) patients had concomitant hepatic and extrahepatic hydatid disease; and 15 (11.1%) patients had only extrahepatic disease. Clinical symptoms in patients with hepatic locations of the disease included abdominal pain localized in the epigastrium or right upper quadrant of the abdomen, tenderness, hepatomegaly with palpable abdominal mass, jaundice, fever, and anaphylactic reaction. All the patients were treated surgically. Surgical techniques included partial cystectomy and drainage, cystectomy and capitonage, cystectomy and omentoplasty, only drainage, left lateral hepatectomy, total pericystectomy, and laparoscopic pericystectomy. Rupture into the bile duct was managed by T-tube drainage or biliodigestive anastomosis. Symptoms and surgical treatment for extrahepatic cysts varied according to the location of the cyst. The median cyst diameter of all patients was 11 cm. The postoperative complication rate was 17.0%. Two patients died (1.5%). The median hospital stay was 18 days. The recurrence rate was 6.7%. The study suggests that treatment of this benign disease should be the less radical surgical technique combined with pre- and postoperative anthelmintic administration. The surgical treatment should be combined with careful use of scolicidal fluids and aspiration of the cyst to avoid contamination and minimize the risk of recurrence.     

Primary Hydatid Cyst of the Pancreas

Background: Hydatid cyst of the pancreas is rare, accounting for less than 1% of the various sites of hydatid disease, even in countries where echinococcosis is endemic. We report a case of pancreatic hydatid cyst to increase awareness for this important condition.

Case report: We describe a 33-year-old male with abdominal discomfort of one-year duration. On abdominal examination, there was mild tenderness with fullness in the right upper quadrant. Laboratory investigations revealed no abnormalities. Abdominal ultrasonography showed a cystic mass over the head of the pancreas. Abdominal CT scan confirmed the presence of a solitary cyst in the pancreatic head, with no enhancement on contrast CT. Indirect hemagglutination test for hydatid disease was negative. A pre-operative diagnosis of cystic neoplasm of the pancreas was made and laparo-tomy was done; on exploration there was a cystic mass arising from the head of the pancreas. A pericystectomy was carried out and the diagnosis of hydatid cyst of the pancreas was confirmed by histopathology. The postoperative period was uneventful and no recurrence was seen after 2 years of follow-up.

Conclusion: Pancreatic hydatidosis, though very rare, should be considered in the differential diagnosis of pancreatic cystic lesions in the appropriate epidaemiological setting.     

Long-term results utilizing the unroofing technique in treating hydatid cysts of the liver

PURPOSE: The aim of this study was to present the long-term follow-up results of liver hydatid cysts treated with unroofing, together with a review of the related literature data. METHODS: Of 700 liver hydatid cyst patients examined and treated at Selcuk University Meram Medical Faculty, General Surgery Department, between 1985 and 2007, 650 had accessible data and the unroofing method had been applied in 189 of them. The clinical and laboratory findings, stages, operations, and complications of patients treated with unroofing were reviewed. In particular, the resolution of residual cyst cavities over time after the application of this method was evaluated using computed tomography. RESULTS: Four hundred and thirty-six (67.07%) of the cases were female [mean age: 35 (range: 10-73) years] and 214 (32.9%) were male [mean age: 46 (range: 12-76) years]. Of the 189 cases treated with unroofing and followed by tomography, the data of 144 were documented. Cavities were classified into five groups (A-E) according to their postoperative appearance. CONCLUSIONS: Unroofing is an easy approach and it does not require extensive experience. This technique is recommended for peripherally localized cysts but may also be applied to those more deeply situated. Unroofing should be applied as deeply as possible and the residual cavity should also be as shallow as possible.     

Conservative Surgery for Treatment of Hydatid Cysts in Children

Human echinococcosis is endemic in Turkey and many other areas of the world. Fifteen years of surgical assessment related to involved structures, operative procedures, complications, and the recurrence rate is analyzed in pediatric patients with pulmonary and abdominal hydatid cysts. Between 1986 and 2001, the records of 42 pediatric patients (15 girls, 27 boys; ages 2–15 years) with pulmonary and abdominal hydatid cysts operated on in our clinic were analyzed retrospectively. The features of the disease, involved structures, operative procedures, complications, and recurrences were noted. A total of 26 patients presented with solitary cysts in the lung (9) and liver (17). Another 11 had multiple cysts in both lung and liver, and 5 had disseminated abdominal disease. Conservative surgical procedures were used for all lung and liver cysts: cystotomy (7) or cystotomy plus capitonnage (13) for lung cysts; partial pericystectomy with capitonnage (25), omentoplasty (28), tube drainage in the presence of bile leakage (5), or a combination of these procedures for liver cysts. Cyst excision was used for omental and peritoneal localizations when feasible. Radical procedures were never used (wedge or major liver and lung resections). Operative mortality was zero, and the morbidity rate was 14%. Three patients with disseminated disease (7%) showed recurrence. We suggest that no partial organ resections are necessary for hydatid disease, and highly successful results can be achieved using conservative surgical approaches, such as cystotomy plus capitonnage for lung cysts and partial pericystectomy with capitonnage, omentoplasty, or both for liver cysts.     

Complications of hepatic hydatidosis]

Fifty cases of complicated hydatid cyst of the liver on a total of 250 cases of hydatid cyst observed were analyzed. The Authors describe the several complications observed (compression, infection, rupture into biliary tract or into the thorax or into the peritoneal cavity, the diagnostic and therapeutic procedures. Total mortality was about 7.6% (3 cases) 2 patient died for intraperitoneal rupture and one for rupture in the biliary tract. Surgical treatment should be as radical as possible performing total or subtotal pericystectomy, hepatic resection is reserved to selected cases. Drainage by Kehr tube of biliary tract is necessary of rupture of the cyst in the biliary tract, while we limit the indication for a papillostomy to the sphincter duct stenosis.     

Renal hydatid cyst treatment: Retroperitoneoscopic “closed cyst” pericystectomy

Cystic hydatid disease is an endemic disease caused by the larval form of Echinococcus spp. Isolated renal involvement is extremely rare. The treatment methods for renal hydatid disease require some form of intervention, ranging from traditional open techniques to laparoscopic techniques. Herein, we present a large hydatid cyst in the lower pole of the left kidney in a 43‐year‐old male patient who was treated by the “closed cyst” method via the retroperitoneal laparoscopic approach to prevent soiling of the peritoneal cavity. To our knowledge, this is the first case of a renal hydatid cyst treated by preserving the renal parenchyma by pericystectomy via the retroperitoneoscopic laparoscopic approach in an adult patient. No complications occurred during the perioperative and postoperative periods. After 9 months of follow up, the patient was asymptomatic with no evidence of clinical recurrence. Retroperitoneoscopic laparoscopic closed cyst pericystectomy can be an alternative minimally invasive treatment technique for the treatment of renal hydatid disease.     

Risk for laparoscopic fenestration of liver cysts

Background: Laparoscopic fenestration is considered the best treatment for symptomatic simple liver cysts. Conversely, the laparoscopic approach for the management of hydatid simple liver cysts is not widely accepted because of the risk for severe complications. Despite improvement in imaging techniques, the probability of preoperatively mistaking a hydatid liver cyst for a simple liver cyst remains about 5%. Therefore, laparoscopic fenestration, planned for a liver cyst could be performed unintentionally for an undiagnosed hydatid liver cyst. Methods: From January 2000 to January 2001, 15 patients with a diagnosis of liver cyst underwent laparoscopy for fenestration. In all cases preoperative serologic and imaging assessment had excluded hydatid liver cyst. To further exclude hydatid liver cyst, preliminary aspiration of the cyst with assessment of cystic fluid characteristics was performed. Results: In two patients with presumedly simple liver cyst, hydatid liver cyst was diagnosed instead at laparoscopy by aspiration of cystic fluid. The procedure was converted to laparotomy with subtotal pericystectomy. Conclusions: The risk of misdiagnosing a hydatid liver cyst for a simple liver cyst, especially in the presence of a solitary cyst, should be considered before laparoscopic fenestration is performed. Intraoperative aspiration of cyst fluid before fenestration can minimize this risk, thus avoiding severe intraoperative and late complications.     

Single-stage transthoracic approach for right lung and liver hydatid disease

OBJECTIVE: Human echinococcosis remains a serious health problem for the Mediterranean countries. Synchronous pulmonary and hepatic hydatid disease may occur in 4% to 25% of cases. Our experience on simultaneous surgical treatment of right lung and liver hydatid disease in patients was reviewed. METHODS: Between 1990 and 2000, 48 patients (33 female patients and 15 male patients) with synchronous right lung and liver dome hydatid cysts were operated with a 1-stage procedure. RESULTS: Six patients had previous surgical treatment of hepatic (n = 2) or pulmonary (n = 4) hydatid cyst. The pulmonary cysts were diagnosed with radiography in 18 patients and thoracic computed tomography scan in 30. The pulmonary cysts of 9 patients were bilateral. Seventy-five pulmonary cysts were seen in radiological examinations. The diagnosis of hepatic cysts was established with ultrasonography in 18 patients and upper abdominal computed tomography in 30. The total number of hepatic cysts was 48. In cases with pulmonary cysts, cystotomy and capitonnage were performed in 32 patients, only cystotomy was done in 14 patients, and wedge resection was performed in 2. Liver cysts were approached to transdiaphragmatically after the lung cysts had been dealt with and were managed with evacuation of the cysts. In the remaining cases, marsupialization (n = 2), pericystectomy (n = 1), and enucleation (n = 1) were performed. Major postoperative complications were hemorrhage (n = 1) and biliocutaneous fistula (n = 1). Hepatic recurrence was seen in 3 patients (6.2%) and pulmonary recurrence in 1 (2.1%). CONCLUSION: Transthoracic approach is a useful and a safe surgical management of both pulmonary and upper surface of hepatic hydatid cysts.     

The laparoscopic approach to abdominal hydatid cysts: a prospective nonselective study using the isolated hypobaric technique.

HYPOTHESIS: The laparoscopic isolated hypobaric technique that we developed and use is safe and feasible for almost all kinds of hepatic and extrahepatic abdominal hydatid cysts. DESIGN: A case series. PATIENTS: Between August 1992 and December 1999, 31 patients with no selection criteria underwent 32 consecutive laparoscopic operations for 52 symptomatic hydatid cysts located in the liver (49), spleen (1), and pelvis (2). Eleven patients underwent surgery for between 2 to 5 cysts. INTERVENTIONS: The main surgical maneuvers (puncture, parasite neutralization, and complete evacuation) were performed through an assembled transparent cannula, in which a vacuum was created, while its tip adhered firmly to the cyst wall. Following evacuation of the cyst contents, we attempted to perform partial pericystectomy, omentoplasty, and closed-suction drainage. MAIN OUTCOME MEASURES: Surgical complications and postoperative disease recurrence. RESULTS: Mean cyst diameter was 8.4 cm (range, 3.5-25 cm). Seven cysts were subdiaphragmatic, and 6 were on the posterior (hidden) aspect of the liver. Mean postoperative follow-up was 49 months. Forty-one cysts contained live parasites, and 11 were secondarily infected. Twenty-four cysts were complex. Perioperative complications occurred in 5 patients, including 1 patient who died 1 month after surgery owing to Candida sepsis. Mean hospital stay was 6 days. No evidence of recurrence was recorded during follow-up. CONCLUSIONS: The isolated hypobaric laparoscopic technique described provides a safe and efficacious approach to almost all types of abdominal hydatid cysts and takes advantage of the recognized benefits of the laparoscopic approach.     

An effective omentoplasty technique in laparoscopic surgery for hydatid disease of the liver.

OBJECTIVES: The objectives of this study were to investigate the characteristics and outcome of patients with hydatid disease of the liver who were laparoscopically managed at our clinic and to define technical details including an effective method of omentoplasty with helical fasteners. METHODS: Between January 1998 and November 2000, 13 patients, mean age 36 years (range 23 to 63 years), with hydatid disease of the liver were considered for laparoscopic surgery in our department. All the patients underwent laparoscopic surgical interventions. RESULTS: In all patients, laparoscopic cystotomy, unroofing, and omentoplasty with helical fasteners, which were originally designed for endoscopic hernia repair procedures, were performed. No conversion to laparotomy was necessary. In 1 case, with a single cyst in the right lobe, bile leakage was observed. No radiological recurrence was observed in an average follow-up of 17 months (range 4 to 36 months). CONCLUSIONS: Obliteration of the residual cystic cavity decreases postoperative complication rates, so an effective omentoplasty is essential especially for laparoscopic procedures. Laparoscopy is quite feasible to perform in hydatid disease of the liver, and the use of helical fasteners allows effective omental flap fixation.