Management of residual cavity after partial cystectomy for hepatic hydatidosis: comparison of omentoplasty with external drainage.

OBJECTIVE: To investigate the role of two approaches to the operative treatment of hepatic hydatid cysts. DESIGN: Prospective study. SETTING: University and teaching hospital, Turkey. SUBJECTS: 108 patients with single uncomplicated hydatid cysts who were operated on in two clinics between 1990 and 1995. INTERVENTION: Introflexion and omentoplasty or external drainage after partial cystectomy in single uncomplicated hydatid cysts more than 5 cm in size. MAIN OUTCOME MEASURES: Morbidity, mortality, and hospital stay. RESULTS: The median hospital stay after introflexion and omentoplasty was 8 days (range 3-15), which was significantly shorter than that after external drainage (12 days, range 7-20). There were 2/35 postoperative complications in the former group compared with 17/73 in the drainage group (p = 0.03). There was one death after introflexion and omentoplasty. CONCLUSION: Introflexion and omentoplasty after partial cystectomy for a single uncomplicated hydatid cyst caused significantly fewer complications than external drainage, and patients left hospital sooner.     

Surgical treatment of hepatic hydatid disease.

The results of surgery in 38 patients with hepatic hydatid disease are described. Cystectomy was done in four patients with small peripheral cysts. For them the mean postoperative stay was 8.2 days. Partial cystectomy, introflexion and omentoplasty were performed in 28 patients with uncomplicated large cysts. The mean postoperative stay for these patients was 8.6 days. One patient in this group died of massive hemorrhage and disseminated intravascular coagulation. Exploration of the common bile duct and choledochoduodenostomy were required in three patients who had large cysts complicated by rupture into the biliary tree. This complication resulted in a mean postoperative stay of 11.5 days. Three patients who had cysts complicated by pyogenic infection were treated with tube drainage. They were discharged with their tubes in place after a mean hospital stay of 26.5 days. Hydrogen peroxide 10% was used as a scolicidal agent and was successful in preventing dissemination. All patients underwent ultrasonography 3 months after surgery, and 28 (74%) were followed up by annual examination. There was no recurrence after a mean follow-up of 2.7 years. The results suggest that surgical treatment of hepatic hydatid disease should be governed by the size, location and complications of the cyst. The combination of partial cystectomy, introflexion and omentoplasty was safe and effective therapy for patients with large hepatic cysts uncomplicated by pyogenic infection.     

Distribution of hydatid cysts into the liver with reference to cystobiliary communications and cavity-related complications

BACKGROUND: This study was designed to test a hypothesis that intrahepatic hydatid cyst location can effect the incidence of cystobiliary communications and the cavity-related complications. METHODS: A total of 121 cysts treated by conservative surgical methods in 113 patients were evaluated prospectively. Cysts were grouped as near to the liver hilum (segment I, III, IVb, V, and VI) and far from the hilum (segment II, IVa, VII, and VIII). RESULTS: There were 58 (48%) hilar and 63 (52%) peripheral cysts. We found more cystobiliary communications (48% versus 27%, P = 0.015), more biliary leakage (36% versus 10%, P <0.001), and more biliary fistula (12% versus 3%, P = 0.080) in the cysts near to the hilum than far from the hilum. Postoperative hospital stay was longer in the cysts near to the hilum (12.3 +/- 3.1 days) than the cysts far from the hilum (7.7 +/- 2.7 days, P = 0.022). CONCLUSIONS: The location of the hydatid cyst near to the liver hilum is a risk factor for the cystobiliary communications and the cavity related complications.     

Surgical management of complicated hydatid cysts of the liver

AIM: To review the clinical presentation and surgical management of complicated hydatid cysts of the liver and to assess whether conservative surgery is adequate in the management of complicated hydatid cysts of liver.METHODS: The study was carried out at Sher-i-Kashmir Institute of Medical Science, Srinagar, Kashmir, India. Sixty nine patients with hydatid disease of the liver were surgically managed from April 2004 to October 2005 with a follow up period of three years. It included 27 men and 42 women with a median age of 35 years. An abdominal ultrasound, computed tomography and serology established diagnosis. Patients with jaundice and high suspicion of intrabiliary rupture were subjected to preoperative endoscopic retrograde cholangiography. Cysts with infection, rupture into the biliary tract and peritoneal cavity were categorized as complicated cysts. Eighteen patients (26%) had complicated cysts and formed the basis for this study.RESULTS: Common complications were infection (14%), intrabiliary rupture (9%) and intraperitoneal rupture (3%). All the patients with infected cysts presented with pain and fever. All the patients with intrabiliary rupture had jaundice, while only four with intrabiliary rupture had pain and only two had fever. Surgical procedures performed in complicated cysts were: infection-omentoplasty in three and external drainage in seven; intrabiliary rupture-omentoplasty in two and internal drainage in four patients. Two patients with intraperitoneal rupture underwent external drainage. There was no mortality. The postoperative morbidity was 50% in complicated cysts and 16% in uncomplicated cysts.CONCLUSION: Complicated hydatid cyst of the liver can be successfully managed surgically with good long term results.     

Diagnosis and management of hydatid disease of the liver. A 15-year North American experience

Since 1967, 40 patients with hydatid disease of the liver have been treated at our hospital. Diagnosis was made using clinical criteria, serology, skin tests, and imaging techniques. Thirty-five patients were operated upon. In 18 patients the cyst was uncomplicated (Group I), and in 17 the cyst was infected or communicated with the biliary tract (Group II). Three forms of surgical treatment were used: A) cyst evacuation, scolicidal irrigation, and primary cyst closure, B) evacuation, irrigation, and external drainage, and C) complete or partial cyst resection. Mebendazole was used in six patients, four of whom were also treated surgically. In Group I, one of 11 patients (8%) treated by primary closure had complications, versus four of five patients (80%) treated with external drainage (p less than 0.001). Mean postoperative hospital stay for these two groups was 11.8 versus 20.8 days, respectively (p less than 0.001). Complication rates in Group II were higher, and were evenly distributed among treatments. Patients have been followed yearly, with a median follow-up of 5 years. Active hydatid disease has been found in three patients, who all had known residual disease at initial operation. The best treatment for an uncomplicated hydatid liver cyst is evacuation, scolicidal irrigation, and primary closure. External drainage is used for infected cysts or those communicating with the biliary tract, and excision for extrahepatic and peripheral, easily resectable cysts. Mebendazole is used for intraperitoneal spillage of cyst contents and in patients with inoperable disease.     

Surgical management of complicated hydatid disease of the liver

Increased worldwide travel and immigration have led to an increase in the incidence of hepatic hydatid disease outside of endemic areas. In nonendemic areas lack of familiarity with the disease may lead to a delay in diagnosis with increased risk for development of complicated disease. Complicated disease is defined as: infected cysts, cysts with a hyperechoic solid pattern or calcified walls, or cysts with biliary rupture. Over a 6-month period six patients with complicated hydatid disease were referred to our institution. All six patients were immigrants from endemic areas and were found to have complicated hepatic hydatid disease including cholangitis and intrabiliary rupture. Patients were treated with oral albendazole for 3 weeks before operation and oral praziquantel for 2 days preoperatively. Surgical therapy consisted of subtotal cystectomy, cholecystectomy in all patients, and cystic duct biliary decompression-drainage in five patients. The one patient without biliary drainage developed a postoperative bile leak that resolved with endoscopic biliary stenting. All patients received albendazole for 3 months postoperatively and were free of disease at 6 to 24 months follow-up. We conclude that although nonoperative management with percutaneous drainage or medical management alone may be successful in patients with uncomplicated disease operation remains the therapy of choice for complicated hydatid disease.     

The results of surgical treatment and percutaneous drainage of hepatic hydatid disease

BACKGROUND: Hydatid disease of the liver remains an important and challenging problem in rural areas. Although, surgery is considered the treatment of choice for hydatid disease of the liver, percutaneous drainage is an alternative treatment method for selected cases. The purpose of this study was to evaluate the results of percutaneous drainage and surgery. METHODS: A total of 66 patients underwent surgery; 36 cases had percutaneous drainage and were evaluated preoperatively for treatment choice according to localization, multiplicity, echographic type and size of the cysts in the liver. The patients were also evaluated postoperatively for systemic complications, e.g. fistula formation, infection of residual cyst, recurrence and hospitalization period for each group. RESULTS: Two groups, those with multiple cysts and cysts bigger than 5 cm, were treated by surgery. At the end of two treatment modalities, systemic complications, biliary fistulizations, recurrence and infection of cyst's cavity were seen more frequently in the surgery group and caused a longer hospital stay. CONCLUSIONS: Percutaneous drainage plus medical treatment can be successfully done for type I, type II and some selected type III hydatid cysts of the liver giving less complications, lower recurrence and shorter hospitalization periods. But, surgery is the primary treatment for big, multiple, complicated and recurrent hydatid cysts of the liver.     

Complicated hydatid cysts of the lung: clinical and therapeutic issues

BACKGROUND: The clinical presentation and the preoperative and postoperative complications associated with pulmonary hydatid cysts depend on whether the cyst is intact or ruptured. The aim of this study was to review the problems encountered in treating ruptured pulmonary hydatid cysts and to highlight the risks associated with chemotherapy and the delay of surgical treatment in pulmonary hydatid disease. METHODS: The medical records for 67 patients of pulmonary hydatidosis were retrospectively investigated. The patients were divided into two groups based on whether the pulmonary cyst was intact (group 1, n = 34) or complicated (group 2, n = 33). A complicated cyst was defined as one that had ruptured into a bronchus or into the pleural cavity. All patients were treated surgically. Data related to symptoms, preoperative complications, surgical procedures performed, postoperative morbidity, hospitalization time, and cyst recurrence were collected from each individual's records, and the group findings were compared. RESULTS: In most cases of intact pulmonary hydatid cysts, the lesions were either incidental findings or the patient had presented with cough, dyspnea and chest pain. In addition to these symptoms, the patients with complicated cyst had presented with problems such as expectoration of cystic contents, repetitive hemoptysis, productive sputum, and fever. The differences between the groups with respect to the rates of preoperative complications and postoperative morbidity, frequency of decortication, and hospital stay were statistically significant (p < 0.05). CONCLUSIONS: Surgery is the primary mode of treatment for patients with pulmonary hydatid disease. Complicated cases have higher rates of preoperative and postoperative complications and require longer hospitalization time and more extensive surgical procedures than uncomplicated cases. This underlines the need for immediate surgery in any patient who is diagnosed with pulmonary hydatidosis.     

Open drainage versus overlapping method in the treatment of hepatic hydatid cyst cavities.

In order to compare the results of open drainage and overlapping methods, 58 consecutive patients with uncomplicated hepatic hydatid disease were investigated between January 1990 and January 1997. The cavities were obliterated by overlapping method in 26 patients and were left open into the peritoneal cavity following partial pericystectomy in 32 patients. Postoperative complications and follow-up results of ultrasonography (US) and computed tomography (CT) were compared between the two groups. In total, there were 56 cysts in the obliterated group and 83 cysts in the open drainage group. There was no significant difference in age, sex, mean diameter of the cysts, US features of the cysts according to the Gharbi classification, and median follow-up. Mean hospital stay was 10 days in the overlapping group and 7.5 days in the open drainage group (P = 0.033). No postoperative complication was observed in the obliterated group and nearly half of the cyst cavities could not be detected in the early postoperative period by US and CT. Pleural effusion (n = 1) and biliary fistula (n = 1) were detected in the open drainage group which disappeared spontaneously. In the open drainage group, US and CT surveillance revealed that the cyst cavities were reduced in size and the echo pattern was changed in the early postoperative period, whereas the appearance changed into pseudotumor view in the late postoperative period. In conclusion, the cyst cavities disappear perfectly in the overlapping group. Treating the cyst cavity by open drainage is an easy, effective and safe technique. Open drainage can be a 'method of choice' for patients with multiple hydatid cysts and for cysts where management is difficult or unamenable to other methods, but the residual cyst cavities may be misinterpreted as a new cyst by an inexperienced radiologist.     

三种开窗引流术治疗老年先天性肝囊肿的回顾性对比研究

目的比较腹腔镜开窗网膜移植术、腹腔镜单纯开窗术和开腹单纯开窗术三种方法治疗年龄60岁及以上先天性肝囊肿的近远期疗效。方法回顾性分析74例老年先天性肝囊肿患者的临床资料,其中网膜组（腹腔镜开窗网膜移植术）25例,单纯组（腹腔镜单纯开窗术）28例,开腹组（开腹单纯开窗术）21例,比较三组的手术时间、术中失血量、禁食时间、下床活动时间、术后引流量、术后白细胞计数、住院时间、术后并发症发生率和复发率等。结果单纯组手术时间较网膜组、开腹组缩短（P〈0．05）。开腹组术中失血量、禁食时间、下床活动时间、术后白细胞计数、住院时间较腹腔镜组增多（P均〈0．05）。网膜组术后引流量和总并发症发生率较单纯组、开腹组减少（P均〈0．05）,但三组术后近期并发症发生率如术后出血、胸腔积液、肺部感染、腹水、胆漏等以及复发率、再手术率差异无统计学意义（P〉0．05）。结论针对老年先天性肝囊肿患者,腹腔镜开窗网膜移植术在减少术后引流量、降低总体并发症发生率上更具优势,腹腔镜单纯开窗术可缩短手术时间。     

Surgical treatment of hepatic hydatid disease

The results of surgery in 48 patients with hepatic hydatid disease are described. In 26 out of 32 patients with uncomplicated cysts, conservative surgery with obliteration of the cyst cavity by omentoplasty gave satisfactory results. In contrast, 16 patients with cysts complicated by pyogenic infection or cholangitis required a variety of surgical procedures, including prolonged tube drainage, exploration of the common bile duct, sphincterotomy/plasty and hepatojejunostomy to achieve a satisfactory outcome. The group with complicated cysts also had a much longer postoperative stay (median 30 days) than those with uncomplicated cysts (median 14 days). Two patients died: in one, post-mortem examination revealed carcinoma in the wall of the cyst.     

Hydatid cysts of the liver opening in the biliary tract. Report of 64 cases

STUDY AIM: The aim of this retrospective study was to report a series of patients with hydatid cyst opened in the biliary tract, who were operated in Morocco. PATIENTS AND METHOD: From 1991 to 1998, among 250 hydatid cysts of the liver operated in the same center, 64 were in communication with the biliary tract (25%). There were 39 men and 25 women. The mean age was 34.2 years (range: 6-60). The revealing symptoms were abdominal pain, jaundice or cholangitis, but the biliary fistula was asymptomatic in more than 50% of the patients. The hydatid cysts were recognized by ultrasonography in all the patients but the biliary fistula was only suspected in 17 patients. The surgical procedure included drainage and sterilization of the cyst, resection of the protruding wall of the cyst (84.4%), unblockage of the main hepatic duct (n = 21) associated with a Kehr drainage, and treatment of the bilio-cystic fistula with suture (n = 23) or double side drainage (n = 24) or cystobiliary disconnection (n = 15). RESULTS: There were two postoperative deaths due to septic shock (n = 1) and encephalopathy secondary to a biliary cirrhosis (n = 1). The morbidity rate was 25%. Among complications, there were four subphrenic abscesses, four prolonged biliary leakages and two intestinal obstructions. The main hospital stay was 20 days. CONCLUSION: The opening of hyatid cysts of the liver into the biliary tract may be silent or revealed by biliary symptoms. The results of this series favour a conservative procedure, including resection of the protruding wall of the cyst and cysto-biliary disconnection, in spite of a high morbidity rate and a long hospital stay.     

Occult cystobiliary communication presenting as postoperative biliary leakage after hydatid liver surgery: are there significant preoperative clinical predictors?

BACKGROUND: Occult cystobiliary communication (CBC) presents with biliary leakage, if the cystobiliary opening cannot be detected and repaired at operation. We investigated the clinical signs associated with the risk of occult CBC in the preoperative period by studying patients who developed biliary leakage after hydatid liver surgery. METHODS: We analyzed the records of 191 patients treated for hydatid liver cyst. Postoperative biliary leakage developed in 41 patients (21.5%). Independent predictive factors were established by logistic regression analysis using clinical parameters, whose cutoff values were determined by receiver operating characteristic (ROC) curves. RESULTS: Postoperative biliary leakage presented as external biliary fistula in 31 (75.6%) of 41 patients, as biliary peritonitis in 6 (14.6%) and as cyst cavity biliary abscess in 4 (9.8%). Independent clinical predictors of occult CBC, represented by biliary leakage, were alkaline phosphatase > 250 U/L, total bilirubin > 17.1 micromol/L, direct bilirubin > 6.8 micromol/L, gamma-glutamyl transferase > 34.5 U/L, eosinophils > 0.09 and cyst diameter > 8.5 cm. Multilocular or degenerate cysts increased the risk of biliary leakage (p = 0.012). Postoperative complication rates were 53.7% in the patients with biliary leakage, and 10.0% (p < 0.001) in those without. The mean postoperative hospital stay was longer in patients with biliary leakage (14.3 [and standard deviation {SD} 1.9] d) than in those without (7.3 [SD 2.3] d) (p < 0.001). Nineteen (61.3%) of 31 biliary fistulae closed spontaneously within 10 days. The remaining 12 (38.7%) fistulae closed within 7 days after endoscopic sphincterotomy. CONCLUSION: Factors that predict occult CBC due to hydatid liver cyst were identified. These factors should allow the likelihood of CBC to be determined and, thus, indicate the need for additional procedures during operation to prevent the complications of biliary leakage.     

肝囊型包虫病胆道并发症284例的诊治分析

目的 探讨肝囊型包虫病胆道并发症的诊断和治疗经验.方法 对新疆医科大学第一附属医院自2002年1月至2009年1月手术治疗的284例肝囊型包虫病合并胆道并发症及胆道相关并发症患者的临床资料进行对比分析.结果 (1)包虫破入胆道并梗阻性黄疸和(或)胆道感染组(51例):腹部超声(SUG)、CT检查、核磁共振胰胆管造影(MRCP)、内镜逆行胰胆管造影(ERCP)分别检查51、42、27、7例,包虫囊肿破入胆道的诊断符合率分别为78.4%,85.7%,100%和100%.术中缝合胆瘘口的28例中3例(10.7%)出现术后残腔胆漏,而未缝合23例中17例出现残腔胆瘘(74%)(P＜0.01),其中3例是严重胆瘘(胆汁引流量＞250 ml/d);(2)包虫与胆道相通并胆道感染和(或)包虫囊肿感染组:经胆囊管探查减压组(A组)术后残腔并发症、术后带管时间与经胆总管探查T管减压组(B组)差异无统计学意义,且胆道并发症显著低于B组(P＜0.05),胆道探查并减压的两组(A组和B组)术后残腔并发症、术后带管时间显著低于未胆道探查减压组(C组);(3)包虫破入胆道致过敏并发症8例,胆道狭窄7例,胆道结石3例,胆道出血1例,术后顽固性胆漏者12例,均实施手术包虫囊肿清除同时处理相应胆道并发症及相关并发症,恢复良好.结论 (1)MRCP对肝囊型包虫合并胆道并发症的诊断具有准确率高和无创等优点,ERCP不仅对肝囊型包虫胆道并发症有确诊意义,而且又是一种有效的治疗方法;(2)缝合胆瘘、胆总管减压是治疗肝囊型包虫破人胆道的简单、安全、有效的方法;(3)术中经胆囊管探查减压可有效解决肝囊型包虫病术后残腔胆漏,且维系胆总管完整性,从而减少了T管相关并发症.

Abstract：

Objective To evaluate the diagnosis and treatment of hepatic cystic echinococcosis with biliary complications. Methods 284 patients with hepatic cystic echinococcosis (CE) with biliary complications were surgically treated from January 2002 to January 2009 in our hospital. A summary of the surgical procedures was categorized and compared in the current study. Results (1) Intrabiliary rupture of CE with obstructive jaundice and (or) inflammation of bile duct (51 patients). The diagnosis of biliary complications of hepatic hydatid cyst was difficult on ultrasound and CT, with sensitivity rates of 78.4% and 85.7%, respectively. MRCP was an effective, noninvasive and useful diagnostic tool in difficult cases; ERCP was used as the gold standard in confirmation. Biliary fistulae were seen in 3 patients (10.7%) treated by suturing the rupture site. In the non-sutured group, 17 patients (74%) developed biliary fistulae after surgery (P＜0.01). In three patients the fistula was a high-output type (the fistula output was greater than 250 ml/d). (2) CE communicated with the bile duct and (or) infection (210 patients): The cavity-related problems and draining time in group C (no bile duct exploration and decompression) were significantly higher than group A (biliary system explored and decompressed through the cystic duct) and group B (biliary system explored and decompressed through the common bile duct), while cavity-related problems and draining time between the A and B groups showed no significant difference. Biliary tract-related problems in group A was significantly lower than group B (P＜0. 05). Conclusions (1) MRCP was an effective, noninvasive and useful diagnostic tool; ERCP was used only as the gold standard in confirming intrabiliary rupture of liver cystic hydatid disease, and also as an effective technique for treating extended postoperative external biliary fistula. (2) This study indicated that suturing the communication at the rupture site and biliary decompression were effective with low morbidity and mortality rates. (3) Cholangiography and common bile duct exploration through the cystic duct could solve the cavity-related problems while avoiding the T-tube related problems.     

Biliary complications after hydatid liver surgery: Incidence and risk factors

The aims of this study were to determine the incidence and risk factors of biliary leakage and biliary fistu lae after hydatid liver surgery and to suggest preventive precautions. From January 1999 to June 2000, 70 cysts were examined from 54 patients who were operated on for hydatid liver disease. Age, sex, primary or recurrent disease, liver function tests, number, location, content, radiological type, and diameter and cav ity management techniques were examined with univariate and multivariate analyses for biliary complica tions. Biliary leakage occurred in 14 cysts (26%) from the patients. Purulent and/or bilious cyst content (61.9% vs. 2.0%; P = 0.022), male gender (40.9% vs. 10.4%; P = 0.038), and pre-operative raised alka line phosphatase and gamma glutamyl transferase levels (34.6% vs. 11.4%; P = 0.047) were found as in dependent risk factors for post-operative biliary leakage. Nine instances of biliary leakage (16.7%) closed spontaneously within seven days. The remaining five instances of biliary leakage (9.3%) persisted for more than 10 days and were accepted as biliary fistulae. Stepwise logistic regression identified cyst con tent was the only risk factor for biliary fistulae (19% vs. 2%; P = 0.036). Described risk factors for post operative biliary complications after hydatid liver surgery may be the guidelines for additional pre-opera tive or intra-operative radiological interventions of the biliary tract and for preventive procedures such as surgical biliary drainage. Preliminary results of this study were presented at the Tenth Anniversary of Eurosurgery, Istanbul, Turkey, June 20–24, 2000.     

Primary choledochorrhaphy after common bile duct exploration

AIM: To prove further the safety of primary closure of the common bile duct. METHOD: Twenty patients among 99 common bile duct explorations underwent primary closure. Pre- and postoperative liver function test, ultrasound and intraoperative cholangiography data, operation time, postoperative complications and the length of postoperative stay were recorded. RESULTS: Nineteen patients did not suffer any biliary complication. One had bile leakage and bile peritonitis, and another had duodenal leakage. One case was complicated by gastric ulcer perforation. The mean postoperative hospital stay except for the 2 patients with complications was 8.72 +/- 0.75 days. Preoperative abnormal liver function tests recovered within 2-3 weeks after the operation. Postoperative ultrasound scan of the biliary tract within 2 months revealed no stenosis and residual stone. CONCLUSION: Primary common bile duct closure is a safe alternative to routine biliary drainage in selected patients.     

Efficacy of Radical Surgery in Preventing Early Local Recurrence and Cavity-Related Complications in Hydatic Liver Disease

Background Hydatic disease of the liver remains to be a complex worldwide problem especially in rural areas. Early local recurrence and cavity-related complications are still a matter of conflict in the management of hydatic liver disease. The aim of this study is to investigate efficacy of the type of surgical treatment in preventing early local recurrence and cavity-related complications of this disease. Here, we present the preliminary results of our study. Methods This study was performed prospectively including 32 patients who were operated for hydatic liver disease between January 2001 and January 2005. Patients were randomized into radical and conservative surgery groups. Recurrences at the primary surgical site in the first 2 years were considered as early local recurrence and biliary leakage, biliary fistula, cavity abscess, etc. were considered as cavity-related complications. Results Early local recurrences were observed only after conservative surgical procedures (p = 0.045). Recurrent cysts were found to be due to satellite cysts or pericystic disease. Cavity-related complications were seen in six patients in the conservative surgery group (p = 0.011). Conclusions In suitable patients, radical surgical resection provides an effective surgical management option in preventing early local recurrence and cavity-related complications when compared to conservative surgical approaches.     

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.     

Diagnosis and Surgical Treatment of Hepatic Hydatid Disease

In this report two hundred and twenty six patients with hydatid disease were admitted to the Surgical Department of Erciyes University (Kayseri) and Şişli Etfal Hospital (Istanbul) between 1978 and 1990 and reviewed retrospectively. One hundred and two patients (45.1%) were male and 124 (54.9%) female. In the patients with hydatid cysts the most frequent symptom was right upper abdominal pain (66%). The most frequent signs were hepatomegaly (43.8%) and palpable mass (39%). One hundred and sixty seven patients (73.9%) were examined with ultrasonography which has a diagnostic value of 94%. Preoperative complications were infection of cyst (7%), intrabiliary rupture (3.5%) and anaphylactic shock (0.4%). All patients were operated on by using various surgical techniques; omentoplasty (101), external drainage of residual cavity (64), marsupialization (25), capitonnage (15), introflexion (10), pericystectomy (6), and hepatic resection (5).The main postoperative complications were wound infection (12%) and biliary fistula (2.6%). The total mortality rate was 1.8% in this series.     

The postoperative appearance of the liver on ultrasonography following hydatid cyst surgery

The postoperative ultrasound pattern in 33 patients with previous surgery for unilocular hydatid disease of the liver was investigated. Each patient was submitted to liver scanning with 99mTc pertecnate, as well as to real time ultrasound examination. The patients were divided into three groups according to the type of surgery performed, namely; omentopexy, introflexion and omentoplexy with introflexion. Postoperative liver scans revealed defects similar to those detected during initial diagnosis in 88% of the patients, regardless of the surgical procedure performed. On the contrary, ultrasonography gave separate specific patterns for each surgical procedure.