A case of sacral hydatid cyst

INTRODUCTION

Hydatid cyst of bone constitutes only 0.5-2% of all hydatidoses. The thoracic spine is the most common site of spinal hydatidoses. Primary hydatid cyst of the sacral spinal canal is rare.

PRESENTATION OF CASE

A 19-year-old man had cauda equina syndrome with pelvic pain 15 days ago, the pelvic radiography shows a lytic image depend on the left sacral wing. MRI showed an intra-pelvic cystic image invading the sacrum T1 hypointense and T2W hyperintense. The Hydatid serology was positive.Surgical treatment consisted of a wide drainage of hydatid cavity dug in the left sacral wing, and by which it communicated intra pelvic, with removal of the entire cyst by gentle aspiration, abundant rinsing with hypertonic saline, release and sacred roots encompassed in a puddle of fibrosis hydatid.The evolution was good with recovery of perineal sensation and anal tone. The sacroiliac joint was considered stable and did not require synthesis or reconstruction.

DISCUSSION

Hydatid cysts predominantly occur in liver and lungs. Involvement of other organs is uncommon. Neither surgery nor medical therapy is generally effective for bone, especially spinal hydatidosis. The initial treatment of choice is surgical excision for neural decompression and establishing diagnosis. Albendazole is the drug of choice against this disease, when suspected, presurgical use of Albendazole in Echinococcus infestations reduces risk of recurrence and/or facilitates surgery by reducing intracystic pressure.

CONCLUSION

A missed diagnosis of hydatid cyst could be devastating. Hence, hydatid cyst should be kept as a differential diagnosis, when encountered with a cystic lesion of sacrum. In addition, longterm follow-up is mandatory as recurrence is high despite use scolicidal agents.     

Endoscopic management of biliary hydatid disease

Objective

To determine the effect of endoscopic sphincterotomy in the management of biliary hydatid disease.

Design

A case study between January 1992 and December 1994.

Setting

A university-affiliated hospital in Adana, Turkey.

Patients

Five patients with biliary hydatid disease, in which the cyst had ruptured into the biliary tree. The follow-up ranged from 3 to 12 months.

Intervention

Endoscopic sphincterotomy.

Main Outcome Measures

Morbidity, mortality and recurrence of the disease.

Results

All patients underwent successful endoscopic sphincterotomy, including removal of daughter cysts. During the follow-up period, ultrasonography and laboratory investigations showed complete cure in all patients. There were no complications due to endoscopic sphincterotomy.

Conclusion

Endoscopic sphincterotomy is the treatment of choice for the management of hydatid cysts that have ruptured into the biliary tract causing obstructive jaundice.     

A giant adrenal cyst difficult to diagnose except by surgery

Introduction

Adrenal cysts represent rare clinical entities. Although surgical indications are well defined, pitfalls arise from the failure to establish an accurate preoperative diagnosis. Cystic lesions of other abdominal organs especially the pancreas complicate the diagnostic field.

Presentation of case

We present the case of a giant adrenal cyst in a young female causing diagnostic dilemma. Imaging studies revealed a large cystic lesion of uncertain origin located between the spleen and the tail of the pancreas. It was decided to perform a laparotomy which confirmed the presence of an adrenal cyst and enucleation of the cyst was performed. Examination at one year confirmed no complications.

Discussion

Adrenal cysts should always be included in the differential diagnosis of cystic abdominal lesions.

Conclusion

When the preoperative diagnosis is uncertain, surgical intervention can be both diagnostic and therapeutic.     

How to Build a Simple and Safe Laparoscopic Hydatid Evaluation System

Background:

One of the most common problems faced in laparoscopic treatment of hydatid cysts is the difficulty in evacuating the particulate contents (daughter cysts and laminated membrane). Although various instruments and laparoscopic techniques have been described to evacuate the contents of hydatid cysts, most are not available at many surgical centers.

Methods:

By assembling disposable, cheap, and available anesthesia equipment with common laparoscopic instruments, a laparoscopic system was made to evacuate the contents of a hydatid cyst. Ten patients with hepatic hydatid disease underwent laparoscopic surgery using this new hydatid system between June 2011 and January 2013.

Results:

The procedure was completely straightforward. Twelve hydatid cysts (2 patients had 2 separated cysts) were evacuated without any spillage. All patients were followed for at least 8 months, with no evidence of recurrence.

Conclusions:

This simple apparatus, which can be assembled anywhere, was safely used to evacuate the contents of hydatid cysts without causing any spillage.     

The management of liver hydatid cysts by percutaneous drainage.

Objective

To investigate the effect of percutaneous drainage on liver hydatid cysts.

Design

A retrospective case study.

Setting

Department of Surgery, Selçuk University, Konya, Turkey.

Patients

Forty-five patients with 83 liver hydatid cysts (types I and II according to the classification of Gharbi and colleagues) followed up for a mean of 30 months (range from 14 to 36 months).

Intervention

The cysts were drained percutaneously with ultrasonographic guidance and then irrigated with 0.05% silver nitrate solution through a fine needle. Albendazole was administered 48 hours before percutaneous drainage and for 2 months after the procedure to prevent the implantation of spilled scolices.

Main outcome measures

Complications of the procedure, decrease in size of the cyst cavity, recurrence and dissemination of the cysts.

Results

All the cysts were treated successfully by percutaneous drainage. Anaphylactic shock developed in 1 (2.2 %) patient, and mild allergic reactions were observed in 2 (4.4 %) patients during the interventional procedure. Follow-up ultrasonography and CT demonstrated a statistically significant (p < 0.01) decrease in the mean cyst size. Recurrence and dissemination were not observed during the follow-up period.

Conclusion

Percutaneous fine-needle aspiration and drainage is effective for managing cystic liver hydatid disease in selected cases.     

Surgical treatment of hydatid cysts of the lung: analysis of 405 patients

Objective

The choice of operation, postoperative success and complications of surgery in patients with pulmonary hydatid cysts.

Design

A series of patients seen over 15 years.

Setting

A university clinic.

Patients

Four hundred and five patients (209 male, 196 female) ranging in age from 4 to 72 years (mean 29 years). Most (367 patients) had isolated lung cysts; 38 had both liver and lung cysts.

Interventions

A variety of procedures to remove cysts, including enucleation and capitonnage, wedge resection, segmentectomy, lobectomy and pneumonectomy. Six patients with bilateral cysts were operated on through a median sternotomy approach. Others underwent posterolateral thoracotomy.

Main outcome measures

Value of diagnostic tests, the most efficacious approach for cyst removal and recurrence and death rates.

Results

Chest radiography gave a correct diagnosis in 99% of patients. The Casoni and Weinberg tests were discontinued because of high false-negative rates (up to 35%). Hospital mortality was 1.2% and postoperative complications occurred in 5.2%. The recurrence rate was 1.5%.

Conclusions

Lung-preserving surgical interventions are the treatment of choice for pulmonary hydatid disease. In patients with bilateral cysts, the median sternotomy approach is preferred, and in the patients with right lung disease and coexisting liver cysts the transdiaphragmatic approach is the one of choice to remove cysts in 1 stage.     

Postoperative recurrence of cystic hydatidosis

Background

Surgical management is the basic treatment for hydatid disease. Overall, the recurrence rate appears to be high (4.6%–22.0%). The purpose of this study was to report our results in the management of recurrent hydatid disease, evaluating the methods for identifying recurrence, prognostic factors and therapeutic options.

Methods

We retrospectively reviewed the medical records of patients who underwent surgery for cystic hydatidosis between 1970 and 2003.

Results

Of the 584 patients who underwent surgery during our study period, follow-up was complete for 484 (82.8%). Cysts recurred in 51 patients (8.7%). Abdominal ultrasonography and computed tomography appeared to be efficient for diagnosing recurrence. The 2 most important determinants for recurrence were minute spillage of the hydatid cyst and inadequate treatment owing to missing cysts or incomplete pericystectomy. All but 2 recurrences required surgery. There were 14 postoperative complications for a rate of 27.0%. Thirteen re-recurrences were observed in the follow-up of these patients and also required surgery.

Conclusion

Avoidance of minute spillage of cyst contents and cautious removal of the parasite with as much of the pericyst as possible are fundamental objectives of primary hydatid surgery. Conservative surgery (removal of the cyst contents plus partial pericystectomy with drainage when necessary) plus chemotherapy and local sterilization is suggested for both primary and secondary operations and appears to achieve satisfactory long-term results. Radical surgery (resection, cystopericystectomy) is preferred only in select patients.     

Traumatic rupture of hydatid cysts

Objective

To stress the relation between rupture of hydatid cysts and trauma.

Design

A case series.

Setting

A university-affiliated hospital for emergency medicine.

Patients

Four college students who suffered traumatic rupture of hydatid cysts. All injuries were sustained during sporting activities.

Interventions

Resection or unroofing of the cysts with careful removal of all hydatid elements, and suture-plication of the residual liver cavities.

Results

The ruptured cysts were located in the liver, spleen and splenic flexure of the colon. At exploration, additional hydatid cysts were found, usually in the liver. Treatment resulted in complete recovery in all patients.

Conclusions

Traumatic rupture of hydatid cysts related to sporting activities may be commoner than indicated by the rarity of reports. Increased awareness of this possibility in areas where hydatid disease is endemic is encouraged.     

The tail of neuroendocrine tumors from lung to pancreas: Two rare case reports

INTRODUCTION

Primary pancreatic neuroendocrine tumors are a well-established disease entity, however, neuroendocrine metastases to the pancreas from other sites have been scarcely documented. Specifically, pancreatic metastases from a pulmonary carcinoid tumor have only previously been described in a single case report.

PRESENTATION OF CASE

We sought to outline our institutional experience of two patients with pulmonary neuroendocrine tumors that developed metastases to the pancreas, confirmed by gross pathology and immunohistochemistry. In both cases, the pancreatic metastases were surgically resected and their pulmonary origin were discovered post-operatively.

DISCUSSION

Our findings should raise awareness to the possibility of metastatic disease when evaluating a pancreatic mass in a patient with a clinical history of pulmonary carcinoid tumor. Expert opinion on immunohistochemically differentiating a primary pancreatic neuroendocrine malignancy from a metastasis should be employed in these cases.

CONCLUSION

Establishing this diagnosis pre-operatively could affect the decision to proceed with surgical resection, given the morbidity of pancreatectomy and the unknown long-term clinical outcome of patients with pulmonary carcinoid tumors metastatic to the pancreas.     

Primary lymph node gastrinoma. A diagnosis of exclusion. A case for duodenotomy in the setting of a negative imaging for primary tumor: A case report and review of the literature

INTRODUCTION

Zollinger–Ellison syndrome (ZES) is caused by uninhibited secretion of gastrin from a gastrinoma. Gastrinomas most commonly arise within the wall of the duodenum followed by the pancreas. Primary lymph node gastrinomas have also been reported in the literature. This is a case of ZES where preoperative localization revealed a gastrinoma in a solitary portacaval lymph node, presumed to be a primary lymph node gastrinoma.

PRESENTATION OF CASE

The patient is a 57 year old female diagnosed with ZES, suspected of having a primary lymph node gastrinoma. The patient underwent an exploratory laparotomy and excision of a portacaval lymph node with a frozen section which was positive for gastrinoma. Intraoperative sonography of the pancreas, upper endoscopy with transillumination of the duodenum, and a duodenotomy with bimanual examination of the duodenal wall were also performed. The patient was found to have a 4 mm duodenal mass near the pylorus, which was excised.

DISCUSSION

Pathology showed that the duodenal mass was primary gastrinoma. Serum gastrin levels taken four months postoperatively were normal and the repeat octreotide scan did not show any evidence of recurrence.

CONCLUSION

Primary lymph node gastrinoma is a diagnosis of exclusion. The duodenum and pancreas must be fully explored to rule out a primary gastrinoma that may be occult.     

Echinococcal lump: An unusual differential diagnosis for a right iliac fossa lump

Aim

To report the rare case of a primary peritoneal hydatid cyst in a 65-year-old lady.

Case Report

A 65-year-old female presented with a 3-month history of a painless progressive swelling in the right lower abdomen. The lump was 10 cm × 8 cm in size, non-tender, cystic in consistency, and was located in the right iliac fossa and part of the right lumbar region; mobility was restricted in all directions. CECT showed a large septated cystic lesion 14 × 9 × 8 cm in size with enhancement, and sharp regular outline in the right lower abdomen along the anterior aspect of the right psoas muscle. The liver and spleen were not affected.

Result

During surgery, a cystic swelling was exposed. Aspiration revealed a clear fluid with some floating material. The cyst wall was incised and fluid along with daughter cysts were removed keeping the pericyst in situ. Histopathological examination confirmed hydatid disease.

Conclusion

Primary peritoneal hydatid cysts, though very rare, should be kept in mind in the differential diagnosis of a right iliac fossa lump in areas where hydatid disease is endemic.

     

Musculoskeletal Echinococcus infection as a rare first presentation of hydatid disease: case report

Background

Hydatid disease (HD) is a cosmopolitan parasitosis caused by Echinococcus granulosus that can potentially affect any part of the human body. Liver and lungs are the most frequent localizations. Primary musculoskeletal hydatidosis are seldom reported in literature and their incidence is unknown.

Case presentation

We deem interesting to report a case of a primary hydatid cyst in a 25-year-old patient who presented with a painful swelling of the right elbow. Meticulous examination and preoperative imaging did not reveal other localizations. Patient was admitted for surgery where total excision of cyst was done without intraoperative spillage and a cutaneous skin flap was subsequently required to make up for soft tissue loss.

Conclusion

Primary hydatid cysts are sometimes difficult to diagnose preoperatively. It should be considered in the differential diagnosis of subcutaneous cystic lesions in regions where hydatid cysts are endemic. Currently, surgical excision is deemed first choice treatment for solitary cysts and antihelminthic treatment should be initiated preoperatively in the case of risk of rupture or in the event of complications.

     

Ganglion cyst on the posterior cruciate ligament: a case report

Objective:

To present the diagnostic and clinical features of a ganglion cyst located on the posterior cruciate ligament and create awareness amongst clinicians of this uncommon diagnosis.

Clinical Features:

A 24-year old woman complaining of intermittent left knee pain brought on by an increase in mileage during her training for a half-marathon. A diagnosis of mild chondromalacia patella and a ganglion cyst on the posterior cruciate ligament was made via diagnostic imaging.

Intervention and outcome:

Patient was followed up with imaging. The patient chose to withdraw a surgical consult due to patient preference. No conservative treatment was provided.

Conclusion:

Although chondromalacia patella is the more probable, a secondary diagnostic consideration in this patient could be a ganglion cyst. A ganglion cyst on the posterior cruciate ligament is an uncommon diagnosis and the clinical manifestations are variable and non-specific. It is important to be aware of its clinical features and to obtain appropriate methods of imaging to generate the diagnosis promptly.     

Hepatobiliary rhabdomyosarcoma mimicking choledochal cyst: Lessons learned

INTRODUCTION

The differential diagnosis of hepatic cystic lesions is a challenging process especially in case of hepatic rhabdomyosarcoma (HRMS) presenting as hepatic cyst.

PRESENTATION OF CASE

We introduce our experience with a case of HRMS in a 3-year-old female patient who was misdiagnosed to have type IV-A choledochal cyst and definitive correct diagnosis was reached after the pathological and immunohistochemical examination of the surgically resected lesion. This case presentation is followed by important practical messages to hepatobiliary surgeons regarding HRMS.

DISCUSSION

HRMS is a rare pediatric tumor. Jaundice is the most common presentation of HRMS followed by abdominal pain and vomiting. Great effort is needed to differentiate the tumor from choledochal cyst and infectious hepatitis. Through evaluation using available imaging studies together with clinical anticipation is mandatory for establishing the correct diagnosis.

CONCLUSION

Differentiation of HRMs from choledochal cyst mandates through evaluation and clinical anticipation. HRMS should be suspected in any child with obstructive jaundice. Once diagnosis is established, multidisciplinary treatment is the best management strategy and it has proved better surgical outcome and long term survival.     

Isolated renal hydatid disease in a non-endemic country: a single centre experience

Objective:

Isolated renal hydatid disease (HD) is rare in non-endemic countries. Clinical and radiological suspicion warrants appropriate serological tests, preoperative treatment and intra-operative precautions. We present a tertiary care centre experience of isolated renal HD in a non-endemic country.

Methods:

We reviewed the medical records of patients with HD treated in the past 20 years. We identified patients with the definitive diagnosis of isolated renal HD and described their management.

Results:

Of the 119 cases with HD, 6 were found to have isolated renal involvement (5%). Their median age was 46.5 (28–70) years. Five patients presented with flank pain and 1 had an incidentally discovered renal mass. Radiologic investigations raised the suspicion of possible HD in 4 cases, while 2 cases were diagnosed as renal tumours. Computerized tomography showed complex renal cyst in 4, solid renal mass with heterogonous enhancement in 2 and calcification in 5. Eosinophilia and indirect hemagglutination test (IHA) were positive in 3 of the 4 suspected cases. Three cases were treated as renal tumours, while 3 were managed as HD. Four cases had total nephrectomy and 2 had partial nephrectomy. Histopathology revealed that all cases had renal HD. Patients were followed for a median of 7.3 (0.4–11.3) years with no evidence of recurrence.

Conclusions:

Isolated renal HD is a challenging preoperative diagnosis in non-endemic countries. The definitive diagnosis is only possible by histopathology. Retrospectively, HD mimicked renal tumours in half the cases and should be considered in the differential diagnosis of renal space occupying lesions.     

Role of Conventional and Diffusion-Weighted Magnetic Resonance Imaging of Spinal Treatment Protocol for Hydatid Disease

Objective:

To demonstrate the role of magnetic resonance imaging (MRI) in determining the treatment protocol for hydatid disease of the spine.

Design:

Case report; literature review.

Findings:

Diffusion-weighted MRI can help differentiate complicated infected hydatidosis from abscesses, epidermoid cysts from arachnoid cysts, and benign from malignant vertebral compression fractures. It is also helpful in differentiating between abscesses and necrotic tumors.

Conclusion:

Diffusion-weighted MRI can help differentiate between infections requiring immediate surgery and those that can be treated medically with antihelmintic treatment.     

Giant chylolymphatic mesenteric cyst and its successful enucleation: A case report

INTRODUCTION

Cysts of the mesentery are among surgical rarities. The clinical presentation is not characteristic and in addition, the preoperative imaging although suggestive is not diagnostic in this case ultrasound and CTscan was consistent with giant mesenteric cyst. In most cases, the diagnosis is confirmed after surgical exploration.

PRESENTATION OF CASE

A 42 yrs old male patient on exploratory laparotomy had a 14cm×10cm×10 cm cysts which was seen arising from the mesentery ofdistal jejunum 80cm from the duodeno jejunal flexure. The cyst was enucleated successfully from themesentery without entailing resection. The cyst contained milky white fluid consistent with a chylolymphatic cyst. The diagnosis was confirmed on histopathology which revealed a cyst wall with lymphoidaggregates. After 3 years of follow-up, the patient is doing well and there is no evidence of recurrence.

DISCUSSION

The cysts may be asymptomatic or maymanifest with abdominal pain, distension lump or intestinal obstruction. Our patient was symptomatic with mild and long standing abdominal pain. The definitive diagnosis of these lesions is difficult prior to surgical exploration as there are no pathognomonic symptoms or characteristic imaging findings.

CONCLUSION

Cysts of the mesentery are among surgical rarities. In most of the cases the diagnosis is confirmed after surgical exploration and removal of thecyst. We would like to emphasize the importance of successful enucleation of the cyst irrespective of its size due to its independent blood supply as opposed to enterogenous cyst which requires bowel resection and anastomosis.     

Diagnosis and surgical treatment of solid pseudopapillary neoplasm of the pancreas: analysis of 24 cases

Background

Our aim was to summarize our experience with the diagnosis and surgical treatment of solid pseudopapillary neoplasm (SPN) of the pancreas to provide a reference for the management of this rare condition.

Methods

We collected and analyzed retrospective data on the clinical presentation, laboratory investigations, radiologic imaging, pathology and operative details of patients with SPN of the pancreas diagnosed between February 2001 and December 2009.

Results

In all, 23 of 24 patients were women, and the mean age of all patients was 31 years. The most common clinical presentation was vague abdominal pain. Abdominal imaging showed solid or solid cystic masses in the pancreas, mostly in the tail or head of the gland. All patients were treated surgically. There were no postoperative deaths. After follow-up ranging from 4 to 109 months (median 68 mo), 20 of 22 patients who underwent curative resection were alive with no evidence of disease recurrence. Of the 2 patients with R1 resections, 1 died 42 months after surgery, whereas the other underwent a second operation and was alive after 36 months’ follow-up.

Conclusion

Solid pseudopapillary neoplasm of the pancreas is a relatively indolent tumour. The initial diagnosis of SPN of the pancreas is suggested by radiologic imaging findings but should be considered in the context of clinical and histopathologic characteristics. We advocate for complete surgical resection once SPN is diagnosed.     

Middle-preserving pancreatectomy for synchronous ampullary carcinoma and solid-pseudopapillary tumor of distal pancreas

Introduction

Total pancreatectomy is the treatment of choice for multicentric diseases involving the pancreas. Middle-preserving pancreatectomy is a recently reported alternative procedure when the pancreatic body is spared from disease.

Presentation of case

We report a 63-year old lady who underwent a combined Whipple''s operation and distal splenopancreatectomy for her synchronous ampullary carcinoma and solid-pseudopapillary tumor of the distal pancreas.

Discussion

For multiple tumors of the pancreas, the choice of surgery should be based on the nature of pathology and follow the principle of oncological resection.

Conclusion

Middle-preserving pancreatectomy is a safe and feasible option for patient with multicentric or synchronous pancreatic pathologies.