Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts

Abstract. Purpose: The most common complication of hydatid liver cysts is spontaneous rupture into the biliary tract. This study was conducted to evaluate the surgical management of spontaneous intrabiliary rupture of a hydatid liver cyst in 41 patients. Methods: The preoperative diagnosis was confirmed by ultrasound in all 41 patients, 37 of whom were jaundiced. Results: According to Gharbi's classification, 39% of the cysts were type III and they ranged from 3 to 18 cm in diameter, with a mean diameter of 9 cm. The mean total bilirubin and alkaline phosphatase values were 6.3 mg/dl and 450 IU, respectively. Partial cystectomy, cholecystectomy, and common bile duct exploration were performed in all patients. In seven patients, the visible biliary duct within the cyst cavity was sutured with 2/0 silk. Intraoperative cholangiography was performed in all patients, and choledochoscopy was performed in 11 patients. A T-tube was inserted after the biliary tract content was thought to have been totally cleaned out in 38 patients (93%), and a choledochoduodenostomy was performed in 3 patients (7%). An external biliary fistula developed in five patients, persisting for 11–25 days. The fistulae healed within a mean period of 5 days after endoscopic sphincterotomy (EST). For patients without a fistula the mean hospitalization time was 8 days and there was no mortality. Conclusion: These results suggest that when a hydatid liver cyst ruptures into the biliary tract, common bile duct exploration should be conducted using intraoperative cholangiography and choledochoscopy. If the biliary tract is cleaned of all cystic content, T-tube drainage should be sufficient, but EST is an effective technique for treating persistent extended external biliary fistulae. Received: September 26, 2001 / Accepted: January 8, 2002     

Surgical management of complicated hydatid cysts of the liver

The most significant complications of hydatid cyst of the liver are rupture and suppuration with an incidence of 6-19%. Rupture into the biliary tract was the most frequent complication and comprised 170 out of 222 complicated hydatid cysts of the liver in the author's series. These jaundiced patients were managed both by obliteration of the residual cavity and restoration of the patency of the biliary tract which was obstructed by daughter cysts of remnants of the laminated membrane. Rupture into the bronchi requires immediate treatment due to bronchopulmonary complications which might ensue. Rupture into blood vessels and into the free peritoneal cavity is accompanied by severe anaphylactic shock which does not readily respond to corticosteroids. The former complication is accompanied by a high mortality rate, while the postoperative mortality of patients experiencing anaphylactic shock amounts to 1.8%.     

超声引导下经皮肝穿抽吸硬化介入治疗肝包虫囊肿

目的探讨超声引导下经皮肝穿抽吸硬化治疗肝包虫囊肿的应用价值。方法在超声引导下对38例肝包虫囊肿患者行经皮肝囊肿穿刺抽吸囊液,抽尽后向囊内注入20%～25%无菌高渗盐水或95%无水乙醇,注入量约为抽出量的25%～50%,保留5～15 min后全部抽出,再注入5～10 ml予以保留,术前术后结合口服抗包虫药阿苯达唑30～50mg/kg治疗。术后定期行超声随访,1年内3个月复查1次,1年后每年复查1次。结果治疗中1次穿刺成功率100%,6个月后16例囊肿缩小50%、22例缩小30%。1年后34例治愈,3例显效,1例好转。其后囊肿逐渐缩小,直至钙化,治愈率达100%。结论超声引导下经皮肝穿抽吸硬化治疗肝包虫囊肿是一种安全、有效、可靠的方法。     

Clinical and radiographic features of simple and hydatid cysts of the liver

The advances of hydatid chemotherapy and the non-operative management of simple (epithelial) hepatic cysts make a correct diagnosis of increasing importance. Twenty-six patients with hepatic hydatid cysts and eleven with simple cysts were reviewed. In both groups clinical presentation was most frequently due to pain. Sex, age and size of the cysts were similar. Hydatid serology was negative in six of the hydatid patients (23 per cent). None of the simple cyst patients had positive serology but one had a borderline titre. Ultrasound and computerized tomography identified daughter cysts within the main cyst in only 17 hydatid cysts (65 per cent) and considerable intra-cyst debris was also present in five of the simple cysts. Seven of the simple cysts were deroofed surgically and the remainder underwent percutaneous aspiration. Sixteen of the hydatid cysts were found to have a biliary communication whereas this was not found with any simple cyst. The difficulties in making a precise diagnosis in some patients with a liver cyst should deter the interventional radiologist and restrain the hydatid chemotherapist.     

Surgical treatment of hydatid disease of the liver: 25 years of experience

Background

The aim of this study was to evaluate the results of conservative and radical treatment of liver hydatid disease.

Methods

Records of patients who underwent surgery for liver hydatid disease between 1980 and 2005 were reviewed. Outcomes measured were operative morbidity and mortality, hospital stay, and recurrence.

Results

Two hundred fourteen patients underwent conservative treatment (external drainage, marsupialization, omentoplasty), and 240 had radical surgery (hepatic resection, cystopericystectomy). Operative morbidity was 79.9% and 16.2% for conservative and radical procedures, respectively (P < .001). Operative mortality was 6.5% for conservative procedures and 9.2% for radical procedures (P = .3). The recurrence rate was 30.4% in patients having conservative surgery and 1.2% in patients undergoing radical surgery (P < .001). No recurrences occurred in patients with clear cysts after conservative surgery.

Conclusions

Cystopericystectomy was a safe and effective procedure that achieved excellent immediate and long-term results. Hepatic resection should be considered only in exceptional cases, because it involves the unnecessary sacrifice of healthy hepatic parenchyma. Conservative surgery and alternative procedures should be restricted to the treatment of clear cysts and to patients who cannot undergo radical surgery.     

Surgical treatment of advanced alveolar hydatid disease of the liver: A report of five cases

We report herein the cases of five patients with alveolar hydatid disease (AHD) of the liver who were diagnosed and underwent surgery at the Department of Surgery of Ankara University between 1989 and 1994. In all five patients, the final diagnosis was established by frozen section of the lesion during laparotomy. Lesions of AHD were found only in the liver. Hepatic resections including right lobectomy and segmentectomy were performed in three patients while palliative procedures were carried out in the remaining two patients with unresectable disease. There was no operative mortality, and only one late death occurred 3 years after the hepatic resection. In this paper, we present the clinical and operative findings of these five patients and their outcomes, followed by a review of the surgical treatment of AHD.     

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.     

The management of hepatic hydatid cysts: Review of 94 cases

In this retrospective study, 94 patients operated for hepatic hydatid cysts were reviewed to compared the advantages and disadvantages of different operative techniques. The patients were divided into four groups according to the type of operation. Group I consisted of 33 patients with peripherally located small cysts, eligible for excision, who underwent cystectomy. Group II consisted of 28 patients with cysts smaller than 5 cm, not suitable for complete removal, who underwent partial cystectomy with capitonnage. Group III were 21 patients with cysts larger than or equal to 5 cm, not suitable for complete removal, who underwent partial cystectomy with omentoplasty. Infection and biliary communication were not seen in groups II and III. Group IV were 12 patients with infected cyst or intrabiliary rupture who underwent partial cystectomy with external drainage. In group IV, hospital stay was longer than in the other groups (P < 0.05). Group I had the shortest hospital stay (P < 0.05). Group IV had the highest morbidity and recurrence rates (P < 0.05). We concluded that cystectomy is the technique of choice in selected patients, as it is associated with low morbidity, low recurrence rates, and short hospital stay. Omentoplasty is preferred if cystectomy is not feasible. If there is biliary contamination and infection, external drainage, rather than omentoplasty, should be performed. Received for publication on June 24, 1997; accepted on Dec. 3, 1997     

Laparoscopic treatment of hydatid cysts of the liver and spleen

Background: The short-term results from laparoscopic treatment of hydatid cysts of the liver and spleen were reported previously. The procedure was shown to be feasible and safe, offering the advantages of laparoscopic surgery. This is the first report on the long-term follow-up of this operation in a large group of patients. Methods: In this study, 108 hydatid cysts of the liver and spleen in 83 consecutive patients (43 males [52%] and 40 females [48%]) were approached laparoscopically. The mean age of the patients was 40 years (range, 13–85 years). There were 104 liver cysts and 4 spleen cysts. The liver cysts were located in the right lobe in 42 patients (53%), in the left lobe in 21 patients (26%) and in both lobes in 16 patients (21%). Of the 104 cysts, 44 (42%) were uniloculated and 60 (58%) were multiloculated. Results: All cysts were approached laparoscopically. The mean operative time was 80 min (range, 40–180 min). The conversion rate was 3%. The mean hospital stay was 3 days (range, 2–7 days). There were no mortalities, and complications occurred in nine patients (11%). All were managed conservatively except one patient in whom a laparotomy was needed. All patients were followed up for a mean period of 30 months (range, 4–54 months) with serological testing and ultrasonography if needed. In three patients (3.6%) recurrence of the disease developed. Conclusion: The laparoscopic approach to uncomplicated hydatid cysts of the liver and spleen is a safe and effective option with favorable long-term results. Received: 27 August 1998/Accepted: 13 July 1999     

Primary hydatid cysts of psoas muscle

Background: Hydatid cysts may occur in any area of the body, but they usually localize to the liver and the lungs. Primary localization in muscle is not common, accounting for 2?3% of all sites; even rarer is the development of multiple cysts. Methods: The patient presented with a painless abdominal mass which gradually increased in size to a diameter of approximately 16 cm. Organ imaging scan revealed multiple hydatid cysts within the right psoas muscle. Because of the proximity of the lesions to the iliac vessels, ureter and nerves to the lower limb, percutaneous drainage and alcoholization under local anaesthesia were ­performed with the aim of reducing the size of the cysts and sterilizing them prior to definitive surgery. This procedure was not effective. Two weeks after percutaneous treatment the patient underwent surgery. Results: At operation the cysts were localized and successfully removed under ultrasound guidance. Postoperative stay was ­uneventful. Two years after surgery the patient has no evidence of recurrent hydatid disease. Conclusions: Ultrasonography is the preferred method for detecting muscular hydatid cyst and for guiding the surgeon during resection.     

Surgical management and long-term outcome of complicated liver hydatid cysts caused by Echinococcus granulosus

BACKGROUND: The aim of this retrospective study was to evaluate clinical presentation and long-term outcome of patients treated surgically for complicated liver hydatid cysts. PATIENTS AND METHODS: Eighty-four patients with liver hydatid cysts underwent an operation at the Geneva University Hospital between 1980 and 1999. Clinical presentation, postoperative morbidity, mortality, and long-term recurrence rate were evaluated. RESULTS: Among the 84 patients with liver hydatid disease, 35 patients (41%) presented complicated cysts (ie, cysts that had developed a fistula into adjacent structures or organs). In most patients, the fistula communicated with the biliary tree (n = 25), but we also observed communication with the right lung (n = 3), the right diaphragm (n = 2), liver parenchyma (n = 1), and peritoneal cavity (n = 1). Complete removal of the cystic disease was possible in 24 of 35 patients (70%). In 11 patients, fragments of cysts were not removed because of their location adjacent to main vessels. Postoperatively, 8 patients (23%) developed a severe complication (grade II and III). There were no postoperative deaths, and no recurrences of hydatid disease were observed with a median follow-up of 8.6 years (complete follow-up was obtained in 69% of patients). CONCLUSIONS: Complicated liver hydatid disease is frequent and was observed in almost half of patients operated for liver hydatid cysts at our center. Using a surgical strategy aimed at complete removal of cystic and pericystic tissue with simultaneous treatment of the fistulous tract, we observed 23% postoperative morbidity, no mortality, and no recurrence of disease with a median follow-up of >8 years.     

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.     

Surgical management of cystic lesions in the liver

Background: Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear. Methods: A Pubmed and Medline literature review using key words non‐parasitic hepatic cysts, polycystic liver disease, echinococcus, hydatid cysts parasitic cysts, Caroli's disease, cystadenoma; liver abscess, surgery, aspiration and treatment was undertaken and papers pertaining to the diagnosis and management of cystic lesions within the liver were retrieved. Results: Asymptomatic simple cysts in the liver require no treatment. Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de‐roofing. At present, insufficient evidence exists to recommend one over the other. Polycystic liver disease presents a unique management problem because of high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work‐up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can effectively be treated by aspiration or drainage. With improved antimicrobial efficacy, prolonged treatment with antibiotics may also be considered. Conclusion: All patients with cystic lesions in the liver require discussion at multi‐disciplinary meetings to confirm and the diagnosis and determine the most appropriate method of treatment.     

遗传性多囊肝与单纯性肝脏多发囊肿的外科处理

目的 研究遗传性多囊肝与单纯性肝脏多发囊肿的外科处理与疗效方面的差异。方法对2001年3月～2004年10月我院收治的肝脏多发囊肿病例,进一步鉴别出遗传性与单纯性,分析外科处理与治疗效果方面的差异。结果单纯性肝脏多发囊肿57例,遗传性多囊肝病30例;外科处理上,单纯性肝脏多发囊肿多采取囊肿开窗术（占43．37％）,而遗传性多囊肝多采用肝切除联合囊肿开窗术（占50％）;术后并发症发生率遗传性多囊肝显著高于单纯性肝脏多发囊肿（52．38％VS13．95％）。遗传性多囊肝行穿刺抽液术易发生囊内出血（发生率为37．5％）。术后囊肿复发与处理方式明显相关,单纯开窗术与穿刺抽液术复发率较高,分别为38．89％、55．56％。结论采用肝切除联合囊肿开窗术治疗遗传性多囊肝,术后易出现胸腹水等并发症。术后囊肿复发与处理方式相关。     

严重多囊肝的外科处理

目的　严重多囊肝外科处理上较困难 ,治疗后症状再发率较高 ,本文探讨目的为提高对严重多囊肝的处理水平。方法　对 2 2例获随访的严重多囊肝病例按治疗方法不同 ,对疗效进行分析 ,讨论了治疗方法的选择与疗效的关系。结果　肝部分切除加开窗术、剖腹肝囊肿开窗术、B超下穿刺治疗及腹腔镜肝囊肿开窗术在术后 0 5～ 7年 (平均 3年 )内症状再发 ,再发率分别为 0 ,2 8.5 % ,6 5 .5 %及 10 0 %。结论　肝部分切除加开窗术是治疗严重肝囊肿的有效方法 ;B超下穿刺治疗更适合作为手术前后暂时缓解症状的辅助手段 ;腹腔镜开窗术应慎用于严重多囊肝病人     

Formalin toxicity in hydatid liver disease

Two cases of formalin toxicity developed within 5 to 10 minutes of the placement of packs soaked in formalin within hepatic hydatid cysts. Hypotension, severe tachycardia, postoperative anuria, tachypnoea, restlessness, unconsciousness and coma developed. There was no response to the treatment given. Treatment was continued for about 12 hours. The problems associated with the use of formalin are discussed.     

Surgical treatment of hydatid cysts of the liver in the era of percutaneous treatment

BACKGROUND: Although surgery is the recommended treatment for liver hydatid disease, percutaneous treatment has been introduced as an alternative to surgery. No previous studies have been reported for patients who have not been suitable for percutaneous treatment and undergone surgery. The aim if this study was therefore to evaluate the patients who have liver hydatid disease and not suitable for percutaneous treatment and to determine the effectiveness of different types of surgical interventions in these patients. PATIENTS AND METHODS: Ninety-five patients who underwent operations for liver hydatid disease were retrospectively reviewed. All patients were radiologically evaluated before surgery for possible percutaneous treatment. Besides other related factors, conventional and radical surgical approaches were compared in terms of complication and recurrence rate. RESULTS: Overall complication and recurrence rates were 40% and 25%, respectively. Conventional surgical approaches and common bile duct exploration were significantly associated with an increased complication and recurrence rate. CONCLUSIONS: Selection of simple liver hydatid cysts for percutaneous treatment had led us to operate more difficult and complicated cases. It seems that routine use of endoscopic retrograde cholangiography in the preoperative period and more efforts to perform radical procedures are two major determinants in the successful treatment of theses complicated cases.     

Surgical treatment of hydatid cysts of the liver

BACKGROUND: Echinococcosis is a zoonotic disease that occurs throughout the world. The purpose of this study was to assess the clinical features and results of surgical treatment of hepatic hydatid cysts. METHODS: One hundred and two patients operated on between 1991 and 2002 were reviewed retrospectively. The patients' demographic data, location, number and size of cysts, type of surgical procedure performed, morbidity, recurrences and duration of hospital stay were recorded. RESULTS: There were 74 male and 28 female patients with ages ranging from 15 to over 60 years. The most frequent symptom was abdominal pain. From the total of 136 hepatic cysts, 54 (39.7 per cent) were managed by cystostomy and drainage, 40 (29.4 per cent) by cystostomy and capitonnage, 16 (11.8 per cent) by cystostomy and omentoplasty, 24 (17.6 per cent) by cystectomy and two (1.5 per cent) by left lateral hepatic resection. Postoperative complications were more frequent following cystostomy with omentoplasty (six of 16 patients) compared with cystectomy (none of 18) (P = 0.005). Choledochotomy increased the length of hospital stay in patients having cystostomy and drainage (P = 0.021) and in those having cystostomy with omentoplasty (P = 0.028). Two recurrences were observed. CONCLUSION: Surgery combined with medical treatment by albendazole is effective in the eradication of hepatic hydatid disease and in the prevention of local recurrence.     

Results of laparoscopic treatment of hydatid cysts of the liver

Background We have previously reported on the laparoscopic treatment of hydatid cysts of the liver. We now report the successful treatment of 18 cysts in 12 patients with a median follow-up of 12 months. Methods The standard treatment in the open technique was performed laparoscopically. The main concern was to prevent spillage of the hydatid fluid, for which the puncture and evacuation of the cyst is carried under scolicidal agents cover using 1% cetrimide, thus decreasing the chances of recurrence. Results In this group of patients we had one biliary leak that ceased spontaneously and one recurrence of hydatid cyst but not in the same lobe. Conclusions We conclude that laparoscopic evacuation of hydatid cysts is a successful operation comparable to the open technique, with the added advantages of the laparoscopic approach.     

The surgical management of congenital liver cysts

BACKGROUND: Most series that report the results of surgical treatment for congenital liver cysts focus more on the technical aspects of the operation than on the late outcome of these patients. In this paper, we emphasize the importance of appropriate patient selection and adequate surgical technique for successful long-term outcome. METHODS: Twenty-four consecutive patients with congenital liver cysts were selected for surgical treatment. According to our own classification, 13 patients had simple liver cysts, nine had multicystic liver disease, and two had type I polycystic liver disease. All of these patients were treated by the fenestration technique. An open approach was used for five patients (group 1) treated between 1984 and 1990. In 19 patients (group 2) treated since 1991, a laparoscopic approach was used. The incidence of complicated liver cysts was 40% in group 1 and 68% in group 2. RESULTS: There were no treatment-related deaths in this series. The mean postoperative hospital stay was significantly shorter for patients who underwent successful laparoscopic fenestration (p < 0.05). In the open group (group 1), there were no postoperative complications, and all patients were alive and free of symptoms during a mean follow-up of 130 months, without any sign of cyst recurrence. In the laparoscopic group (group 2), four patients were converted to open surgery. One of these patients had an inaccessible posterior cyst; another had bile within the cystic cavity. A further two cases had complicated liver cysts with an uncertain diagnosis between congenital and neoplastic cysts. Four patients (21%) developed peri- or postoperative complications. During a mean follow-up time of 38.5 months, none of the patients with simple liver cysts incurred late symptoms or signs of cyst recurrence. In the six patients with multicystic liver disease, one developed disease-related cyst progression (17%) and required reoperation. One of the two patients with type I polycystic liver disease (50%) developed asymptomatic disease-related cyst progression. CONCLUSIONS: When patients are carefully selected and a proper surgical technique is employed, excellent long-term results with a low morbidity rate can be achieved in patients with congenital liver cysts. Patients with multicystic liver disease or type I polycystic liver disease are more prone to late cyst recurrence. A tailored approach is thus indicated for patients with congenital liver cystic disease. However, the laparoscopic approach appears to be the gold standard for the treatment of highly symptomatic or complicated simple liver cysts.