Hydatid Cyst Disease

Optimal Management of Complex Liver Involvement

Jacob Moore, BA; Varun Gupta, MD; Mohammed Y. Ahmed, MD; Barbu Gociman, MD, PhD

Disclosures

South Med J. 2011;104(3):222-224. 

In This Article

Discussion

Contemporary medicine usually emphasizes medical management as a first approach to many medical conditions. However, when considering treatment of hydatid cyst disease, the recommended approach supported by experience is a surgical one.

Chemotherapy with albendazole, which has proved the most effective chemotherapeutic agent thus far, should be used in most cases as an adjunct to surgical treatment, and as primary therapy for a select set of conditions. It is used in patients either with cysts deep in the hepatic parenchyma (making them difficult to approach surgically), with multiple small cysts displaying hepatic dissemination, with multiple cysts located in numerous viscera, or with recurrent cysts. It is also used in patients refusing surgery.

In a small prospective study, when albendazole was given for one month or three months preoperatively, it was found to decrease cyst viability at the time of surgical exploration from 50% in the control group to 28% and 8% respectively.[2] When used as the primary treatment modality, cure can be expected in 10 to 30% of patients, with significant regression of the disease in 50 to 70% of patients. Nevertheless, the relapse rate was as high as 30%.[3] A recent analysis showed that based on the size of the cysts, the outcome of the disease after an albendazole treatment showed a response rate of 50 to 60% for cysts less than 6 cm and 25 to 50% for cysts larger than 6 cm. The recurrence rate was 25% at two years, and in cases of second recurrence, the relapse rate was 60%.[4]

Although multiple surgical treatment modalities have been described in the literature, when confronted with a particular clinical situation, choosing the most adequate operative intervention can be difficult. The lack of large randomized studies has led to the preferential use of treatment modalities largely based on expert opinion, each biased towards the existing practice patterns specific to different endemic areas.

Conceptually, treatment is straightforward and entails removal of the parasite with avoidance of spillage, which in turn can lead to recurrence, or in rare circumstances, to an anaphylactic reaction. In addition, removal of the parasitic focus should be done with minimal disruption of anatomical structures involved by the disease. Following removal, control of the residual cavity should be accompanied by an attempt to prevent local complications such as leaks or abscesses. Traditionally, surgical management options have been categorized in two different groups: tissue-sparing procedures and radical resection. Ideally, the procedure performed should fall somewhere along a continuum of increasing invasiveness, ranging from simple drainage, to marsupialization, unroofing, or partial cystopericystectomy with all its modifications (omentoplasty, intraflexion, capitonnage), up to hepatectomy.

A study comparing simple drainage to other methods of controlling the remnant cavity showed a complication rate of 28.1% and a mean hospitalization time of 7.3 days in patients who underwent tube drainage. While the mean postoperative hospitalization time was similar, in the group of patients who underwent any additional procedure to control the remnant cyst cavity (omentoplasty, intraflexion, or capitonnage) the complication rate was 17.5%, although these differences did not reach statistical significance.[5] Similarly, a study comparing external drainage with omentoplasty and capitonnage showed fewer complications in the group of patients who underwent omentoplasty.[6] Furthermore, in another attempt to determine the superior method to manage a remnant cyst cavity, one study looked retrospectively at outcomes for patients treated with omentoplasty alone, omentoplasty combined with other techniques such as external drainage, intraflexion, or capitonnage, and techniques without omentoplasty. Overall morbidity rates were 8.8% for the omentoplasty-only group, 19% for the patients in the group that underwent omentoplasty combined with other techniques, and 25% for techniques without omentoplasty. Significant differences in mean hospital stay were noted between the three groups as 7.6 days, 11.9 days, and 15.8 days respectively.[7]

More radical procedures should be used selectively. Radical pericystectomy avoids the complications related to opening the cyst, and so some authorities recommend it as the procedure of choice in every instance, citing lower recurrence rates as the reason for the preference.[8] However, when dealing with very large cysts that method becomes impractical. The pericyst frequently involves important biliary and vascular structures, which often forces ligation or reconstruction of major structures. Formal liver resections have a much higher technical difficulty and a greater length of procedure, and in many cases, removal of significant viable liver parenchyma is not warranted. In the setting of very large cysts, at least a lobectomy would be required.

Biliary leaks should be controlled intraoperatively with identification and ligation of the involved ductal structures, and postoperatively using endoscopic sphincterotomy.[9] PAIR (puncture, aspiration, injection, and reaspiration of scolicidal) was introduced as a percutaneous treatment modality. Although theoretically very appealing, its utility is limited to the management of simple cysts. There is insufficient evidence to support or refute PAIR with or without benzimidazole coverage for treating patients with uncomplicated hepatic hydatid cysts.[10] PEVAC (percutaneous evacuation of cyst content), a modification of PAIR, was developed to address some of the shortcomings of PAIR. The technique involves the insertion of a large bore catheter to allow aspiration and evacuation of daughter cysts and endocysts by injection and reaspiration of isotonic saline. The catheter allows cystography, injection of a scolicidal agent if applicable, and if no cystobiliary fistula is present, external drainage of cystobiliary fistulae.[11]

Finally, as laparoscopy becomes more prevalent in everyday surgical practice, reports of increasingly complex clinical scenarios of successful laparoscopic management of hydatid cysts have been presented in the literature. Initially restricted to simple cysts with the availability of a grinder-aspirator, the laparoscopic approach can be extended to the treatment of more complex cysts.[12] The major drawback of any laparoscopic intervention for hydatid disease is the inability to completely eliminate the risk of spillage. For this reason, its use should probably be restricted to cases in which control of spillage can easily be achieved.

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