Liver hydatid cyst: Pattern and methods of surgical treatment drainage versus omentoplasty

Liver hydatid cyst: Pattern and methods of surgical treatment drainage versus omentoplasty

Omar Eissa,a MD; Mohamed Rady,b MD; Nader Kotb,b MD;

Ans Meshal, b MD; Ahmed Gamal EL-Din,b MD

a) Department of General Surgery, Menia University, Menia, Egypt.

b) Department of General Surgery, Ain Shams University, Cairo, Egypt.

Abstract

Background: The surgical treatment technique for liver hydatic cyst (LHC) cannot be standardized, and the surgical technique should be tailored according to the extent ofthe cyst and any adjunct complications  of hydatid disease. Liver is the most common site of infection and several methods of surgery have been described to treat this common disease. In this study we aimed to compare the results of two common methods of surgery;simple drainage versus omentoplasty.

Patients and methods: Inthis prospective study 25 patients with hepatic hydatid cyst underwent surgery from January 2008 to January 2013. 15 patients were treated with omentoplasty (group I) and the other ten patients were treated with simple tube drainage (group II). The results of surgery including mortality, complications and recurrences were recorded.

Results: There was no case of mortality in each group of patients.Postoperative complications were seen in 6.7% of group I, 15% of group II patients. The mean duration of hospital stay was

4.5 and 8.6 days in group I and group II patients. During a mean period of 18.6 month follow up there was no recurrence in each group of patients.

Conclusion:  According  to the results of this study we suppose that omentoplasty  of cyst cavity -if feasible- is preferred to tube drainage.

Key words: Drainage, hydatid cyst, omentoplasty.

Introduction:

Hydatid disease has been known since the time of Hippocrates and is described as a 'liver full of water'. 1 Hydatid disease is a zoonosis caused mainly by Echinococcus  granulosus, or less frequently by Echinococcus multilocularis  and Echinococcus oligarthrus. The  primary  carriers  are  dogs  and  wolves. The intermediate hosts are sheep, cattle, and deer. Humans are alternative I accidental secondary hosts and are infected by ingestion of ova from the feces of dogs.2

Endemic regions of human cystic disease include South America, the Mediterranean regwn     including    North    Africa,    Spain,

Protugal,  Turkey, the  Middle  East,  central Asia   and   many   regions   in   China.3  The parasite  "Echinococcus  granulosus"  is a cestode that grows in the small intestine of its definite host usually a dog. The host puts off eggs of the parasite within stools  and when an intermediate host (sheep or human) ingest vegetables contaminated with definite host feces, larvae of the parasite exit the eggs in the  duodenum.  The  larvae  pass through  the intestinal  wall  and  reach  the  liver  via  the portal system where they form cysts.

In humans  50 %to 75% of hydatid cysts

occur in the liver, 25% are found in the lungs and 5% to 10% are distributed to other tissues

along the arterial system.4

Without  treatment,  cysts  grow  and eventually form  fistulas  into adjacent  organs or  rupture  into  the  peritoneal cavity.  Older cysts  have an increased risk of daughter cyst formation, which  is an important factor for recurrence of disease  after surgery.5

Several types  of treatment have been described to treat hydatid  cyst of the liver. Medical  therapy alone  is insufficient to  cure the  disease,  although stabilization of disease has  been  reported  with  albendazole alone or in combination with praziquantel. Surgical approaches  vary   from   complete    resection (e.g.  total   pericystectomy  or  hepatectomy) to minimal  invasive procedures (e.g. percutaneous  aspiration of cysts).

Complictions  are  observed   in  one  third of   patients    with    liver    hydatid        cysts.6

Anaphylactic  shock,   cyst   infection  of  the biliary  tree, and rupture  into the peritomeum are the most common    complications. Intrabiliary rupture is reported to be seen in a range of 6.1-17%.7

Symptoms are created  by the compression or displacement of other structures or  organs, with   subsequent  jaundice,    adverse   effects on hollow organ motility, and exceptionally spontaneous or traumatic rupture.8

The choice  of therapy  depends  on several factors: general  condition of the patient, number  and localization of the cysts, the surgeon's experience and the presence  of special  services  such  as intensive care  unit. This study  presents  the  long-  term  results  of two surgical  techniques in treating hepatic hydatid cyst and compares their postoperative complications, morbidity and  recurrence of the disease.

Most  patients  with  a hydatid  cyst  in the liver have no symptoms, and its presence becomes evident when the liver is found to be enlarged  or a cystic  lesion  is noted  when the liver is imaged for other reasons.  Large cysts may be painful, but otherwise symptoms may be the  result  of a number  of  complications. They may rupture  into the biliary  system and then  the  patient   presents   with  cholangitis. Cysts may also become infected  or obstruct major   intrahepatic  bile  ducts.   Subcapsular

cysts  may  rupture  into the  peritoneal cavity and the patient  may experience anaphylactic shock.9

Patients and methods:

Twinty-five patients, who  underwent surgery for hepatic hydatid cysts between January  2009 and December 2013,  were included  in this study.  Patients  were divided into two groups.  The first group consisted of

15  patients   treated   with  omentoplasty  and the second group were 10 patients treated surgically with tube drainage ofthe cyst cavity. In all cases abdominal ultrasonography and abdominal CT were done. Hepatic  infestation with Echinococcus granulosus was confirmed histologically in all patients.  Surgical techniques were  compared  with  respect  to post-operative complications, hospital stay and recurrence of the  disease.  Patients  were invited to be visited every 3 months,  at which clinical  examination, ultrasonography and serological tests were performed.

Surgical techniques:

In  both  techniques we  used  an  extended right  subcostal          incision.  After  entering  the abdominal   cavity,   routine    exploration  of abdominal viscera  was   done  as well  as the liver  and  the  cyst.  The  surgical   field   was covered   with  packs  immersed in  scolicidal agent (silver nitrate 0.5% or hypertonic saline

20%) to prevent the spread of the parasite and reduce  the risk of intraperitoneal soiling and contamination.

Then the cyst was evacuated  by aspiration

with a closed system suction device. After complete  aspiration of cyst contents, the cyst was unroofed and the germinal  layer and  the remaining daughter cysts were removed. Then we put clean sponges  over the  inner layer of the cyst to define bile leakage from biliary openings.  If there  was  any  biliary  opening, each one was ligated to prevent  postoperative bile leakage.  Then  the cyst cavity  was filled with silver nitrate immersed sponges for a few minutes  to sterilize the cavity of the cyst and then sponges  were removed. At this point, the first group  of patients  were considered  to fill the cavity of their cysts with omentum  and the second  group  were treated  with  simple  tube

drainage (closed suction) of the cyst cavity.

Results:

25 patients (16 male and 9 female) were included  in this  study  with  a mean  age of

31.8  years  (rang   14-65  years).    22(88%)

cysts were located in the right lobe and three(l2%)  in  the   left  lobe  of  the   liver. The mean diameter of the cysts was 12 em (rang 6-25cm). Postoperative complications including atelectasia, wound infection and abscess formation were compared in two groups of patients. Atelectasia as a common complication of abdominal surgery was common in both groups of patients with no significant difference. Wound infection was seen in two patients (20%)  of group II and one patient (6. 7%) of group I. Intraabdominal abscess formation occurred in one (10%) patient of group II. Overall complication rate in group I patients was (6. 7%) and in group II patients it was 15% (p < 0.05).

The   mean   postoperative    hospital   stay was significantly longer after drainage procedures (8.6 days) than those treated with omentoplasty (4.5 days) (p < 0.05). In a mean period of 18.6 (range 13-29) month offollow up  there  was  no  case  of  recurrence  based on physical serologic tests in each group of patients.

Dissension:

The  natural   history   of   echinococcosis is insidious and usually asymptomatic till reaching   a  large  size   stretching   Glissons (liver) capsule or complicated by infection or hemorrhage,  hence high index of suscpision is necessary to diagnose and prevent life threatening    complications    and   morbidity. If  the  cyst  ruptures,  scolices  can  grow  in the  peritoneum,  pleura,  bronchial  tree,  and bile ducts.lO Liver hydatidosis  is a common problem,  associated  with  chronic  morbidity and   has   variable   clinical   manifestations, for these reasons it should be included in differential diagnosis of any abdominal pain, mass or acute abdomen.ll

The majority of patients have single-organ involvement(87%) and a solitary cyst (72%) at the right lobe of the liver. These findings are

nearly the same as in our study results where we have (88%)  a single organ  involvement and (80%)  solitary cyst  located in the right lobe ofthe liver. The right lobe ofthe liver is more affected  in our study and other similar studies due to its largest blood supply.l2

In  contrast  to  western  countries    where the  disease  is  incidental  finding,  in  middle east and our study the commonest presenting symptoms   is  upper   abdominal   pain  and/ or   discomfort,   which   reflect   a  delay   in medical consultation among our patients and under assessment of patients clinically and radiologically. It is known that (6%) of acute abdomen is due to interaperitoneal rupture of liver hydatid cysts.l3

Different  surgical  techniques   and procedures  have  been  carried  out  and even in some cases, a liver transplant has been required. Advances in drug therapy has been influenced by the introduction of albendazole and accelerated  by addition  of praziquantel, but this requires a long  period  of treatment i.e. up to a year or more, and is not effective for everyone.

Surgical treatment     still remains the treatment of choice in the management of hydatid disease. However, supplementary medical therapy may be necessary to prevent recurrence in high risk group.l2

The    principles     of    hydatid     surgery include removal of all infective cyst parts; inactivation  of the cyst cavity, avoidance of intra-abdominal spillage ofthe cyst contents, elimination of all viable elements (endo cyst with its contents; scolices, fluid and daughter cysts)  and management  of the residual cavity.l4

Two   main   operative   approaches   have been described in this study; (1) drainage procedure, (2) the obliteration of the cavity after evacuation of the cystic contents.  Many debatable  results have been reported  in relation to the surgical treatment of  cystic cavity. The procedures performed depend on the  location  and characteristics  of the  cysts and on the general condition of the patient. Traditionally,  various   surgical   alternatives have been described such as pericystectomy, cystectomy    (partial    or    complete)    with

external  drainage,  marsupilisation, capiitonage or omentoplasty.l5 Particularly, these  procedures  are  not  always  applicable and a few of them have been abandoned nowadays. In contrast, the laparoscopic approach is rapidly developing following the progress of modem laparoscopic equipments (e.g  perforator  grinder,  aspirator  apparatus and locking umbrella trochar).l6 The reported advantages of laparoscopic approach are minimal     invasiveness,     shorter     hospital stay and reduced wound complications. Disadvantages of such approach include the limited manipulation area, potentional risk of spillage during puncture and the high risk of bleeding in centrally located cyst.l7 Recently, laparoscopy is quite feasible to perform in hydatid disease of the liver, and the use of helical  fasteners   allows  effective  omental flap fixation.l8

Pericystectomy may be hazardous or even impossible to perform and is usually limited to  small,  peripheral  cysts  of  anterior  right lobe  or left lobes.l9  Such  operations   have high  morbidity  and  mortality  rates  and can be considered radical procedures for such a bengin disease . Hepatic resection should only be considered for Echinococcus alveolaris cases that are located on one hepatic lobe.

Total pericystectomy is usually restricted to small, peripherally located liver cysts that are only partially surrounded  by parenchyma.20

Cystectomy and omentoplasty is safe, simple  and  effective  where  the  omentum acts as a biological drain and natural sealing agent.21

Drainage procedures can be followed  by various   post-oprative   complications,   such as  hepatic  abscess,  biliary    fistula,  and  a longer hospital stay. Therefore omentoplasty for   a   single   uncomplicated   hydatid   cyst caused   significantly    fewer   complications than external drainage, and reduced hospital stay.22  However,  in  our  experience  in  the group treated by drainage ofthe cystic cavity increased there was  post-oprative  morbidity in comparison with the other group treated by omentoplasty. The difference was statistically significant  (P>0.05).  The  restriction  of activity  in  patients  with tube  drainage  was

also an important predisposing factor for pulmonary infection and thromboembolism. Furthermore,  The  drain  was  an  important factor  in the  enterance  of  microorganisms into  the   peritoneum   thus   increasing peritoneal infections. However, external tube drainage retains its value as a simple and safe procedure. 23

Omentoplasty seems to be the best possible surgical alternative  for the radical treatment of hepatic hydatid cysts. The management of liver hydatid cysts should be flexible, taking into consideration a number of factors and variables.l5

Omentoplasty  should be the standard surgical   procedure    because    it    is    safe, simple and effectively meets all criteria of surgical treatment for hydatid disease: entire elimination ofthe parasite, no intra operative spillage, and saving healthy tissues.24

Therfore no single method can be recommended for the treatment of hepatic hydatid cysts but the choice of the surgical methods must be made according to the complications  of the  cyst.  Omentoplasty  is the procedure of choice for uncomplicated cysts  with  low  complication  rate  and relatively short hospital stay. External tube drainage  is recommended  for  infected  cysts and a biliary drainage procedure should be added to external tube drainage for cysts with intrabiliary rupture.

Conclusion:

As   many   other   authors,   we   conclude from this study, that excision of the cyst and omentoplasty   is  the  procedure   of  choice; having  the  lowest morbidity  rate. Thus surgical procedures  do not employ drainage as the treatment of choice in the management of patients with hydatid cyst of the liver External drainage could occasionally be reserved   for  more  complicated   cases  and where there is sepsis of the biliary tree.

References:

1- Sayek I, Yalin R, Sanae Y: Surgical treatment  of hydatid  disease  of the liver. Arch Surg 1980; ll5: 847-850.

2- Harris KM, Morris DL, Tudor R, Toghill