Minimally invasive treatment of hepatic hydatid cysts
Minimally Invasive Treatment of Hepatic Hydatid Cysts
ªtefan Octavian Georgescu1, Liviu Dubei1, Eugen Tarcoveanu1, Costel Bradea1, Daniel Lazescu1,
Felicia Crumpei2, Iulian Stratan3
1) 1st Surgical Clinic. 2) Department of Radiology. 3) Intensive Care Unit, University Hospital “St. Spiridon”,
University of Medicine and Pharmacy “Gr. T. Popa”, Iaºi
Abstract
Background. Hydatid cyst is a parasitosis caused by
Taenia Echinococcus. In the last 10 years, new methods of
treatment of the hydatid cyst have been proposed (percuta-
neous or laparoscopic). Method. This retrospective study
includes 24 patients with hepatic hydatid cyst (HHC) who
were treated by a minimally invasive approach, 18 women
and 6 men (average age 49.3 years), representing 10% of all
patients with HHC. Results. The average operative time
was shortened to about 70 minutes. The conversion rate
was 25%. In all cases managed laparoscopically, the
prophylactic flooding of the peritoneal cavity was realized
with peroxide solution 10‰ or with hypertonic saline 30%.
The inactivation of the cyst was performed with hypertonic
saline in most of the cases. Most cysts were univesicular
(62.5%), but there were also multivesicular cysts (37.5%). In
two cases patients presented hepatic and pulmonary
hydatid disease which were also approached in a minimally
invasive manner. The average postoperative period of the
cases treated laparoscopically was 6 days and for the
converted cases it was 13.3 days. Conclusion. The open
surgical approach of HHC is highly expensive due to the
postoperative period, therefore a laparoscopic approach may
be advocated. The minimally invasive method shortens the
postoperative hospitalization period, reduces the number
of complications as well as the overall costs and facilitates
a rapid social reintegration. All these arguments recommend
the laparoscopic approach as a standard procedure for
hepatic hydatid disease.
Key words
Minimally invasive treatment - hepatic hydatid cyst -
laparoscopy - albendazole - peroxide solution
Romanian Journal of Gastroenterology
September 2005 Vol.14 No.3, 249-252
Address for correspondence: St. O. Georgescu, MD
1st Clinic Surgery
“St. Spiridon” Hospital
Bd. Independenþei, no.1
700111 Iaºi, Romania
E-mail: sgeorge@iasi.mednet.ro
Rezumat
Premize. Chistul hidatic este o parazitozã provocatã de
Taenia echinococcus. În ultimii 10 ani, noi metode de
tratament al chistului hidatic au fost propuse (percutane ºi
videoscopice), care ne-au incitat sã le aplicãm. Metodã.
Studiul nostru retrospectiv include 24 de bolnavi cu chist
hidatic hepatic care au fost trataþi prin metode minim
invazive, 18 femei ºi 6 bãrbaþi, reprezentând 10 % din numãrul
total al pacienþilor cu chist hidatic hepatic (vârsta medie a
fost de 49,3 ani). Rezultate. Durata medie a unei intervenþii
chirurgicale a fost scurtatã la 70 de minute, iar rata de
conversie a fost de 25%. In toate cazurile tratate laparoscopic
s-a efectuat inundarea profilacticã a cavitãþii peritoneale cu
soluþie de peroxid 10‰ sau soluþie cloruratã hipertonã 30%.
Inactivarea chistului a fost realizatã în majoritatea cazurilor
cu soluþie salinã hipertonã. Marea majoritate a cazurilor au
fost chisturi univeziculare (62,5%), dar s-a intervenit minim
invaziv ºi în chisturi multiveziculare (37,5%). Doi pacienþi au
prezentat localizãri duble, hepatice ºi pulmonare, cele
pulmonare fiind abordate de asemenea minim invaziv, dar
înaintea celor hepatice în cursul aceleiaºi intervenþii. Durata
medie de spitalizare a tuturor cazurilor tratate laparoscopic a
fost de 6 zile, iar în cazul conversiilor a fost de 13 zile.
Concluzie. Abordul chirurgical clasic determinã cheltuieli
de spitalizare foarte mari, iar tratamentul laparoscopic poate
fi soluþia. Tratamentul minim invaziv scurteazã durata de
spitalizare, reduce numãrul complicaþiilor parietale
postoperatorii ºi permite reintegrarea socioprofesionalã
rapidã. Toate acestea ne-au determinat sã recomandãm acest
abord ca procedurã standard de tratament al chistului hidatic
hepatic.
Introduction
Hydatid cyst disease is a parasitosis caused by Taenia
Echinococcus. Human disease is a „dead end” which inter-
rupts the biological cycle of the parasite. Hepatic localization
is the most frequent (60%), because the infestation occurs
by digestive way, and liver is the first filter on this way. The
disease is endemic in the Balkan Area and in Eastern Europe.
250
Man is an accidental host for the parasite; the dog is the
final host and the cow, the sheep and the pig are intermediary
hosts.
In Romania, the prevalence of the disease is of 5-6 cases
to 100,000 inhabitants. Statistic data show an increasing
incidence of this disease in our country, so urgent measures
are required for its eradication by a national program (1-3).
Hydatid disease may have any localization. Except for the
most frequent localizations (hepatic – HHC - 60% and
pulmonary – 30%), brain, spleen, bones, kidney, mesocolon,
ovary and pelvic are known as potential sites.
The diagnosis is established, with few exceptions, by
paraclinical investigations, especially by imaging techniques
(ultrasonography, conventional radiology, computed
tomography) as well as by immunological studies (ELISA).
Unlike the thoracic hydatid cyst, where diagnosis is rarely
established by clinical examination, in the case of HHC
symptoms are suggestive, but the certain diagnosis has to
be established by imaging and immunological techniques
(2,4,5).
Although drug treatment has been followed by many
failed attempts, today we can witness its revival due to the
new drugs (mebendazol, albendazole) which completely
destroy the univesicular hydatid cyst in 50-80% of the cases
after 3 months of treatment. Some authors reported a
sterilization rate of 95% (6,7).
Nevertheless, the treatment of choice remains surgical.
Many surgical techniques have been described, some of
them conservative and some of them radical. Among the
conservative surgical methods, the most frequently used
are reduction with or without drainage of the cyst, partial
pericystectomy with drainage. Among the radical ones, there
is the ideal cystectomy or visceral resection. The aim of the
surgical treatment is to cure the parasitosis with a minimal
visceral sacrifice. In the last 10 years, new therapeutical
methods have been proposed, such as the minimally invasive
ones: percutaneous or laparoscopic approach, which was
also applied by us.
Patients and methods
The study is a retrospective one and was performed for
the period 1st Jan. 1999 to 1st Feb. 2003. During this period,
281 patients were admitted and treated for hydatid cyst: 240
of them had hepatic localization, 30 had thoracic localization
and 11 patients had other localizations (spleen - 5, kidney -
1, multiple: hepatic, spleen, mesocolon, ovary and pelvic -
5). Among the patients with hepatic localization, 24 were
treated using a minimally invasive approach, 18 women and
Table I Hepatic localization of the hydatid cysts in our series of patients
Location Left hepatic Right hepatic lobe
lobe anterolateral
segment
% 19.23 38.46
Georgescu et al
6 men, representing 10% of all the patients with HHC. The
mean age of the study group was 49.3 years (ranges 14 and
75).
Results
The minimally invasive approach of HHC proved very
efficient, the intraoperative visibility being excellent and the
mean duration of intervention being shortened to about 70
min (limits 90 and 150 min). The laparoscopic approach used
three trocars in 20% of the cases and four trocars in 80% of
the cases. The localization of HHC is shown in Table I. In
two cases, the patients presented hepatic and pulmonary
hydatid cyst, which were both approached in a minimally
invasive manner. First, we performed the thoracoscopic
treatment of the cyst, in a separate session or in the same
surgical session.
The conversion rate was 25% (6 cases). The most
frequent causes of conversion were the absence of
externalization, and the impossibility to identify the hydatid
cyst (2 cases). Other causes were the occurrence of a
hemorrhage uncontrolled by laparoscopic means (1 case),
uncertain anatomy (1 case), the suspicion of hepatoma (1
case), the breaking of the cyst after a sport trauma (1 case),
when the intervention was performed in emergency, in order
to establish diagnosis.
In all the cases that were successfully managed
laparoscopically, the prophylactic flooding of the peritoneal
cavity was performed with peroxide solution - 10‰ or with
hypertonic saline 30%. Inactivation of the cyst was
performed with hypertonic saline in most of the cases, but
also with peroxide solution. After inactivation, the contents
were aspirated with an adjustable pressure vacuum machine
and then a small operculectomy was performed, through
which the proligera were extracted. In all cases the
laparoscopic intracystic drainage was set up. Most of the
hydatid cysts were univesicular (15 cases – 62.5%), but we
also operated multivesicular hydatid cysts. In three cases,
we closed a biliary fistula using a titanium clip.
Early complications were billiary fistulas (4 cases) which
were treated conservatively or with endoscopic
sphincterotomy, infections of the residual cavity and wound
infections (which were converted). We encountered one
hepatic abscess in a patient who was hospitalized again8
weeks after surgery, and it was drained by a classical
approach (Table II).
The average postoperative hospitalization was 6 days
(range 4–17) for the cases managed by the laparoscopic
method, 13.3 days (range 8 - 20) for the cases converted and
Multiple Multiple
posterolateral hepatic visceral
segment locations locations
42.31 8.33 8.33
Minimally invasive treatment of hepatic hydatid cysts
Table II The postoperative complications in our series of patients
Complication No.of cases %
Billiary fistula 4 16.66
Infection of residual cavity 2 8.33
Wound infection 5 20.80
Hepatic abscess 1 4.16
7.9 days for all cases (Table III). In two cases, the patients
presented also a pulmonary hydatid cyst which were also
approached in a minimally invasive manner. First, we per-
formed the thoracoscopic treatment of the cyst, in a separate
session (1 case) or in the same surgical session (1 case).
Table III Duration of the postoperative
hospitalization
No. of days No. of cases
4 2
5 4
6 3
7 4
8 2
9 1
12 1 dome, avoiding the risk of hemorrhage and of biliary tract or
17 1
Discussion
Minimally invasive techniques (percutaneous or
laparoscopic) have well known advantages that have
increased their practice. Their use in the treatment of HHC
started about 12 years ago, when Khoury et al (1991) and
Acunas (1992) performed percutaneous drainage, and
Saglam (1992) performed laparoscopic drainage of HHC (8,
9). These minimally invasive methods were and still are of
little use in the treatment of HHC and they do not rate
important in the literature (Table IV). We found some studies
similar to our series, which presented the laparoscopic
treatment of HHC and recommended the use of minimally
invasive techniques under the cover of modern scolicidal
drugs.
An experimental percutaneous technique was first
described in 1985 and was performed on the human body
for the first time after 6 years (8). Bastid et al reported 14
cases of HHC with diameters between 42 and 180 mm that
were treated by this method (10). This treatment is good for
the young HHC with thin walls (hydatid cyst type I, II or III
after Gharbi classification). The inactivation was done with
hypertonic saline 30%. In the absence of billiary fistula,
the residual cavity was treated with alcohol mixed with
lipiodol. There was no anaphylactic shock, no complication
or relapse during the first 18 months. The hospitalization
period in this group was 24-72 hours (practically no
hospitalization).
Saglam proposed the laparoscopic technique as a method
for treating HHC (9). In 1996, Bickel et al reported 10 cases
of HHC treated laparoscopically without mortality or relapse
(9,11,12). In 1996, Alper reported 16 cases of HHC solved by
laparoscopy with 4 postoperative abscesses and no relapse
251
Table IV Recent studies regarding laparoscopic treatment of hepatic
hydatid cysts
Year Author No. cases
1996 Saglam (9) 6
1996 Khoury (11) 11
1996 Alper (13) 16
1998 Marks (4) 3
1998 Verma (5) 1
1998 Ertem (16) 12
2002 Kayaalp (15) 19
Present study 24
(13,14) (Table IV). Initially, Alper’s trial included 33 patients
for whom a laparoscopic intervention was decided; 11 cases
were not indicated for laparoscopy (multiple localizations
or relapse after classical treatment) and 22 cases remained
to be solved by laparoscopy. Among these, 6 cases were
converted because of adhesions or difficult localization.
The laparoscopic method implies the reduction of the
cyst with the extraction of proligera, intracystic and
subhepatic drainage. This procedure has many advantages
among which are the limitation of the dissection to the cystic
hepatic veins injuries. It is very important to protect the
surgical area with scolicidal substances in order to avoid
the dissemination in case of leakage of hydatid contents.
There are many scolicidal agents that have been used, but
two of them remain to dispute the place as first choice:
hypertonic saline 30% and peroxide solution10‰. Other
scolicidal agents, such as alcohol or formalin can produce
sclerosing cholangitis if they reach the biliary tract.
Peroxide solution 10‰ is by far the most effective
scolicidal agent but because of the effervescent properties,
it increases intracystic pressure with possible conse-
quences: the break of the cyst into the peritoneal cavity
followed by anaphylactic shock. In the case of biliary fistula,
the penetration of hydatid contents and peroxide solution
into the biliary ducts can produce their dilatation with
possible breaks or occurrence of sclerosing inflammation of
the papilla of Vater, as well as embolic accidents with gas or
hydatid vesicles. Peroxide solution is extremely useful in
protecting the surgical area in spite of its effervescent nature.
We used hypertonic saline as intracystic scolicidal agent in
17 cases (70.8%) and peroxide solution in 7 cases (29.2%).
The surgical area was protected with peroxide solution in 16
cases (66.66%) but we used also hypertonic saline. We did
not observe an increased plasma natrium level following
this procedure. Some surgeons use as a scolicidal agent
cetrimide 0.5% and chlorhexidine 0.05% in combination.
The evacuation of the hydatid content requires a
powerful aspirator and a trocar with a large diameter (at
least 10 mm) in order to extract all vesicles. After the
evacuation, a small operculectomy is performed, through
which the proligera is extracted and the tube is inserted for
intracystic drainage (4,15,16).
This technique has two major disadvantages: first, it
leaves a large residual cavity with the risk of residual abscess
(13); secondly, it presents the risk of relapse by incomplete
252
sterilization in case of calcified walls. Using laser or
electrocauterization, the risk of relapse decreases very much,
and the calcified walls can be destroyed. Laparo-scopy, in
comparison with the percutaneous technique, has many
advantages, mainly the possibility of controlling the location
of the cyst, and of protecting the surgical area from hydatid
leaks. It also allows the sterilization of the remaining walls,
the detection of possible biliary fistulas, the treatment of
biliary complications, and also the treatment of the cystic
cavity using the omentum.
Usually, postoperative care is easy, with an average
hospitalization of 8-10 days in the published trials. Drainage
is the cause of a prolonged postoperative period after
laparoscopic intervention. In our series, the average
postoperative hospitalization was 6.05 days (ranges 4-17),
prolonged drainage being the major cause of a longer stay.
Residual hepatic cavity disappeared in about 12 months
after the intervention, even in two months in some cases.
Until now (6 year follow up), we observed no relapse after
the laparoscopic cure of the HHC. Hydatid relapse has been
reported only in one study (Diez et al, 1998)(cit.16) and was
cured by laparoscopy.
These procedures should be considered with care
because of allergic and anaphylactic risk and because of
the risk of hydatid spreading. Moreover, the new scolicidal
agents, if administrated before and especially after surgical
intervention, can prevent recurrences. Mebendazole and
albendazole reduce as much as possible the risk of the
spreading of the hydatid cyst. Albendazole seems to be the
most recommended; Gil Grande et al. showed that albendazole
(10 mg/kg/b.i.d.) sterilizes the cyst in 72% of cases after the
first month of treatment and in 94% after 3 months of
treatment (6, 7). The serious side effect of albendazole is the
transient abnormality in the liver function tests. A weekly
check of aminotransferases is required and the treatment
should be stopped if these increase more than three times
above normal values.
In spite of reservations and doubts, the results obtained
until now show that hepatic hydatid disease may be treated
by a minimally invasive approach.
We consider that, if the hydatid cyst is fit for a minimally
invasive surgical approach, drug treatment should be given
for 3 months before the surgical intervention. If this is not
possible, medical treatment should applied for at least 2
weeks before surgery and then continued, after surgery, for
3 months. In Alper’s trial, the medical treatment was given
10 days before surgery and continued for 3 months after
surgery. No relapse was reported. In our trial, albendazole
was administrated only to 11 patients. We had no long-term
hydatid recurrence.
Conclusion
The classical surgical treatment of HHC implies major
costs due to prolonged hospitalization, so laparoscopic
Georgescu et al
surgery may be a solution. Its place in the treatment of
hydatid disease must be reconsidered for the benefit of
patients and of the society. The conversion rate (25%)
should not discourage surgeons, as the procedure is at the
beginning in our clinic and in Romania. This is why only
10% of our patients with HHC were operated laparo-
scopically. The shorter postoperative hospitalization, the
limited postoperative complications, the decreased
hospitalization costs, and the quick social and professional
reinsertion are arguments that have determined us to
recommend this surgical procedure.
References
1. Burlui D, Roºca M. The surgery of hepatic hydatid cyst. Ed Med
Bucureºti 1977
2. Ghelase F, Georgescu I, Nemeº R. Chirurgie generalã. Ed Did
Pedag Bucuresti, 1999, 291- 308
3. Proca E, Coman C, Coman B. Tratat de patologie chirurgicalã.
Patologie chirurgicalã toracicã. Ed Med Bucuresti 1991, 191-
233
4. Marks J, Mouiel J, Katkhouda N, Gugenheim J, Fabiani P.
Laparoscopic liver surgery. A report on 28 patients. Surg Endosc
1998; 12: 331-334
5. Verma GR, Bose SM. Laparoscopic treatment of hepatic hydatid
cyst. Surg Laparosc Endosc 1998; 8: 280-282
6. Gil-Grande LA, Boixeda D, Ledo L. Tratamiento actual de la
hydatidosis humana. Enferm Infect Microbiol Clin 1987; 5:
627-632
7. Gil-Grande LA, Rodriguez Caabeiro F, Prieto JG et al.
Randomised controlled trial of efficacy of albendazole in
intraabdominal hydatid disease. Lancet 1993; 342: 1269-
1272
8. Khoury G, Jabbour-Khoury S, Bikhazi K. Results of laparo-
scopic treatment of hydatid cysts of the liver. Surg Endosc
1996; 10: 57-59
9. Saglam A. Laparoscopic treatment of liver hydatid cysts. Surg
Laparosc Endosc 1996; 6: 16-21
10. Bastid C, Azar C, Doyer M, Sahel J. Percutaneous treatment of
cyst under sonographic guidance. Dig Dis Sci 1994; 39: 1576-
1580
11. Bickel A, Eitan A. The use of a large, transparent cannula, with
a beveled tip, for safe laparoscopic management of hydatid
cysts of liver. Surg Endosc 1995; 9: 1304-1305
12. Bickel A, Loberant N, Shtamler B. Laparoscopic treatment of
cyst of the liver: initial experience with a small series of patients.
J Laparoendosc Surg 1994; 4: 127-133
13. Alper A, Emre A, Acarli K, Bilge O, Ozden I, Ariogul O.
Laparoscopic treatment of hepatic hydatid disease. J
Laparoendosc Surg 1996; 6: 29-33
14. Alper A, Emre A, Hazar H et al. Laparoscopic surgery of hepatic
hydatid disease: initial results and early follow-up of 16 patients.
World J Surg 1995; 19: 725-728
15. Kayaalp C. Evacuation of hydatid liver cysts using laparoscopic
trocar. World J Surg 2002; 26: 1324-1327
16. Ertem M, Uras C, Karahasanoglu T, Erguney S, Alemdaroglu K.
Laparoscopic approach to hepatic hydatid disease. Dig Surg
1998; 15: 333- 336