Management of cystic echinococcosis complications and dissemination: where is the evidence?

Superinfection of a Dead Hepatic Echinococcal Cyst with a Cutaneous Fistulization

Cystic echinococcosis (CE), also known as "hydatid disease" (HD), is a zoonotic infection caused by the larval stage of Echinococcus granulosus, which infects humans as intermediate hosts through the orofecal route. Carried by the intestinal venous blood, the embryos released by the eggs of the tapeworms can reach every organ, especially the liver, turning into a hydatid cyst. Usually asymptomatic, the cysts can be incidentally detected through radiological examinations performed for other reasons. We show an unusual case of superinfection of a hydatid cyst with typical radiological features of inactivity (WHO-type CE5) with an even rarer skin fistulization passing through a subcutaneous-abdominal abscess involving the right iliac muscle.

[Trans-hepatico cystic coledochostomy for the opening hydatid cyst in the biliary tract: Indications and outcome evaluation of 25 cases]

The treatment of hydatid cysts of the liver opened in the bile ducts is sometimes difficult and complex. The trans-hepaticocystic coledochostomy (CTHK) is one of these processes. We conducted a review of the indications for this surgical procedure and its perioperative outcomes through a series of 25 patients and then we analyzed predictor factors of complications. During the period's study, 909 patients with liver hydatid cyst went under the surgery. Ninety two (92, i.e. 10.1%) of them had an opening in the bile ducts through a large fistula. Twenty five (25, i.e. 27%) had a trans-hepaticocystic coledochostomy. The sex ratio was 0.6. The population was young with an average age of 47 years. The trans-hepaticocystic coledochostomy was performed because of a thick pericyst associated with a nonsutured fistula in 18 cases, a voluminous residual cavity with a soft pericyst but the fistula was unexposed in six cases and in a case where the pericyst was thick, fistula was exposed. Its suture was associated with a high risk of bile duct stenosis. Specific morbidity was 20% due to a length of the intraductal coledochostomy under 2 cm (P = 0.016), the absence of an epiploplasty (P = 0.004) and the existence of a leak of contrast material outside the fistula on the cholangiography (P = 0.005). The trans-hepaticocystic coledochostomy is a safe and reliable technique, often indicated when other conservative methods are failing. The application of its technical requirements and avoidance of mounting errors allow reducing its morbidity.

The Echinococcoses: Diagnosis, Clinical Management and Burden of Disease

The echinococcoses are chronic, parasitic diseases that are acquired after ingestion of infective taeniid tapeworm eggs from certain species of the genus Echinococcus. Cystic echinococcosis (CE) occurs worldwide, whereas, alveolar echinococcosis (AE) is restricted to the northern hemisphere, and neotropical echinococcosis (NE) has only been identified in Central and South America. Clinical manifestations and disease courses vary profoundly for the different species of Echinococcus. CE presents as small to large cysts, and has commonly been referred to as 'hydatid disease', or 'hydatidosis'. A structured stage-specific approach to CE management, based on the World Health Organization (WHO) ultrasound classification of liver cysts, is now recommended. Management options include percutaneous sterilization techniques, surgery, drug treatment, a 'watch-and-wait' approach or combinations thereof. In contrast, clinical manifestations associated with AE resemble those of a 'malignant', silently-progressing liver disease, with local tissue infiltration and metastases. Structured care is important for AE management and includes WHO staging, drug therapy and long-term follow-up for at least a decade. NE presents as polycystic or unicystic disease. Clinical characteristics resemble those of AE, and management needs to be structured accordingly. However, to date, only a few hundreds of cases have been reported in the literature. The echinococcoses are often expensive and complicated to treat, and prospective clinical studies are needed to better inform case management decisions.

[Disseminated peritoneal hydatidosis manifested as intestinal ischaemia]

BACKGROUND

The hydatid disease, or echinococcosis, is endemic in Mediterranean countries, as well as in Australia, Asia, Africa, South America, and Canada. Among its complications is intraperitoneal rupture, a rare form of presentation, with highly variable symptoms. The treatment of choice is surgery plus adjuvant medical treatment in most patients.

OBJECTIVE

A case is presented of a patient with disseminated peritoneal hydatidosis manifested as intestinal ischaemia.

CLINICAL CASE

A 50-year-old male was admitted to the emergency room with a history of chronic abdominal pain that worsened in the last 24hours. He showed signs of sepsis in the physical examination and was subjected to surgery, in which intestinal ischaemia was found due to a disseminated peritoneal cystic disease, which had led to mesentery retraction. An intestinal resection with an end-ileostomy was performed. The results of the biopsy of the cystic lesions was disseminated peritoneal echinococcosis. Medical treatment was started with albendazole and praziquantel.

CONCLUSION

This case shows a rare presentation of disseminated peritoneal hydatidosis, which led to intestinal ischaemia.

Current status of diagnosis and treatment of hepatic echinococcosis

Echinococcus granulosus (E. granulosus) and Echinococcus multilocularis (E. multilocularis) infections are the most common parasitic diseases that affect the liver. The disease course is typically slow and the patients tend to remain asymptomatic for many years. Often the diagnosis is incidental. Right upper quadrant abdominal pain, hepatitis, cholangitis, and anaphylaxis due to dissemination of the cyst are the main presenting symptoms. Ultrasonography is important in diagnosis. The World Health Organization classification, based on ultrasonographic findings, is used for staging of the disease and treatment selection. In addition to the imaging methods, immunological investigations are used to support the diagnosis. The available treatment options for E. granulosus infection include open surgery, percutaneous interventions, and pharmacotherapy. Aggressive surgery is the first-choice treatment for E. multilocularis infection, while pharmacotherapy is used as an adjunct to surgery. Due to a paucity of clinical studies, empirical evidence on the treatment of E. granulosus and E. multilocularis infections is largely lacking; there are no prominent and widely accepted clinical algorithms yet. In this article, we review the diagnosis and treatment of E. granulosus and E. multilocularis infections in the light of recent evidence.

Hydatid cyst of the gallbaldder: A systematic review of the literature

AIM

To evaluate all the references about primary gallbladder hidatidosis looking for best treatment evidence.

METHODS

Search: 1966-2015 in MEDLINE, Cochrane Library, SciELO, and Tripdatabase.

KEY WORDS

"gallabladder hydatid disease" and "gallbladder hydatid cyst". We found 124 papers in our searches but only 14 papers including 16 cases were about hydatid cyst of the gallbladder (GBHC).

RESULTS

Eight cases of GBHC were women and seven men. One not mentioned. Median age was 48.3 years. The most frequent clinical symptom was abdominal pain (94%) usually in the right upper quadrant. Ultrasound was performed in ten patients (62.5%) but in most cases a combination of several techniques was performed. The location of the cysts was intravesicular in five patients. Five patients presented GBHC and liver hydatid cysts. Two patients presented cholelithiasis and one choledocholithiasis. The most frequent surgical technique was cholecystectomy by laparotomy (81.25%). Simultaneous surgery of liver cysts was carried out in five cases. Eleven patients did not present postoperative complications, but one died. The mean hospital stay was seven days. No recurrence of GBHC was recorded.

CONCLUSION

In GBHC, the most frequent symptom is right hypocondrium pain (evidence level V). Best diagnostic methods are ultrasound and computed tomography (level V, grade D). Suggested treatment is open cholecystectomy and postoperative albendazole (level V, grade D) obtaining good clinical results and none relapses.

An Unusual Case of Anaphylaxis after Blunt Abdominal Trauma

BACKGROUND

Due to current human migratory patterns, emergency physicians in developed countries are facing emergent clinical presentations of neglected tropical diseases with increasing frequency. In those situations, the clinician's diagnosis is often delayed due to a lack of familiarity with the disease.

CASE REPORT

We present the case of a 25-year-old Peruvian man who presented to the Emergency Department complaining of dyspnea and abdominal pain after upper abdominal trauma. His physical examination revealed mouth and eyelid edema in association with epigastric pain. An abdominal computed tomography scan revealed a liver hydatid cyst. Emergent surgical evacuation of the cyst was required to control the anaphylactic reaction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Anaphylaxis in the setting of a complicated hydatid cyst is a life-threatening disease. Critical care management and emergent surgical evacuation of the cyst are indicated.

Changing paradigms in the surgical management of cystic liver hydatidosis improve the postoperative outcomes

AIM OF THE STUDY

Our aim was to propose and examine the outcomes of a comprehensive strategy for the management of cystic liver hydatidosis (CLH) based on extensive intraoperative assessments and optimal management of cystobiliary communications.

BACKGROUND DATA

Although operative intervention remains the preferred treatment for CLH, and the presence of a cystobiliary communication remains a well-established predictive factor for postoperative complications, no internationally accepted management strategy integrates the specific management of cystobiliary communication into the choice of surgical approach.

METHODS

Early postoperative outcomes were compared before (1990-2004; P1 group; n = 664) and after (2005-2013; P2 group; n = 156) the implementation of a CLH surgical management strategy for CLH in our overall group of patients in subgroups selected by risk factors (as determined by multivariate analysis), and in 2 propensity score-matched groups.

RESULTS

Specific complications related to the hepatic procedure (intraabdominal complications) were independently associated with the presence of ≥ 3 cysts (P = .013), a fibrotic pericyst (P = .005), a cystobiliary communication (P < .001), and the P1 treatment period (P = .002). Between P1 and P2 groups, the rate of specific complications decreased in the overall group of patients with CLH (18.3% vs 4.5%; P < .001). The rate also decreased in risk factor-based subgroups: patients with ≥ 3 cysts (31.0% vs 4.0%; P = .005), a fibrotic pericyst (23.1% vs 9.2%; P = .011), and a cystobiliary communication (33.0% vs 13.2%; P = .006). After propensity score matching among 123 well-balanced matched pairs of patients, the overall complication rate, specific hepatic surgery-related complication rate, and median duration of hospital stay decreased between the P1 and P2 groups: 23.6% vs 12.2% (P = .02), 21.1% vs 4.9% (P < .001), and 7 vs 5 days (P < .001), respectively.

CONCLUSION

Implementation of a CLH surgical management strategy based on specific intraoperative assessment and optimal management of cystobiliary communications improved early postoperative outcomes.

Development of a cutaneous fistula following hepatic cystic echinococcosis

Hydatid cyst is an infectious disease characterized by cysts formed primarly within the gastrointestinal tract by echinococci. Hepatic hydatid disease, which is the most common form, remains asymptomatic until complications occur. In this report, we present an 80 years old patient who presented with a hepatic hydatid cyst which fistulized to the abdominal skin into the Emergency Department. Computed tomography of the abdomen showed inactive grade 5 cyst. Drainage without removal of the cyst failed to reveal active disease but the microbiological examination showed Klebsiella pneumonia that was sensitive to ampicillin-sulbactam as the causative agent. The treatment of the cyst with a combination of surgical and medical treatment was the successful treatment of Hepatic Hydatid Disease presenting with a cutaneous fistula.

Surgical management of liver hydatid disease: subadventitial cystectomy versus resection of the protruding dome

BACKGROUND

The aim of this study was to compare postoperative outcome and long-term results after management of liver hydatid cysts (LHC) by subadventitial cystectomy (SC) and resection of the protruding dome (RPD) in two tertiary liver surgery centers.

METHODS

Medical records of 52 patients who underwent SC in one center, and 27 patients who underwent RPD in another center between 1991 and 2011 were reviewed. Patients underwent long-term follow-up, including serology tests and morphological examinations.

RESULTS

Postoperative mortality was nil. The rate of severe morbidity was 7.7 and 22% (p = 0.082), while the rate of serological clearing-up was 20 and 13.3% after SC and RPD, respectively (p = 1.000). After a mean follow-up of 41 months (1-197), four patients developed a long-term cavity-related complication (LTCRC) after RPD (including one recurrence) and none after SC (p = 0.012). All LTCRCs occurred in patients with hydatid cysts located at the liver dome; three required an invasive procedure by either puncture aspiration injection re-aspiration (N = 1) or repeat surgery (N = 2).

CONCLUSIONS

RPD exposes to specific LTCRC, especially when hydatid cysts are located at the liver dome, while SC allows ad integrum restoration of the operated liver. Therefore, SC should be considered as the standard surgical treatment for LHC in experienced hepato-pancreato-biliary centers.

Surgical treatment of multiple hydatid cysts in the liver of a pediatric patient

Multiple hydatid cysts in the liver rarely occur in the pediatric population. Here, we present the case of a 16-year-old girl who presented with six hydatid cysts in the liver. The cysts were surgically removed and all found to be infertile. Interestingly, the patient had post-operative eosinophilia. From this experience, we conclude that individualized treatment is necessary for patients with multiple hydatid cysts.

Non-surgical and non-chemical attempts to treat echinococcosis: do they work?

Cystic echinococcosis (CE) and alveolar echinococcosis (AE) are chronic, complex and neglected diseases. Their treatment depends on a number of factors related to the lesion, setting and patient. We performed a literature review of curative or palliative non-surgical, non-chemical interventions in CE and AE. In CE, some of these techniques, like radiofrequency thermal ablation (RFA), were shelved after initial attempts, while others, such as High-Intensity Focused Ultrasound, appear promising but are still in a pre-clinical phase. In AE, RFA has never been tested, however, radiotherapy or heavy-ion therapies have been attempted in experimental models. Still, application to humans is questionable. In CE, although prospective clinical studies are still lacking, therapeutic, non-surgical drainage techniques, such as PAIR (puncture, aspiration, injection, re-aspiration) and its derivatives, are now considered a useful option in selected cases. Finally, palliative, non-surgical drainage techniques such as US- or CT-guided percutaneous biliary drainage, centro-parasitic abscesses drainage, or vascular stenting were performed successfully. Recently, endoscopic retrograde cholangiopancreatography (ERCP)-associated techniques have become increasingly used to manage biliary fistulas in CE and biliary obstructions in AE. Development of pre-clinical animal models would allow testing for AE techniques developed for other indications, e.g. cancer. Prospective trials are required to determine the best use of PAIR, and associated procedures, and the indications and techniques of palliative drainage.

ACG clinical guideline: the diagnosis and management of focal liver lesions

Focal liver lesions (FLL) have been a common reason for consultation faced by gastroenterologists and hepatologists. The increasing and widespread use of imaging studies has led to an increase in detection of incidental FLL. It is important to consider not only malignant liver lesions, but also benign solid and cystic liver lesions such as hemangioma, focal nodular hyperplasia, hepatocellular adenoma, and hepatic cysts, in the differential diagnosis. In this ACG practice guideline, the authors provide an evidence-based approach to the diagnosis and management of FLL.

In vivo study of the efficacy of the aromatic water of Zataria multiflora on hydatid cysts

Gas chromatography (GC) and gas chromatography-mass spectrometry (GC-MS) were employed to determine the chemical composition of the essential oil (EO) from aromatic water (AW) of Zataria multiflora. Thymol (66.9%), carvacrol (15.2%), and carvone (7.3%) were found to be the major EO constituents. Eighty laboratory BALB/c mice were infected intraperitoneally by injection of 1,500 viable protoscolices and were divided into prevention (40 mice) and therapeutic (40 mice) groups. To prove the preventive effect of the Z. multiflora AW on development of hydatid cysts, the 40 infected mice were allocated into three treatment groups, including the albendazole group (10 mice that received 150 mg/kg body weight/day for 10 days), the Z. multiflora AW group (15 mice that received 20 ml/liter in drinking water for 8 months), and a control group (15 mice that received no treatment). To estimate the therapeutic effect of the Z. multiflora AW on the hydatid cyst, after 8 months of infection, the 15 remaining mice were allocated into three experimental treatment groups of five animals each, including the albendazole group (300 mg/kg/day for 20 days), Z. multiflora AW group (40 ml/liter in drinking water for 30 days), and control group (no treatment). All mice were then euthanized, and the sizes and weights of the cysts as well as their ultrastructural changes were investigated. The weights and sizes of the hydatid cysts significantly decreased upon treatment with the Z. multiflora AW in both the preventive and therapeutic groups (P < 0.05). The results of scanning electron microscopy also showed considerable damage in the germinal layer of the hydatid cysts recovered from the treated animals.

Preventive and therapeutic effects of Zataria multiflora methanolic extract on hydatid cyst: an in vivo study

The phenolic compounds of Zataria multiflora extract, were identified by HPLC analysis. Gallic acid, catechin, caffeic acid, and quercetin were found to be the major phenolic compounds. Eighty healthy laboratory Balb/C mice were infected intraperitoneally by injection of 1500 viable protoscoleces and were divided into prevention (40 mice) and therapeutic (40 mice) groups. To prove the preventive effect of Z. multiflora extract on development of hydatid cyst, the 40 infected animals were allocated into three treatment groups including Z. multiflora (4 g/l in drinking water for 8 months), albendazole (150 mg/kg BW/day for 10 days) and untreated (control) group. To estimate the therapeutic effect of Z. multiflora extract on the hydatid cyst, after 8 months of infection, the infected mice were allocated into three experimental treatment groups including Z. multiflora (8 g/l in drinking water for 30 days), albendazole (300 mg/kg BW/day for 20 days) and untreated (control) group. At the end of the treatment period, all mice were euthanized and necropsied, the hydatid cysts were carefully removed, weighed and their size were recorded. Weight and size of the hydatid cysts significantly decreased (p<0.05) upon the treatment with Z. multiflora extract in both prevention and therapeutic groups. The germinal layer of the hydatid cysts recovered from the treated mice, either from the prevention or therapeutic group, were completely damaged at ultrastructural level by scanning electron microscopy.

Pulmonary hydatid disease is difficult recognized in children

PURPOSE

Pulmonary hydatid disease is a significant health problem for children in endemic areas. Pulmonary hydatid disease is more frequent than hepatic hydatid disease in children. The aim of this study was to evaluate the characteristics of pulmonary hydatid disease for children in our province which is endemic for echinococcosis.

PATIENTS AND METHODS

This study was performed retrospectively between 2007 and 2012 by reviewing the medical records of patients (≤17 years) who were diagnosed with pulmonary hydatid disease. The medical records of these patients were evaluated with respect to the demographic characteristics of patients, management strategies, length of hospital stay, and outcomes.

RESULTS

A total of 120 (52.9% boys and 46.3% girls) patients with the diagnosis of pulmonary hydatid disease were enrolled in this study. The mean age was 10.15 ± 3.93 years. The significant numbers of patients were admitted with a ruptured hydatid disease and managed with lung preservation. The mean follow-up was 11.3 ± 3.8 (3-24) months. Recurrence was detected in three patients during follow-up.

CONCLUSION

Pulmonary hydatid disease is usually symptomatic. Hydatid disease must be considered in differential diagnosis while evaluating thoracic lesions in endemic areas.

Radical versus conservative surgical treatment of liver hydatid cysts

BACKGROUND

The management of liver hydatid cysts is controversial. Surgery remains the basic treatment, and can be divided into radical and conservative approaches. The purpose of this study was to compare the results of radical and conservative surgery in the treatment of liver hydatid cysts.

METHODS

Data from all patients with liver hydatid cyst treated in a hepatobiliary surgical unit, between January 1990 and December 2010, were retrieved from a retrospective database. To minimize selection bias, propensity score matching was performed, based on 17 variables representing patient characteristics and operative risk factors. The primary outcome measure was hydatid cyst recurrence.

RESULTS

One hundred and seventy patients were matched successfully, representing 85 pairs who had either a radical or a conservative approach to surgery. At a median (i.q.r.) follow-up of 106 (59–135) and 87 (45–126) months in the radical and conservative groups respectively, the recurrence rate was 4 per cent in both groups (odds ratio (OR) 1.00, 95 per cent confidence interval 0.19 to 5.10). There were no statistically significant differences between conservative and radical surgery in terms of operative mortality (1 versus 0 per cent; P=0.497), deep abdominal complications (12 versus 16 per cent; OR 1.46, 0.46 to 3.49), overall postoperative complications (15 versus 19 per cent; OR 1.28, 0.57 to 2.86), reinterventions (0 versus 4 per cent; P=0.246) and median hospital stay (7 (i.q.r. 5–12) days in both groups; P=0.220).

CONCLUSION

This study could not demonstrate that radical surgery reduces recurrence and no trend towards such a reduction was observed.

Frank intrabiliary rupture in liver hydatidosis located in the hilar plate: a surgical challenge

BACKGROUND

Frank intrabiliary rupture (FIR) is a severe complication that occurs in around 30% of patients with liver hydatidosis. When FIR is present, the contents of the cyst may pass into the common bile duct and cause a variety of complications. If the FIR is located in the hilar confluence, surgical repair is a challenge. Currently there are no data regarding its optimum treatment.

MATERIAL AND METHODS

Between May 2007 and December 2012, we treated 59 patients with liver hydatidosis. Four patients, all women, with a mean age of 51.7 years, had hydatid cysts located between segments IVb and V and FIR affecting the hilar plate. In 3 cases, the initial clinical condition was obstructive jaundice. The fourth patient presented recurrence after having undergone two operations as a child.

RESULTS

In each patient a major hepatectomy was performed with hilar plate reconstruction (3 left and 1 right). Morbidity included mild biliary fistula (1 patient) and abdominal collection resolved by percutaneous drainage (1 patient). There was no mortality. During follow-up (47 months), no recurrences of the disease or biliary strictures were recorded.

CONCLUSIONS

FIR is a severe complication of liver hydatidosis. When it is located in the hilar confluence, liver resection may be the best surgical option for definitive resolution of the problem.

Primary multilocular hydatid cyst of neck with unique presentation: a rare case report and literature review

Hydatid cyst (HC) is a parasitic infection caused by larva form of Echinococcus. It occurs frequently in liver and lungs. Primary HC of neck is extremely rare occurrence and here we report it with unusual presentation. A 35-year-old male presented with slowly growing painless swelling in right side of neck for 6-7 years. The swelling measured 11 × 6 cm and cough impulse elicited on local examination. MRI scan revealed a multiloculated cystic lesion in neck. Fine needle aspiration cytology yielded fluid aspirate and smear showed fragment of laminated membrane, suggestive of HC. The intact cyst was removed surgically and histopathologic examination confirmed the diagnosis of HC. Both clinicians and radiologists should consider HC in differential diagnosis of head and neck swelling for proper management.

A single-center large-volume experience in the surgical management of hydatid disease of the lung with and without extrapulmonary involvement

BACKGROUND

We compared the number of incisions, surgical procedures, hospital duration, and complications in hydatid cyst patients with unilateral or bilateral thoracic involvement and concomitant involvement of the extrathoracic organs.

METHODS

A total of 76 hydatid cyst cases surgically treated between the years 2007 and 2012 were divided into three groups according to radiological evidence of other organ involvement and surgical procedures: group 1 had only unilateral thoracic involvement and a single incision; group 2 had additional involvement of the contralateral thoracic side or extrathoracic organs and at most two incisions were performed at the same session; and group 3 had two or more incisions performed at separate sessions in addition to the involvement features of group 2.

RESULTS

We had 46 (60.5 %) cases with only thoracic involvement and 30 others (39.5 %) with extrathoracic organ involvement. Complications were seen in only one patient each in the first and second groups, and in 6 patients in the third group. Duration of hospital stay was 7.04 ± 0.86 (5-9) days in group 1.8.33 ± 1.87 (7-13) days in group 2, and 13.95 ± 2.03 (9-18) days in group 3.

CONCLUSIONS

Although multiple session surgery is used to decrease the risk of complications, contamination, and infection in multiple or bilateral pulmonary hydatid cyst cases, or in patients with other organ involvement, single-session surgery can be used in selected cases taking into account the operative trauma, financial consequences, and psychological profile.

Spontaneous intraperitoneal rupture of a hepatic hydatid cyst with subsequent anaphylaxis: a case report

Hydatid cyst rupture into the abdomen is a serious complication of cystic hydatid disease of the liver (Cystic Echinococcosis) with an incidence of up to 16% in some series and can result in anaphylaxis or anaphylactoid reactions in up to 12.5% of cases. At presentation, 36–40% of hydatid cysts have ruptured or become secondarily infected. Rupture can be microscopic or macroscopic and can be fatal without surgery. Hydatid disease of the liver is primarily caused by the tapeworm Echinococcus granulosus and occurs worldwide, with incidence of up to 200 per 100,000 in endemic areas. Our case describes a 24-year-old Bulgarian woman presenting with epigastric pain and evidence of anaphylaxis. Abdominal CT demonstrated a ruptured hydatid cyst in the left lobe of the liver. A partial left lobe hepatectomy, cholecystectomy, and peritoneal washout was performed with good effect. She was treated for anaphylaxis and received antihelminthic treatment with Albendazole and Praziquantel. She made a good recovery following surgery and medical treatment and was well on follow-up. Intraperitoneal rupture with anaphylaxis is a rare occurrence, and there do not seem to be any reported cases from UK centres prior to this.

Minimal invasive treatment of abdominal multiorgan echinococcosis

Hydatid disease is a severe zoonosis, exerting a high economic and social impact through its numerous complications, leading to disabilities, even death. Because of technical developments, especially the increasing experience of surgeons, laparoscopic surgery has been extended so that it can be successfully applied to abdominal hydatid cysts. We present the case of a 16-year-old patient who came to our clinic for upper abdominal pain. The abdominal ultrasonography and computed tomography (CT) showed 2 cyst-like tumors, with hydatid features: one affecting the eighth liver segment and the other located at the upper pole of the spleen. We performed the surgical intervention using a laparoscopic approach, with an uneventful postoperative follow-up and the patient was discharged home on postoperative day 4. The postoperative images at 6 and 12 months showed a decrease in size of the remnant cystic cavities.

In vitro and in vivo treatments of Echinococcus granulosus with Huaier aqueous extract and albendazole liposome

The aim of this study was to investigate the in vitro and in vivo efficacies of chemotherapy employing albendazole liposome (L-ABZ), Huaier aqueous extract, and a Huaier aqueous extract/L-ABZ combination against Echinococcus granulosus. Protoscolices of E. granulosus were incubated in vitro with the two drugs, either separately or in combination, at the following final concentrations: 2 mg/mL Huaier aqueous extract, 10 μg/mL L-ABZ, and 2 mg/mL Huaier aqueous extract + 10 μg/mL L-ABZ. Huaier aqueous extract and L-ABZ displayed slower protoscolicidal activity when applied separately than when used in combination. The maximum protoscolicidal effect was found with the combination Huaier aqueous extract + L-ABZ. Despite the low Huaier aqueous extract + L-ABZ concentrations used, protoscolex viability dropped rapidly. In vivo studies were performed on mice injected with protoscolices of E. granulosus. Huaier aqueous extract and L-ABZ were administered three times a week for a period of 4 months by the oral route. Huaier aqueous extract in E. granulosus-infected mice was effective. Combined application of both drugs did increase the treatment efficacy. In conclusion, the outcomes obtained clearly demonstrated that in vitro and in vivo treatment with Huaier aqueous extract and L-ABZ is effective against E. granulosus.

Cestode infestations: hydatid disease and cysticercosis

Although humans can be definitive hosts for cestodes (tapeworms), major pathologic conditions occur during cestode larval stages when humans serve as the intermediate host for these parasites. The most relevant forms of human disease caused by cestode larvae are echinococcosis, caused by Echinococcus granulosus (cystic echinococcosis) and Echinococcus multilocularis (alveolar echinococcosis), and cysticercosis, caused by Taenia solium. These infections occur worldwide, but their relevance is particularly high in developing countries, where poor hygiene conditions facilitate the transmission of the parasites. The therapeutic approach is often complex, requiring surgery and/or chemotherapy or, in the case of cystic echinococcosis, percutaneous treatments.

Cysto-biliary communication in liver hydatidosis

BACKGROUND

Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree.

AIM

The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree.

RESULTS

Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm.

CONCLUSIONS

The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

Rupture of right hepatic duct into hydatid cyst

Echinococcal disease can develop anywhere in the human body. The liver represents its most frequent location. Hepatic hydatid cysts may rupture into the biliary tract, thorax, peritoneum, viscera, digestive tract or skin. We report a rare case with rupture of the right hepatic duct into a hydatid cyst in a woman with known hydatid disease and choledocholithiasis. The increased intra-luminal pressure in the biliary tree caused the rupture into the adjacent hydatid cyst. The creation of the fistula between the right hepatic duct and the hydatid cyst decompressed the biliary tree, decreased the bilirubin levels and offered a temporary resolution of the obstructive jaundice. Rupture of a hydatid cyst into the biliary tree usually leads to biliary colic, cholangitis and jaundice. However, in case of obstructive jaundice due to choledocholithiasis, it is possible that the cyst may rupture by other way around while offering the patient a temporary relief from his symptoms.

Peritoneal echinococcosis: anatomoclinical features and surgical treatment

BACKGROUND

Peritoneal hydatid disease is a rare and poorly known disease. We report our experience with 17 patients treated for peritoneal echinococcosis. The main objectives were to analyze and discuss the specific features of the anatomic peritoneal lesions along with their surgical treatment.

METHODS

We analyzed retrospectively all patients treated in our unit for peritoneal echinococcosis between January 2001 and December 2008. Preoperative description of the lesions, and the surgical procedures were carefully reported.

RESULTS

Peritoneal hydatidosis represented 6.3% of all abdominal localizations. There were 10 women (58.8%) and 7 men (41.2%). Median age was 34 years. Ten patients (58.8%) had had previous surgery for abdominal echinococcosis. Ten patients (58.8%) had synchronous abdominal localization of hydatid disease, and two patients had synchronous pulmonary localization. Sixteen patients were operated on by laparotomy. We classified the anatomic lesions into four groups: localized form (n = 6, 37.4%), disseminated form (n = 8, 50%), "hydatid carcinomatosis" (n = 3, 18.7%), hydatidoperitoneum (n = 1, 6.25%). One patient had a ruptured hydatid cyst of the left liver. We performed total cystectomies in 10 patients, partial cystectomies in 8 patients, and omentectomy in 5 patients. Two patients (12.5%) had surgical complications. One patient (6.25%) died owing to a pulmonary embolism. Anthelmintic chemotherapy was given to two patients before surgery and to nine patients postoperatively. Recurrences were seen in two patients (14.2%).

CONCLUSIONS

Peritoneal echinococcosis can cause a large variety of specific and complex anatomic lesions. The disseminated form is the most common, and therefore the surgical treatment is challenging in most cases.

Peritoneal and hepatic hydatid disease causing major bile duct destruction

Echinococcosis is endemic in Mediterranean regions and is found primarily in the liver. Biliary fistula is a common complication, but major biliary duct involvement is very rare, and occurs in 0.47% of patients with hepatic hydatid disease. Cyst rupture causing secondary peritoneal hydatidosis is a rare but serious complication. We report the case of a 27-year-old man with multiple peritoneal and hepatic hydatid cysts. The patient came to our attention with cholestatic jaundice. Imaging exams showed numerous peritoneal cysts and massive hydatid disease of the liver, which involved the hepatic confluence, with destruction of the right hepatic duct and fistula formation to the left hepatic duct. The patient was treated with pre-operative albendazole therapy and radical surgery, which consisted of resection of all peritoneal cysts and extended right hepatectomy with biliary reconstruction. No recurrence was seen on CT investigations on the 12th month following surgery. Radical surgical approach remains the treatment of choice.

Management of a ruptured hydatid cyst involving the ribs: Dealing with a challenging case and review of the literature

INTRODUCTION

Hydatid liver cysts can rupture into neighboring structures in 15-60% of patients, and most often involves the bile duct, the bronchi, and the peritoneal/pleural cavities. Rarely, chest or abdominal wall involvement occurs that are challenging to manage. This case report and literature review describes the management of patients with chest wall and rib invasion.

PRESENTATION OF CASE

A 74-year-old woman, of Spanish origin, presented with right upper quadrant abdominal pain and tender localized swelling. On computer tomography (CT) assessment, the rupture of a hydatid cyst into the right anterior chest wall was identified. Partial involvement of the 10th and 11th rib were noted. The diagnosis was confirmed by a serological test. Surgical treatment involved a radical en bloc right hepatic resection together with resection of the involved ribs, diaphragm and subcutaneous tissue. Primary diaphragm and wall closures were performed. The postoperative course was uneventful with three weeks of albendazole treatment. CT follow-up at six months demonstrated the absence of recurrence.

DISCUSSION

Complete resection is the gold standard treatment of patients with hydatid cysts with the aim to remove all parasitic and pericystic tissues.

CONCLUSION

The present report illustrates that an aggressive surgical en bloc resection is feasible and should be preferred for the treatment of hydatid cysts with rupture into the chest wall, even when the ribs are involved.

[Pelvic hydatid cyst: differential diagnosis with a bacterial abscess with cutaneous fistula]

The genus Echinococcus is a worldwide tapeworm with a two host mammalian cycle. Among the six described species, Echinococcus granulosus (EG) and Echinococcus multilocularis are the most important in respect to their public health importance. Infected human, as an intermediate accidental host, presents single to several cysts, mainly located in the liver. We are describing the clinical, radiological and histological findings of a woman born in Morocco, recently arrived in France and presenting a pelvic hydatid cyst. The misknowledge of such a diagnosis conducted to initial surgery and thus a risk of further metastasised lesions. We are suggesting that any hypoechogenic pelvic lesion in a patient originated from a Mediterranean country should be considered as a pelvic localization of EG.

Evaluation of nitazoxanide for the treatment of disseminated cystic echinococcosis: report of five cases and literature review

We aimed to evaluate the effectiveness of nitazoxanide in disseminated cystic echinococcosis (DCE) that failed to respond to surgical and antiparasitic therapy. We report on seven patients (five of them with bony involvement): two cases from the literature and five patients who were included in a compassionate trial of nitazoxanide therapy in our hospital. Median follow-up time until nitazoxanide therapy was 12 years and all patients had received prior medical treatment and extensive surgery. Nitazoxanide (500 mg/12 h) in combination with albendazole, with/without praziquantel, was administered for 3-24 months. Three patients improved: one with muscle involvement (clinico-radiological response), one with lung involvement (radiological response), and another with soft tissue and bony involvement (clinico-radiological response of soft tissue cysts). There was one discontinuation after 15 days of starting therapy. Nitazoxanide combination therapy could have a role in the treatment of DCE when there is no bony involvement. Long-term safety profile seems to be favorable.

Unusual locations of hydatid disease: diagnostic and surgical management of a case series

BACKGROUND

Hydatid disease is endemic in many areas of the world, where it is an important public health problem. The aim of this study was to describe a series of patients with atypically located primary hydatid disease, accompanied by a literature review.

METHODS

Six male and four female patients with atypically located hydatid cysts who presented to the Kars State Hospital between September 2004 and March 2008 were evaluated. The mean age was 42.5 years (range 17-72 years). Hydatid cysts were identified by using a combination of serology tests, ultrasonography, and computed tomography (CT).

RESULTS

Six of the patients underwent surgical treatment. Three patients (two with pericardial hydatid involvement and one with pancreatic involvement) were sent to a tertiary medical center for surgery, and one patient died from cardiac and renal failure two days after diagnosis.

CONCLUSIONS

Although this disease is seen most often in the liver and lungs, it can be found in any part of the body. Hydatid disease must be considered in the differential diagnosis of cystic lesions, especially in patients who have spent time in endemic areas.

Pulmonary cystic echinococcosis

PURPOSE OF REVIEW

Pulmonary cystic echinococcosis, a zoonosis caused by the larvae of the dog tapeworm Echinococcus granulosus, is considered as a major public health problem in countries where dogs are used to care for large herds. Despite its frequency and widespread endemicity, the literature on pulmonary cystic echinococcosis is scarce and not systematic. We aimed to summarize currently available information to provide a comprehensive overview for clinicians facing cases of pulmonary cystic echinococcosis.

RECENT FINDINGS

Despite discrepancies in the literature, some patterns can be discerned. The ratio of lung:liver involvement is higher in children than in adults. Most pulmonary cases are discovered incidentally on routine radiograph evaluation; also most infected individuals remain asymptomatic until the cyst enlarges sufficiently to cause symptoms. Symptoms are usually caused by mass effect from the cyst. Complications (cyst rupture, aggregated infection) change the clinical presentation, producing cough, chest pain, hemoptysis, or vomica. Diagnosis is obtained by chest radiographs or computed tomography, and supported by serology. Presurgical chemotherapy reduces the chances of seeding and recurrence. Treatment with benzimidazoles is an option when surgery is unavailable or complete removal is unfeasible.

SUMMARY

Diagnosis of pulmonary cystic echinococcosis is primarily made by imaging, and surgery remains the main therapeutic approach.

Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans

The earlier recommendations of the WHO-Informal Working Group on Echinococcosis (WHO-IWGE) for the treatment of human echinococcosis have had considerable impact in different settings worldwide, but the last major revision was published more than 10 years ago. Advances in classification and treatment of echinococcosis prompted experts from different continents to review the current literature, discuss recent achievements and provide a consensus on diagnosis, treatment and follow-up. Among the recognized species, two are of medical importance -Echinococcus granulosus and Echinococcus multilocularis - causing cystic echinococcosis (CE) and alveolar echinococcosis (AE), respectively. For CE, consensus has been obtained on an image-based, stage-specific approach, which is helpful for choosing one of the following options: (1) percutaneous treatment, (2) surgery, (3) anti-infective drug treatment or (4) watch and wait. Clinical decision-making depends also on setting-specific aspects. The usage of an imaging-based classification system is highly recommended. For AE, early diagnosis and radical (tumour-like) surgery followed by anti-infective prophylaxis with albendazole remains one of the key elements. However, most patients with AE are diagnosed at a later stage, when radical surgery (distance of larval to liver tissue of >2cm) cannot be achieved. The backbone of AE treatment remains the continuous medical treatment with albendazole, and if necessary, individualized interventional measures. With this approach, the prognosis can be improved for the majority of patients with AE. The consensus of experts under the aegis of the WHO-IWGE will help promote studies that provide missing evidence to be included in the next update.