Percutaneous treatment of pulmonary hydatid cysts

Percutaneous treatment of liver hydatid cysts: to PAIR or not to PAIR

PURPOSE OF REVIEW

The aim is to review recent literature for percutaneous treatment of liver hydatid cysts (cystic echinococcosis: CE) via different techniques such as PAIR (puncture, aspiration, injection, and reaspiration), standard catheterization, and modified catheterization technique (MoCaT).

RECENT FINDINGS

PAIR is an established technique and considered to be safe and effective for CE1 and CE3a as it is associated with lower morbidity, mortality, recurrence, and shorter hospital stay as compared with surgery. Standard catheterization is also dedicated for the treatment of CE1 and CE3a. PAIR should be preferred for treatment of liver CE1 and CE3a cysts, since PAIR is associated with lower major complication rates and shorter hospital stay. However, standard catheterization technique is indicated when cysto-biliary fistula develops or any technical difficulty arises during the PAIR. In these cases it is needed to switch PAIR to standard catheterization to complete the procedure.

SUMMARY

For CE1 and CE3a cysts, PAIR and standard catheterization are the choice for percutaneous treatments, while MoCaT is a treatment option for CE2 and CE3b cysts.

Parasitic lung diseases

Parasitic lung diseases are caused by a number of parasites as a result of transient passage in the lung or as a result of an immunologic reaction. The clinical presentation may be in the form of focal or cystic lesions, pleural effusion or diffuse pulmonary infiltrates. With increasing globalisation, it is important to consider parasitic infections in the differential diagnosis of lung diseases. This is particularly important since early identification and prompt therapy result in full cure of these conditions. In this review, we summarise the most common parasitic lung diseases.

A Case of Echinococcal Cyst of the Lung

Echinococcosis, also known as Hydatid disease, is caused by the larvae of the tapeworm Echinococcus. It is globally prevalent and is a major clinical health concern. It is endemic in most underdeveloped regions including Asia, the Mediterranean, South America and Africa. There are four species within the genus Echinococcus, with E. granulosus and E. multilocularis being the most common, causing Cystic Echinococcosis (CE) and Alveolar Echinococcosis (AE). The clinical presentation of the disease is non-specific. It commonly involves the liver, lungs, brain and adrenal glands. Pulmonary disease is significant for its propensity to affect children and young adults. This young population accounts for ∼50% of pulmonary hydatid cysts [1]. Cysts are known to grow extensively in size. Many patients are asymptomatic and have only a solitary cyst. Symptoms arise from enlargement of the cyst and from eroding and pressure applied by the cyst to blood vessels and organs. If rupture of the cyst occurs it can lead to immunologic reactions such as asthma and anaphylaxis. Echinococcus in the lung can pose diagnostic dilemmas, as their homogeneous density and tendency to occur alone may cause them to be confused with squamous cell carcinoma, adenocarcinoma, solitary metastasis, and abscess [2]. Our case is of such a patient who was found to have a 6 cm mass in the right middle lobe (RML) found on a chest X-ray during evaluation of back pain. Echinococcus should always be included in a differential diagnosis of any mass lesions especially in immigrant populations from endemic countries.

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.

Can Large Hydatid Cysts Resolve with Medical Treatment Alone?

A 66-year-old female from a rural area in South Africa presented with non-life-threatening haemoptysis. Radiologic and serological investigations attributed her symptoms to bilateral, large echinococcal cysts. She declined surgery despite her lung physiologic parameters, which deemed her eligible. Medical therapy with oral albendazole was initiated with excellent clinical and radiologic response during a follow-up period of 18 months. To our knowledge, this is one of the first reported cases in the literature that shows complete resolution of bilateral large echinococcal cysts with medical treatment alone in an adult patient.

Cystic pulmonary hydatidosis

Cystic echinococcosis (CE) is a zoonotic parasitic disease caused by the larval stages of the cestode Echinococcus granulosus. Worldwide, pulmonary hydatid cyst is a significant problem medically, socially, and economically. Surgery is the definitive therapy of pulmonary hydatidosis. Benzimidazoles may be considered in patients with a surgical contraindication. This review will focus on pathogenesis, lifecycle, clinical features, and management of pulmonary hydatid disease.

A Hydatid Cyst of the Appendix which Mimicked a Tubo-ovarian Mass: A Case Report and Review of the Literature

Hydatid disease, an endemic in the cattle grazing areas, particularly in the Asian region, is a parasitic infection which is caused by the cestode tapeworm, Echinoccocus granulosus. There is involvement of the intra-abdominal organs apart from the liver, in 10-15% of the cases. We are reporting a case, wherein the appendix was involved with this parasitosis and we have discussed the review of the literature regarding the diagnostic, surgical and the newer percutaneous approaches for the management of this disease.

Surgical treatment of intrathoracic hydatid disease: a 5-year experience in an endemic region

PURPOSE

To present our recent surgical experience in treating patients with intrathoracic hydatidosis.

METHODS

This study reviewed the files of patients with pulmonary/intrathoracic extrapulmonary hydatid cysts treated surgically between 2003 and 2009. Demographic, laboratory and radiological data, clinical manifestations, site of the cyst, surgical approaches, and final outcome were noted and analyzed.

RESULTS

Forty patients underwent 42 operations (21 females, 19 males, mean age 36 years). Thirty-six patients (90%) had pulmonary (56.7% were intact/uncomplicated), three (7.5%) had intrathoracic extrapulmonary, and one (2.5%) had both pulmonary/intrathoracic extrapulmonary hydatid cysts. The right lung was involved in 64.9%. Larger pulmonary cysts ruptured more commonly (P = 0.007). Most patients (95%) were symptomatic, mostly dyspneic (72.5%). The mean forced expiratory volume in 1 s value was significantly reduced in cases with a large (P < 0.0001), or ruptured cyst (P = 0.05). The erythrocyte sedimentation rate was elevated in case of rupture (P = 0.05). A thoracotomy was performed for all patients. A cystotomy and capitonnage was performed more commonly than cystotomy without capitonnage for the pulmonary, and total excision was performed for the intrathoracic extrapulmonary hydatid cysts. The mortality was 0% and the morbidity was 17.5%. All patients received antihelminthic therapy postoperatively. There was no recurrence.

CONCLUSION

Surgery is considered to be the optimal treatment for intrathoracic hydatid disease. In addition, recurrence is very low when all such patients receive postoperative antihelminthic therapy.

Liver hydatid cyst with transdiaphragmatic rupture and lung hydatid cyst ruptured into bronchi and pleural space

The aim of this case study is to present effectiveness of percutaneous drainage as a treatment option of ruptured lung and liver hydatid cysts. A 65-year-old male patient was admitted with complicated liver and lung hydatid cysts. A liver hydatid cyst had ruptured transdiaphragmatically, and a lung hydatid cyst had ruptured both into bronchi and pleural space. The patient could not undergo surgery because of decreased respiratory function. Both cysts were drained percutaneously using oral albendazole. Povidone-iodine was used to treat the liver cyst after closure of the diaphragmatic rupture. The drainage was considered successful, and the patient had no recurrence of signs and symptoms. Clinical, laboratory, and radiologic recovery was observed during 2.5 months of catheterization. The patient was asymptomatic after catheter drainage. No recurrence was detected during 86 months of follow-up. For inoperable patients with ruptured liver and lung hydatid cysts, percutaneous drainage with oral albendazole is an alternative treatment option to surgery. The percutaneous approach can be life-saving in such cases.

Long-term follow-up of the percutaneous treatment of hydatid cyst in the adrenal gland: a case report and review of the literature

Although the most involved organs are liver and lung, hydatid cysts occur in adrenal glands, rarely, and constitute only 0.5% of hydatid cysts. Herein, we demonstrate and discuss, for the first time in the literature to the best of our knowledge, the radiological features of adrenal hydatid disease and evaluate the long-term results (57 months of follow-up) of the percutaneous treatment of hydatid cyst in the adrenal gland in a patient.

Cystic echinococcosis of the liver and lung treated by radiofrequency thermal ablation: An ex-vivo pilot experimental study in animal models

AIM: To evaluate radiofrequency thermal ablation (RTA) for treatment of cystic echinococcosis in animal models (explanted organs).

METHODS: Infected livers and lungs from slaughtered animals, 10 bovine and two ovine, were collected. Cysts were photographed, and their volume, cyst content, germinal layer adhesion status, wall calcification and presence of daughter or adjacent cysts were evaluated by ultrasound. Some cysts were treated with RTA at 150 W, 80°C, 7 min. Temperature was monitored inside and outside the cyst. A second needle was placed inside the cyst for pressure stabilization. After treatment, all cysts were sectioned and examined by histology. Cysts were defined as alive if a preserved germinal layer at histology was evident, and as successfully treated if the germinal layer was necrotic.

RESULTS: The subjects of the study were 17 cysts (nine hepatic and eight pulmonary), who were treated with RTA. Pathology showed 100% success rate in both hepatic (9/9) and lung cysts (8/8); immediate volume reduction of at least 65%; layer of host tissue necrosis outside the cyst, with average extension of 0.64 cm for liver and 1.57 cm for lung; and endocyst attached to the pericystium both in hepatic and lung cysts with small and focal de novo endocyst detachment in just 3/9 hepatic cysts.

CONCLUSION: RTA appears to be very effective in killing hydatid cysts of explanted liver and lung. Bile duct and bronchial wall necrosis, persistence of endocyst attached to pericystium, should help avoid or greatly decrease in vivo post-treatment fistula occurrence and consequent overlapping complications that are common after surgery or percutaneous aspiration, injection and reaspiration. In vivo studies are required to confirm and validate this new therapeutic approach.

Experience with video-assisted thoracoscopic removal of pulmonary hydatid cysts in children

Pulmonary hydatid disease is prevalent in many parts of world including India. In our small series of 5 pediatric patients, all patients were diagnosed with clinical and radiological findings on plain X-ray chest and CT (Computed Tomography) chest. All of them received oral albendazole 10 mg/kg/day soon after diagnosis except in one patient in which preoperative differential diagnosis was bronchogenic cyst and lung abscess (case 4). All underwent video assisted thoracoscopy. Simple endotracheal intubation was utilized in all cases along with CO(2) insufflation. Complete thoracoscopic removal was successful in 3 cases, while conversion to open thoracotomy was required in 2 cases. All of them showed rapid recovery except for one patient in whom prolonged intercostal drainage was present for 2 weeks. The average duration of procedure was 150 minutes and average length of hospital stay was 4.5 days except case 2, which was discharged on day 15 due to prolonged air leak. Histopathology in all cases was suggestive of hydatid cyst. At mean follow up of 6 months, all patients are asymptomatic and doing well.

Sonographic spectrum of hydatid disease

Hydatid disease, caused by Echinococcus granulosus, is a parasitic disease that is endemic in many parts of the world. Hydatid cyst demonstrates a variety of imaging features, varying according to growth stage, associated complications, and affected tissue. The radiologic findings range from purely cystic lesions to a completely solid appearance. Ultrasound is the most important imaging modality for liver hydatid disease and clearly demonstrates the floating membranes, daughter cysts, and hydatid sand characteristically seen in purely cystic lesions. The radiologist's familiarity with the imaging findings of the disease is very important for earlier diagnosis and an appropriate treatment. There are several classification schemes for liver hydatid cysts based on their ultrasound appearances; the initial classification by Gharbi et al and the World Health Organization classification are the most commonly preferred. Computed tomography and magnetic resonance imaging play a key role in recognizing the complications such as rupture and infection of cysts associated with hydatid disease. Today, percutaneous treatment of liver hydatid cysts, a safe, easily applicable, and well-tolerated method, has become the most effective and reliable treatment procedure in most cases if the hydatid cyst is viable. In patients treated with the percutaneous treatment technique, a decrease in the dimensions of the cyst, solidification of the cyst contents, and irregularity in the walls of cysts are signs suggestive of cure. The radiologist should also be familiar with the postoperative follow-up ultrasound findings of hydatid cyst to prevent misinterpretation of the hypoechoic, anechoic, or hyperechoic appearance of posttreatment hydatid disease appearance as recurrence.

Diagnosis and percutaneous treatment of soft-tissue hydatid cysts

The purpose of this study is to demonstrate and discuss the radiological features of four patients with muscular hydatid disease and to evaluate the results of percutaneous treatment in these patients. Four patients (three female and one male) with six muscular hydatid cysts underwent percutaneous treatment and were followed up. The mean age of patients was 35 years (range: 12-60 years). Type I (n = 2), type II (n = 1), and type III (n = 3) hydatid cysts were observed in the thigh (n = 3) and gluteal (n = 1) region on radiologic examination. All interventions were performed under sonographic and fluoroscopic guidance. According to the type of the cyst, the procedure was carried out by either a "catheterization technique with hypertonic saline and alcohol" or a "modified catheterization technique." The mean cathaterization time was 13.7 days, ranging from 1 to 54 days. The dimensions of the residual cavity were noted at every sonographic control, and an average of 96.1% volume reduction was obtained in six cysts of four patients. No sign of viability was observed during the follow-up period. Cavity infection and cellulitis were observed as complications, which resolved after medical therapy. Percutaneous treatment is a safe and effective procedure in patients with soft-tissue hydatid cysts and should be considered as a serious alternative to surgery.

Unusual imaging characteristics of complicated hydatid disease

Hydatid disease, a worldwide zoonosis, is caused by the larval stage of the Echinococcus tapeworm. Although the liver and the lungs are the most frequently involved organs in the body, hydatid cysts of other organs are unusual. Radiologically, they usually demonstrate typical imaging findings, but unusual imaging characteristics of complicated cyst of hydatid disease, associated with high morbidity and mortality, are rarely described in the literature. The purpose of this study is to review the general features of hydatidosis and to discuss atypical imaging characteristics of the complicated hydatid disease in the human, with an emphasis on structure and rupture of the cystic lesion as well as ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) features of the disease. In our study, the available literature and images of the cases with complicated hydatidosis involving liver, lung, brain, spine and orbit were reviewed retrospectively. In hydatid disease, there are many potential local and systemic complications due to secondary involvement in almost any anatomic location in humans. Radiologically, in addition to the presence of atypical findings such as perifocal edema, non-homogenous contrast enhancement, multiplicity or septations and calcification, various unusual manifestations due to rupture or infection of the cyst have been observed in our cases with complicated hydatid disease. To prevent subsequent acute catastrophic results and the development of recurrences in various organs, it should be kept in mind that complicated hydatid cysts can cause unusual USG, CT, and MRI findings, in addition to typical ones, in endemic areas. Therefore, familiarity with atypical radiological appearances of complicated hydatid disease may be valuable in making a correct diagnosis and treatment.

Modified PAIR technique for percutaneous treatment of high-risk hydatid cysts

PURPOSE

This paper presents a modification of the known method for percutaneous treatment of hydatid cyst, the PAIR technique. It aimed to achieve safe aspiration of large symptomatic cysts and cysts with a danger of impending rupture.

METHODS

We designed a coaxial catheter system to achieve concomitant evacuation of cyst contents while infusing scolicidal agent. Hypertonic saline is used to wash out cyst contents and to kill protoscolices. This was followed by injection of a sclerosant (ethyl alcohol 95%) into the residual cyst cavity to prevent formation of a cyst collection after the procedure. Seventeen cysts in 14 patients were successfully aspirated. Follow-up plain radiographs, ultrasonography and CT were performed weekly in the first 4 weeks and then at 3, 6 and 12 months for all patients. Seven patients (9 drained cysts) were followed up for 2 years and 1 patient for 3 years.

RESULTS

All cysts were successfully aspirated. The following morphologic changes were noticed: a gradual decrease in cyst size (17 cysts, 100%), thickening and irregularity of the cyst wall due to separation of endocyst from pericyst (7 cysts, 41%), development of a heterogeneous appearance of the cyst components (8 cysts, 47%) and development of pseudotumor (2 cysts, 12%). None of the treated cysts disappeared completely. No significant procedure-related complications were encountered.

CONCLUSION

This modified PAIR technique is a reliable method for percutaneous treatment of risky and symptomatic hydatid cysts.

Treatment options for hepatic cystic echinococcosis

A number of surgical and non-surgical options exist to treat cystic echinococcosis of the liver. For decades, surgical excision via a conservative or radical approach was the recommended approach for hepatic hydatid cysts. The availability of chemotherapeutic agents with significant activity against Echinococcus granulosis has made it possible to undertake ultrasound- or computed tomography-guided transhepatic percutaneous drainage (termed puncture, aspiration, injection, and re-aspiration (PAIR)) of hydatid cysts. Pre- and post-intervention chemotherapy with albendazole or mebendazole offers the advantage of reducing the risk of disease recurrence and intraperitoneal seeding of infection that may develop via cyst rupture and spillage occurring spontaneously or during surgery or needle drainage. PAIR appears to have greater clinical efficacy (i.e. a higher incidence of cure), lower rates of major and minor complications, mortality, and disease recurrence, and fewer days of hospitalization compared to patients treated surgically. For patients who fail drug therapy alone, PAIR is a safe and effective procedure of choice for patients with hepatic echinococcosis, and perhaps other anatomic sites of infection such as lung, peritoneum, kidney, and other viscera. Surgery should be reserved for patients with hydatid cysts refractory to PAIR because of secondary bacterial infection or for those with difficult-to-manage cyst-biliary communication or obstruction.

Preauricular hydatid cyst: an unusual location for echinoccosis

Hydatid disease is an important medical problem in countries of the temperate zones. A 21-year-old female patient was admitted to our outpatient clinics with a complaint of a progressive swelling in the left preauricular region. The case of the patient with hydatid disease that developed in the left preauricular region is presented in detail. Hydatid cyst in this location is rare.

Is capitonnage unnecessary in the surgery of intact pulmonary hydatic cyst?

BACKGROUND

Hydatid disease, a parasitosis, is still an important health problem in Turkey. Surgery is the choice of treatment for pulmonary hydatid cyst. In this study, cystotomy and capitonnage were compared to cystotomy.

METHODS

Fifty-nine patients with 70 pulmonary intact hydatid cysts were surgically treated between 1993 and 1999. There were 11 females and 48 males (range 4-58 years). Cystotomy and closure of bronchial openings were performed in all patients. The patients were divided into two groups. In Group A (n = 32 patients, n = 38 cysts), the cavity was closed (capitonnage), and in Group B (n = 27 patients, n = 32 cysts) capitonnage was not performed. The patients treated by other surgical methods (pericystectomy, lobectomy, and others) were not included in this study.

RESULTS

Prolonged air leak (> 5 days) was found in one patient in Group A, and in four patients in Group B. Atelectasis developed in one patient in Group A, and in three patients in Group B. Additionally, in Group B pseudocystic appearance occurred in two patients and empyema in one patient. The duration of hospitalization was 9.8 +/- 2.1 days for Group A, and 12.4 +/- 3.2 days for Group B. There was a significant difference between the groups for hospital time (p < 0.01). There was no mortality in either group.

CONCLUSION

This study shows that capitonnage is a procedure that should not be easily abandoned, despite the current contrary opinions, because of its low complication rate.

Percutaneous aspiration-injection-reaspiration drainage plus albendazole or mebendazole for hepatic cystic echinococcosis: a meta-analysis

Using meta-analysis methodology, we compared the clinical outcomes for 769 patients with hepatic cystic echinococcosis treated with percutaneous aspiration-injection-reaspiration (PAIR) plus albendazole or mebendazole (group 1) with 952 era-matched historical control subjects undergoing surgical intervention (group 2). The rate of clinical and parasitologic cure (P<.0001) was greater in patients receiving PAIR plus chemotherapy. Disease recurrence (P<.0001), major complications (anaphylaxis, biliary fistula, cyst infection, liver/intra-abdominal abscess, and sepsis; P<.0001), minor complications (P<.0001), and death (P<.0824) occurred more frequently among surgical control subjects. Fever (P<.002) and minor allergic reactions subjects (P<.0001) were more common among PAIR-treated subjects. The mean durations of hospital stay were 2.4 days for group 1 and 15.0 days for group 2 (P<.001). Compared with surgery, PAIR plus chemotherapy is associated with greater clinical and parasitologic efficacy; lower rates of morbidity, mortality, and disease recurrence; and shorter hospital stays.

Past to present: echinococcosis in Turkey

Echinococcosis is a zoonotic infection caused by Echinococcus spp. and is one of the most important helminthic diseases worldwide. Two forms of echinococcosis occur in Turkey, i.e. Echinococcus granulosus and E. multilocularis. The life cycle of E. granulosus is predominantly in dogs and sheep, and most sheep farmers in Turkey keep a dog or two. Stray dogs are numerous and prevention or treatment of infection in these dogs is very difficult. Cystic echinococcosis (CE) occurs throughout Turkey whereas alveolar echinococcosis (AE) predominantly occurs in the eastern Anatolian region of the country. Both CE and AE are known to be endemic but few surveys have been performed. Most data on human CE and AE have been collected from hospital records. The first reference of echinococcosis, "Kyste hydatique multiloculaire", in Turkey dates as far back to 1872 by an Ottoman Physician, C.R. Katibian. The results of the first Turkish study on E. granulosus were published in 1928. According to Ministry of Health records, 21303 patients had operations to treat or confirm CE in the period 1987-1994 which corresponds to approximately 2663 patients per year. The estimated surgical case rate of CE is 0.87-6.6 per 100000 in Turkey. The prevalence of E. granulosus infection in dogs in Turkey is between 0.32 and 40% and varies widely with geographical location. The reported prevalence of CE in domestic animals in Turkey has ranged from 11.2 to 50.7% and has varied widely with geographical location. Although no detailed information has been published on AE in domestic and wild animals in Turkey, the main definitive and intermediate hosts of E. multilocularis are assumed to be rodents and red foxes, respectively. However, there has been only a single published report of E. multilocularis in a wild animal (fox) in the northwest in 1965 by Merdivenci. The first human case of AE in Turkey was reported by Mutlu in 1939, and total cumulative reported case number is 202 between 1980 and 1998.

Repeated unintentional transthoracic needle aspiration of a pulmonary hydatid cyst

Transthoracic needle aspiration is not a recommended diagnostic modality in hydatid disease. Percutaneous aspiration of a suspected hydatid cyst is believed to be associated with the risk of allergic reactions which can result in systemic anaphylaxis and possible spreading of the cyst contents. We present herein a illustrative case of pulmonary hydatid cyst and multiple mediastinal lymphadenopathies which was diagnosed after repeated transthoracic fine needle aspirations.

Treatment of hydatid disease

Hydatid disease caused by Echinococcus granulosus presents medical, veterinary and economic problems worldwide. Hydatidosis can be treated by medical, surgical and percutaneous modalities. Benzoimidazole carbamates are effective against E. granulosus. Although mebendazole, the first benzoimidazole used, has some beneficial effects on the disease in selected patients, it has also been associated with treatment failure in some cases, perhaps because of its poor absorption. Albendazole, a more recently developed benzoimidazole, is more effective than mebendazole. Praziquantel, an isoquinoline derivative, has recently shown value in the treatment of human echinococcal disease and its use in combination with albendazole is recommended in some patients. Ultrasound guided cyst puncture is another choice of treatment which has been used successfully in selected patients, although anaphylactic and allergic reactions due to spillage of the cyst contents have occurred. Surgical therapy in echinococcal hydatid disease is indicated for large cysts with multiple daughter cysts, superficially located single liver cysts which have a risk of rupture, complicated cysts such as those accompanied by infection, compression or obstruction, and cysts located in vital organs or which are exerting pressure on adjacent vital organs. However, surgical therapy carries high risk of mortality, morbidity or recurrence. Therefore, medical therapy may be an alternative option in uncomplicated cysts and in patients at high risk from surgery. The adjuvant use of drugs with surgery and percutaneous treatment can also be recommended for some patients.

Surgical treatment of pulmonary hydatid cysts in children

OBJECTIVE

Hydatid disease is a parasitosis and endemic in many sheepraising areas; it is still an important health problem in Turkey. We report our experience with childhood hydatid cyst and discuss the concepts of treatment.

METHODS

The clinical courses of 128 children with thoracic and liver hydatid cyst operated on from 1994 to 2000 were reviewed. The group consisted of 71 boys and 57 girls aged from 8 months to 16 years. Intact cysts were found in 144 patients and ruptured cysts in 68.

RESULTS

In the postoperative course we have encountered 20 perioperative complications in 16 patients. The most common complication was residual pleural space and delayed air leakage, which occurred in 9 patients. There was no early death.

CONCLUSION

Surgery is the treatment of choice for most patients with pulmonary hydatid disease. The aim of surgery is evacuation of the cyst, removal of the endocyst, and management of the residual cavity. Conservative surgical methods that preserve lung parenchyma should be preferred.

Percutaneous treatment of liver hydatid cysts

Hydatic disease caused by Echinococcus granulosus is an endemic disease and an important public health problem in some countries of the world. The results of surgical treatment are associated with a high rate of mortality, morbidity, postoperative recurrence and a long period of hospital stay and the medical treatment results are still controversial. Although the percutaneous aspiration and treatment of liver hydatid cysts were considered to be contraindicated due to risks of anaphylactic shock and dissemination of clear-crystal fluid into the abdomen, several reports of successful percutaneous treatment of liver hydatid cysts have been published in the literature. Today, percutaneous treatment of liver hydatid cysts is the most effective and reliable treatment procedure in the selected cases. In this review, indications, contraindications, method and techniques, healing criteria, complications, results and importance of the percutaneous treatment of liver hydatid cysts are discussed.

Hydatid disease in childhood: a retrospective analysis of 376 cases

During a 20-year period, 376 children with hydatid disease were treated at Hacettepe University Ihsan Doğramaci Children's Hospital. There were 223 males and 153 females with a mean age of 8.9+/-0.1 years. Hydatid cysts were localized in the lungs in 222 patients, in the liver in 56 patients, and in other organs in the remaining patients. Cough, fever, and abdominal pain were the most common symptoms. One hundred eight patients had medical, 182 patients had surgical, 73 patients had medical and surgical, and 4 patients had medical and percutaneous drainage treatment as the initial therapy. When evaluating the results of therapy, the relapse rate was higher in surgically treated patients than medically treated patients. We conclude that medical treatment of childhood hydatidosis is best, except in cases with complications such as infection, parenchymal compression or obstruction of airways, bile duct or viscera; all of these are indications for surgical therapy.

Percutaneous treatment of an orbital hydatid cyst: a new therapeutic approach

PURPOSE

To describe the percutaneous treatment of an orbital hydatid cyst as an alternative approach to conventional surgery.

METHODS

In a 21-year-old man with diplopia and right proptosis, radiologic studies disclosed a 25 x 25 x 20-mm purely cystic mass in the right retrobulbar area. Based on the presumptive diagnosis of hydatid cyst, the cyst was treated percutaneously under ultrasonographic guidance with aspiration, 15% hypertonic saline injection, and reaspiration without any complication.

RESULTS

A substantial decrease in the size of the cyst was observed in the 3 months after treatment. Nine months after treatment, the shrunken cyst had a volume of only 0.5 ml, and the patient was asymptomatic. Twenty-one months after the procedure, the findings were consistent with those at 9 months of follow-up.

CONCLUSION

Percutaneous treatment of orbital hydatid cysts, which is more satisfactory to both the patient and the physician, may be a safe and effective alternative to surgical extirpation.

Nonsurgical therapy for pulmonary hydatid cyst disease

Therapeutic and diagnostic aspiration of Echinococcus granulosus liver cysts, but not pulmonary cysts, are increasingly being performed. Documented herein is the utility of percutaneous drainage and of albendazole treatment in a patient with a large recurrent, isolated, pulmonary echinococcal cyst for whom traditional therapy would have resulted in severe morbidity. Therapeutic options and possible complications are discussed.

Percutaneous management of hepatic abscess: a perspective by interventional radiologists

Techniques for treating hepatic abscess have evolved rapidly during the past decade. For many years, the traditional treatment was surgical drainage. The development of modern imaging modalities, such as CT and US, has not only made the diagnosis more certain, but has also introduced a variety of percutaneous treatment options. Pyogenic hepatic abscess is now accepted as a medical/radiologic disease requiring surgical intervention only for correctable offending causes or for failed radiologic evacuation. Drainage via an indwelling catheter has been the traditional method of percutaneous treatment. However, indwelling catheters have disadvantages, including patient discomfort, the nuisance of catheter maintenance, and postprocedural complications. The technique of simple aspiration and intracavitary antibiotics as advocated by McFadzian et al, with excellent results confirmed by Giorgio et al, is a promising alternative to prolonged catheter drainage, and may be the biggest advancement in the management of hepatic abscess in 80 years. Surgeons have recently accepted radiologic drainage; now we need to see if interventional radiologists and surgeons will accept evacuation without indwelling catheter drainage. The role of interventional techniques for nonpyogenic hepatic abscesses will vary considerably. Mortality will still occur in the pyogenic varieties but should be related to underlying disease rather than the abscess itself.