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

Hepatic and extra-hepatic hydatid cysts: A case series of radiological and clinical insights

Hydatid disease, caused by Echinococcus granulosus, is a parasitic infection that primarily affects the liver but can also involve other organs, including the spleen, kidney, and peritoneum. This case series examined 9 patients with hydatid cysts, highlighting their clinical presentations, radiological findings, and management strategies. This study analyzed 9 patients diagnosed with hepatic and extrahepatic hydatid cysts. Comprehensive evaluations were performed for all patients, including clinical history and contrast-enhanced computed tomography (CT) imaging. The cases included cystic lesions in the liver (7 patients), spleen (3 patients), kidney (2 patients), and peritoneum (1 patient). Typical radiological features, such as the "double-wall sign," daughter cysts, and peripheral calcifications, were observed. The management strategies varied from surgical excision to medical therapy with albendazole. Hydatid disease presents diverse clinical and radiological features. Early diagnosis using advanced imaging techniques and a multidisciplinary approach is critical for effective management and prevention of complications.

In vitro, in vivo, and cellular mechanisms of Astragalus onobrychis L. extract against protoscoleces and hydatid cysts of Echinococcus granulosus

Introduction

In this study, we evaluated the in vitro, ex vivo, and in vivo effects of the chloroform extract of Astragalus onobrychis L. (Fabaceae family) (AOCE) on apoptosis induction and DNA damage in protoscoleces and hydatid cysts of Echinococcus granulosus.

Methods

The protoscolicidal properties of AOCE were examined through both in vitro and ex vivo studies on hydatid cyst protoscoleces, utilizing the eosin exclusion assay. Additionally, we evaluated the effects of AOCE on apoptosis induction and DNA damage in the protoscoleces using a colorimetric protease assay and real-time PCR analysis, respectively. The in vivo efficacy was determined by measuring the quantity, dimensions, and mass of hydatid cysts in infected murine subjects.

Results

The findings indicated that AOCE, particularly at a concentration of 45.0 mg/mL, effectively eliminated protoscoleces of hydatid cysts within a 30-min exposure period. Additionally, AOCE demonstrated prolonged anti-parasitic effects in ex vivo conditions, in contrast to the immediate lethal effects observed in vitro (p < 0.001). AOCE significantly (p < 0.01) induced caspase-3 activation in protoscoleces obtained from hydatid cysts relative to the control normal saline group. Furthermore, the results from Real-time PCR analysis indicated a significant (p < 0.001) upregulation in the expression levels of the EgATM and EgP53 genes following treatment with AOCE. By in vivo, we found that treatment with AOCE mainly at 200 mg/kg significantly (p < 0.001) reduced the number, size, and weight of hydatid cyst relative to the control group treated with normal saline group. Biochemical analysis also demonstrated that administration of AOCE to infected mice, led to a marked improvement and a reduction in serum levels of liver function factors.

Conclusion

The results indicated that AOCE exhibits considerable in vitro and ex vivo scolicidal properties against hydatid cyst protoscoleces. Furthermore, the results highlighted AOCE's capacity to eradicate protoscoleces through the induction of apoptosis and the infliction of DNA damage. Additionally, AOCE demonstrated significant therapeutic efficacy in managing hydatid cysts in murine models. However, further studies are required to clarify the specific mechanisms underlying its action and to assess its efficacy in clinical trials, which may facilitate the application of AOCE in the context of hydatid cyst surgical procedures.

Therapeutic Effects of Green Synthesized Copper Nanoparticles Against Hydatid Disease Through Inhibiting Inflammation, Oxidative Stress, and Apoptosis

PURPOSE

This study aimed to green synthesized copper nanoparticles (CNP) using Lupinus arcticus extract and assess the protoscolicidal effects and the effectiveness of these nanoparticles in experimental animal settings to combat hydatid cysts.

METHODS

The protoscolicidal properties of CNP were examined in vitro on hydatid cyst PS via the eosin exclusion assay. The in vivo effectiveness of CNP at doses of 20, 40, and 80 mg/kg/day for 28 days on hydatid cyst-infected mice was determined by assessing the number, size, weight of hydatid cysts the gene expression levels of caspase-3, antioxidant (glutathione peroxidase (GPx) and superoxide dismutase (SOD)) and inflammatory cytokines (Interleukin-4 (IL-4), IL-10, and inducible nitric oxide synthase (iNOS)) in the infected mice were also assessed by Real-time PCE.

RESULTS

Analyses revealed that the CNP had a spherical shape, ranging in size from 10 to 85 nm. The half-maximal inhibitory concentration (IC50) values for CNP against protoscoleces ranged from 39.9 to 341.3 µg/mL. Caspase-3 gene expression in the PS treated with CNP at 1/3 IC50, ½ IC50, and IC50 was 1.79-, 3.11-, and 5.39-fold change (p < 0.001). Upon administration of CNP, particularly at doses of 80 mg/kg, a significant decrease (p < 0.001) in hydatid cysts' quantity, size, and weight was evident. CNP treatment caused a notable reduction in oxidative stress markers and inflammatory cytokines and increased the gene expression of antioxidant enzymes (p < 0.001), whereas it modulated the serum levels of liver function parameters.

CONCLUSION

The study indicated the potential of green-synthesized CNP for eliminating the protoscoleces and in managing hydatid cysts through leveraging its antioxidant and anti-inflammatory characteristics. Nevertheless, additional investigations are necessary to elucidate the precise mechanisms of action and evaluate its effectiveness in clinical trials.

CLINICAL TRIAL NUMBER

Not applicable.

A Comprehensive Analysis of Echinococcus granulosus Infections in Children and Adolescents: Results of a 7-Year Retrospective Study and Literature Review

Cystic echinococcosis (CE) is a neglected tropical parasitic disease linked with significant social and economic burdens worldwide. The scientific community has minimal information on echinococcosis in Romanian people, and hospital medical records are the only sources that may be used to investigate its status. A 7-year retrospective clinical study on pediatric patients with CE from Southeast Romania was performed, and 39 children and adolescents were included, aged 2-15 years old. They were hospitalized with cystic echinococcosis in the Pediatric Department and Pediatric Surgery Department of Constanta County Clinical Emergency Hospital "St. Apostle Andrew" between 1 January 2017 and 1 October 2024. Twenty-nine (74.36%) pediatric patients came from rural zones, and 10 (25.64%) had urban residences. In total, 28 children (71.79%) had contact with four different animals (dogs, goats, pigs, and sheep); only four were from urban zones, and they had contact only with dogs. Data regarding the length of hospital stay, cyst location, and complications were collected and analyzed. According to the medical files, the diagnosis was established using imaging techniques and serological tests for CE. IgE and IgG reported appreciable variations in correlation with all parameters, and significant differences (p < 0.05) were recorded. IgE levels considerably increased in cases of no animal contact, pulmonary involvement, complications, surgical treatment, and multiple hospitalizations. Moderate IgE values were recorded in cases of urban residences, pig and sheep contact, and hepatic involvement. The IgG concentration considerably increased with sheep contact and moderately increased in cases of rural zones, hepatic involvement, complications, and surgical treatment. The results show that incidental discovery, symptoms, complications, multiple dissemination, pulmonary involvement, and dog and pig contact increase the hospitalization time. Extensive data analysis supports our results. Our findings highlight the complexity of managing E. granulosus infections in children and evidence the importance of a multidisciplinary approach, combining early diagnostic tools, tailored medical therapy, and careful surgical intervention when necessary.

Spleen salvation: A successful case of spleen-preserving surgery for hydatid cyst

INTRODUCTION AND SIGNIFICANCE

Hydatid disease is a parasitic infection caused by tapeworm larvae that can affect different organs, including the spleen. While isolated hydatid cysts in the spleen are rare, they are usually asymptomatic and are frequently discovered incidentally. Treatment options depend on several factors, such as cyst location, size, and number.

CASE PRESENTATION

We present the case of a 9-year-old child who lives in rural areas. He was suffering from pain in the left flank for 3 months. An ultrasound and CT scan of the abdomen were performed. It was found that there was a solitary hydatid cyst in the spleen, about half the size of the spleen. Surgical intervention was performed and the cyst was completely removed without opening the cyst and with preservation of normal splenic tissue.

CLINICAL DISCUSSION

In cases of splenic cysts, the spleen must be preserved and the cyst must be removed with caution so as not to rupture it. Therefore, protecting the child from the possibility of hydatid cyst spread and anaphylactic shock.

CONCLUSION

In conclusion, this article underscores the importance of differential diagnosis of a hydatid cyst in the spleen and taking the necessary preventive measures before and during surgery to avoid the rupture of the cyst.

A pilot study of microRNAs expression profile in plasma of patients with hydatid disease: potential immunomodulation of hydatid disease

Echinococcosis is a zoonotic disease, which seriously endangers human health. The immune game between parasite and host is not fully understood. Exosomes are thought to be one of the ways of information communication between parasite and host. In this study, we attempted to explore the communication between Echinococcus granulosus and its host through the medium of exosomes. We collected plasma from E. granulosus patients (CE-EXO) and healthy donors (HD-EXO) and extracted exosomes from the plasma. The expression profile of miRNA in plasma was determined by second generation sequencing. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) were used to annotate the function of target genes of differential miRNAs. Meanwhile, we co-cultured plasma exosomes from healthy donors and plasma exosomes from E. granulosus patients with Jurkat T cells with or without phytohaemagglutinin (PHA) stimulation. The expression of CD69 on Jurkat T cells was detected by flow cytometry. The results showed that the miRNA of exosomes between healthy donors and E. granulosus patients was significantly different. GO and KEGG were used to annotate the function of target genes of differential miRNAs. The results indicate that many important pathways are involved in inflammation, metabolism, and immune response after parasite infection, such as p53 signaling pathway, PI3K-Akt signaling pathway, and glycolysis/gluconeogenesis. Flow cytometry showed that CE-EXO reduced the expression of CD69 + on Jurkat T cells. Our present results suggest that these differentially expressed miRNAs may be important regulators of parasite-host interactions. Meanwhile, functional prediction of its target genes provides valuable information for understanding the mechanism of host-parasite interactions. These results provide clues for future studies on E. granulosus escape from host immune attack, which could help control E. granulosus infection.

Potential use of silver nanoparticles green synthesized using Astragalus spinosus extract for treating cystic echinococcosis

The present investigation aims to develop and evaluate silver nanoparticles (AgNP) synthesized through environmentally friendly methods and to assess their effectiveness against hydatid cysts through in vitro, ex vivo, and in vivo experiments. The green synthesis of ANP was accomplished using the precipitation technique with Astragalus spinosus extract. The in vitro protoscolicidal effects of ANP were evaluated on hydatid cyst protoscoleces (PTS) through eosin exclusion test. The study also investigated the effect of ANP on the gene expression levels of caspase-3 and 9, as well as the external morphology of PTS. The in vivo efficacy was assessed by analyzing the quantity, dimensions, and weight of hydatid cysts in infected mice. Real-time PCR was used to analyze the gene expression levels of antioxidant and inflammatory cytokines. ANP exhibited significant (p < 0.001) in vitro protoscolicidal activity in a dose- and time-dependent manner. Treatment with ANP resulted in creases and protrusions on the plasma membrane, indicating bleb formation and an increase in the expression of caspase-3 and caspase-9 genes. Notably, there was a significant (p < 0.001) reduction in the number, size, and weight of hydatid cysts following ANP treatment. Administration of ANP resulted in a significant increase in the expression of antioxidant genes (glutathione peroxidase and superoxide dismutase) and a notable decrease in oxidative stress markers, as well as in the expression levels of Interleukin-4 (IL-4) and IL-10. Due to its antioxidant and anti-inflammatory properties, ANP shows potential as a scolicidal agent and holds promise in managing hydatid cysts in a mouse model. Nevertheless, further clinical trials are imperative to validate the efficacy of ANP in treating hydatidosis.

Hydatid Cyst or Echinococcosis: A Comprehensive Review of Transmission, Clinical Manifestations, Diagnosis, and Multidisciplinary Treatment

Echinococcosis, a parasitic infection caused by Echinococcus tapeworms, can cause various symptoms depending on the location and size of the cysts. This article explores the complexities of echinococcosis, including its transmission cycle, clinical manifestations, diagnosis, and treatment approaches. The review highlights the challenges associated with diagnosing the different echinococcosis types, including cystic echinococcosis, alveolar echinococcosis, and polycystic echinococcosis. Each form of the disease necessitates a unique diagnostic approach that often combines serological tests, imaging techniques, and histological analysis. The article explores treatment options for each type of echinococcosis, including surgical resection, medication, and minimally invasive procedures such as puncture-aspiration-injection-reaspiration (PAIR). The article acknowledges current treatment methods' limitations and emphasises the need for further research into improved diagnostics, drug targets, and preventative measures. This review aims to provide a comprehensive overview of echinococcosis, encompassing its transmission, clinical presentation, diagnosis, and treatment modalities. By outlining the complexities of the disease and highlighting areas for future research, the article hopes to contribute to improved disease management and control. Key findings of the review include the identification of significant diagnostic challenges in differentiating between cystic, alveolar, and polycystic echinococcosis, the varying efficacy of treatment modalities such as surgical resection and PAIR, and the urgent need for further research into enhanced diagnostic methods, novel drug targets, and effective preventative strategies.

Imaging features and management of focal liver lesions

Notably, the number of incidentally detected focal liver lesions (FLLs) has increased dramatically in recent years due to the increased use of radiological imaging. The diagnosis of FLLs can be made through a well-documented medical history, physical examination, laboratory tests, and appropriate imaging methods. Although benign FLLs are more common than malignant ones in adults, even in patients with primary malignancy, accurate diagnosis of incidental FLLs is of utmost clinical significance. In clinical practice, FLLs are frequently evaluated non-invasively using ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Although US is a cost-effective and widely used imaging method, its diagnostic specificity and sensitivity for FLL characterization are limited. FLLs are primarily characterized by obtaining enhancement patterns through dynamic contrast-enhanced CT and MRI. MRI is a problem-solving method with high specificity and sensitivity, commonly used for the evaluation of FLLs that cannot be characterized by US or CT. Recent technical advancements in MRI, along with the use of hepatobiliary-specific MRI contrast agents, have significantly improved the success of FLL characterization and reduced unnecessary biopsies. The American College of Radiology (ACR) appropriateness criteria are evidence-based recommendations intended to assist clinicians in selecting the optimal imaging or treatment option for their patients. ACR Appropriateness Criteria Liver Lesion-Initial Characterization guideline provides recommendations for the imaging methods that should be used for the characterization of incidentally detected FLLs in various clinical scenarios. The American College of Gastroenterology (ACG) Clinical Guideline offers evidence-based recommendations for both the diagnosis and management of FLL. American Association for the Study of Liver Diseases (AASLD) Practice Guidance provides an approach to the diagnosis and management of patients with hepatocellular carcinoma. In this article, FLLs are reviewed with a comprehensive analysis of ACR Appropriateness Criteria, ACG Clinical Guideline, AASLD Practice Guidance, and current medical literature from peer-reviewed journals. The article includes a discussion of imaging methods used for the assessment of FLL, current recommended imaging techniques, innovations in liver imaging, contrast agents, imaging features of common nonmetastatic benign and malignant FLL, as well as current management recommendations.

A Novel Technique for the Management of Persistent Biliary Fistulas Developing After Liver Hydatid Cyst Surgeries: Drain Clamping Technique

BACKGROUND

External biliary fistula, where the residual cyst is associated with the biliary tree, is one of the most common complications after liver hydatid cyst surgery. Surgical procedures become a consideration for patients in whom the biliary fistula persists despite all endoscopic procedures. However, reoperation for biliary fistula after hydatid cyst surgery leads to additional complications and increases morbidity and mortality.

AIM

This study aims to treat persistent biliary fistulas that develop after liver hydatid cyst surgery using a simple noninvasive technique.

MATERIALS AND METHODS

External drainage surgery was performed on 295 patients with liver hydatid cysts. Endoscopic treatment methods were used in patients who developed biliary fistula after surgery. Despite all endoscopic treatment methods, 14 patients developed persistent biliary fistulas. These patients were subsequently treated using the drain clamping technique.

FINDINGS

All persistent fistulas occluded in 11.86 days (with a range of 8-20 days). No complications were observed in the one-year follow-up visits.

CONCLUSION

Drain clamping, a novel approach to the treatment of persistent biliary fistulas developed despite all available endoscopic methods, can be safely used. This technique resulted in a complete recovery in patients without the need for surgical procedures.

Diagnosis and treatment experience of atypical hepatic cystic echinococcosis type 1 at a tertiary center in China

BACKGROUND

Some hydatid cysts of cystic echinococcosis type 1 (CE1) lack well-defined cyst walls or distinctive endocysts, making them difficult to differentiate from simple hepatic cysts.

AIM

To investigate the diagnostic methods for atypical hepatic CE1 and the clinical efficacy of laparoscopic surgeries.

METHODS

The clinical data of 93 patients who had a history of visiting endemic areas of CE and were diagnosed with cystic liver lesions for the first time at the People's Hospital of Xinjiang Uygur Autonomous Region (China) from January 2018 to September 2023 were retrospectively analyzed. Clinical diagnoses were made based on findings from serum immunoglobulin tests for echinococcosis, routine abdominal ultrasound, high-frequency ultrasound, abdominal computed tomography (CT) scan, and laparoscopy. Subsequent to the treatments, these patients underwent reexaminations at the outpatient clinic until October 2023. The evaluations included the diagnostic precision of diverse examinations, the efficacy of surgical approaches, and the incidence of CE recurrence.

RESULTS

All 93 patients were diagnosed with simple hepatic cysts by conventional abdominal ultrasound and abdominal CT scan. Among them, 16 patients were preoperatively diagnosed with atypical CE1, and 77 were diagnosed with simple hepatic cysts by high-frequency ultrasound. All the 16 patients preoperatively diagnosed with atypical CE1 underwent laparoscopy, of whom 14 patients were intraoperatively confirmed to have CE1, which was consistent with the postoperative pathological diagnosis, one patient was diagnosed with a mesothelial cyst of the liver, and the other was diagnosed with a hepatic cyst combined with local infection. Among the 77 patients who were preoperatively diagnosed with simple hepatic cysts, 4 received aspiration sclerotherapy of hepatic cysts, and 19 received laparoscopic fenestration. These patients were intraoperatively diagnosed with simple hepatic cysts. During the follow-up period, none of the 14 patients with CE1 experienced recurrence or implantation of hydatid scolices. One of the 77 patients was finally confirmed to have CE complicated with implantation to the right intercostal space.

CONCLUSION

Abdominal high-frequency ultrasound can detect CE1 hydatid cysts. The laparoscopic technique serves as a more effective diagnostic and therapeutic tool for CE.

Primary Hydatid Cyst of the Gluteal Muscle: A Case Report

Hydatid disease, also known as cystic echinococcus, is a parasitic infection initiated by Echinococcus granulosus. It primarily affects the lungs and liver, but it can also occur in other organs. Hydatid cysts in the gluteal muscle are an exceedingly rare phenomenon, even in areas with high prevalence. We report the case of a 29-year-old farmer who presented with a painful mass in the gluteal region. The diagnostic findings unveiled the existence of a hydatid cyst within the gluteal muscle managed with complete pericystectomy and chemotherapy with antiparasitic drugs. In regions where hydatid cysts are prevalent, it is essential to include them in the list of potential diagnoses for any cystic mass. Diagnosing such cases can be difficult, and surgery remains the most effective treatment.

A rare case of an isolated primary hydatid cyst in the uterus in a 7-year-old child: Case report and review of the literature

INTRODUCTION AND SIGNIFICANCE

Hydatidosis is one of the diseases caused by tapeworms that infect humans during their life cycle and still pose a major problem. A review of the medical literature has reported a few cases of serous cysts in the uterus. In most cases, pelvic cysts are asymptomatic and may sometimes cause compressive symptoms or complications when ruptured.

CASE PRESENTATION

We presented a case of a serous cyst of the uterus that was discovered through vague abdominal pain. The definitive diagnosis of the case was made during surgery when the cyst was opened, where it was removed and the cavity was closed completely.

CLINICAL DISCUSSION

The diagnosis of a serous cyst is based on a good clinical history, with the help of serological tests, in addition to radiological investigations that help to determine the number of cysts, their location, and their surroundings, in order to choose the appropriate therapeutic intervention according to the size of the cyst and its location, for the best patient care.

CONCLUSION

Hydatid cysts of the uterus are rare, but they should be included in the differential diagnosis of pelvic cysts to avoid the accidental rupture of the cyst during surgery and the occurrence of an allergic reaction that can sometimes be fatal.

Hydropneumothorax caused by complete rupture of a pulmonary hydatid cyst: A rare case report

Hydatid disease is a zoonotic disease endemic in developing regions. It is usually caused by infection with the tapeworm Echinococcus granulosus due to contaminated food or drinks or by close contact with dogs. The lungs are the second most affected organ (25%) after the liver (>65%). Cyst rupture is the most frequent complication. Enlarging pulmonary cysts are more vulnerable to rupture, with rupturing in the bronchial tree being the most common (20%-40%). Hydropneumothorax is a consequence of complete cyst rupture into the pleural cavity and occurs in rare cases (2%-4%). Superinfection is a common complication of the ruptured cyst, which might lead to empyema. A 26-year-old male presented to our clinic with dyspnea that had progressed recently and made him unable to walk a few meters. He had a history of cough and exertional dyspnea and was examined by three different clinics without performing a chest X-Ray. Physical examination revealed fever and a sick appearance. Chest X-ray revealed complete pneumothorax with an air-fluid level in the left hemithorax. Computerized tomography demonstrated two cysts, and one of them was ruptured, causing hydropneumothorax and empyema. The patient was treated with surgery, and follow-up showed recovery with a fully re-expanded lung. Rupture of pulmonary hydatid cyst is seen in the most of cases, the clinicians must be aware of such presentation and management of the pulmonary hydatid disease.

Unusual Presentation of Hydatid Cyst in Submandibular Region- A Case Report and Literature Review

Hydatid cyst is a parasitic infection of humans caused by the larval stage of Echinococcus. Hydatid cyst of the head and neck region is not very common and the involvement of salivary glands, especially the submandibular gland is very rare. Here present a case of hydatid cyst of the right submandibular region. A 13year-old female presented with a slowly growing swelling of the right submandibular region for 2 months. Fine needle aspiration cytology yielded fluid aspirate and the smear showed occasionally lymphocytes and diagnosis is unconclusive. The cyst was excised as a whole and it was sent for histopathological examination. Pathological examination confirmed the swelling to be a hydatid cyst of the right submandibular region.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03368-8.

Histopathological and immunological study of rats liver hydatid cysts isolated from human, sheep, goat and cows

In endemic places, liver hydatidosis is a life-threatening health issue. Many consequences such as hepatomegaly, infiltration with inflammatory cells and histopathological changes might arise as a result of liver hydatidosis. This study aimed to look into pathogenic changes in the livers of the rats that experimentally infected with hydatid cysts. These hydatid cysts were isolated from naturally infected humans, sheep, goats and cows. Liver hydatid cysts were collected from the main abattoir of Al-Muthanna province while human hydatid cysts were collected from Al-Hussein Teaching Hospital in Al-Muthanna province. The hydatid cysts were grossly and histology examined for inspection of hydatid cysts. The in vivo experiments were done by injection of hydatid protoscoleces or sand (fluid) in rats intraperitoneally. The results showed that the gross signs were same in all infected livers which range from paleness, hepatomegaly, hemorrhage and calcification. The hydatid cysts isolated from sheep and goat livers were highly fertile compared to others isolated from humans and cows. Injection of hydatid protoscoleces and hydatid fluid isolated from sheep and goat livers in rats induced the highest immune response compared to that isolated from humans and cows. The liver sections of rats that were injected with human, goat and sheep hydatid protoscoleces and fluids showed hyperplasia in the bile duct, aggregation nonnuclear cells with congested blood vessels. While liver sections of rats were received goat hydatid fluid, cow hydatid protoscoleces and hydatid fluid showed normal liver tissue. These findings suggested that the immunogenicity of hydatid materials is different according to the host and the component of hydatid cysts.

Benign liver lesions 2022: Guideline for clinical practice of Associazione Italiana Studio del Fegato (AISF), Società Italiana di Radiologia Medica e Interventistica (SIRM), Società Italiana di Chirurgia (SIC), Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Associazione Italiana di Chirurgia Epatobilio-Pancreatica (AICEP), Società Italiana Trapianti d'Organo (SITO), Società Italiana di Anatomia Patologica e Citologia Diagnostica (SIAPEC-IAP) - Part I - Cystic lesions

Benign liver lesions are increasingly diagnosed in daily clinical practice due to the growing use of imaging techniques for the study of the abdomen in patients who have non-specific symptoms and do not have an increased risk of hepatic malignancy. They include simple or parasitic cysts and solid benign tumors which differ widely in terms of prevalence, clinical relevance, symptoms and natural history and often lead to significant clinical problems relating to diagnosis and clinical management. Following the need to have updated guidelines on the management of benign focal liver lesions, the Scientific Societies mainly involved in their management have promoted the drafting of a new dedicated document. This document was drawn up according to the present Italian rules and methodologies necessary to produce clinical, diagnostic, and therapeutic guidelines based on evidence. Here we present the first part of the guideline, concerning the characterization of focal hepatic lesions detected by ultrasound, and the diagnosis and clinical management of simple and parasitic hepatic cysts, and of polycystic liver disease.

Isolated giant renal hydatid cyst with a simple renal cyst appearance: a case report

Background

Isolated renal hydatid cysts of the kidney are a rare occurrence that account for about 2–3% of all hydatidoses. They can stay asymptomatic for years and could have a variable presentation on imaging techniques, which results in a challenging diagnostic process.

Case presentation

We report a 22-year-old Caucasian male with a large cyst on the upper pole of the left kidney that had no septations nor membrane calcifications on computed tomography, which led to mistakenly considering it a simple renal cyst. The true diagnosis was identified intraoperatively and proven postoperatively by pathology.

Conclusions

This case highlights the importance of keeping echinococcosis in mind when treating suspected renal cysts and tumors to avoid incorrect treatment and possible content spillage, anaphylaxis, and peritoneal dissemination.

Turkish HPB Surgery Association consensus report on hepatic cystic Echinococcosis (HCE)

OBJECTIVES

Cystic Echinococcosis (CE) is one of the important problems of the Eurasian region. We aimed to prepare a consensus report in order to update the treatment approaches of this disease. This study was conducted by Turkish HPB Surgery Association.

MATERIAL AND METHODS

This study was conducted with the modified Delphi model. For this purpose, we conducted a three-stage consensus-building approach.

RESULTS

Six topics, including diagnosis, medical treatment, percutaneous treatment, surgical treatment, management of complications and posttreatment follow-up and recurrences in HCE were discussed.

CONCLUSION

The expert panel made recommendations for every topic.

In vitro and in vivo assessment of biocompatibility of AZ31 alloy as biliary stents: a preclinical approach

INTRODUCTION

Biomaterial technology due to its lack of or minimal side effects in tissues has great potential. Traditionally biomaterials used were cobalt-chromium, stainless steel and nitinol alloys. Biomaterials such as magnesium (Mg) and zinc (Zn) have good biocompatibility and consequently can be a potential material for medical implants. To date, the effects of AZ31 alloy stent on cell apoptosis are still unclear. The current investigation was designed to determine the effect of AZ31 alloy stent on necrosis and apoptosis of common bile duct (CBD) epithelial cells.

MATERIAL AND METHODS

We experimented with application of different concentrations of AZ31 alloy stent to primary mouse extrahepatic bile epithelial cells (MEBECs) and estimated the effect on apoptosis and necrotic cells. Apoptosis and pro-apoptosis expression were estimated through real-time PCR. For in vivo protocol, we used rabbits, implanted the AZ31 bile stent, and estimated its effect on the CBD. AZ31 (40%) concentration showed an effect on the apoptotic and necrotic cells.

RESULTS

Real-time PCR revealed that AZ31 (40%) concentration increased the apoptotic genes such as NF-κB, caspase-3, Bax and Bax/Bcl-2 ratio as compared to the control group. In the in vivo experiment, AZ31 alloy stents were implanted into the CBD and showed an effect on the alteration the hematological, hepatic and non-hepatic parameters.

CONCLUSIONS

To conclude, it can be stated that AZ31 induces apoptosis via alteration in genes including nuclear factor kappa-B (NF-κB), caspase-3, Bax and Bax/Bcl-2 ratio and improved the hematological, hepatic and non-hepatic parameters.

An unusual manifestation of hydatid disease: A case in a 20-year old male patient

Echinococcosis is a re-emerging public health issue in developing countries as most communities are homes to dogs and other domesticated animals while cattle raising is a major habit of most sub-Saharan countries. The usual presentations include liver and lung cysts. While few documentations and publications have been made on extra-pulmonary intrathoracic hydatid cysts in other parts of the world, there has been no published document on extra-pulmonary intrathoracic hydatid cysts consisting of eighty or more cystic masses in a single patient in Ethiopia. We present a case of right sided extra-pulmonary intrathoracic hydatid cysts in a 20-year old Ethiopian male patient with compressive respiratory symptoms and significant social history of cohabiting with dogs throughout childhood. The patient was treated by surgery via a posterolateral thoracotomy and had a smooth Post-operative course and discharged home on postoperative day 15 on albendazole and analgesics. Intraoperative findings included approximately 1500 ml of cystic fluid, eighty cystic masses and collapsed lung.

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Echinococcosis is a re-emerging public health issue in developing countries.

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Echinococcosis is among the most neglected tropical diseases.

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Extrapulmonary hydatid cyst is rare entity and occurs in any part of thorax.

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We present a case of right sided extrapulmonary hydatid cysts in a 20-year male.

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We extracted eighty cystic masses intraoperatively, which is a rear discovery.

The Epidemiology, Clinical Manifestations, Radiology, Microbiology, Treatment, and Prognosis of Echinococcosis: Results of NENEHATUN Study

Aim: Echinococcosis, caused by Echinococcus species, is an important zoonotic disease causing major health problems in humans and animals. Herein, we aimed to evaluate the epidemiology, clinical and laboratory parameters, radiological, serological, pathological, and treatment protocols of followed-up cases of hydatidosis. Methods: A total of 550 patients diagnosed with hydatid cyst disease were included in this study. Patients who were positive for one or more of the enzyme-linked immunosorbent assay or indirect hemagglutination test, pathological results, or radiological findings were examined. The data analyzed were collected from nine centers between 2008 and 2020. Records were examined retrospectively. Results: Among the patients, 292 (53.1%) were women and 258 (46.9%) were men. The patients' mean age was 44.4 ± 17.4 years. A history of living in rural areas was recorded in 57.4% of the patients. A total of 435 (79.1%) patients were symptomatic. The most common symptoms were abdominal pain in 277 (50.4%), listlessness in 244 (44.4%), and cough in 140 (25.5%) patients. Hepatomegaly was found in 147 (26.7%), and decreased breath sounds were observed in 124 (22.5%) patients. Radiological examination was performed in all cases and serological methods were also applied to 428 (77.8%) patients. The most frequently applied serological test was IHA (37.8%). A single cyst has been found in 66% patients. Hepatic involvement occurred in 327 (59.4%), pulmonary involvement was found in 128 (23.3%), whereas both of them were recorded in 43 (7.8%) patients. Splenic involvement was only detected in nine (1.6%) patients. Echinococcus granulosus (72.5%) was most frequently detected. Cyst diameters of 56.9% of the patients were in the range of 5-10 cm. A total of 414 (75.2%) patients received albendazole as an antiparasitic. Mortality was noted in nine (1.6%) patients. Conclusion: Echinococcosis is an important public health problem in Turkey. It can affect the social, economic, and political structures of the community. Public education and awareness are extremely important.

Hepatic Hydatid Cyst With Cystobiliary Communication and Cystoduodenal Fistula

The liver is the most common site affected by hydatid disease. Hepatic hydatid cyst (HHC) with cystoduodenal fistula is an unusual and infrequent complication. We present a 48-year-male diagnosed with an HHC with cystobiliary communication (CBC) and cystoduodenal fistula. The patient underwent partial cystectomy. Intraoperative demonstration of CBC was done with injection propofol, followed by primary closure of the CBC. The duodenal fistula was closed primarily with an omental patch, also known as a Graham patch. The patient improved well without any complications, and there was no recurrence of the symptoms for the subsequent five-month follow-up.

[Echinococcosis of the liver: evolution of surgical treatment]

OBJECTIVE

To analyze the development of surgical approaches for hepatic echinococcosis.

MATERIAL AND METHODS

We have analyzed diagnosis and treatment of 349 patients with liver echinococcosis; 97 patients were treated at the Botkin Clinical Hospital for the period from 2009 to 2019 and 252 patients were treated in surgical hospitals of Moscow city for the period from 2014 to 2019.

RESULTS

General and specific postoperative complications, relapses and surgical approaches were assessed. The number of echinococcectomies performed in surgical hospitals of Moscow is 3 times higher compared to the Botkin Hospital. The number of liver resections is comparable in both groups. The number of pericystectomies is more than 2 times higher in the Botkin Hospital. PAIR technique was more common in surgical hospitals of Moscow.

CONCLUSION

Evolution of surgical treatment from open echinococcectomy to anatomical liver resections and subsequent pericystectomy with PAIR technique becomes another round of evolutionary spiral in the development of surgical treatment of liver echinococcosis.

Closed Cyst Resection for Liver Hydatid Disease: a New Standard

BACKGROUND

Although radical resections are recommended for the surgical management of liver hydatid disease (LHD), whether closed (CCR) or opened (OCR) cyst resections should be performed remains unclear. The aim of this study was to compare the postoperative and long-term outcomes of CCR and OCR for primary and recurrent LHD.

MATERIALS AND METHODS

Medical charts of patients who underwent surgery at a single centre were retrospectively reviewed and compared with respect to major postoperative complications and recurrence rates.

RESULTS

Seventy-nine CCRs and 37 OCRs were included. The major morbidity rates were 19% and 5% in the OCR and CCR groups, respectively (P = 0.036). In multivariate analysis, OCR (P = 0.030, OR = 5.37) and the operative time (P < 0.001, OR = 18.88) were the only independent predictors of major complications. The 5-year and 10-year recurrence rates were both 0% in the CCR group compared to 18% and 27%, respectively, in the OCR group (P < 0.001). The mean time to recurrence was 10.5 (± 8) years.

DISCUSSION

Closed cyst resection for LHD is a safe and effective approach with a low risk of recurrence. Considering that recurrence could appear more than 10 years after surgery, follow-up of patients should be adapted.

Pulmonary Echinococcosis or Lung Hydatidosis: A Narrative Review

Background: Lung hydatidosis is a zoonosis related to infection by the Echinococcus tapeworm species. Lung involvement in this condition is second only to the liver echinococcosis. Diagnosis ordinarily results from an accidental finding in a direct chest radiograph evaluation because of the delayed growth of the cysts. Moreover, a consistent treatment regimen or approach may not be feasible because of the variability of pulmonary echinococcosis. In this review, we expect to sum up the main features of lung hydatidosis with a perspective on medical and surgical treatment. Methods: Cochrane Library and PubMed were the databases used to perform a narrative literature review. Search terms included "pulmonary echinococcosis" and "lung hydatidosis." The MeSH terms were "lung" [All Fields] AND {"echinococcosis" [MeSH Terms] OR ("hydatidosis" [All Fields] OR "pulmonary" [All Fields] AND "echinococcosis" [All Fields] OR "hydatidosis." A search period from September 1980 to May 2020 was chosen to compare studies from different decades, given the changes in pulmonary echinococcosis management. Results: A uniform treatment regimen or approach may not be feasible because of the variability of pulmonary echinococcosis. No clinical trials have analyzed and compared all the diverse treatment approaches. Cyst size, characteristics, position in the lung and clinical presentation, and the availability of medical/surgical expertise and equipment are the mainstays of echinococcosis management. When feasible, surgery is as yet the principal therapeutic choice to eliminate the cysts; anti-parasitic drugs may minimize complications during high-risk surgery or be used as definitive therapy in some instances with contraindications to surgery. Conclusions: Lung hydatidosis management must become less heterogeneous. We support treatment directed to the subject established on the clinical scenario, host factors, and surgical risk. Strict cooperation in this process between infectious disease specialists and surgeons may optimize best practices to help create shared practical guidelines to simplify clinicians' decision-making. Furthermore, we need a consensus for lung hydatidosis treatment and inserting this disease to global surgery agenda will have a positive impact on acquiring high-quality data that enables us to create an evidence-based guideline for this disease.

Intact and Perforated Pulmonary Hydatid Cyst: A Comparative Study from Damascus, Syria

Background

Hydatidosis is a major health problem around the world, especially in the Mediterranean region. Cysts can break open or develop secondary bacterial infections, altering the clinical presentation.

Methods

Patients who underwent hydatid cyst surgery at Al-Mouassat University Hospital in Damascus, Syria between January 2006 and December 2017 were evaluated. Cases involving isolated hepatic cysts were excluded. The patients were divided into those with perforated hydatid cysts (group 1) and those with intact hydatid cysts (group 2).

Results

This study included 224 cases 113 in group 1 (50.4%) and 111 in group 2 (49.6%). The median chest tube duration, hospitalization time, and postoperative complication rate were higher in group 1 than in group 2 (p=0.003, p=0.002, and p=0.006, respectively). In both groups, the most common symptom was cough (present in 178 patients in total [79.5%]), while chest pain (121 patients [54%]) and dyspnea (113 patients [50.4%]) were also common. Cough, hemoptysis, fever, and expectoration of cystic contents were significantly more frequent in group 1 than in group 2 (p<0.001).

Conclusion

The early discovery and treatment of intact pulmonary hydatid cysts reduced the hospitalization time, chest tube duration, and postoperative complication rate. Relative to intact cysts, perforated cysts are more complex and are associated with more expensive and time-consuming surgical treatment.

Management of complex liver cystic hydatidosis: challenging benign diseases for the hepatic surgeon: A case series report from an endemic area

Hydatid cysts of the liver are benign lesions which require a wide range of surgical strategies for their treatment. We hypothesized that cysts larger than 15 cm, or compressing main vascular structures, or located in both hemilivers should be considered, as well as complicated cysts, in the category of complex hydatid cysts.In a retrospective study including 55 patients, we evaluated the characteristics of complex hydatid cysts, and compared surgical outcomes between patients operated on for complex cysts (Complex Group) and those operated on for non-complex cysts (non-Complex Group).In the Complex Group, 19% of patients had cysto-biliary communication with recurrent cholangitis, 9.5% had cysts eroding the diaphragm or chest wall, or communicating with the bronchial tree, 31% had cysts with contact with main vascular structures, 11.9% had multiple bilobar cysts, 14.3% had giant cysts with organ displacement, and 14.3% had a combination of the above-mentioned types. Type of surgical treatment was different between the two groups (P < .001). Additional procedures were statistically more frequent in the Complex Group (P = .02). Postoperative morbidity was higher in the Complex Group, although not in a significant manner (P = .07). Median hospital stay was longer in the Complex Group (12 vs 7 days, P < .001). No 30-day mortality occurred. Four patients (7.3%), all belonging to the Complex Group, required reoperation for postoperative complications.Surgery for complex hydatid cysts of the liver is potentially burdened by serious complications. This kind of benign liver disease requires skill-demanding procedures and should be treated in centers with expertise in both hepato-biliary surgery and hydatid disease management.

A non-klatskin tumor: A case report and review of intrabiliary hydatid cyst rupture

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There’s no consensus on definitions & types of intrabiliary hydatid rupture.

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Original classification included either frank or occult rupture.

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Hydatid cyst rupture should always be ruled out as a cause of biliary obstruction.

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MRI may miss the diagnosis, and ERCP is valuable in diagnosis and treatment.

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Surgical removal of the mother cyst is essential for treatment.

Introduction

A 64-year-old lady was diagnosed with having a klatskin type 3A tumor based on imaging, however, an alternative diagnosis was achieved during surgery.

Presentation of case

We present a case of a 64-year-old lady who presented for new-onset jaundice and was diagnosed with type 3A klatskin tumor based on MRCP findings. During surgery, it was revealed that the obstruction was caused by a frank intrabiliary hydatid cyst perforation. Choledocoscopy with irrigation, cholangiography, and removal of the mother cyst were performed, and an end-to-end biliary anastomosis over a t-tube was then done. The patient tolerated the intervention and recovered well.

Discussion

Hydatid cyst disease of the liver usually follows a benign course, however, intrabiliary rupture is one of the common complications associated with this disease. Intrabiliary rupture is classified into either frank or occult. Frank perforation, which is more common, is when hydatid material passes into the biliary ducts, and it may cause biliary obstruction and cholangitis with a high mortality rate. Occult perforation is when the hydatid cyst becomes infected itself, which usually leads to a silent presentation, and may only cause signs of suppuration. Diagnosis is usually achieved by imaging and relevant history. Treatment consists of medical and surgical intervention. Intraoperative cholangiography, choledocoscopy, and t-tube drainage are recommended during surgery for frank rupture.

Conclusion

Intrabiliary hydatid cyst perforation can mimic cholangiocarcinoma and must be considered as an alternative diagnosis in these patients prior to surgery.

Brain and Cardiac Concomitant Localization of the Hydatid Cyst

Hydatid cyst is a parasitic infestation that is usually observed in the liver and lungs. The localization in the brain and the heart is exceptional. Here, we report a 11-year-old boy who was diagnosed to have two large hydatid cysts of the heart and brain. We discuss this unusual presentation of hydatid cyst and its management.

[Anaphylaxis due to a ruptured hydatid cyst]

HISTORY AND CLINICAL FINDINGS

We report the case of a 27-year-old Syrian patient who came to the emergency department with a syncopal episode. No medical history could be raised due to a language barrier and so the clinical presentation was leading.

INVESTIGATIONS AND DIAGNOSIS

The patient exhibited signs of shock, accompanied by an exanthema as well as perioral hematin. In an ultrasound sonography free intraabdominal fluid and an obscure change in the upper abdomen could be visualized. An esophagogastroduodenoscopy showed evidence of an ulcer, however did not explain all symptoms. In a CT abdomen, signs of a ruptured cyst could be demonstrated.

TREATMENT AND COURSE

The patient stabilized under the treatment protocol for anaphylaxis. Due to the clinical course and country of origin the patient received albendazole and a partial liver resection for a suspected echinococcus cyst.

CONCLUSION

Obscure clinical symptoms alongside signs of shock, should always considered to be an allergic reaction in absence of sepsis or hemorrhage. In anaphylaxis, echinococcosis should always be included in the differential diagnosis.

Hepato-pericardial fistula revealed by a massive pericardial effusion: A case report of an exceptional complication of the hydatid liver cyst

INTRODUCTION

The rupture of the hydatid liver cyst in the pericardium is a very exceptional and serious complication that can cause sudden death following cardiac tamponade or anaphylactic shock.

CASE PRESENTATION

We report a case of a 25 years-old woman with a massive pericardial effusion due to fistulization of hepatic hydatid cyst. Surgical closure of the fistula and the resection of the tow hydatid cysts were successful in managing this rare case.

DISCUSSION

Hepato-pericardial fistula is an extremely rare complication of hydatid liver cyst. Only 6 similar cases were previously reported in the literature. The Hepato-pericardial fistula may result in an acute pericarditis that progress to either cardiac tamponade or constrictive pericarditis. Its diagnosis is based on ultrasound and CT imaging. The surgical treatment with supportive therapy seems to improve the outcomes.

CONCLUSION

Pericardial effusion secondary to rupture of hepatic hydatid cyst should always be suspected in endemic countries.

An integrated surgical training program for hepatic cystic echinococcosis in Xinjiang of China

Background

Human cystic echinococcosis (CE) is one of the commonest zoonoses, and it is endemic in many parts of the world including China. Complications and recurrences after the surgical treatment of hepatic CE (HCE) incur a large personal, healthcare, and societal burden. There has been some progress in HCE prevention, diagnosis, and treatment, but there is no “one size fits all” approach, and surgery still remains the cornerstone of treatment for some cyst stages and locations or in areas with little knowledge or access to other treatment modalities. In 2009 we designed and implemented a program to improve surgical outcomes from HCE in Xinjiang province, China.

Methodology/Principal findings

A multimodal HCE training program was implemented in eleven primary hospitals in Xinjiang province, China, which provided education and training on HCE clinical knowledge and practice, the application of diagnostic and treatment options, and optimal surgery. The management of HCE cases was analyzed before and after program implementation. Contrast enhanced CT use, application of scoloicidal agents, removal of necrotic cyst wall remnants, appropriate perioperative drug use, and the use of optimal surgical approach increased after program implementation. Further, postoperative recurrences and residual cavity complications creased from 7.4% to 1.3% and 15.2% to 9.0% after program implementation, respectively.

Conclusions/Significance

Tis integrated surgical training program is useful for improving outcomes of patients with HCE and can be used in institutions in other endemic areas.

Hepatic cystic echinococcosis (HCE) is an endemic and neglected global disease. Many deprived areas in China still lack the knowledge and expertise to successfully treat HCE surgically, which results in high postoperative complication and recurrence rates that further decrease postoperative quality of life. In this study, we aimed to transfer our extensive experience in the development and implementation of effective surgery for HCE to eleven hospitals in the Echinococcus granulosus endemic province of Xinjiang to improve the surgical treatment of HCE. Our results indicate that our training program effectively reduces recurrence and complication rates and will be of use in other endemic areas.

Spontaneous rupture of isolated splenic hydatid cyst without acute abdomen: A case report

Isolated splenic hydatid cyst is a very rare manifestation of hydatid cyst. Rarely, patients present late after the cyst is ruptured. They might not present with usual presentations such as the acute abdomen, anaphylaxis, or urticarial rashes but only with a distended abdomen. Splenectomy is the emergency operative management.

A case report of complicated appendicular hydatid cyst mimicking an appendiceal mucocele

Retaining the etiology of a cystic lesion in the right iliac fossa can be difficult. Appendicular hydatid cyst is a very uncommon cause of a such lesion. In some cases, diagnosis is not obvious. It can radiologically mimic an appendix mucocele, a complicated ovarian cyst, an appendicular lymphangioma or an abscess. Our case highlights the difficulties encountered in this kind of situation and despite the contribution of imaging. We present a case of a 75 years-old woman presented with a right lower quadrant continuous pain. Abdominal CT-scan revealed a multilocular cystic and hydro-aeric mass. The diagnosis of an appendiceal mucocele complicated with gelatinous peritonitis was suspected. An open debulking surgery with right hemicolectomy was performed. The pathological exam has concluded to an infected appendicular hydatid cyst with thick calcified walls. The aim of this work is to report a case of an appendicular hydatid cyst that has imitated an appendicular mucocele to discuss the importance of differential diagnostic reflections and the appropriate treatment.

First Reported Case of Echinococcal Disease on a Renal Graft Successfully Treated With Albendazole

Echinococcal disease is an endemic disease for eastern Mediterranean countries. Various types of kidney involvement have been reported. Here, we report the first case of echinococcal disease on a transplanted kidney in a patient who was successfully treated with albendazole alone. The patient (a 38-year-old female) was evaluated for elevated creatinine levels 7 months after receiving a living-donor allograft. Standard immunosuppression therapy protocols were applied. Tacrolimus level was normal, and the patient was compliant with treatment. Creatinine level was 1.91 mg/dL (baseline: 1.2 mg/dL); proteinuria level was 1300 mg/day. The graft was found to be normal, as evaluated with standard sonographic methods. A kidney biopsy was performed, which showed that part of the cortical parenchyme was infiltrated by echinococcal protoscolices with hooklets. Because there were no cysts present on the graft, we concluded that disease was at an early stage. The patient was given albendazole for 3 months. After therapy, all echinococcal structures disappeared. Her creatinine level dropped to baseline, and proteinuria resolved. Echinococcal disease can affect transplanted kidneys. Albendazole is a valuable treatment option for patients who are not candidates for surgical resection.

Differentiation between hepatic cystic echinococcosis types 1 and simple hepatic cysts: A retrospective analysis

This study aims to evaluate the clinic value of ultrasound, computed tomography (CT) and serological testing in the differentiation between hepatic Cystic Echinococcosis (CE) types 1 and simple hepatic cysts.Totally 50 patients with CE Types 1 and 50 patients with simple hepatic cysts were included. All patients examined by ultrasound, CT and serological testing respectively. The receiver operating characteristic (ROC) curve of diagnosis methods was drawn and their sensitivity, specificity, Youden index, positive likelihood ratio, negative likelihood ratio, positive predictive value and negative predictive value were compared. Pathology result was used as golden standard.The area under ROC curve of ultrasound was 0.97 and of CT and serological testing was 0.79 and 0.71 respectively. The sensitivity of ultrasound in the diagnosis of CE Types 1 was 96.00%, specificity was 98.00%, the positive likelihood ratio was 48.00, and negative likelihood ratio was 0.04. Disease prevalence was 50%, positive predictive value was 97.96%, and negative predictive value was 96.08%. The sensitivity of CT was 80.00%, specificity was 62.00%, positive likelihood ratio was 2.11, and negative likelihood ratio was 0.32. Disease prevalence was 50%, positive predictive value was 67.80%, and negative predictive value was 75.61%. The sensitivity of immunological test was 86.00%, specificity was 72.00%, positive likelihood ratio was 3.07, and negative likelihood ratio was 0.19. Disease prevalence was 50%, positive predictive value was 75.44%, and negative predictive value was 83.72%. Combined ultrasound and immunological test, the sensitivity and the specificity was 82% and 100% respectively. Combined CT and immunological test, the sensitivity the specificity was 70% and 82% respectively.In the differentiate diagnosis of CE Types 1 and simple hepatic cyst, ultrasound is better than CT with high sensitivity and specificity, therefore recommended. Immunological examination is an important complement to the imaging examination.

A case of Extrapulmonary intrathoracic hydatidosis with pseudochylothorax

Echinococcus is a great re-emerging public health issue. Intrathoracic and extra pulmonary hydatid cysts with pseudochylothorax are rare. There is no standard treatment in case of hydatidosis with pseudochylothorax. Pharmacotherapy approaches may be an option in case of long duration of disease and high risk for surgery.

Hepatic Echinococcosis with Thoracic Involvement. Clinical Characteristics of a Prospective Series of Cases

INTRODUCTION

Thoracic involvement (TIHE) is one of the evolutionary complications of hepatic echinococcosis (HE).

AIM

The aim of this study was to describe the clinical characteristics and postoperative morbidity (POM) of a series of patients with TIHE treated surgically.

MATERIAL AND METHODS

Series of cases of patients treated for TIHE between 2000 and 2014 in the Hospital Regional and Clínica Mayor in Temuco, Chile, with a minimum 12-month follow-up. The outcome variable was "development of POM". Descriptive statistics were used.

RESULTS

The series was composed of 37 patients with a mean age of 53.2 ± 47.4 years (51.4% female). Mean cyst diameter was 19.4 ± 15.5 cm, and 75.7% of the lesions were located in the right hepatic lobe. The most frequent surgical technique used for the cyst was subtotal pericystectomy (56.8%); the residual cavity was treated by capitonnage (27.0%) or omentoplasty (21.6%), and a phrenoplasty with or without prosthetic material was performed for the TIHE. Mean hospital stay was 6.0 ± 5.7 days and follow-up was 61.4 ± 79.9 months; a mortality rate of 2.7% (one patient) and a POM of 24.3% (9 patients) were verified.

CONCLUSION

TIHE is an uncommon evolutionary complication of HE associated with significant POM rate.