Radical versus conservative surgical treatment of liver hydatid cysts: A paired comparison analysis

Current considerations for the management of liver echinococcosis

Echinococcosis or hydatid disease is induced mainly by Echinococcus granulosus and occasionally by Echinococcus multilocularis (alveolaris) and affects the liver predominantly. Hepatic alveolar echinococcosis is similar to carcinoma in appearance, and without treatment, it can lead to death. Diagnosis is based on current imaging modalities. Surgical management is the cornerstone of treatment. Complete removal of the cyst (total pericystectomy or hepatectomy) ensures a permanent cure and should be the first-choice treatment for cystic disease. Cyst evacuation, partial cystectomy, and drainage or omentoplasty, may be alternative choices in difficult cases. Albendazole, mebendazole and praziquantel are options for treating small cysts and preventing recurrence after surgery. Despite the efforts, alveolar echinococcus is not usually amenable to surgical management, except in the early stage, which is less common, and management by albendazole is indicated. However, there are few recent reports of major operations (ex-vivo hepatectomy, autotransplantation and vascular reconstruction) in advanced stages.

Evaluation of the necessity of simultaneous cholecystectomy in patients undergoing liver hydatid cyst surgery

Introduction

Liver hydatid cysts remain a significant public health issue in Turkey, the Middle East, East Asia, and Russia. Surgical treatments are often employed for certain stages of this disease. However, the necessity of simultaneous cholecystectomy during these procedures remains unclear. Treating symptoms related to subsequent cholelithiasis can become more challenging. This study investigates the necessity of simultaneous cholecystectomy by following patients who underwent hydatid cyst surgery with or without concurrent cholecystectomy.

Materials and methods

Patients who underwent surgery for hydatid cysts between 2019 and 2024 at the General Surgery Clinic of Ankara Bilkent City Hospital were retrospectively reviewed. A total of 97 patients were included, with 56 (54.32 %) undergoing cholecystectomy along with hydatid cyst surgery (Group 1) and 41 (45.68 %) not undergoing cholecystectomy (Group 2).Preoperative clinical, laboratory, and radiological findings, as well as intraoperative data, morbidity, mortality, and postoperative symptoms, were analyzed.

Results

Patients in Group 1 had longer hospital stays, higher blood loss, and significantly higher Clavien-Dindo complication scores. In the postoperative follow-up of Group 2, 8 patients (19.51 %) developed stones or sludge, and 1 patient (2.4 %) developed polyps. Four patients (9.75 %) presented to the emergency department with cholecystitis symptoms. A total of 5 patients (12.19 %), including 4 with symptomatic cholelithiasis (9.7 %) and 1 with gallbladder polyps (2.4 %), underwent elective cholecystectomy. Two (40 %) of these cholecystectomies were performed laparoscopically, while three (60 %) were converted to open cholecystectomy.

Conclusion

Simultaneous cholecystectomy during liver hydatid cyst surgery may prevent difficulties associated with treating symptoms related to subsequent cholelithiasis.

Efficiency of Anatomical Hepatectomy in the Treatment of Hepatic Cystic Echinococcosis

Introduction: Total cystectomy and hepatectomy are the main radical surgical procedures for hepatic cystic echinococcosis (CE). When CE lesions severely invade intrahepatic biliary ducts and vessels or single or multiple lesions occupy one hepatic lobe, performing total cystectomy is not indicated. This study aimed to analyze the clinical efficiency of anatomical hepatectomy in the treatment of patients with hepatic CE. Methods: Clinical data of 74 patients with hepatic CE who received anatomical hepatectomy were retrospectively analyzed from January 2005 to January 2022. The patients were classified into the intrahepatic biliary duct invasion group (group A), the intrahepatic vessel invasion group (group B), and the hepatic lobe occupation group (group C). Results: Among these 74 patients who received anatomical hepatectomy, right hepatectomy was performed in 20 cases (27.03%), left hepatectomy in 26 cases (35.13%), right posterior lobectomy in nine cases (12.16%), and left lateral sectionectomy in 19 cases (25.68%). Short-term post-operative complications occurred in seven cases (9.50%), including abdominal abscess in one case, pleural effusion in three cases, intestinal obstruction in one case, incision infection in one case, and ascites in one case. Long-term post-operative complications occurred in four cases (5.4%), including recurrences of CE in two cases and incisional hernias in another two cases. There were no statistical differences in the concentrations of total bilirubin, alanine aminotransferase, and aspartic transaminase before and after surgery between groups (p > 0.05). However, differences in operative time, short-term post-operative complications, average hospital stay, and number of open hepatectomy cases were statistically significant between groups (p < 0.05). The differences in cases receiving hepatic portal occlusion, intra-operative blood loss, and intra-operative blood transfusion were not statistically significant between groups (p > 0.05). Conclusions: Anatomical hepatectomy is an effective and feasible surgical procedure for patients with hepatic CE with severe invasion of intrahepatic biliary ducts and vessels or patients with huge lesions occupying one hepatic lobe, which effectively avoids residual cavity-related complications.

Perioperative outcomes and hospitalization costs of radical vs. conservative surgery for hepatic cystic echinococcosis: A retrospective study

BACKGROUND

Surgical intervention is a crucial treatment for hepatic cystic echinococcosis. However, the choice between radical and conservative surgery remains controversial. This study aimed to compare the perioperative outcomes and hospitalization costs between radical and conservative surgery for hepatic cystic echinococcosis.

METHOD

A retrospective cohort study was conducted on patients undergoing surgical treatment at the First People's Hospital of Kashi Prefecture from July 1, 2012, to October 1, 2023. Propensity score-matching analysis was utilized to mitigate patient selection bias between the two surgical groups.

RESULT

Of the 434 patients included, 324 underwent conservative surgery and 110 underwent radical surgery. After propensity score-matching, 182 conservative surgery and 102 radical surgery patients were compared. Radical surgery patients experienced longer operative time, higher intraoperative blood loss, increased blood transfusion, and higher costs compared to conservative surgery patients. However, no differences were observed in short-term outcomes, including overall morbidity, death, bile leak, effusion, pulmonary infection, incision infection, intestinal obstruction, ICU stay, abdominal drainage time, and postoperative hospital stays.

CONCLUSION

This study suggests that radical surgery is associated with greater surgical complexity and higher hospitalization costs, while it doesn't offer a significant short-term advantage. Conservative surgery may be a viable option in resource-limited settings or for patients unsuitable for complex procedures. Further research with long-term follow-up is needed to determine the optimal approach.

Therapeutic Options in Hydatid Hepatic Cyst Surgery: A Retrospective Analysis of Three Surgical Approaches

Hydatid disease is endemic in certain geographical areas where animal breeding is common, frequently challenging the medical services in these regions. Hydatid cysts most often affect the liver, with damage to other organs accounting for around one-third of the total cases. The alternative to interventional or pharmacological approaches is surgical treatment, available in variants such as laparoscopy, laparoscopy with special instruments for hydatid disease, or open surgery. This article aims to analyze the outcomes of these three types of surgical approaches, considering preoperative indications, operative techniques and efficiency, and immediate and long-term postoperative results. A total of 149 patients from two different surgical units were analyzed over a period of seven years. It was observed that males were more affected by this pathology (53.02%), with the majority of patients coming from rural areas (62.42%). The distribution by surgical procedure type showed that 50.34% were operated on using open surgery, 33.56% by means of a laparoscopic approach with the usual instruments, and 16.11% by means of a laparoscopic approach with special instruments. The laparoscopic procedure with special instruments presented a lower rate of conversion to open surgery compared to the usual laparoscopic approach (p = 0.014). The analysis of the average operative duration revealed statistically significant differences between the three types of surgical techniques (p < 0.05), noting that interventions with specialized instruments had the shortest duration, while open surgery had the longest operative time (72.5 ± 27.23 min vs. 154 ± 52.04 min). In terms of intraoperative complications, they were documented in 8.34% of cases for the group operated on with special instruments, in 12.24% of cases for the standard laparoscopy group, and in 16% of cases for the open surgery group. Maximal cystectomy was the preferred method for resolving these cysts using minimally invasive surgery (p < 0.001), while Lagrot pericystectomy was preferred in the open approach (p < 0.001). The most frequent postoperative complication was biliary fistula (24.16%), encountered in varying percentages across each technique but without significant statistical difference (p > 0.05). Open surgery was associated with a longer length of hospitalization compared to minimally invasive procedures (p < 0.05), a higher number of late postoperative complications (p = 0.002), and a significantly higher number of recurrences (p < 0.001) compared to the other two techniques. The present study highlights the effectiveness of minimally invasive surgery for hydatid cysts as a safe alternative with fewer complications and superior results compared to open surgery. Additionally, it provides a comparative analysis of these surgical approaches (special instruments, standard laparoscopy, and open surgery) to hydatid disease for the first time. Under the circumstances where pharmacological treatment is recommended as a supportive measure before and after procedures, and using medication alone as the primary treatment option shows only modest efficacy, there is a necessity to consider invasive treatment methods. Percutaneous procedures represent the least invasive form of treatment, yielding results comparable to surgery in terms of efficacy. However, their effectiveness is influenced by factors such as the cyst's stage of development, its location, and the challenges in achieving complete intra-procedural isolation. Laparoscopy, particularly when using specialized instruments tailored to the tactical and technical demands of managing hydatid disease, serves to address the limitations of percutaneous methods. Open surgery's role is increasingly restricted, primarily serving as a fallback option in laparoscopic procedures or in cases complicated by hydatid disease. In conclusion, despite the rising popularity of percutaneous methods, surgery remains a viable therapeutic option for treating hydatid disease. Minimally invasive surgical interventions are increasingly versatile and yield comparable outcomes, further solidifying the role of surgery in its management.

Standardized approach to the conservative surgery of hepatic cystic echinococcosis: A prospective study

OBJECTIVE

Surgery is the mainstay of hepatic cystic echinococcosis (HCE). The conservative surgery of HCE carries a non-negligible risk of recurrence and significant morbidity, dominated by Deep Surgical Site Infections (DSSI). To address these issues, we have improved and standardized this technique, which could reduce complications and achieve better postoperative outcomes.

PATIENTS AND METHODS

We conducted a prospective study from June 2017 to June 2022 involving of patient operated using a standardized open technique for uncomplicated HCE at Habib Bourguiba University Hospital, Sfax, Tunisia. The aim was to obtain results at least similar to radical management in terms of DSSI. Patients with large cystobiliary fistulas or patients with complicated cysts were excluded.

RESULTS

Fifty patients with 106 cysts were operated using the standardized technique comprising of liver mobilization, intraoperative ultrasound, systematic methylene blue injection to detect cystobiliary fistulas and omentoplasty. The median age of the patients was 44(semi-interquartile range: 16) years. The main symptom described by the patient was pain in 43 cases (86%). An abnormal liver test was found in 20 cases (40%). On imaging studies, the cyst had a median size of 7.4(3.0) cm. Cyst of the hepatic dome accounted for 38 cases (35.8%) with most cysts being situated in the right hemi-liver. Visual inspection of the cavity and Methylene blue testing allowed for the discovery of 57 cysts (53.7%) that had cystobiliary fistulas that were sutured. Omentoplasty was performed in 77 cysts (72.6%). Postoperatively, only 2 cases (1.9%) developed a DSSI in the form of an external bile leak with resolved with conservative management. No case of recurrence was found after a median follow-up of 24 months.

CONCLUSION

The standardized conservative surgical technique, in selected patients, shows promise in reducing DSSI rates and overall morbidity, and achieve as equally good result as radical management.

Success in managing a giant hepatic hydatid cyst: a case report of successful conservative surgical intervention in an endemic setting

Introduction and importance:

Echinococcosis, also known as a hydatid cyst, arises from a parasitic infection caused by the larval form of the tapeworm Echinococcus granulosus in humans. This endemic disease in Tunisia presents a significant public health challenge. The case highlights the enormous size of the liver hydatid cyst, emphasizing the importance and success of conservative surgical treatment.

Case Presentation:

A 45-year-old female shepherdess presented with abdominal pain and a mass, diagnosed as a giant hepatic hydatid cyst. A computed tomography scan revealed a dysmorphic liver with a large multivesicular cyst. Surgical intervention included the resection and closure of multiple cystic fistulas. Postoperative recovery was uneventful and at the 6-month follow-up, the patient displayed no indications of recurrence.

Clinical discussion:

Echinococcosis, prevalent in livestock-farming regions, primarily affects the liver and lungs. It often remains asymptomatic, detected incidentally. Diagnosis relies on imaging, with surgical excision as the primary treatment. Percutaneous options exist but are less effective. Serologies are underused. Management challenges include complications and recurrence. Conservative surgery is common but faces complications. Radical surgery is more effective, albeit complex. Albendazole preoperatively proves promising, reducing cyst viability. Regular follow-up is crucial for recurrence detection.

Conclusion:

Managing giant hepatic hydatid cysts requires tailored approaches, especially in endemic regions. Our success with conservative surgical treatment highlights its effectiveness in confronting formidable cyst sizes, informing clinical practice, and contributing to the medical literature.

Biliary fistula and late recurrence of liver hydatid cyst: Role of cysto-biliary communication: A prospective multicenter study

BACKGROUND

Hydatid cyst disease (HCD) is common in certain locations. Surgery is associated with postoperative biliary fistula (POBF) and recurrence. The primary aim of this study was to identify whether occult cysto-biliary communication (CBC) can predict recurrent HCD. The secondary aim was to assess the role of cystic fluid bilirubin and alkaline phosphatase (ALP) levels in predicting POBF and recurrent HCD.

AIM

To identify whether occult CBC can predict recurrent HCD. The secondary aim was to assess the role of cystic fluid bilirubin and ALP levels in predicting POBF and recurrent HCD.

METHODS

From September 2010 to September 2016, a prospective multicenter study was undertaken involving 244 patients with solitary primary superficial stage cystic echinococcosis 2 and cystic echinococcosis 3b HCD who underwent laparoscopic partial cystectomy with omentoplasty. Univariable logistic regression analysis assessed independent factors determining biliary complications and recurrence.

RESULTS

There was a highly statistically significant association (P ≤ 0.001) between cystic fluid biochemical indices and the development of biliary complications (of 16 patients with POBF, 15 patients had high cyst fluid bilirubin and ALP levels), where patients with high bilirubin-ALP levels were 3405 times more likely to have biliary complications. There was a highly statistically significant association (P ≤ 0.001) between biliary complications, biochemical indices, and the occurrence of recurrent HCD (of 30 patients with recurrent HCD, 15 patients had high cyst fluid bilirubin and ALP; all 16 patients who had POBF later developed recurrent HCD), where patients who developed biliary complications and high bilirubin-ALP were 244.6 and 214 times more likely to have recurrent hydatid cysts, respectively.

CONCLUSION

Occult CBC can predict recurrent HCD. Elevated cyst fluid bilirubin and ALP levels predicted POBF and recurrent HCD.

Rupture of a liver hydatid cyst into the right portal vein leading to right portal vein thrombosis: a case report and literature review

Hydatid disease (HD) is a worldwide parasitic disease. HD is endemic in many sheep- and cattle-raising areas, with a high prevalence of 5% to 10% in the Mediterranean region. Fistulation of liver hydatid cysts (LHC) in the bile ducts is the most common complication, followed by rupture of cysts in the peritoneal and thoracic cavities. Vascular complications are a rare complication of HD. We describe the case of a 70-year-old woman who was admitted with the chief complaint of pain in the abdominal right upper quadrant for 6 months. Abdominal computed tomography revealed a large LHC in the right liver that had ruptured into the right portal vein branch, with venous thrombosis. Intraoperatively, the right portal vein was opened longitudinally, and the hydatid contents were evacuated. Right hepatectomy was performed to completely excise the LHC. The penetration of a cyst into an adjoining vessel is very rare, and portal vein invasion by HD is extremely rare, with only 10 cases published in the literature, to the best of our knowledge.

Association between radical versus conservative surgery and short-term outcomes of hepatic cystic echinococcosis in Nyingchi, China: a retrospective cohort study

BACKGROUND

Radical or conservative surgical treatment for hepatic Cystic Echinococcosis (hepatic CE) is controversial. We aimed to measure the association between radical surgery (RS) versus conservative surgery (CS) and short-term outcomes in our cohort.

METHODS

Medical records of hepatic CE patients' demographic, clinical, radiological, operative and postoperative details who underwent surgical treatment between January 3, 2017 and January 3, 2018 at the Department of General Surgery, Nyingchi People's Hospital, Nyingchi, China, were retrieved and analyzed. The primary outcome was overall morbidity. The secondary outcomes included: (i) bile leakage; (ii) complications of lung, pleura, heart, liver, pancreas and biliary tract; (iii) incision infection and residual cavity abscess formation; (iv) anaphylactic reaction and shock; (v) tear of surrounding tissues; (vi) hospital and post-operative length of stay (LOS); (vii) length of surgery; (viii) blood loss during surgery. Multivariable logistic/linear regression models with various adjustment strategies for confounders were performed to evaluate the association.

RESULTS

A total of 128 hepatic CE patients were included with 82 (64.1%) and 46 (35.9%) receiving CS and RS, respectively. After fully adjusted, RS was associated with 60% lower risk of overall complication (aOR 0.4; 95%CI, 0.2-0.9) and 0.6-h shorter surgical time (aβ 0.4; 95%CI,-0.0-0.8) comparing to CS. However, RS was associated with more blood loss during surgery (aβ 179.3; 95%CI, 54.2-304.5).

CONCLUSION

To conclude, RS was associated with a 60% reduction in developing overall complication in the short term, but may result in more blood loss during surgery than CS.