Percutaneous treatment of liver hydatid cysts

[Ruptured pulmonary Echinococcus granulosus cyst: A rare cause of severe pneumogenic sepsis]

Parasitic infections by Echinococcus granulosus are rare in Germany, and predominantly affect individuals with a migration background. Liver and lungs are the most commonly affected organs. Pulmonary cysts often remain asymptomatic until rupture, at which point symptoms may manifest. The diagnostic approach typically involves a combination of imaging modalities and serological tests, occasionally supplemented by molecular genetic methods. Given the global movements of migration, considerations of the epidemiology of common diseases in the country of origin should also be taken into account in the differential diagnosis. We present the unusual case of a pneumogenic sepsis in a young man from Syria, where the combination of medical history alongside radiological, serological, and molecular genetic investigations ultimately led to the diagnosis of a severe pulmonary echinococcosis with rupture.

Two Cases of Disseminated Alveolar Echinococcosis: The Diagnosis, Management, and Differential Considerations for Liver Lesions

Alveolar echinococcosis (AE), caused by Echinococcus multilocularis, is an aggressive and potentially critical infestation that primarily affects the liver and can metastasize to any part of the body. We herein report two cases of echinococcosis, which could be differentiated from malignancy on imaging studies, with infections of the liver and mediastinal lymph nodes, and also associated with systemic disseminated lesions. AE is a very invasive infectious disease, and in order to detect such lesions at an early stage when they are still resectable, it is necessary to understand the characteristic imaging findings and determine the patient's current medical history.

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.

ULTRASOUND-GUIDED PERCUTANEOUS TREATMENT OF HEPATIC HYDATIDOSIS IN TWO RED-SHANKED DOUC LANGURS (PYGATHRIX NEMAEUS)

Hydatid disease caused by Echinococcus ortleppi is a major cause of morbidity and mortality for critically endangered captive langurs in northern Vietnam. The most common sites for hydatid cyst development are the liver and the lungs. Chemotherapy trials with albendazole alone or in combination with praziquantel in these langurs had varying results and in most cases were ineffective. Ultrasound-guided percutaneous aspiration of cystic fluid followed by instillation and re-aspiration of a scolicidal agent (PAIR technique), has gained importance in the treatment of active hepatic cysts in humans and in many cases is preferred over surgical and endoscopic approaches. The PAIR technique was used in two red-shanked douc langurs (Pygathrix nemaeus) for the treatment of unilocular active hepatic cysts. The technique was found to be fairly easy to perform, safe, and effective and should be a useful treatment tool for hepatic hydatidosis in langurs and other nonhuman primate species.

Percutaneous Treatment of Giant Hydatid Cysts and Cystobiliary Fistula Management

RATIONALE AND OBJECTIVES

To investigate the efficacy and safety of percutaneous treatment in cystic echinococcosis (CE) type 1 and 3a giant cysts (with at least one diameter>10 cm) according to the World Health Organization classification and to evaluate the management of complications, especially cystobiliary fistulas (CBFs).

MATERIALS AND METHODS

This retrospective study included 66 patients with 68 CE1 and CE3a giant cysts treated with percutaneous catheterization between January 2016 and December 2021. The characteristics of the cysts, major and minor complications, time to catheter removal, and length of hospital stay were recorded.

RESULTS

Among the 68 cysts, CBFs occurred in 35 (51.5%), cavity infections in 11 (16.1%), recollection in five (7.4%), and anaphylaxis in three (4.5%). There was no mortality. Biliary drainage was observed intraoperatively in 20 (29.4%) and only postoperatively in 15 (22.1%) of the 35 cysts with CBFs. A plastic biliary stent was placed in 18 (51.5%) of the 35 cysts with CBFs. The patients with CBFs had a longer hospital stay and time to catheter removal than those without fistulas (15.3 ± 10.9 vs. 6.1 ± 2.6 days and 32.7 ± 51.8 vs. 6.2 ± 3.1 days, respectively; P < 0.001). Of the patients who developed recollection, three were treated with secondary catheterization, and two underwent surgery. In total, three patients underwent surgery. The rate of clinical success was 95.4%. All cysts were followed up for an average of 19.1 (range, 12-60) months, and there was an average 88.8% reduction in cyst volume compared to the initial evaluation.

CONCLUSION

CE1 and CE3a giant cysts can be treated effectively and safely with high clinical success using the catheterization technique. Contrary to what has previously been reported for these patients, the rate of CBFs is high, but these patients can successfully be treated with percutaneous drainage and/or endoscopic retrograde cholangiopancreatography without the requirement of surgery.

Percutaneous treatment of giant hydatid cysts: a single-center experience of 58 cysts

PURPOSE

The aim of this study is to evaluate the efficacy of percutaneous treatment in hydatid cysts (HCs) with at least one diameter larger than 10 cm.

MATERIALS AND METHODS

58 CE1 or CE3a HCs with at least one diameter larger than 10 cm which were treated with catheterization between September 2016 and December 2021 were retrospectively analyzed.

RESULTS

Mean age was 40 ± 17.7 (18-80). Majority of HCs were in the liver (89.6%). Median follow-up was 28 months. Technical success rate was 100%; however, a second procedure was needed in 13 cysts due to recollection (n = 4), infection (n = 6), and recurrence (n = 3).

CONCLUSIONS

Giant HCs can be effectively treated with catheterization with low complication rates.

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.

Renal Cystic Echinococcosis: Long-Term Outcomes of Percutaneous Treatment

PURPOSE

To evaluate the long-term outcomes of percutaneous treatment of renal cystic echinococcosis (CE) stratified by cyst stages according to the World Health Organization (WHO) classification.

MATERIALS AND METHODS

Between January 1997 and February 2019, 34 patients with renal CE (18 women; mean age, 38 years) were treated with 3 different percutaneous techniques. According to the World Health Organization classification, the cysts were classified as CE1, CE2, CE3a, and CE3b. Puncture, aspiration, injection, reaspiration (PAIR) or standard catheterization was used for the dimension-based treatment of CE1 and CE3a cysts. Modified catheterization (MoCaT) was used to treat all CE2 and CE3b cysts. Technical and clinical success, complications, and reduction in cyst cavities were evaluated.

RESULTS

The technical success rate was 100%. PAIR, standard catheterization, and MoCaT were used to treat 12, 9, and 13 cysts, respectively. The only severe adverse event was a bacterial superinfection that occured in the cyst cavity of a patient (3%) treated with MoCaT. Four patients (12%) experienced mild/moderate periprocedural allergic adverse events and were managed conservatively. The mean length of hospital stay was 1, 5, and 7 days for patients treated with PAIR, standard catheterization, and MoCaT, respectively. The clinical success rate was 97%. In 1 of 34 cysts (3%), recurrence was detected and the cyst was successfully re-treated. During the 10.5-year follow-up period, 95% volume reduction was achieved. The median final cyst volume was 10 mL.

CONCLUSIONS

Renal CE can be successfully treated with minimum adverse events and recurrence rates using appropriate percutaneous techniques selected according to their stages as classified according to WHO.

MicroRNA expression profile in patients with cystic echinococcosis and identification of possible cellular pathways

Cystic echinococcosis (CE) is a neglected tropical disease, caused by metacestode (larval) form of the Echinococcus granulosus sensu lato (sl) in humans. MicroRNAs (miRNAs) are small, stable, tissue-specific RNA molecules encoded by the genome that are not translated into proteins. Circulating miRNA expression profiles vary in health and disease. The aim of this study is to determine the altered cellular pathways in CE by comparing the miRNA profiles of controls and CE patients with active or inactive cysts. Following abdominal ultrasonography (US) examination, 20 patients diagnosed with active CE (CE1, CE2, CE3a and CE3b) or inactive CE (CE4 and CE5) and three healthy controls were included in the study. The expression profiles of 372 biologically relevant human miRNAs were investigated in serum samples from CE patients and healthy controls with miScript miRNA HC PCR Array. Compared with the control group, expression of 6 miRNAs (hsa-miR-4659a-5p, hsa-miR-4518, hsa-miR-3977, hsa-miR-4692, hsa-miR-181b-3p, hsa-miR-4491) and one miRNA (hsa-miR-4687-5p) were found to be downregulated in CE patients with active and inactive cysts, respectively (p < 0.05). For downregulated miRNAs in this study, predicted targets were found to be associated mainly with cell proliferation, apoptosis, cell-cell interactions and cell cycle regulation. Further studies in this direction may elucidate the pathogenesis of human CE and the relationship between CE and other pathologies.

Treatment of Gharbi Type III Hepatic Hydatid Cysts: A Clinical Dilemma

This article aims to compare available treatment options for type III liver hydatid cysts, including surgery and percutaneous techniques. Hydatid disease is a helminthic infection caused by Echinococcus granulosus and is a serious public health problem in endemic regions of the world. Hydatid cyst of the liver is the most common clinical presentation of Echinococcus granulosus. According to Gharbi classification, hydatid cysts of the liver are classified into 5 types. Type III hydatid cysts are those with fluid collection and septa. Treatment of Gharbi type III hydatid cysts is still controversial. Some researchers think that Gharbi type III hydatid cysts are not suitable for percutaneous drainage, and surgery is the suitable treatment option. There are not enough prospective studies comparing percutaneous and surgical techniques for the treatment of type III hydatid disease of the liver. A proper meta-analysis does not seem to be possible with the available studies in current medical literature.

Clinical management of cystic echinococcosis: state of the art and perspectives

PURPOSE OF REVIEW

This review draws attention to patients with cystic echinococcosis migrating from highly endemic to non-endemic countries with limited experience in cystic echinococcosis management, to ultrasound-based cyst staging, and to the WHO cyst classification as a powerful, to date underused tool to triage patients into the four currently available treatment modalities.

RECENT FINDINGS

In non- and low-prevalence countries, cystic echinococcosis is often misclassified. Differential diagnoses, such as simple cysts and other benign and malignant space-occupying lesions, have similar appearances on imaging. Serology is confirmatory but often disappointing due to sensitivity and specificity problems. There is increasing confidence in assigning uncomplicated cystic echinococcosis cysts to the four treatment modalities [drug treatment (benzimidazoles), percutaneous methods, surgery, watch and wait] on the basis of cyst stage (WHO cyst classification), size and location. However, current best practice is still not widely implemented outside cystic echinococcosis treatment centres, and further consolidation is needed by well-designed clinical trials. Recently published long-term follow-up studies have shown that patients with inactive cyst stages CE4 and CE5 benefit, especially since they do not need any treatment at all if they have not received prior benzimidazole or percutaneous therapy. Instead, cysts that have reached cyst stages CE4 and CE5 through drug treatment do need careful follow-up as they often relapse. Surgical procedures in which the cysts are opened and percutaneous approaches require very careful control of cyst content spillage to the peritoneum, pleura and intravascularly to prevent dissemination - a still too often neglected issue with severe consequences for patients.

SUMMARY

Though a neglected disease with predominantly expert-opinion-based treatment strategies, cystic echinococcosis patients can greatly benefit from interdisciplinary management in cystic echinococcosis treatment centres and cyst-stage-based assignment of treatment modalities. Increased suspicion for cystic echinococcosis in migrants from endemic to non-endemic countries is urgently needed at the current level of global mobility.

Knowledge Domain and Emerging Trends on Echinococcosis Research: A Scientometric Analysis

The echinococcosis of humans and animals is a chronic helminthic disease caused by the larva of genus Echinococcus tapeworms. It is a globally distributed disease which is an important socioeconomic and public health problem in many low and middle-income countries. This research aimed to firstly quantitatively analyze the publications with bibliometrics software and evaluated the hot topics and emerging trends of echinococcosis research from 1980 to 2017. A total of 7688 references on echinococcosis research were retrieved from the Web of Science Core Collection database. Then the reference was analyzed with CiteSpace software to make the knowledge network maps. The largest cluster (#0) with 83 members was cystic echinococcosis, and cystic echinococcosis, mebendazole, antibody and transmission were the four keywords with the strongest citation bursts in the echinococcosis research field. Furthermore, cystic echinococcosis, chemotherapy and immunodiagnosis, management of definitive and intermediate host are the top four research hot topics and emerging trends in the echinococcosis field. This research presents an insight into the echinococcosis field and valuable visualizing information for echinococcosis researchers to detect new viewpoints on cooperative countries/institutions, potential co-workers and research frontiers.

Percutaneous treatment of hepatic cystic echinococcosis: the success of alcohol as a single endocavitary agent in PAIR, catheterization, and modified catheterization techniques

OBJECTIVES

This retrospective study aims at demonstrating the success rate, effectiveness, and advantages of alcohol as a scolicidal and sclerosing agent for the percutaneous treatment of liver hydatid cysts.

METHODS

A total of 554 liver hydatid cysts obtained from 347 patients admitted between January 2008 and February 2016 were retrospectively investigated. Of these, 435 (78.5%), 91 (16.4%), and 28 (5%) were classified as Gharbi type 1, 2, and 3, respectively. Type 1 and 2 cysts were treated using PAIR (puncture, aspiration, injection, respiration) and single puncture catheterization methods; type 3 lesions were treated using a modified catheterization technique. Alcohol was used as a scolicidal and sclerosing agent in all procedures.

RESULTS

After excluding three lesions (0.5%) because of lack of parenchymal support during catheterization, 274 (49.7%), 250 (45.3%), and 27 (4.9%) of 551 lesions were treated with PAIR, single puncture catheterization, and modified catheterization techniques, respectively. Therefore, a 99.5% of technical success rate was obtained. Major complications in 2 patients (0.5%) and minor complications were observed in 36 patients (10.3%). Mean hospital stay was 1.55±2.3 days (range: 0-23 days). Patients were followed-up for mean 19.6 months (range: 6-83 months), during which recurrences were detected in 19 patients (5.4%).

CONCLUSIONS

The use of alcohol as a scolicidal and sclerosing agent during the percutaneous treatment of liver hydatid cysts is associated with a high success rate and low rates of recurrence and complications, and should be considered an important alternative to surgical procedures.

Preliminary Evaluation of Percutaneous Treatment of Echinococcal Cysts without Injection of Scolicidal Agent

Puncture, Aspiration, Injection of scolicidal agent, Re-aspiration is the most widely used percutaneous treatment of cystic echinococcosis (CE). Among its perceived risks is chemical sclerosing cholangitis, a serious complication due to the caustic effect of the scolicidal solution on the biliary tree, when a patent cystobiliary fistula occurs. To simplify the protocol, we decided to omit injection and reaspiration of the scolicidal agent and to implement a full course of albendazole (ABZ) therapy instead of the routine 1-month ABZ prophylaxis. We searched our databases for patients with CL (Cystic Lesion, suspected for CE), CE1, and CE3a cysts treated between October 2007 and January 2017 with percutaneous aspiration followed by at least 1 month of oral ABZ and with an ultrasound follow-up of at least 6 months. Fifteen patients matched our inclusion criteria. Follow-up ranged from 7 to 75 months. The oral ABZ course after the aspiration procedure ranged from 1 to 18 months. Eleven subjects (73.3%) had undergone a course of ABZ before the percutaneous procedure (min 15 days, max 16 months). Ten cysts (62.5%) had reached solidification (stage CE4) in 3 to 69 months. Four other cysts (26.7%) remained stable in stage CE3a, whereas two cysts (13.3%) reactivated to stage CE3b. Procedural perioperative complications occurred in 13.3% of patients, whereas complications during the follow-up occurred in 20% of patients. These proof-of-concept preliminary results are overall comparable with those reported in the literature for other percutaneous treatments, both in terms of response rate, relapse rate, and morbidity.

Incidence and risk factors of biliary fistulation from a hepatic hydatid cyst in clinically asymptomatic patients

Biliary fistulation from a hepatic hydatid cyst is its most frequent complication. If unrecognised, this may cause difficulties during and after surgical intervention. Our study looked into its incidence and also the possible risk factors in a retrospective investigation of 60 patients (34 women) who had undergone surgery or percutaneous treatment. Demographics and anatomical characteristics, such as cyst type, location, number, diameter and laboratory findings were examined. A full 50% had biliary fistulation, with increased risk if the cyst diameter was ≥8.8 cm.

Percutaneous treatment of liver hydatid cysts in 190 patients: a retrospective study

Background Hydatid liver disease (HLD) is a significant health problem, especially in endemic areas worldwide. Percutaneous treatment is an effective alternative therapeutic option. Purpose To present the clinical and radiological results of percutaneous treatment of HLD in 190 patients. Material and Methods Percutaneous treatment of HLD between April 2005 and March 2015 was analyzed retrospectively. The demographic data, numbers and types of cysts, initial and final volumes of the cysts, types of percutaneous treatment, and procedure-related complications were determined. Results A total of 190 patients (95 male patients and 95 female patients; age range, 5-82 years) with 283 liver hydatid cysts who underwent percutaneous treatment were included in the study. Of the 283 cysts, 234 (83%) were cystic echinococcosis CE1, 31 (11%) were CE3a, and 18 (6%) were CE2 cysts, according to the World Health Organization (WHO) classification. The percutaneous procedure was successful in all patients. A total of 12 (6.3%) major complications, including anaphylaxis, allergic skin reaction, perihepatic hemorrhage, and cavity infection, were seen. No mortality was noted. Recurrence in one patient and an additional cyst in one patient were seen. All patients were asymptomatic during the follow-up period. Mean volume reduction was 77.5%, with a mean follow-up period of 18 months. Conclusion Percutaneous treatment is an effective and safe method for the treatment of HLD. It should be regarded as a first-line treatment method for uncomplicated hydatid cysts.

Successful percutaneous treatment of extrahepatic cystic echinococcosis through PAIR and single puncture catheter techniques

PURPOSE

To demonstrate the successful percutaneous treatment of extrahepatic cystic echinococcosis as an alternative to surgical procedures.

MATERIALS AND METHODS

A total of 27 extrahepatic hydatid cysts in 12 patients, the spleen in 8 patients, muscles and soft tissues in 3 patients each and right adrenal gland in 1 patient were treated with PAIR (puncture, aspiration, injection, respiration) or single puncture catheterization methods. As a scolicidal and sclerosing agent, alcohol was used in all patients.

RESULTS

Of 27 extrahepatic lesions of hydatid cysts, 24 (88.9%) were Gharbi type 1 (WHO CE 1), and 3 (11.1%) were Gharbi type 2 (WHO CE 3A). Of hydatid cystic lesions, 20 with PAIR and 7 with single puncture catheterization methods were treated. No major complications developed in any patients. Abscesses were detected in two patients (16.6%). Mean total hospital stay was calculated between 1 and 14 days (mean 2.3 days). Follow-up periods ranged between 10 and 62 months (mean 22.3 months).

CONCLUSION

Percutaneous treatment for extrahepatic hydatid cystic lesions is an important alternative to surgical procedures because of the high therapeutic success rate, lower rate of complications and shorter hospital stays.

A novel modified PAIR technique using a trocar catheter for percutaneous treatment of liver hydatid cysts: a six-year experience

PURPOSE

We aimed to demonstrate the success and reliability of a novel puncture, aspiration, injection, and reaspiration (PAIR) technique in liver hydatid cysts.

METHODS

Percutaneous treatment with ultrasonographic guidance was performed in 493 hepatic hydatid cysts in 374 patients. Patients were treated with a new PAIR technique by single puncture method using a 6F trocar catheter. The results of this novel technique were evaluated with regards to efficacy and safety of the procedure and complication rates.

RESULTS

Out of 493 cysts, 317 were Gharbi type I (WHO CE 1) and 176 were Gharbi type II (WHO CE 3A). Of all cysts, 13 were referred to surgery because of cystobiliary fistulization. Recurrence was observed in 11 cysts one month later. Therefore, the success rate of the PAIR technique was 97.7% (469/480). Minor complications (fever, urticaria-like reactions, biliary fistula) were seen in 44 treated patients (12%, 44/374); the only major complication was reversible anaphylactic shock which was observed in two patients (0.5%, 2/374).

CONCLUSION

This novel modified PAIR technique may be superior to catheterization by Seldinger technique due to its efficiency, easier application, lower severe complication rate, and lower cost. Further comparative studies are required to confirm our observations.

Comparison of Long-Term Results of Percutaneous Treatment Techniques for Hepatic Cystic Echinococcosis Types 2 and 3b

OBJECTIVE

The purpose of this study was to determine the long-term results of a modified catheterization technique for percutaneous treatment of hepatic cystic echinococcosis (CE) types 2 and 3b and to retrospectively compare the results of puncture, aspiration, injection, and reaspiration (PAIR); standard catheterization; and the modified catheterization technique.

MATERIALS AND METHODS

Seventy-three patients (37 male, 36 female; 75 cysts) with CE types 2 and 3b who underwent percutaneous treatment from March 1991 to August 2008 were included. Informed consent from all patients and approval of the ethics board were obtained. Patients were 6-79 years old. Twenty-three cysts (30.6%) were treated with PAIR, 26 (34.7%) with standard catheterization, and 26 (34.7%) with the modified catheterization technique. The results of the three techniques were statistically compared.

RESULTS

Among all patients, the cysts decreased in volume by 61.1% (range, 5-100%). Cysts recurred in 11 (47.8%) patients treated with PAIR, three (11.5%) treated with standard catheterization, and one (3.8%) treated with the modified catheterization technique. The recurrence rate was not significantly different between standard catheterization and the modified catheterization technique (p > 0.05), whereas significantly more recurrences developed after PAIR than with the other two techniques (p < 0.05). Twelve (16.4%) major and 16 (21.9%) minor complications developed. Significantly fewer major complications occurred with PAIR than with the modified catheterization technique, but the difference between standard catheterization and the other two techniques was not significant.

CONCLUSION

Treatment of CE types 2 and 3b with the modified catheterization technique was associated with a recurrence rate lower than what is seen with other techniques, and therefore it appears to be a safe, reliable, and efficient alternative.

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.

Comparison of mid-term clinical outcomes of laparoscopic partial cystectomy versus conventional partial cystectomy for the treatment of hepatic hydatid cyst

Background:

The aim of this study was to compare the mid-term outcomes of open and laparoscopic partial cystectomy (LPC).

Methods:

The medical records of patients who underwent conventional partial cystectomy (CPC) and LPC for liver hydatid cyst from May 2010 to February 2015 were retrospectively reviewed. Operative time, blood loss, length of hospital stay, post-operative morbidity, mortality and mid-term follow-up outcomes were evaluated.

Results:

Amongst 130 patients, 38 patients were underwent LPC and 92 underwent CPC. Blood loss and post-operative complications were similar in both groups. The mean operative time in the LPC and the CPC groups was, respectively, 95.4 ± 13.1 and 63.5 ± 15.6 min, which showed a significant difference between the both groups. The mean length of hospital stay in CPC group was significantly longer when compared the LPC group. The mean diameter of cyst in LPC group was 6.1 ± 1.1 cm and 7.8 ± 2.1 cm in CPC group with a significant difference. The overall complication rates were 13.1% in LPC group and 17.3% in CPC group without significant difference. The most common complication was biliary leakage and surgical site infection.

Conclusion:

LPC for the surgical treatment of liver hydatid cyst appears to be safe and effective method with low morbidity rates in selected patients.

Minimally Invasive Treatment of Liver Hydatidosis

Background and Objectives:

Open surgery has been the mainstay treatment for liver hydatidosis in the past. Today, for treatment of simple and uncomplicated cysts, we have a variety of choices: antihelmintic therapy, the PAIR (puncture, aspiration, injection, and respiration) technique, and the laparoscopic approach. We reviewed our series of 267 cases of hepatic hydatidosis submitted to surgery over a period of 20 years, from 1995 through 2014, comparing the results of these minimally invasive treatments.

Methods:

In 92 patients (25.7% of cases) who presented with complicated liver hydatid cysts, we performed open surgery. In 16.4% of cases (59 patients), we used a laparoscopic approach, and in 208 patients (57.9% of cases), we used the PAIR technique. All patients were monitored after surgery for a mean of 61.7 months (range, 16–127). Postoperative follow-up consisted of clinical examination, laboratory investigation, abdominal ultrasound, and magnetic resonance imaging.

Results:

Almost all patients (198, 95.2%) treated with the PAIR technique and 55 patients (93.2%) treated with the laparoscopic approach were cured. Six patients (2.8%) from the echo-guided puncture group had to undergo a repeat of the procedure because the cavity did not disappear after 2 years. In 4 patients (2%), we performed open surgery for 2 biliary fistulas and 2 hepatic abscesses. Four patients from the laparoscopic group needed additional procedures. Open surgery was necessary in 2 patients for a recurrence after 2 years; 1 patient had developed a liver abscess and the other had a biliary fistula.

Conclusions:

In conclusion, open surgery remains the viable option for complicated cysts, with biliary communication, with multiple daughter vesicles, or with calcified walls. For simple, uncomplicated hydatid cysts, both methods (the PAIR technique and laparoscopic procedure) are safe and efficient, with very good results and low morbidity rates.

Effectiveness of single-session ultrasound-guided percutaneous ethanol sclerotherapy in simple breast cysts

PURPOSE

We aimed to evaluate the effectiveness of single-session ultrasound-guided percutaneous ethanol sclerotherapy in simple breast cysts.

METHODS

From January 2002 to January 2014, 35 simple breast cysts (mean volume, 8.2 mL; range, 4-33 mL) in 28 females (mean age, 39 years) were evaluated. In a single session, all cysts were aspirated using 20G needles, refilled with 99% ethanol (90% of the volume of the aspirated fluid), and reaspirated completely after 10 minutes of exposure under ultrasound guidance. Follow-up ultrasonography examinations were performed at one week, one month, three months, and six months for all patients and 12 months, 18 months, and 24 months for available patients. Follow- up duration varied between 6 and 24 months (mean, 15 months).

RESULTS

The technical success rate of ultrasound-guided percutaneous etha-nol sclerotherapy was 97%. The needle tip was dislocated and ethanol was given into the breast parenchyma in one patient (3%). One cyst (3%) was reaspirated at the first week follow-up due to intracystic hemorrhage. Of the 34 cysts treated, 25 (74%) completely responded to therapy and were no longer detectable on follow-up examinations. Eight cysts (24%) significantly decreased in size and then completely disappeared at six months. At the end of the follow-up period, the clinical success rate reached 100%, and none of the cysts were visible. Except mild to moderate sensation of burning or pain which disappeared or subsided significantly in a couple of minutes, no other complications were observed in patients.

CONCLUSION

Ultrasound-guided ethanol sclerotherapy is a fast, safe, and highly effective method in the treatment of simple breast cysts.

Three complications of Pair (puncture, aspiration, injection, reaspiration) in one case: Recurrent hemobilia, cyst infection and pneumonia

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Percutaneous aspiraton injection and reaspiration technique can have multiple complications like cysts infection, pneumonia and hematobilia.

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Hematobilia is a rare complication; however, early diagnosis is the key feature.

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When complicated, treatment procedure can be challenging with elonged hospital stay and multiple other investigations like ERCP.

Introduction

With the appropriate indications, puncture, aspiration, injection and reaspiration (PAIR) is the most effective minimal invasive method used in the treatment of hydatic cysts. Hemobilia is the hemorrhagia in bile ducts in consequence of any reason. In literature there is no case with hemobilia because of PAIR. This is the first case with recurrent hemobilia, infection in cyst cavity and pneumonia because of PAIR.

Case

A 66 years old female patient was admitted to hospital with complaints of abdominal pain, hematemesis and melaena. She gave the history of PAIR for two hydatic cysts. At physical examination, there were jaundice, tenderness at right subcostal area and melaena at rectal digital examination. Hemobilia was detected by abdominal ultrasonography and magnetic resonance cholangiopancreaticography (MRCP). An endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy were performed. The patient was discharged after 6 days hospital stay. One day after the discharge the patient was admitted to hospital with the same complaints again. Performing ERCP and balloon extraction, the hematoma filling the common bile duct was removed. After the patient was hemodynamically stable for 3 days, she was discharged from the hospital. A week after that the patient was admitted to hospital with the clinical findings of infected hydatic cyst and pneumonia. The patient was treated medically with mechanical ventilation support for 8 days.

Conclusion

It should not be underestimated that, there can be serious complications of PAIR like hemobilia. Therefore, PAIR should be performed only in centers having appropriate medical and surgical facilities.

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

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

Hepatic cystic echinococcosis: percutaneous treatment as an outpatient procedure

OBJECTIVE

To demonstrate utility and safety of the puncture aspiration injection and reaspiration (PAIR) technique for outpatients.

METHODS

Percutaneous treatment with US guidance was applied to 33 patients for 44 cysts. Patients treated with the PAIR technique, were outpatients. PAIR and catheterization technique were evaluated for efficacy and safety of procedure and complication rates.

RESULTS

Thirty-five of 44 cysts were treated with the PAIR and 9 of 44 were treated with the catheterization technique. The success rate of the cysts Gharbi type 1 (CE1) and type 2 (CE3a) treated with the PAIR technique was 100%. In the follow up of 9 cysts treated with the catheterization technique, 2 of them (22%) developed cyst infection and 1 (11%) developed a biliary fistula.

CONCLUSIONS

The PAIR technique was found to be an effective and safe approach in order to treat Gharbi type 1 and type 2 cysts percutaneously for outpatients. It has a very low complication rate in comparison with the catheterization technique. So every effort should be made to finish the treatment with PAIR technique.

The role of laparoscopy in the management of liver hydatid cyst: a single-center experience and world review of the literature

Surgery is still the main modality in the treatment of hepatic hydatid disease. Laparoscopic methods, with their low morbidity, have gained prominence in many fields and, in some cases, have nearly replaced open surgery. In this report, a laparoscopic method for the treatment of hepatic hydatid disease is described, and the results in the 46 cases are presented and the published articles were reviewed. The method involves laparoscopic cystectomy, pericystectomy, and liver resection for hydatid disease. The postoperative courses of the patients were very comfortable and no complication related to the laparoscopic technique occurred. The postoperative parameters and the early follow-up results (average, 18 mo) are very encouraging. Laparoscopic treatment of liver hydatid disease is safe and effective in selected patients and offers all the advantages of a laparoscopic surgery. In experienced hands, laparoscopic pericystectomy have lower morbidity and recurrence rate compared with cystectomy.

Case report: Percutaneous treatment of multiple honeycomb-like liver hydatid cysts (type III CE2, according to WHO classification)

Percutaneous treatment has been developing as a reliable and effective alternative to surgery in the treatment of liver hydatid cysts. However, percutaneous treatment is strongly recommended only for some types of hydatid cysts (types I and II). We report a patient with type III (CE2, according to the WHO classification) multiple liver hydatid cysts treated with the PAIR (puncture-aspiration-injection-reaspiration) technique. The patient developed a secondary biliary fistula, which ultimately healed.

Cystic echinococcosis of the liver: experience from a Danish tertiary reference center (2002-2010)

BACKGROUND

Cystic echinococcosis (CE) of the liver can be treated with ultrasound-guided puncture, aspiration, injection, and re-aspiration (PAIR), with surgery and with benzimidazole derivatives. The aim of this study was to review available data concerning treatment modality and outcome for patients treated for CE of the liver in a Danish tertiary reference center.

METHODS

A search was made for patients treated for CE infection between January 1, 2002 and January 1, 2010. All relevant patient records and radiology exams were scrutinized and all cysts were re-classified according to the WHO-IWGE, blinded as to which treatment the patient had received. PAIR was performed as a first choice treatment and surgery was reserved for cases where PAIR was impossible. Inactive cyst stages received medical treatment only.

RESULTS

The search revealed 26 cases with confirmed CE of the liver. Nine patients underwent PAIR and nine patients surgery as a first choice treatment. Three patients were treated with PAIR secondary to surgery and one patient was treated with surgery secondary to PAIR. For all PAIR treatments, the success rate was 58% regardless of cyst stage and for surgery the success rate was 70%. The difference between the rates was not statistically significant (p = 0.67).

CONCLUSION

CE is a rare disease in Denmark and our study is the first describing clinical management of CE in our institution.

Hydatid cysts of the liver in children: percutaneous treatment with ultrasound follow-up

BACKGROUND

Hydatid disease is a serious public health problem in endemic areas. Percutaneous treatment is an effective alternative to surgical and medical therapy in hydatid liver disease (HLD).

OBJECTIVE

To present clinical and radiological results of percutaneous treatment of HLD in children.

MATERIALS AND METHODS

Twenty-five children (16 males; age range, 5-15 years; mean age, 9.6 years) with a total of 30 hydatid cysts of the liver underwent ultrasound US guided percutaneous treatment using hypertonic saline as the scolicidal agent.

RESULTS

The percutaneous procedure was successful in all patients. All children were asymptomatic at follow-up. A hypersensitivity reaction occurred in one child (4%) during the procedure. No other complications occurred. The reduction in cyst volume was 14-100% (mean, 64%) at follow-up (mean 13.8 months). On US at follow-up, the treated cysts were semisolid with a heterogeneous echo pattern (n = 17), solid hypoechoic (n = 10) or solid with calcification (n = 2). One treated cyst disappeared sonographically.

CONCLUSION

Percutaneous treatment of HLD is effective, safe and well-tolerated in children.

Clinical applications of gadobenate dimeglumine-enhanced magnetic resonance cholangiography: an expanded pictorial review

Gadobenate dimeglumine (Gd-BOPTA) is taken up by functioning hepatocellular cells and is partially excreted into the biliary system; therefore, it can be used as a potential intrabiliary contrast agent for magnetic resonance cholangiography applications for various clinical conditions such as obstructive disorders (e.g., choledocholithiasis, hepatolithiasis), inflammatory disorders (e.g., acute cholecystitis, cholangitis), benign biliary disorders, and pre- and postprocedural evaluation of the biliary system. In this pictorial review, we aimed to demonstrate the clinical applications of Gd-BOPTA as an intrabiliary contrast agent for imaging various biliary pathologies.

Percutaneous needle aspiration, injection, and re-aspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts

BACKGROUND

Hepatic hydatid cyst is an important public health problem in parts of the world where dogs are used for cattle breeding. Management of uncomplicated hepatic hydatid cysts is currently surgical. However, the puncture, aspiration, injection, and re-aspiration (PAIR) method with or without benzimidazole coverage has appeared as an alternative over the past decade.

OBJECTIVES

To assess the benefits and harms of PAIR with or without benzimidazole coverage for patients with uncomplicated hepatic hydatid cyst in comparison with sham/no intervention, surgery, or medical treatment.

SEARCH STRATEGY

The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, DARE, and ACP Journal Club and full text searches were combined (all searched October 2010). Reference lists of pertinent studies and other identified literature were scanned. Researchers in the field were contacted.

SELECTION CRITERIA

Only randomised clinical trials using the PAIR method with or without benzimidazole coverage as the experimental treatment of uncomplicated hepatic hydatid cyst (ie, hepatic hydatid cysts, which are not infected and do not have any communication with the biliary tree or other viscera) versus no intervention, sham puncture (ie, performing all steps for puncture, pretending PAIR being performed, but actually not performing the procedure), surgery, or chemotherapy were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, and the risk of bias in each trial was assessed by the authors. Principal authors of the trials were contacted to retrieve missing data.

MAIN RESULTS

We found no randomised clinical trials comparing PAIR versus no or sham intervention. We identified only two randomised clinical trials, one comparing PAIR versus surgical treatment (n = 50 participants) and the other comparing PAIR (with or without albendazole) versus albendazole alone (n = 30 participants). Both trials were graded as 'adequate' for allocation concealment; however, generation of allocation sequence and blinding methods were 'unclear' in both. Compared to surgery, PAIR plus albendazole obtained similar cyst disappearance and mean cyst diameter with fewer adverse events (32% versus 84%, P < 0.001) and fewer days in hospital (mean + SD) ( 4.2 + 1.5 versus 12.7 + 6.5 days, P < 0.001). Compared to albendazole, PAIR with or without albendazole obtained significantly more (P < 0.01) cyst reduction and symptomatic relief.

AUTHORS' CONCLUSIONS

PAIR seems promising, but there is insufficient evidence to support or refute PAIR with or without benzimidazole coverage for treating patients with uncomplicated hepatic hydatid cyst. Further well-designed randomised clinical trials are necessary to address the topic.

Surgical treatment of hydatid disease of the liver: 25 years of experience

BACKGROUND

The aim of this study was to evaluate the results of conservative and radical treatment of liver hydatid disease.

METHODS

Records of patients who underwent surgery for liver hydatid disease between 1980 and 2005 were reviewed. Outcomes measured were operative morbidity and mortality, hospital stay, and recurrence.

RESULTS

Two hundred fourteen patients underwent conservative treatment (external drainage, marsupialization, omentoplasty), and 240 had radical surgery (hepatic resection, cystopericystectomy). Operative morbidity was 79.9% and 16.2% for conservative and radical procedures, respectively (P < .001). Operative mortality was 6.5% for conservative procedures and 9.2% for radical procedures (P = .3). The recurrence rate was 30.4% in patients having conservative surgery and 1.2% in patients undergoing radical surgery (P < .001). No recurrences occurred in patients with clear cysts after conservative surgery.

CONCLUSIONS

Cystopericystectomy was a safe and effective procedure that achieved excellent immediate and long-term results. Hepatic resection should be considered only in exceptional cases, because it involves the unnecessary sacrifice of healthy hepatic parenchyma. Conservative surgery and alternative procedures should be restricted to the treatment of clear cysts and to patients who cannot undergo radical surgery.

Refractory cystobiliary fistula secondary to percutaneous treatment of hydatid cyst: treatment with N-butyl 2-cyanoacrylate embolization

A 27-year-old female with a type 2 hydatid cystic lesion in the liver according to the Gharbi classification (CE 3A according to the WHO classification) was referred for percutaneous treatment after albendazole treatment for 1 year. A catheterization technique was performed but hypertonic saline and alcohol were not given into the cavity due to cystobiliary leakage. During the 4-month follow-up period, sequential cavitography revealed biliary fistula, and bile-stained drainage had not been ceased despite the sphincterotomy, nasobiliary drainage catheter, and plastic stent. Since the patient refused to surgery, we embolized the biliary fistula using N-butyl 2-cyanoacrylate for the first time in the literature. At the 3-month follow-up, the patient's course was uneventful and ultrasound, multidetector-row CT, and MRI examinations revealed no collection in or adjacent to the cavity.

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.

Recurrent liver hydatid disease: when does it become symptomatic and how does one diagnose it?

BACKGROUND

Echinococcosis is a zoonotic disease that mainly occurs in sheep-grazing areas. Recurrence of the disease and its diagnosis are relatively new areas of investigation due to the limited number of cases. The aim of this study was to evaluate the diagnosis of the symptomatic recurrent liver hydatid disease and the efficacy of abdominal ultrasonography (US).

MATERIALS AND METHODS

Between 1988 and 2006, 412 patients with hydatid cyst of the liver were operated at Erciyes University Medical Faculty. We have considered a growing cyst at the original operative site or at the neighboring hepatic tissue as recurrence and investigated 38 of them for the recurrence of the disease (9.2%).

RESULTS

The recurrence usually occurred after 2 years. The majority of the cases were Types 2 and 3 (24 cases; 8 were Type 4 and 6 were Type 1) according to Gharbi classification. In 35 patients with recurrent disease approved after surgical exploration, US was successful in preoperative diagnosis (100%). Overall, the recurrence was demonstrated correctly by means of US in 35 patients (92.1%), and 23 of 26 patients (88.4%) were correctly diagnosed with the use of computed tomography. In our study, in the first 2 years after the operation, the success rate of US examination was 72.7%. The success rate of US rose up to 100% when the frequency of recurrence is highest.

CONCLUSION

Beyond 2 years after surgery, US examination alone might be enough for the diagnosis of symptomatic recurrent liver hydatid disease in patients with the suspicion of recurrence. Postoperative early US profile and annual US examination must be performed for at least 5 years to prevent misinterpretation in doubtful cases.

Use of albendazole sulfoxide, albendazole sulfone, and combined solutions as scolicidal agents on hydatid cysts (in vitro study)

AIM: To establish which scolicidal agents are superior and more suitable for regular use.

METHODS: Echinococcus granulosus protoscoleces were obtained from 25 patients with liver hydatid cysts. Various concentrations of albendazole sulfone, albendazole sulfoxide, and albendazole sulfone and albendazole sulfoxide mixed together in concentrations of 50 &mgr;g/mL, and H₂O₂ in a concentration of 4%, NaCl 20%, and 1.5% cetrimide-0.15% chlorhexidine (10% Savlon-Turkey) were used to determine the scolicidal effects. Albendazole (ABZ) derivatives and other scolicidal agents were applied to a minimum of 100 scoleces for 5 and 10 min. The degree of viability was calculated according to the number of living scolices per field from a total of 100 scolices observed under the microscope.

RESULTS: After 5 min, ABZ sulfone was 97.3% effective, ABZ sulfoxide was 98.4% effective, and the combined solution was 98.6% effective. When sulfone, sulfoxide and the combined solutions were compared, the combined solution seemed more effective than sulfone. However, there was no difference when the combined solution was compared with sulfoxide. After 10 min, hypertonic salt water, sulfone, sulfoxide, and the combined solution compared to other solutions looked more effective and this was statistically significant on an advanced level. When sulfone, sulfoxide, and the combined solutions were compared with each other, the combined solution appeared more effective than sulfone. When the combined solution was compared with sulfoxide, there was no difference.

CONCLUSION: Despite being active, ABZ metabolites did not provide a marked advantage over 20% hypertonic saline. According to these results, we think creating a newly improved and more active preparation is necessary for hydatid cyst treatment.

Metabolic viability assessment of cystic echinococcosis using high-field 1H MRS of cyst contents

Cystic echinococcosis is a worldwide disease caused by larval stages of the parasite Echinococcus granulosus (canine tapeworm). In clinical practice, staging of cyst development by ultrasonography (US) has allowed treatment options to be tailored to individual patient needs. However, the empirical correlation between cyst morphology and parasite viability is not always dependable and has, until now, required confirmation by invasive assessment of cyst content by light microscopy (LM), for example. Alternatively, high-field 1H MRS may be used to examine cyst fluid ex vivo and prepare detailed quantitative metabolite profiles, enabling a multivariate metabolomics approach to cyst staging. One-dimensional and two-dimensional 1H and 1H/13C MRS at 600 MHz (14.1 T) was used to analyze 50 cyst aspirates of various US and LM classes. MR parameters and concentrations relative to internal valine were determined for 44 metabolites and four substance classes. The high concentrations of succinate, fumarate, malate, acetate, alanine, and lactate found in earlier studies of viable cysts were confirmed, and additional metabolites such as myo-inositol, sorbitol, 1,5-anhydro-D-glucitol, betaine, and 2-hydroxyisovalerate were identified. Data analysis and cyst classification were performed using univariate (succinate), bivariate (succinate vs fumarate), and multivariate partial least squares discriminant analysis (PSL-DA) methods (with up to 48 metabolite variables). Metabolic classification of 23 viable and 18 nonviable cysts on the basis of succinate alone agreed with LM results. However, for seven samples, LM and MRS gave opposing results. Reclassification of these samples and two unclassified samples by PLS-DA prediction techniques led to a set of 50 samples that could be completely separated into viable and nonviable MRS classes with no overlap, using as few as nine variables: succinate, formate, malate, 2-hydroxyisovalerate, acetate, total protein content, 1,5-anhydro-D-glucitol, alanine, and betaine. Thus, future noninvasive in vivo applications of MRS would appear promising.

Echinococcosis of the liver

Echinococcosis, also known as hydatid disease, is an infection of larval stage animal tapeworm, Echinococcus. The larvae reside in the liver and lungs, producing multiloculated fluid-filled cysts. Imaging findings of Echinococcosis caused by E. granulosus are single, unilocular cyst or multiseptated cysts, showing "wheel-like", "rosette-like" or "honeycomb-like" appearances. There may be "snow-flakes" sign, reflecting free floating protoscoleces (hydatid-sand) within the cyst cavity. Degenerating cysts show wavy or serpentine bands or floating membranes representing detached or ruptured membranes. Degenerated cysts show heterogeneous, solid-looking pseudotumor that may show "ball of wool sign". Dead cysts show calcified cyst wall. Echinococcosis caused by E. multilocularis produces multilocular alveolar cysts with exogeneous proliferation, progressively invading the liver parenchyma and other tissues of the body. Imaging findings are ill-defined infiltrating lesions of the liver parenchyma, consisting of multiple small clustered cystic and solid components. On sonography, lesions are heterogeneous with indistinct margins, showing "hailstorm appearance" or "vesicular or alveolar appearance". CT and MR imaging displays multiple, irregular, ill-defined lesions. Multiple small round cysts with solid components are frequent. Large lesions show "geographical map" appearance. Calcifications are very frequent, appearing as peripheral calcification or punctuate scattered calcific foci. Invasion into the bile ducts, portal vein or hepatic vein may occur. Direct spread of infected tissue may result in cysts in the peritoneal cavity, kidneys, adrenal gland or bones.

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.

Long-term results of percutaneous treatment of hydatid liver cysts: a single center 17 years experience

BACKGROUND

Liver cystic echinococcosis is considered a relatively benign disease, nevertheless, treatment is mandatory in symptomatic cysts and recommended in active cysts because of the risk of severe complications. Surgery is still considered the gold standard treatment. In the last two decades percutaneous injection of scolicidal agents has been developed with excellent results in terms of disappearance of the cyst, very low side effects and low mortality rate.

MATERIALS AND METHODS

One hundred sixty eight patients with 225 liver cysts were studied. A total of 108 patients with 151 viable hydatid liver cysts underwent Double Percutaneous Aspiration and Injection of alcohol of the cyst without re-aspiration of the ethanol, which remained in situ.

RESULTS

The mortality rate was 0.9% (1 patient), the overall morbidity was 8.6% with only 2.5% of major side effects. The mean hospital stay was very short (2.9 days). Follow-up ranged from 14 to 204 months (median 48 months). Ultrasonography showed complete disappearance of the cyst with reconstitution of liver parenchyma in 109 out of 225 (48.4%) cysts; in the remaining cysts a solid or a liquid findings were observed in 104 (46.2%) and 12 (5.3%), respectively, with a decreased volume of 50-80%.

CONCLUSION

These data show that Double Percutaneous Aspiration and Injection of alcohol for hydatid liver cysts can achieve comparable results to open surgery. The low incidence of side effects shows that this technique is safe and cost effective, compared to radical or conservative surgery.

MR imaging for diagnosing cysto-biliary fistulas in cystic echinococcosis

OBJECTIVE

To evaluate the sensitivity and specificity of magnetic resonance imaging (MR imaging) including MR cholangiography for the identification of cysto-biliary fistulas in patients with hepatic hydatid disease.

PATIENTS AND METHODS

Retrospective analysis of 3 groups of patients (20 patients with 51 echinococcal cysts) in a cohort of 103 patients with cystic echinococcosis with different pretest probabilities for cysto-biliary fistulas. Patients who had MR imaging/MR cholangiography with symptoms and signs of biliary obstruction (5 patients with 16 cysts, group I), before surgery for other reasons than biliary obstruction (9 patients with 14 cysts, group II) and for cyst staging (6 patients with 21 cysts, group III). All MR images were evaluated before surgery for the presence of cyst wall defects and hydatid debris in bile ducts. In groups I and II MR results were compared with surgical, parasitological, and biochemical findings of each individual cyst.

RESULTS

Based on direct (i.e. defects in the cyst wall and continuity of dilated biliary ducts into adjacent cysts), and indirect MR imaging/MR cholangiography imaging signs (i.e. intraluminal debris) our best estimate of sensitivity and specificity (stage-specific, WHO type CE3 and CE4) for cysto-biliary fistulas was 75% and 95%, respectively.

CONCLUSIONS

MR imaging with MR cholangiography is a valuable non-invasive imaging technique to assess the risk of cysto-biliary fistula-related complications and for planning of surgery.

Effects of honey as a scolicidal agent on the hepatobiliary system

AIM: To examine the effects of 10% diluted honey, which has been shown to be scolicidal, on the liver and biliary system and determine whether it could be used as a scolicidal agent in the presence of biliary-cystic communication.

METHODS: Thirty Wistar-Albino rats were divided into two groups. Honey with 10% dilution in the study group and 0.9% saline (NaCl) in the control group were injected into the common bile ducts of rats through a 3-mm duodenotomy. The animals were sacrificed 6 mo after the procedure. Histopathological, biochemical, and radiological examinations were performed for evaluation of side effects.

RESULTS: At the end of the sixth month, liver function tests were found to be normal in both groups. The tissue samples of liver and ductus choledochus of the honey group showed no histomorphologic difference from the control group. No stricture on the biliary tree was detected on the retrograde cholangiograms.

CONCLUSION: According to these results, we concluded that 10% diluted honey could be used as scolicidal agent safely in the presence of biliary-cystic communication.

Efficacy of radical surgery in preventing early local recurrence and cavity-related complications in hydatic liver disease

BACKGROUND

Hydatic disease of the liver remains to be a complex worldwide problem especially in rural areas. Early local recurrence and cavity-related complications are still a matter of conflict in the management of hydatic liver disease. The aim of this study is to investigate efficacy of the type of surgical treatment in preventing early local recurrence and cavity-related complications of this disease. Here, we present the preliminary results of our study.

METHODS

This study was performed prospectively including 32 patients who were operated for hydatic liver disease between January 2001 and January 2005. Patients were randomized into radical and conservative surgery groups. Recurrences at the primary surgical site in the first 2 years were considered as early local recurrence and biliary leakage, biliary fistula, cavity abscess, etc. were considered as cavity-related complications.

RESULTS

Early local recurrences were observed only after conservative surgical procedures (p=0.045). Recurrent cysts were found to be due to satellite cysts or pericystic disease. Cavity-related complications were seen in six patients in the conservative surgery group (p=0.011).

CONCLUSIONS

In suitable patients, radical surgical resection provides an effective surgical management option in preventing early local recurrence and cavity-related complications when compared to conservative surgical approaches.

Migrating and herniating hydatid cysts

OBJECTIVE

To present the prevalence and imaging findings of patients with hydatid disease (HD) showing features of migration or herniation of the hydatid cysts (HCs) and underline the clinical significance of this condition.

MATERIALS AND METHODS

Between May 2003 and June 2006, 212 patients with HD were diagnosed by abdomen and/or thorax CT, searched for migrating or herniating HC. Imaging findings of 7 patients (5 women, 2 men with an age range of 19-63 years; mean+/-S.D., 44+/-19 years) with HD showing transdiaphragmatic migration (6 subjects) or femoral herniation (1 subject) were evaluated. Diagnosis of all the patients were established by pathologic examination and migration or herniation was confirmed by surgery in all patients.

RESULTS

Liver HD were identified in 169 (79.7%) of 212 patients with HD. Transdiaphragmatic migration of HCs were identified in 6 (3.5%) of the 169 patients with liver HD. In one patient, femoral herniation of the retroperitoneal HC into the proximal anterior thigh was identified. All of these seven patients exhibiting migration or herniation of HCs had active HCs including 'daughter cysts'. Two patients had previous surgery because of liver HD and any supradiaphragmatic lesion was not noted before operation. Findings of migration or herniation were confirmed by surgery.

CONCLUSION

Active HCs may show migration or herniation due to pressure difference between the anatomic cavities, and in some of the patients, by contribution of gravity. Previous surgery may be a complementary factor for migration as seen in two of our patients. The possibility of migration or herniation in patients with HD should be considered before surgery.