Surgical management of cystic lesions in the liver

Endoscopic observation of a lumen of a large hepatic cyst with aspiration and ethanol sclerotherapy: Case report and literature review

INTRODUCTION AND IMPORTANCE

A large hepatic cyst cause abdominal bloating and other symptoms. Surgical deroofing or ethanol sclerosis has been reported as the treatment options. We have treated patients surgically. However, an experience with postoperative bile leakage prompted us to reexamine our treatment options. It has been reported that the cause of bile leakage is the connection between the hepatic cyst and the bile duct. Therefore, we planned to observe the lumen of the hepatic cyst by endoscopy to evaluate the bile duct connection.

CASE PRESENTATION

An 82-year-old woman presented to our hospital for abdominal bloating. An abdominal computed tomography (CT) scan revealed a large hepatic cyst. Respiratory function was decreased due to diaphragmatic compression caused by the cyst. Endoscopic observation of the cyst was performed to evaluate the bile duct connection. There were no obvious abnormalities in her cyst. The patient was discharged 7 days after this procedure.

CLINICAL DISCUSSION

Laparoscopic deroofing is recommended for the treatment of a large hepatic cyst when a patient can take surgery. However, deroofing has the potential for postoperative bile leakage. Careful consideration should be given to the treatment approach for each patient. Ethanol sclerotherapy has the potential for recurrence, but in this case, we confirmed the absence of bile duct connection. The ethanol sclerosis was effective, and there was no postoperative bile leakage.

CONCLUSION

Endoscopic observation during puncture of the hepatic cyst allowed the evaluation of bile duct connection and search for malignant disease. Ethanol sclerotherapy was also effective.

Congenital hepatic cyst: Eleven case reports

BACKGROUND

Liver cysts in infants are uncommon. With modern diagnostic imaging, we can achieve an early diagnosis of congenital hepatic cysts. Our purpose was to investigate the clinical features, surgical treatment methods and prognosis of infants with congenital hepatic cysts. Herein, we report a case series of congenital hepatic cysts.

CASE SUMMARY

Eleven infants with hepatic cysts were retrospectively analysed. Ten of them had simple hepatic cysts, and a girl with a large hepatic mass was diagnosed with a solitary intrahepatic biliary cyst accompanied by a choledochal cyst. Among the ten simple hepatic cysts, eight were solitary and two were multiple. A total of 87.5% (7 of 8) of infants with solitary hepatic cysts were detected before delivery, and 86% (6 of 7) of those cysts were located in the right lobe of the liver. Surgical intervention was required for symptomatic hepatic cysts. Cyst resection or unroofing with fulguration of the cyst bed was employed. No recurrence of cysts was observed in these infants.

CONCLUSION

Congenital hepatic cyst is a condition with a narrow differential diagnosis. Accurate diagnosis is essential for appropriate management. Unroofing is the favoured treatment in infants with symptomatic cysts. Most infants with congenital hepatic cysts have a good prognosis.

Machine Learning-Based Radiological Features and Diagnostic Predictive Model of Xanthogranulomatous Cholecystitis

Background

Xanthogranulomatous cholecystitis (XGC) is a rare benign chronic inflammatory disease of the gallbladder that is sometimes indistinguishable from gallbladder cancer (GBC), thereby affecting the decision of the choice of treatment. Thus, this study aimed to analyse the radiological characteristics of XGC and GBC to establish a diagnostic prediction model for differential diagnosis and clinical decision-making.

Methods

We investigated radiological characteristics confirmed by the RandomForest and Logistic regression to establish computed tomography (CT), magnetic resonance imaging (MRI), CT/MRI models and diagnostic prediction model, and performed receiver operating characteristic curve (ROC) analysis to prove the effectiveness of the diagnostic prediction model.

Results

Based on the optimal features confirmed by the RandomForest method, the mean area under the curve (AUC) of the ROC of the CT and MRI models was 0.817 (mean accuracy = 0.837) and 0.839 (mean accuracy = 0.842), respectively, whereas the CT/MRI model had a considerable predictive performance with the mean AUC of 0.897 (mean accuracy = 0.906). The diagnostic prediction model established for the convenience of clinical application was similar to the CT/MRI model with the mean AUC and accuracy of 0.888 and 0.898, respectively, indicating a preferable diagnostic efficiency in distinguishing XGC from GBC.

Conclusions

The diagnostic prediction model showed good diagnostic accuracy for the preoperative discrimination of XGC and GBC, which might aid in clinical decision-making.

Contemporary Management of Hepatic Cyst Disease: Techniques and Outcomes at a Tertiary Hepatobiliary Center

BACKGROUND

Hepatic cyst disease is often asymptomatic, but treatment is warranted if patients experience symptoms. We describe our management approach to these patients and review the technical nuances of the laparoscopic approach.

METHODS

Medical records were reviewed for operative management of hepatic cysts from 2012 to 2019 at a single, tertiary academic medical center.

RESULTS

Fifty-three patients (39 female) met the inclusion criteria with median age at presentation of 65 years. Fifty cases (94.3%) were performed laparoscopically. Fourteen patients carried diagnosis of polycystic liver disease. Dominant cyst diameter was median 129 mm and located within the right lobe (30), left lobe (17), caudate (2), or was bilobar (4). Pre-operative concern for biliary cystadenoma/cystadenocarcinoma existed for 7 patients. Operative techniques included fenestration (40), fenestration with decapitation (7), decapitation alone (3), and excision (2). Partial hepatectomy was performed in conjunction with fenestration/decapitation for 15 cases: right sided (7), left sided (7), and central (1). One formal left hepatectomy was performed in a polycystic liver disease patient. Final pathology yielded simple cyst (52) and one biliary cystadenoma. Post-operative complications included bile leak (2), perihepatic fluid collection (1), pleural effusion (1), and ascites (1). At median 7.1-month follow-up, complete resolution of symptoms occurred for 34/49 patients (69.4%) who had symptoms preoperatively. Reintervention for cyst recurrence occurred for 5 cases (9.4%).

CONCLUSIONS

Outcomes for hepatic cyst disease are described with predominantly laparoscopic approach, approach with minimal morbidity, and excellent clinical results.

Giant simple hepatic cyst with multiple elevated serum tumor markers: A case report

BACKGROUND

Simple hepatic cysts are relatively common in adults, and mostly appear as asymptomatic incidental radiologic findings. Occasionally, a large cyst will cause symptoms. Elevations in the serum biomarkers protein induced by vitamin K absence (PIVKA)-II, cancer antigen (CA) 12-5, and CA19-9 are often associated with malignant tumors in the liver or bile ducts. This is the first report to describe a case of hepatic cyst with elevated levels of PIVKA-II and CA12-5.

CASE SUMMARY

An 84-year-old Chinese woman was admitted with gradual abdominal distension. Her symptoms started 1 year ago, and she had poor appetite and a weight loss of 5 kg within the past 2 wk. She denied any symptoms associated with abdominal pain, fever and chills, nausea and vomiting, etc. The abdomen was enlarged, more in the right upper quadrant, without tenderness. Laboratory examination showed significantly increased serum levels of PIVKA-II, CA12-5, and CA19-9. A computed tomography scan revealed multiple round cysts in the liver with clear boundaries. The largest cyst was 20.1 cm × 12.2 cm × 19.6 cm in size, located in the right lobe of the liver with mild dilatation of the intrahepatic bile duct, but there was no contrast enhancement. Percutaneous drainage on the largest hepatic cyst and polycinnamol sclerosing agent injection into the cyst cavity were performed. After treatment, the patient's symptoms relieved and the elevated serum tumor makers reduced to the normal levels dramatically.

CONCLUSION

The present report identifies an unusual case of a giant hepatic cyst with marked elevation of serum tumor marker levels of PIVKA-II, CA12-5, and CA19-9. After treatment, these three serum markers dramatically decreased to normal levels. The mechanisms for the elevation of these tumor markers may be as follows: (1) A giant hepatic cyst compresses the liver, causing injury to the hepatocytes, which may lead to secretion of a large amount of PIVKA-II; and (2) Some tumor-associated antigens, such as carcinoembryonic antigen, CA19-9, CA12-5, and CA15-3, are expressed on inflammatory cells.

Xanthogranulomatous cholecystitis: experience in 100 cases

Background

Xanthogranulomatous cholecystitis (XGC) is a rare presentation of chronic cholecystitis, characterized by xanthogranuloma, severe foam cells and fibrosis, and can be an inducement of difficulty in cholecystectomy. The purpose of this study was to review the clinical findings and imageology features of XGC and to optimize the treatment option.

Methods

This retrospective study collected clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications of 100 patients with XGC after evaluating 50005 cholecystectomy specimens between 2009 and 2018 in a single institute. heir clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications were collected and analyzed.

Results

Patients showed various clinical symptoms, ultrasonography was performed in all patients, CT and MRI were further arranged selectively before the operation, but none of the patients were prediagnosed. Fifty-two patients received open cholecystectomy. Laparoscopic cholecystectomy (LC) was planned in 48 patients within whom 8 cases were converted to open cholecystectomy. No partial cholecystectomy was performed. The intraoperative findings included cholecystolithiasis, choledocholithiasis, thickened gallbladder wall, lesions infiltrating into adjacent tissues, disordered Calot’s triangle anatomy, enlarged regional lymph nodes, internal gallbladder fistula, and hepatic abscesses. Frozen-section analysis was performed in 48 patients under the suspicion of gallbladder carcinoma (GBCa), but only 2 cases were finally confirmed.

Conclusions

The preoperative diagnosis of XGC was challenging. Open cholecystectomy was the most preferred treatment, and conversion to open was often necessary after LC.

Infected hepatic cyst following pancreatoduodenectomy treated with transhepatic drainage and minocycline hydrochloride injection: A case report

INTRODUCTION

Asymptomatic hepatic cysts, often observed on computed tomography, have never been reported as a risk factor for infection following pancreatoduodenectomy. Symptomatic liver cysts are treated surgically or non-surgically. We encountered a case of infected hepatic cyst following pancreatoduodenectomy.

PRESENTATION OF CASE

An 88-year-old woman underwent pancreatoduodenectomy for adenocarcinoma in the duodenum papilla of Vater. She was discharged (postoperative day 23), following an uneventful course. However, 7 days later, she was re-admitted because of a high fever; postoperative cholangitis was suspected. A peripheral-venous blood bacterial culture was negative. Her C-reactive protein level and white blood cell count were 0.57 mg/dl and 5290/μl, respectively. Antibiotics were administered, but her high fever only temporarily decreased. Contrast-enhanced computed tomography showed ring enhancement surrounding the largest of several hepatic cysts. Percutaneous transhepatic drainage was performed; thereafter, minocycline hydrochloride was repeatedly injected into the infected cyst through the drain to prevent infection recurrence. The drain was removed 49 days after drainage. On contrast-enhanced computed tomography at 6 months postoperatively, the infected hepatic cyst had reduced in size from 6.0 to 1.7 cm and no findings of bile duct stenosis were observed. No further infectious events have been observed.

DISCUSSION

Relatively large hepatic cysts may be at risk of infection following pancreatoduodenectomy and, in particular, biliary reconstruction.

CONCLUSION

Transhepatic drainage, rather than antibiotic administration, is essential, and minocycline hydrochloride injection into infected cyst that have no evidence of communication with the biliary tree is effective in preventing infection recurrence, without the complication of bile duct stenosis.

Giant simple biliary cyst infection treated with minimally invasive percutaneous drainage

We describe a minimally invasive alternative approach in a patient with infected hepatic cyst to stabilize the patient before definitive surgery. A 58-year-old man presented with fever and hypotension after 2 weeks of asthenia, chills, weight loss, slight abdominal pain, and a previous asymptomatic simple hepatic cyst. On ultrasound, a giant heterogeneous hepatic cyst with thick wall was noted. A positron emission tomography-computed tomography scan was indicated and demonstrated high uptake (standardized uptake value = 7.6) in the wall of the cyst, suggestive of infection. He underwent percutaneous drainage guided by the tomography. A 12 Fr drain was positioned inside the collection and 5 L of purulent material was aspirated from the cyst, and at day 12^th, surgical resection was performed. Histopatological analysis confirmed a simple biliary cyst. The patient remains asymptomatic on 1-year follow-up. Percutaneous drainage before surgical treatment allowed the definitive approach to be performed with the patient in better clinical conditions.

Long-term outcomes and quality of life after surgical or conservative treatment of benign simple liver cysts

BACKGROUND

Benign liver cysts are common and are often detected incidentally. Most patients do not require intervention. Occasionally, large dominant or multifocal small cysts cause symptoms as a result of rapid growth, secondary infection, intra-cystic bleeding or compression of adjacent organs.

AIM

To compare presenting symptoms and outcomes of a consecutive series of patients with benign liver cysts treated either conservatively or by surgical intervention. Long-term quality of life (QoL) was also assessed.

METHODS

Retrospective analysis of prospectively collected data was conducted. Long-term general and disease-specific quality of life was also documented.

RESULTS

Ninety-five patients were included in the study (46 treated operatively, 49 treated conservatively). 80% were female, and the mean age of the cohort was 58 years. Those who had surgical intervention were older (62 vs 55 years, p = 0.004), were more likely to have shortness of breath at presentation (11 vs 5%, p = 0.018) and had larger cysts (12 vs 4 cm, p < 0.001) compared with those offered conservative treatment. Laparoscopic stapled excision was the most common operative procedure (70%) and the overall complication rate was 20%. At a median follow-up of 64 months, 17% (8/46) of the surgically treated patients had radiological evidence of cyst recurrence but only 9% (4/46) were symptomatic. At median follow-up of 71 months, 37% (14/38) of conservatively treated patients had unchanged or new symptoms compared to the first presentation. Furthermore, 10% (4/38) of this group had additional radiological or surgical intervention for persistent symptoms during the follow-up period. Overall, there was no difference in long-term QoL between the two groups.

CONCLUSION

Surgical intervention for selected patients with symptomatic benign liver cysts results in low long-term recurrence rates and excellent patient-reported outcomes and quality of life. Laparoscopic-stapled excision can be done safely and reliably in carefully selected patients.

Kidney Injury due to Ureteral Obstruction Caused by Compression from Infected Simple Hepatic Cyst

Simple hepatic cysts are common and most often asymptomatic. In symptomatic cases, hemorrhage, rupture, and infection are major complications. However, urinary tract obstruction caused by a simple hepatic cyst is rare. We treated an 82-year-old Japanese man with an infected giant hepatic cyst causing right hydronephrosis who had a past history of left nephrectomy for renal cell carcinoma. The patient underwent ultrasound-guided percutaneous drainage and sclerotherapy with minocycline hydrochloride for the infected hepatic cyst. Right hydronephrosis was relieved, and renal dysfunction improved with regression of the hepatic cyst after treatment. This is the first report of hydronephrosis due to ureteral obstruction caused by compression from a hepatic cyst.

Huge echinococcal cyst of the liver managed by hepatectomy: Report of two cases

INTRODUCTION

Echinococcocal cysts are predominantly located in the right liver. They are usually solitary and asymptomatic, but large cysts can cause compression symptoms.

CASE REPORTS

We report two cases of huge (25cm and 20cm in diameter, respectively) echinococcal cysts located in the left liver, which presented as a large palpable mass causing compression symptoms. Diagnosis was established with CT scan showing a cystic mass with the characteristic daughter cysts and reactive layer (pericystic wall) consisting of fibrous connective tissue and calcifications. Both patients were treated radically with left hepatectomy and had uneventful postoperative course and no recurrence upon follow-up.

DISCUSSION

The treatment of liver echinococcal cysts represent a unique surgical challenge. Even though conservative approaches are less technically demanding, the radical approach with resection has better outcome with less recurrences, when performed by experienced surgeons.

CONCLUSION

Resection rather than drainage is the management of choice for such huge liver echinococcal cysts.

Medical therapy for polycystic liver disease

Introduction Somatostatin analogues and rapamycin inhibitors are two classes of drugs available for the management of polycystic liver disease but their overall impact is not clearly established. This article systematically reviews the literature on the medical management of polycystic liver disease. The outcomes assessed include reduction in liver volume and the impact on quality of life. Methods The English language literature published between 1966 and August 2014 was reviewed from a MEDLINE(®), PubMed, Embase™ and Cochrane Library search. Search terms included 'polycystic', 'liver', 'sirolimus', 'everolimus', 'PCLD', 'somatostatin', 'octreotide', 'lanreotide' and 'rapamycin'. Both randomised trials and controlled studies were included. References of the articles retrieved were also searched to identify any further eligible publications. The studies included were appraised using the Jadad score. Results Seven studies were included in the final review. Five studies, of which three were randomised trials, investigated the role of somatostatin analogues and the results showed a mean reduction in liver volume ranging from 2.9% at six months to 4.95 ±6.77% at one year. Only one randomised study examined the influence of rapamycin inhibitors. This trial compared dual therapy with everolimus and octreotide versus octreotide monotherapy. Liver volume reduced by 3.5% and 3.8% in the control and intervention groups respectively but no statistical difference was found between the two groups (p=0.73). Two randomised trials investigating somatostatin analogues assessed quality of life using SF-36(®). Only one subdomain score improved in one of the trials while two subdomain scores improved in the other with somatostatin analogue therapy. Conclusions Somatostatin analogues significantly reduce liver volumes after six months of therapy but have only a modest improvement on quality of life. Rapamycin inhibitors do not confer any additional advantage.

Single-incision laparoscopic management of a giant hepatic cyst

Large symptomatic hepatic cysts may warrant surgical management. Traditional multiport laparoscopic technique is typically preferred over open laparotomy, but the use of the single-incision laparoscopic approach for this diagnosis is not well documented. Here, we describe the case of a 68-year-old woman who underwent complete anterior wall fenestration, excision and cauterization of a simple hepatic cyst via a single-incision laparoscopic technique through an incision at the umbilicus. The objective of this case report is to document single-incision laparoscopy as a safe, feasible and cosmetically appealing approach for the management of a large hepatic cyst.

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

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

Young women with polycystic liver disease respond best to somatostatin analogues: a pooled analysis of individual patient data

BACKGROUND & AIMS

Clinical trials have shown that in patients with polycystic liver disease (PLD), short-term treatment with somatostatin analogues (SAs) reduces liver volumes by 4.5%-5.9%, compared with placebo. However, the effects of SA therapy vary among individuals. We collected data from individual patients with PLD to identify subgroups that benefit most from SA therapy.

METHODS

We analyzed data from 107 patients with PLD from 3 randomized placebo-controlled trials (67 received SAs, 52 received placebo). We used multiple linear regression analysis to determine the effects of SAs based on patients' age, sex, baseline liver volume, and diagnosis (autosomal dominant polycystic liver or kidney disease). The primary outcome was change in liver volume after 6-12 months of treatment.

RESULTS

The effects of SA therapy did not differ significantly among patients with different diagnoses or baseline liver volumes; the overall difference in liver volume between groups receiving SAs therapy vs placebo was 5.3% (P < .001). Among subjects given placebo, young women (48 years old or younger) had the greatest increase in polycystic liver volume (4.8%; 95% confidence interval: 2.2%-7.4%), and mean liver volumes did not increase in older women and men. Women 48 years old or younger had a greater response to therapy (a reduction in liver volume of 8.0% compared with placebo; P < .001) than older women (a reduction in liver volume of 4.1% compared with placebo; P = .022).

CONCLUSIONS

Based on a pooled analysis of data from individual patients with PLD, treatment with somatostatin analogues is equally effective for patients with autosomal dominant polycystic kidney disease or polycystic liver disease; efficacy does not depend on size of the polycystic liver. Young female patients appear to have the greatest benefit from 6-12 months of SA therapy, which might avert the progressive course of the disease in this specific group.