METHODS OF TREATMENT IN OBSTRUCTIVE JAUNDICE CAUSED BY LIVER HYDATID CYST
Authors: Simona Manciu, J. Avram, I. Avram, Mihaela Avram, Mihaela Pasztori, A. Cucui, Maria Mogoseanu
Received for publication: 2009-08-31
Revised: 2009-11-10
SUMMARY: (Hide the summary)
Key Words:
INTRODUCTION
The incidence of hydatid disease (caused by E.granulosus) is a public health problem in some areas inthe world, including countries of Central America andSouth America, Western and Southern/SoutheasternEurope, the Middle East and North Africa, somesub-Saharan countries, Russia and adjacent countries,China. The annual incidence rates per 100,000inhabitants vary widely, from less than 1 case per100,000 to high levels as Bulgaria: 3 cases for 100 000inhabitants, Greece - 13 cases per 100,000 persons, ruralregions of Uruguay - 75 cases per 100,000 persons, ruralregions of Argentina - 143 cases per 100,000 persons inRio Negro province, parts of Xinjiang province of China -197 cases per 100,000 persons, parts of the Turkanadistrict of Kenya - 220 cases per 100,000 persons.
MATERIAL AND METHODS
We studied a group of patients with obstructivejaundice caused by hydatid cyst admitted in the I-st Clinicof Surgery, County Hospital Timisoara, in the periodJanuary 2002 – January 2009. The patients represented2.6% of obstructive jaundice causes from a group of 752patients.
The obstructive jaundice in hydatid cysts appears inthe following situations:
- obstruction of the common bile duct (CBD) by theouter membranous layer after cyst rupture in a bileduct
- compression of the CBD by the cyst
- association with CBD lithiasis or cirrhosis
- infection of the hydatid cyst with fistula in a bile duct70% of cases presented communications of the cystwith bile ducts and 25% - migration of hydatidmembranes. The mean age of the patients was 44 yearsand the distribution by gender was: 70% - women and30% - men.
The clinical signs and symptoms found for hydatidcyst with communication in bile ducts were:
- icterus – 100% of cases
- hepatomegaly – 50% of cases
- dyspeptic biliary syndrome – 30% of cases
- intermittent pains – 70% of cases
- skin pruritus – 30% of cases
The surgical treatment was performed in 16 cases(80% of cases) and it consisted of:
- treatment of the cyst
- desobstruction of the common bile duct
- efficient drainage of the residual cavity andcommon bile duct
The types of surgical interventions were:
- partial pericystectomy (Lagrot operation): 87.5 % ofcases
- associated cholecystectomy: 62.5 % of cases
- Kehr drainage: 25% of cases
- transcystic drainage: 37.5% of cases
- residual cavity drainage: 100% of cases
- total pericystectomy: 12.5% of cases
The conservative treatment was applied in 4 caseswhen the diameter of the cyst was lesser than 1 cm orthe patients didn’t agree with surgery. (Fig. 1)
The main problem in the surgical treatment of thisdisease is the pericystic cavity that remains afterremoval of the parasite. The majority of the postoperativecomplications are due to the inadequacy of the surgicalprocedure to the morphologic particularities of the cavity.
There are 2 main types of surgical procedures: oneso-called „conservative” that abandons the pericysticcavity or resects only a little of the pericyst and othercalled “radical” that removes totally the pericysticmembrane, with more or less hepatic resection.
The presence of the biliary fistula in the cyst is a mainproblem for the evolution of the cavity and determines thesurgical procedure of choice. If we can not detectpreoperatively the presence of the biliary fistula we mustsurely do intraoperatively when we see the bile leakagein the interior of the cyst. So, for cysts without biliaryfistula we may perform:
- Pericystotomy and suture of the pericysticmembrane without drainage; the risks are:accumulation of secretions ( lymph, fragments ofpericyst, blood ) in a closed cavity that may develop ahepatic abscess
- Pericystotomy and external drainage of the cavityThese 2 types of methods are indicated for recent,unilocular cysts, with thin walls, mostly observed atyoung patients.
- Partial pericystectomy (Lagrot operation) – indicatedmostly for the cysts on the visceral part of the liver;the drainage of the residual cavity is necessary andcan be performed also trans-thoracic-diaphragmaticor transomphalic; this is the procedure preferred byus and used in the majority of our cases associatedwith cavity drainage
- Percutaneous ultrasonography guided puncture ofthe cyst
- Laparoscopic resection
For the cysts with biliary fistula there are someprocedures of choice:
- Partial pericystectomy with suture of the fistula – notalways very easy because the visual andinstrumental access in the cavity may be difficult; thesuture of a lateral fistula on an important biliary ductmay determine stenosis of the biliary duct withsubsequent biliary stasis.
- Partial pericystectomy with extern bipolar drainageof the residual cavity: it associates the externdrainage of biliary ducts (by Kehr tube – in cases withimportant biliary fistula and migration of hydatidmaterial in the biliary tree or transcystic tube – incases without migration of hydatid material in thebiliary tree, CBP with normal diameter) and the cavitydrainage. There is also the possibility of interndrainage of CBP by endoscopic or intraoperativesphincteropapilotomy; this procedure is preferred byus because it prevents the formation of the residualcavity filled with bile from the fistula with subsequentinfection and developing a liver abscess
- Pericysto-biliary drainage: extern - with a “T” tube –one branch in the cavity crossing the fistula and otherbranch in CBP, with suture of the cavity; intern – byendoscopic papilosphincterotomy; this type ofdrainage is suitable for a large and low situatedfistula’s orifice.
- Pericysto-digestive drainage: it consists of ananastomosis between the cystic cavity and ajejunum loop type “en Roux”
- Total pericystectomy: only in a few cases – cystslocated at the anterior edge of the liver or at its left orright extremities; for deeper locations in the liverparenchyma the technique may be difficult due to therisk of biliary branch or vascular lesions
- Atypical hepatectomy: used for important cysts thatoccupy a big territory of hepatic parenchyma(segments 2 and 3)
The best investigation for establishing the suitablesurgical procedure is abdominal computer tomographythat points the precise location of the cyst, its diameters,the aspect – unilocular or multilocular, the thickness of itsmembrane, the neighboring with major liver vessels andbiliary tree. (Fig 2)
Also ultrasonography is a good investigation thatmakes the difference between a solid and a liquid tumorof the liver and show the interior of the cyst – unilocularor multilocular, the number of cysts in the liverparenchyma. (Fig.3)
The main operation was puncture of the cyst,aspiration of the liquid, inactivation with 98% alcohol,extraction of hydatid membranes, partial pericystectomyassociated with cholecystectomy for tactical reasons orfor prevention of an early acute postoperativecholecystitis. The biliary drainage (transcystic or Kehr)(performed in 10 of our cases) was a good maneuver forprevention the appearance of the residual cavity filledwith bile that could develop an infection - a liver abscess.
So we observed that in all cases with biliary drainagethere was no residual cavity and no postoperativecomplications. These patients were discharged at 7 dayspostoperative by comparing with the cases withoutbiliary drainage (6 patients) from which 3 developed liverabscess with a good evolution but in a longer time(average of hospitalization 14 days). (Fig.4)
The postoperative evolution was good in all cases,with a residual cavity at 1 month in 37.5% (6 cases) (allthe cases were without biliary drainage) but with it’sdisappearance at 2 months after surgery. In 3 of thesecases a liver abscess was developed but it was drainedby ultrasonography guide puncture and subsequentlavage. The treatment is continued with albendazole 800mg / day, 3 cures of 28 days with 14 days pause betweenthem. The patients were discharged at 11 days (inaverage) after operation. (Fig. 5)
CONCLUSIONS
This disease is frequently observed in our region butthere are not many cases associated with obstructivejaundice. The age of patients is decreasing in the lastyears. The main investigations for the diagnosis areultrasonography and CT. The most involved segments ofthe liver are V, VI, VII and VIII.
The efficient treatment is surgical – in our study –wechose partial pericystectomy associated withcholecystectomy, extern cavity drainage (in all ourcases) and biliary drainage (transcystic or Kehr tube)when is associated a biliary fistula with or without signsof hydatid material inside the biliary tree (when is neededa Kehr tube). The hospitalization time was 7 days for themajority of our cases and 14 days for the complicatedcases. The medical treatment is associated pre- andpost-operative: albendazole 800 mg / day.
REFERENCES
1. Elsebaie SB, El-Sebae MM, Esmat ME, Nasr MM, Kamel MM. Modified endocystectomy versus pericystectomy inechinococcus granulosus liver cysts: a randomized controlled study, and the role of specific anti-hydatid IgG4 in detection ofearly recurrence. J Egypt Soc Parasitol. Dec 2006;36(3):993-1006.
2. Filippou D, Tselepis D, Filippou G, Papadopoulos V. Advances in liver echinococcosis: diagnosis and treatment. ClinGastroenterol Hepatol. Feb 2007;5(2):152-9.
3. Flisser A. Larval cestodes. In: Collier L, Balows A, Sussman M, eds. Topley and Wilson’s Microbiology and MicrobialInfections. Parasitology. Vol 5. 9th ed. New York, NY: Oxford University Press; 1998:539-60.
4. Gargouri M, Ben Amor N, Ben Chehida F, Hammou A, Gharbi HA, Ben Cheikh M, et al. Percutaneous treatment ofhydatid cysts (Echinococcus granulosus). Cardiovasc Intervent Radiol. Jun-Jul 1990;13(3):169-73.
5. Guidelines for treatment of cystic and alveolar echinococcosis in humans. WHO Informal Working Group onEchinococcosis. Bull World Health Organ. 1996;74(3):231-42.
6. Kjossev KT, Losanoff JE. Hydatid cysts of the liver: TN(R)C classification. Int Surg
7. Gall TM, Oniscu GC, Madhavan K, et al. Surgical management and longterm follow-up of non-parasitic hepatic cysts. HPB(Oxford). 2009;11(3):235-41.
8. Delis SG, Bakoyiannis A, Karakaxas D, et al. Hepatic parenchyma resection using stapling devices: peri-operative andlong-term outcome. HPB (Oxford). 2009;11(1):38-44.
9. Morino M, De Giuli M, Festa V, Garrone C. Laparoscopic management of symptomatic nonparasitic cysts of the liver.Indications and results. Ann Surg. Feb 1994;219(2):157-64.
10. Hansen P, Bhoyrul S, Legha P, et al. Laparoscopic treatment of liver cysts. J Gastrointest Surg. Jan 1997;1(1):53-47.
11. Fiamingo P, Tedeschi U, Veroux M, Cillo U, Brolese A, Da Rold A, et al. Laparoscopic treatment of simple hepatic cystsand polycystic liver disease. Surg Endosc. Apr 2003;17(4):623-6.
12. Fabiani P, Iannelli A, Chevallier P, Benchimol D, Bourgeon A, Gugenheim J. Long-term outcome after laparoscopicfenestration of symptomatic simple cysts of the liver. Br J Surg. May 2005;92(5):596-7.
13. Cirenei A, Bertoldi I. Evolution of surgery for liver hydatidosis from 1950 to today: analysis of a personal experience. WorldJ Surg. Jan 2001;25(1):87-92.
14. Diez J, Decoud J, Gutierrez L, Suhl A, Merello J. Laparoscopic treatment of symptomatic cysts of the liver. Br JSurg. Jan 1998;85(1):25-7.
15. Dziri C, Haouet K, Fingerhut A. Treatment of hydatid cyst of the liver: where is the evidence?. World JSurg. Aug 2004;28(8):731-6.
16. Elhamel A. Pericystectomy for the treatment of hepatic hydatid cysts. Surgery. Mar 1990;107(3):316-20.
17. Hughes MA, Petri WA Jr. Amebic liver abscess. Infect Dis Clin North Am. Sep 2000;14(3):565-82, viii.
18. Khoury G, Abiad F, Geagea T, Nabout G, Jabbour S. Laparoscopic treatment of hydatid cysts of the liver and spleen. SurgEndosc. Mar 2000;14(3):243-5.
19. Pedrosa I, Saíz A, Arrazola J, Ferreirós J, Pedrosa CS. Hydatid disease: radiologic and pathologic features andcomplications. Radiographics. May-Jun 2000;20(3):795-817.
20. Seven R, Berber E, Mercan S, Eminoglu L, Budak D. Laparoscopic treatment of hepatic hydatidcysts. Surgery. Jul 2000;128(1):36-40.
21. Smego RA Jr, Bhatti S, Khaliq AA, Beg MA. Percutaneous aspiration-injection-reaspiration drainage plus albendazole ormebendazole for hepatic cystic echinococcosis: a meta-analysis. Clin Infect Dis. Oct 15 2003;37(8):1073-83.
22. Taylor BR, Langer B. Current surgical management of hepatic cyst disease. Adv Surg. 1997;31:127-48.
Correspondence to:
Dr. Simona Manciu, e-mail: smanciu@yahoo.com