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Hydatid disease of the liver
Hydatid Disease of the Liver William L. Weirich, MD, FACS, Riyadh, Saudi Arabia
Hydatid disease of the liver is caused by the tapeworm Echinococcus granulosus and has a wide geographic distribution. The highest incidence of human parasitization occurs in sheep- and cattle-raising areas [I-3]. The incidence is relatively high in the Middle East and humans are frequently infected in childhood. The small intestine of the dog and related carnivores is the reservoir for the mature worm, whose eggs are shed in the excreta. Sheep, goats, cattle, camels, and man then become intermediate hosts by ingestion of the eggs. The life cycle of this tapeworm is illustrated in Figure 1. The members of the Department of Surgery of the King Faisal Specialist Hospital and Research Centre have treated 20 cases of hepatic hydatid disease since the hospital was opened 42 months ago. Fifteen male and 5 female patients, aged 7 to 71 years, have been treated. Five patients had been operated on one to four times for the disease before being treated at our hospital. As one would expect from the streaming of the portal circulation, the right lobe of the liver was involved more often (12 patients) than the left lobe (3 patients). Both lobes were involved in five cases. The presenting complaints of patients with uncomplicated hydatid cysts of the liver have been related to the size of the cysts. Low grade upper abdominal pain was present in 12 patients, awareness of a large tense mass in the upper abdomen in 10, premature satiation in 8, and epigastric fullness or pressure in 8. The appearance of well-being of the patients belied the size of the abdominal mass, in contrast to patients with large neoplasms of the liver, who looked ill at the time they presented. Diagnosis When a large, smooth, tense, usually nontender upper abdominal mass is found in a patient who lives in an en-
From the Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. Requests for reprints should be addressed to William L. Weirich. MD, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Post Office Box 3554, Riyadh, Kingdom of Saudi Arabia. Presented at the 31st Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 23-26. 1979.
Vohme 139, December 1979
demic region, the diagnosis of hepatic hydatid cyst is suspected. Because immunologic tests for hydatid disease were not available during the first 36 months of our hospital’s existence, the clinical staff was forced to seek other reliable diagnostic procedures, some of which proved valuable. A useful diagnostic study that helped confirm the clinical impression of a hydatid cyst of the liver was computerized axial tomography of the liver (Figure 2). The scan was diagnostic when viable cysts were present, especially when they contained daughter cysts. Hepatic ultrasound demonstrated the presence of a cystic lesion or lesions, and if daughter cysts were present intracystic echoes were visible. The presence of a heavily calcified cyst on kidney, ureter, and bladder x-ray film was practically diagnostic of a nonviable hydatid cyst. Unless the cyst was symptomatic no treatment was undertaken. Hepatic arteriography, cholecystography, and intravenous cholangiography have not been used routinely. Operative Management Several operative techniques were used initially by the surgeons at the King Faisal Specialist Hospital and Research Centre, and after evaluating each technique the staff selected what they considered to be a safe and effective operation. Early in this series, total cystectomy was performed in seven patients, and contamination or spillage secondary to rupture of a cyst occurred in three patients. Fortunately, no anaphylactic reactions occurred, and to date there has been no evidence of secondary echinococcosis. These patients are being followed up closely. This operative complication must be avoided, and there is no excuse for its occurrence. Small cysts (less than 5 cm) at the edge of the liver may be excised with a wedge of surrounding liver tissue, but most cysts are large with an average volume of 1 liter and do not lend themselves to this technique. In this series the volume of the cysts ranged from 150 to 9,000 ml, and the cysts usually excavated a large part of the involved lobe of the liver. For this reason, total cystectomy was considered a high risk operation for a disease that could be managed in a safer and more expeditious fashion [4-6]. The same is true of hepatic lobectomy. Lobectomy has not been necessary in any patient. Three patients were treated by evacuation of cysts and open drainage or marsupialization. This technique was
805
Weirich
CYSTIC
Figure 1. The life cycle of echinococcus granulosus. C. N.S. = central nervous system.
STAGE
abandoned when two serious infections of the avascular exocysts occurred and one patient died. The operation found to be the safest and most effective has been used on the last 10 patients without complication. This operation involves exposing the cysts through an appropriate upper abdominal incision placed over the most prominent part of the cyst. After exploration of the abdomen, the operative field is reduced to a small area on the surface of the exocyst. This is accomplished with two layers of laparotomy tapes that have been soaked in sterile 20 per cent saline solution; the first layer is dry and the second layer, which is placed over the first, is in direct contact with the exocyst. The exocyst is not opened because the brittle chitinous membrane of the mother cyst fractures easily and, since the contents are under pressure, peritoneal contamination can occur. Instead, the exocyst wall is penetrated with a no. 13 catheter that is connected through a three-way stopcock to a vacuum bottle, and the hydatid
fluid and sand is evacuated. The volume of hydatid fluid removed is replaced with an equal amount of sterile 20 per cent saline solution. After 5 minutes, the saline is aspirated and the cyst filled again with the hypertonic solution. After a second interval of 5 minutes the fluid is aspirated, the exocyst opened, and any fluid present in the dependent part of the cavity is suctioned until the exocyst is empty. The mother cyst, which has collapsed to the bottom of the exocyst, is grasped with sponge forceps and removed from the field. If a large number of daughter cysts are present, they are ladled from the interior of the exocyst. Any grumous material is wiped from the interior of the cyst after it is flooded with hypertonic saline solution. After the cyst has been evacuated, the lobe of the liver containing the cyst literally deflates. Gowns and gloves are changed at this point. Then a large gauge (no. 28-32) Foley catheter is inserted in the cavity of the exocyst and the incision in the exocyst is closed tightly about the catheter. The Foley catheter is brought out of a stab wound in the abdominal wall and connected to a closed vacuum system at -15 cm of water. Bile drained from 8 of the 10 exocysts after operation; however, the drainage practically ceased in 3 to 5 days. When the 24 hour volume of drainage decreased to 50 cm, the vacuum was discontinued and the catheter was connected to closed gravity drainage. The Foley catheter was removed when the drainage decreased to 30 ml in 24 hours or less. All but one drainage tube was removed by the seventh postoperative day. The exception was a cyst that originally contained 2,500 ml and more than 400 daughter cysts, in which it was necessary to leave the tube in place for 13 days. The patients were discharged about 3 days after the catheter was removed. To date, there have been no complications and no evidence of recurrence in a follow-up period of 4 to 15 months. Comments
Figke 2. Computerized axial tomographic scan the of liver demonstrating viable hydatid cyst with daughter cysts.
806
Certain surgical principles should be observed in the management of hydatid cysts of the liver. First, spillage of the cyst contents must be avoided. Second, since the intact cyst communicates with the small The American Journal of Surgery
Hydatid Disease of the Liver
biliary ducts in 80 per cent of adult cases, bile leakage into the exocyst occurs after the removal of the parasite; therefore, drainage must be used. Third, a closed vacuum drainage system is effective in reducing the incidence of fistula formation and infection. To my knowledge, this method of handling the exocyst after evacuation of its contents has not been reported previously. Fourth, open drainage or marsupialization must be avoided because of the complications (persistent fistulas and infection) associated with this technique [5]. The surgical literature enumerates many methods of treating hydatid cysts of the liver [4-61. Saidi and Nazarian [ 71 described a method of freezing a funnel to the exocyst wall, opening the exocyst, and instilling 0.5 per cent silver nitrate solution in 53 large hydatid cysts. They state that spillage is difficult to avoid, and they are correct if the exocyst is opened before aspirating the hydatid fluid. The dangers of anaphylaxis and secondary echinococcosis are real whenever spillage occurs, which is precisely the reason for evacuating the cyst before the exocyst is opened. Any open system of handling the parasite should be avoided. The uncomplicated hydatid cyst of the liver can be removed expeditiously, and the key to success is evacuation of the hydatid fluid combined with neutralization of the parasite with a safe and effective scolocidal solution (such as sterile 20 per cent saline) before the exocyst is opened. Formalin and other toxic chemicals should not be instilled in a cyst because serious and occasionally fatal reactions may occur [S]. It is important to keep the exocyst deflated postoperatively. If this is done through a closed vacuum system, liver regeneration is enhanced, fistula formation is minimized, and infection is avoided. Results
Twenty cases of hydatid cysts of the liver are reported. The one patient who died was treated by marsupialization, and that method has been abandoned. The author believes that evacuation of the cyst contents by means of a vacuum system and flooding of the parasitic cysts with sterile 20 per cent saline solution before opening the exocyst to evacuate its solid contents
is an important
No complication
has
managed
“closed
drainage
by the
of the exocyst
occurred
principle in the
technique”
to observe. last
with
10 cases vacuum
cavity.
Summary
Twenty cases of hydatid disease of the liver are described. The clinical manifestations of hydatid cyst Volume 138, December 1979
of the liver and diagnostic procedures such as ultrasound and computerized axial tomographic scan of the liver are presented. In the last 10 cases, aspiration of hydatid fluid without opening the exocyst initially reduced the incidence of complications significantly. The application of a vacuum suction to the exocyst postoperatively enhances liver regeneration. References 1. Lewis JW Jr, Koss N, Kerstain MD: A review of echinococcal disease. Ann Surg 181: 390, 1975. 2. Amir-Jahed AK, et al: Clinical enchinococcosis. Ann Surg 182: 541,1975. 3. Nourmand A: Hydatid cysts in children and youths. AmJ Trap A&d Hyg 25: 845, 1976. 4. Cohen 2, Stone RM, Langer B: Treatment of hydatid disease of the liver. CanJSurg 19: 416, 1976. 5. Pissiotis CA, Wander JV, Condon RE: Surgical treatment of hydatid disease. Arch Surg 104: 454, 1972. 6. Maingot R: Abdominal Operations, Vol 2, 6th edition. New York, Appleton-Century-Crofts, 1974. 7. Saidi F, Nazarian I: Surgical treatment of hydatid cysts by freezing of cyst wall and instillation of 0.5 per cent silver nitrate solution. N Engl J Med 284: 1346, 1971, 8. Yousef M: Personal communication.
Discussion James A. McAllister (Salt Lake City, UT): I would like to make one comment supporting the author’s total excision experience with hepatic hydatid cyst. Unfortunately, there is an endemic area for this disease in Utah, Colorado, Wyoming, and Idaho that we did not see until we started importing sheep and dingo dogs from Australia. I think it was in 1962 that 37 cases were reported. Peculiarly, in our area the disease has primarily affected the lung; the liver has been a much less frequently treated organ. Rut in the cysts that we excised, hemihepatectomy was necessary in two instances to prevent bilious drainage. I would like to ask Dr. Weirich what he does with the calcified cysts. Erich W. Pollak (Kansas City, MO): I refer to my surgical experience in Uruguay because Uruguay had once the very sad distinction of having the second largest incidence of hydatidosis in the world. It should be emphasized that hydatidosis is not a cancer and thus should be treated as a benign disease. Although the surrounding hepatic parenchyma flattens due to intracystic pressure, it recovers completely after removal of the cystic contents and the cystic membranes, which are the only things that should be removed at operation. Hence, there is no reason for doing hepatectomy procedures in these patients. On the other hand, calcified cysts represent serious problems in management because degeneration and calcification of the surrounding hepatic parenchyma has also occurred. I would like to know Dr. Weirich’s approach to this particular lesion. To ensure collapse of a calcified cavern, we know of no procedure better than painstaking removal of all the calcium from the wall, which predisposes to massive bleeding that may be difficult to control. Occasionally good
Weirich
results have also been obtained by implanting pediculated omentum in the residual cavity. The second point to be emphasized concerns drainage of the cystic cavity. There is no way to ensure adequate drainage without using dependent drainage. Anterior drainage of a calcified cyst is inadequate. The third point concerns complications of echinococcal hepatic cyst. We saw all of the complications, some of them more than once, because in Uruguay the average housestaff physician operated on two to four hydatid cysts every week in the 195Os, when I was there. The complications included portal hypertension, cystic rupture in the biliary tree, obstructive jaundice, hemobilia, peritoneal seeding, and recurrent small bowel obstruction. Some patients have been reoperated on more than 20 times because of recurrent bowel obstruction. Hepatobronchial transit manifested itself by evacuation of scolices and clear fluid during cough efforts. Anaphylaxis was by far the most dramatic complication and was occasionally lethal. Biologic treatment of echinococcosis with vaccines has been tried with less than optimal results. Experimental work on this subject continues. William L. Weirich (closing): Heavily calcified cysts are usually dead cysts, and we do not treat them unless they are symptomatic. Fortunately, we have not had to perform
any extensive surgery for this type of problem. I did not touch on the complications of hydatid disease primarily because that is the subject of another paper. The time to take care of these patients is when they have an uncomplicated cyst of the liver or whatever organ is involved, because the complications are extremely serious. Of course, when one is faced with complications of infection, perforation, generalized peritonitis, subphrenic abscess, rupture through the diaphragm, lung abscess, or pleural involvement, then that is an entirely different matter and much more extensive care is required. The scolicidal agent mebendazole, which was introduced in Liege, Belgium, is now being used. Mebendazole has been used for other parasitic infestations. The dose is approximately 1,500 mg/day, and the initial reports on it are quite favorable. In patients with secondary hydatid involvement of the lower lobe of the lung from the liver with bronchobiliary fistula, I recommend a transabdominal approach and transabdominal evacuation of the cyst. The fistula will usually close. Bronchiectasis, if present, will have to be treated later. If bronchobiliary fistulas are approached transthoracically, serious complications may occur in approximately 50 per cent of the cases, and the most common complication is biliary duct obstruction with jaundice and acute cholangitis.
The American Journal of Surgery
Hydatid disease of the liver is caused by the tapeworm Echinococcus granulosus and has a wide geographic distribution. The highest incidence of human parasitization occurs in sheep- and cattle-raising areas [I-3]. The incidence is relatively high in the Middle East and humans are frequently infected in childhood. The small intestine of the dog and related carnivores is the reservoir for the mature worm, whose eggs are shed in the excreta. Sheep, goats, cattle, camels, and man then become intermediate hosts by ingestion of the eggs. The life cycle of this tapeworm is illustrated in Figure 1. The members of the Department of Surgery of the King Faisal Specialist Hospital and Research Centre have treated 20 cases of hepatic hydatid disease since the hospital was opened 42 months ago. Fifteen male and 5 female patients, aged 7 to 71 years, have been treated. Five patients had been operated on one to four times for the disease before being treated at our hospital. As one would expect from the streaming of the portal circulation, the right lobe of the liver was involved more often (12 patients) than the left lobe (3 patients). Both lobes were involved in five cases. The presenting complaints of patients with uncomplicated hydatid cysts of the liver have been related to the size of the cysts. Low grade upper abdominal pain was present in 12 patients, awareness of a large tense mass in the upper abdomen in 10, premature satiation in 8, and epigastric fullness or pressure in 8. The appearance of well-being of the patients belied the size of the abdominal mass, in contrast to patients with large neoplasms of the liver, who looked ill at the time they presented. Diagnosis When a large, smooth, tense, usually nontender upper abdominal mass is found in a patient who lives in an en-
From the Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. Requests for reprints should be addressed to William L. Weirich. MD, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Post Office Box 3554, Riyadh, Kingdom of Saudi Arabia. Presented at the 31st Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 23-26. 1979.
Vohme 139, December 1979
demic region, the diagnosis of hepatic hydatid cyst is suspected. Because immunologic tests for hydatid disease were not available during the first 36 months of our hospital’s existence, the clinical staff was forced to seek other reliable diagnostic procedures, some of which proved valuable. A useful diagnostic study that helped confirm the clinical impression of a hydatid cyst of the liver was computerized axial tomography of the liver (Figure 2). The scan was diagnostic when viable cysts were present, especially when they contained daughter cysts. Hepatic ultrasound demonstrated the presence of a cystic lesion or lesions, and if daughter cysts were present intracystic echoes were visible. The presence of a heavily calcified cyst on kidney, ureter, and bladder x-ray film was practically diagnostic of a nonviable hydatid cyst. Unless the cyst was symptomatic no treatment was undertaken. Hepatic arteriography, cholecystography, and intravenous cholangiography have not been used routinely. Operative Management Several operative techniques were used initially by the surgeons at the King Faisal Specialist Hospital and Research Centre, and after evaluating each technique the staff selected what they considered to be a safe and effective operation. Early in this series, total cystectomy was performed in seven patients, and contamination or spillage secondary to rupture of a cyst occurred in three patients. Fortunately, no anaphylactic reactions occurred, and to date there has been no evidence of secondary echinococcosis. These patients are being followed up closely. This operative complication must be avoided, and there is no excuse for its occurrence. Small cysts (less than 5 cm) at the edge of the liver may be excised with a wedge of surrounding liver tissue, but most cysts are large with an average volume of 1 liter and do not lend themselves to this technique. In this series the volume of the cysts ranged from 150 to 9,000 ml, and the cysts usually excavated a large part of the involved lobe of the liver. For this reason, total cystectomy was considered a high risk operation for a disease that could be managed in a safer and more expeditious fashion [4-6]. The same is true of hepatic lobectomy. Lobectomy has not been necessary in any patient. Three patients were treated by evacuation of cysts and open drainage or marsupialization. This technique was
805
Weirich
CYSTIC
Figure 1. The life cycle of echinococcus granulosus. C. N.S. = central nervous system.
STAGE
abandoned when two serious infections of the avascular exocysts occurred and one patient died. The operation found to be the safest and most effective has been used on the last 10 patients without complication. This operation involves exposing the cysts through an appropriate upper abdominal incision placed over the most prominent part of the cyst. After exploration of the abdomen, the operative field is reduced to a small area on the surface of the exocyst. This is accomplished with two layers of laparotomy tapes that have been soaked in sterile 20 per cent saline solution; the first layer is dry and the second layer, which is placed over the first, is in direct contact with the exocyst. The exocyst is not opened because the brittle chitinous membrane of the mother cyst fractures easily and, since the contents are under pressure, peritoneal contamination can occur. Instead, the exocyst wall is penetrated with a no. 13 catheter that is connected through a three-way stopcock to a vacuum bottle, and the hydatid
fluid and sand is evacuated. The volume of hydatid fluid removed is replaced with an equal amount of sterile 20 per cent saline solution. After 5 minutes, the saline is aspirated and the cyst filled again with the hypertonic solution. After a second interval of 5 minutes the fluid is aspirated, the exocyst opened, and any fluid present in the dependent part of the cavity is suctioned until the exocyst is empty. The mother cyst, which has collapsed to the bottom of the exocyst, is grasped with sponge forceps and removed from the field. If a large number of daughter cysts are present, they are ladled from the interior of the exocyst. Any grumous material is wiped from the interior of the cyst after it is flooded with hypertonic saline solution. After the cyst has been evacuated, the lobe of the liver containing the cyst literally deflates. Gowns and gloves are changed at this point. Then a large gauge (no. 28-32) Foley catheter is inserted in the cavity of the exocyst and the incision in the exocyst is closed tightly about the catheter. The Foley catheter is brought out of a stab wound in the abdominal wall and connected to a closed vacuum system at -15 cm of water. Bile drained from 8 of the 10 exocysts after operation; however, the drainage practically ceased in 3 to 5 days. When the 24 hour volume of drainage decreased to 50 cm, the vacuum was discontinued and the catheter was connected to closed gravity drainage. The Foley catheter was removed when the drainage decreased to 30 ml in 24 hours or less. All but one drainage tube was removed by the seventh postoperative day. The exception was a cyst that originally contained 2,500 ml and more than 400 daughter cysts, in which it was necessary to leave the tube in place for 13 days. The patients were discharged about 3 days after the catheter was removed. To date, there have been no complications and no evidence of recurrence in a follow-up period of 4 to 15 months. Comments
Figke 2. Computerized axial tomographic scan the of liver demonstrating viable hydatid cyst with daughter cysts.
806
Certain surgical principles should be observed in the management of hydatid cysts of the liver. First, spillage of the cyst contents must be avoided. Second, since the intact cyst communicates with the small The American Journal of Surgery
Hydatid Disease of the Liver
biliary ducts in 80 per cent of adult cases, bile leakage into the exocyst occurs after the removal of the parasite; therefore, drainage must be used. Third, a closed vacuum drainage system is effective in reducing the incidence of fistula formation and infection. To my knowledge, this method of handling the exocyst after evacuation of its contents has not been reported previously. Fourth, open drainage or marsupialization must be avoided because of the complications (persistent fistulas and infection) associated with this technique [5]. The surgical literature enumerates many methods of treating hydatid cysts of the liver [4-61. Saidi and Nazarian [ 71 described a method of freezing a funnel to the exocyst wall, opening the exocyst, and instilling 0.5 per cent silver nitrate solution in 53 large hydatid cysts. They state that spillage is difficult to avoid, and they are correct if the exocyst is opened before aspirating the hydatid fluid. The dangers of anaphylaxis and secondary echinococcosis are real whenever spillage occurs, which is precisely the reason for evacuating the cyst before the exocyst is opened. Any open system of handling the parasite should be avoided. The uncomplicated hydatid cyst of the liver can be removed expeditiously, and the key to success is evacuation of the hydatid fluid combined with neutralization of the parasite with a safe and effective scolocidal solution (such as sterile 20 per cent saline) before the exocyst is opened. Formalin and other toxic chemicals should not be instilled in a cyst because serious and occasionally fatal reactions may occur [S]. It is important to keep the exocyst deflated postoperatively. If this is done through a closed vacuum system, liver regeneration is enhanced, fistula formation is minimized, and infection is avoided. Results
Twenty cases of hydatid cysts of the liver are reported. The one patient who died was treated by marsupialization, and that method has been abandoned. The author believes that evacuation of the cyst contents by means of a vacuum system and flooding of the parasitic cysts with sterile 20 per cent saline solution before opening the exocyst to evacuate its solid contents
is an important
No complication
has
managed
“closed
drainage
by the
of the exocyst
occurred
principle in the
technique”
to observe. last
with
10 cases vacuum
cavity.
Summary
Twenty cases of hydatid disease of the liver are described. The clinical manifestations of hydatid cyst Volume 138, December 1979
of the liver and diagnostic procedures such as ultrasound and computerized axial tomographic scan of the liver are presented. In the last 10 cases, aspiration of hydatid fluid without opening the exocyst initially reduced the incidence of complications significantly. The application of a vacuum suction to the exocyst postoperatively enhances liver regeneration. References 1. Lewis JW Jr, Koss N, Kerstain MD: A review of echinococcal disease. Ann Surg 181: 390, 1975. 2. Amir-Jahed AK, et al: Clinical enchinococcosis. Ann Surg 182: 541,1975. 3. Nourmand A: Hydatid cysts in children and youths. AmJ Trap A&d Hyg 25: 845, 1976. 4. Cohen 2, Stone RM, Langer B: Treatment of hydatid disease of the liver. CanJSurg 19: 416, 1976. 5. Pissiotis CA, Wander JV, Condon RE: Surgical treatment of hydatid disease. Arch Surg 104: 454, 1972. 6. Maingot R: Abdominal Operations, Vol 2, 6th edition. New York, Appleton-Century-Crofts, 1974. 7. Saidi F, Nazarian I: Surgical treatment of hydatid cysts by freezing of cyst wall and instillation of 0.5 per cent silver nitrate solution. N Engl J Med 284: 1346, 1971, 8. Yousef M: Personal communication.
Discussion James A. McAllister (Salt Lake City, UT): I would like to make one comment supporting the author’s total excision experience with hepatic hydatid cyst. Unfortunately, there is an endemic area for this disease in Utah, Colorado, Wyoming, and Idaho that we did not see until we started importing sheep and dingo dogs from Australia. I think it was in 1962 that 37 cases were reported. Peculiarly, in our area the disease has primarily affected the lung; the liver has been a much less frequently treated organ. Rut in the cysts that we excised, hemihepatectomy was necessary in two instances to prevent bilious drainage. I would like to ask Dr. Weirich what he does with the calcified cysts. Erich W. Pollak (Kansas City, MO): I refer to my surgical experience in Uruguay because Uruguay had once the very sad distinction of having the second largest incidence of hydatidosis in the world. It should be emphasized that hydatidosis is not a cancer and thus should be treated as a benign disease. Although the surrounding hepatic parenchyma flattens due to intracystic pressure, it recovers completely after removal of the cystic contents and the cystic membranes, which are the only things that should be removed at operation. Hence, there is no reason for doing hepatectomy procedures in these patients. On the other hand, calcified cysts represent serious problems in management because degeneration and calcification of the surrounding hepatic parenchyma has also occurred. I would like to know Dr. Weirich’s approach to this particular lesion. To ensure collapse of a calcified cavern, we know of no procedure better than painstaking removal of all the calcium from the wall, which predisposes to massive bleeding that may be difficult to control. Occasionally good
Weirich
results have also been obtained by implanting pediculated omentum in the residual cavity. The second point to be emphasized concerns drainage of the cystic cavity. There is no way to ensure adequate drainage without using dependent drainage. Anterior drainage of a calcified cyst is inadequate. The third point concerns complications of echinococcal hepatic cyst. We saw all of the complications, some of them more than once, because in Uruguay the average housestaff physician operated on two to four hydatid cysts every week in the 195Os, when I was there. The complications included portal hypertension, cystic rupture in the biliary tree, obstructive jaundice, hemobilia, peritoneal seeding, and recurrent small bowel obstruction. Some patients have been reoperated on more than 20 times because of recurrent bowel obstruction. Hepatobronchial transit manifested itself by evacuation of scolices and clear fluid during cough efforts. Anaphylaxis was by far the most dramatic complication and was occasionally lethal. Biologic treatment of echinococcosis with vaccines has been tried with less than optimal results. Experimental work on this subject continues. William L. Weirich (closing): Heavily calcified cysts are usually dead cysts, and we do not treat them unless they are symptomatic. Fortunately, we have not had to perform
any extensive surgery for this type of problem. I did not touch on the complications of hydatid disease primarily because that is the subject of another paper. The time to take care of these patients is when they have an uncomplicated cyst of the liver or whatever organ is involved, because the complications are extremely serious. Of course, when one is faced with complications of infection, perforation, generalized peritonitis, subphrenic abscess, rupture through the diaphragm, lung abscess, or pleural involvement, then that is an entirely different matter and much more extensive care is required. The scolicidal agent mebendazole, which was introduced in Liege, Belgium, is now being used. Mebendazole has been used for other parasitic infestations. The dose is approximately 1,500 mg/day, and the initial reports on it are quite favorable. In patients with secondary hydatid involvement of the lower lobe of the lung from the liver with bronchobiliary fistula, I recommend a transabdominal approach and transabdominal evacuation of the cyst. The fistula will usually close. Bronchiectasis, if present, will have to be treated later. If bronchobiliary fistulas are approached transthoracically, serious complications may occur in approximately 50 per cent of the cases, and the most common complication is biliary duct obstruction with jaundice and acute cholangitis.
The American Journal of Surgery