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Laparoscopic surgical techniques in patients with hepatic hydatid cyst
The American Journal of Surgery 194 (2007) 243–247
Laparoscopy
Laparoscopic surgical techniques in patients with hepatic hydatid cyst Wang Chen, B.A.*, Li Xusheng, B.A. No 80, Cuiyinmen, Linxia Rd, Chengguanqu, Centre of Laparoscopic Surgery, Second Hospital, Lanzhou University, Gansu Province, PRC 730030 Manuscript received April 19, 2006; revised manuscript November 14, 2006
Abstract Objective: The aim of this study was to describe in detail the laparoscopic treatment of patients with liver hydatid cyst. Method: Seventy-six consecutive patients with 104 liver hydatid cysts were considered for laparoscopic treatment from October 2000 to October 2005. Results: A laparoscopic surgical technique was used in all cases. The method involved treatment of the residual pericystic cavity and removal of the contents of the cyst. The operating time (mean ⫾ SD) was 81 ⫾ 9 minutes (range 40 –120). Complications were observed in 5 patients (6.58%) after surgery. Sixty-eight patients (89.47%) were followed-up for a mean of 14 months (range 6 –38). No recurrence was found in any of the cases. The mean postoperative hospital stay was 7.6 ⫾ 1.0 days (range 6 –15). Conclusions: This laparoscopic hepatic hydatid surgical technique is a safe and effective method of treatment in selected patients. It can be a useful alternative for treating patients with liver hydatidosis. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Hepatic hydatid cyst; Laparoscopic surgery; Treatment
Hydatid disease is a parasitic infection carried by the larvae of Echinococcus granulosus, which is a small tapeworm [1,2]. Man acquires the disease by ingesting parasitic eggs, which develop into hydatid cysts, usually in the liver or lung and less commonly in other organs; the most common site of infection is the liver, with an infection rate of 50% to approximately 70% [3,4]. Human infection is acquired by ingesting parasite eggs from infected animals. E granulosus causes cystic echinococcosis in humans, a condition that is found throughout the world and is endemic in large sheep-raising areas in Europe, Asia, the Mediterranean, South America, and northern Kenya [5]. With immigration, the prevalence of the disease has increased in Europe, North America, and particularly in northwestern China. Benzimidazole compounds have recently been favored for medical treatment of the disease, but surgery is still the mainstay of treatment despite advances in medical treatment and interventional radiologic techniques [6,7]. Laparoscopic surgery is a new therapeutic method for the treatment of hepatic echinococcosis. However, some controversy exists as to the selection of laparoscopic surgical procedures for
* Corresponding author. Tel.: ⫹011-00869318469898; fax: ⫹01100869318469898. E-mail address: [email protected]
hepatic hydatid cyst. The aim of this study was to describe laparoscopic surgical techniques in the treatment of patients with hepatic echinococcosis. Patients and Methods Seventy-six patients with 104 cysts were considered for laparoscopic management at the Centre of Laparoscopic Surgery, Second Hospital, Lanzhou University, between October 2000 and October 2005. There were 52 (68.42%) male and 24 (31.58%) female patients, with a mean age of 38 years (range 21– 67). Most of them came from rural areas and worked in farms or came into contact with domestic animals. Four patients (5.26%) had previously undergone ⱖ1 operation for hydatid disease of the liver. Seventy-six patients with hydatid cyst in the liver were described according to sex, age, cyst size and number, reoperation, and complications (Table 1). Preoperative radiologic studies consisted of abdominal computed axial tomography (CAT; all patients) and ultrasonography. Hepatic infestation with E granulosus was confirmed histologically in all patients. Several main indexes—such as postoperative complications, hospital stay, and recurrence rate of the disease— were monitored in those patients treated using laparoscopic surgical techniques. Patients were contacted to attend every 6 months, at which time clinical examination, computed
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.11.033
244
W. Chen and L. Xusheng / The American Journal of Surgery 194 (2007) 243–247
Table 1 Main patient characteristics N Mean age in years (range) Male Female Mean diameter of cysts (cm) Cases with reoperation Cyst number Complicated cysts
76 38 (21–67) 52 24 10.5 4 104 9
tomography, ultrasonography, and serologic tests were performed. Surgical techniques In all 76 patients, treatment of the residual pericystic cavity with laparoscopic surgery was performed. Patients received oral albendazole (10 mg/kg) for 5 days before surgery and continued albendazole treatment for a further 3 months after surgery. All patients received a single dose of 3 g caefotaxime during surgery. Patients underwent endotracheal general anesthesia and were placed in a supine position on the operating table. The surgeon stood on the appropriate left or right side of the patient (in keeping with the location of the cyst), and the first assistant was positioned on the opposite side. After pneumoperitoneum was established, the first 10-mm trocar was inserted infraumbilically. Intraabdominal pressure was maintained at 12 to 13 mm Hg. Exposure of the hepatic hydatid cyst was obtained through a 30° laparoscope. Laparoscopic ultrasonography was used in selected cases to localize the cyst and to determine its relationship with major vascular structures. The exact position of hydatid cyst was exposed (Fig. 1). Other puncture points were chosen according to the exact position of the cyst in the liver. After routine exploration, a second 10-mm trocar was inserted from a point as close as possible to the cyst. Using this trocar, 2 to 4 pieces of gauze soaked with hydrogen peroxide were introduced into the abdominal cavity and placed
Fig. 1. Exact position of exposed hydatid cyst.
Fig. 2. Two to 4 pieces of gauze with hydrogen peroxide were introduced into the abdominal cavity and placed around the cyst.
around the cyst (Fig. 2). The purpose of this was to prevent the spread of parasites and leakage of the hydatid fluid. A 20% hypertonic sodium chloride solution, 50 to 150 mL according to the size of the hydatid cyst, was injected into the cystic cavity. This procedure is known as “primary inactivation.” After a 10-minute waiting period to inactivate the cyst contents, a 10-mm suction tip with a sharp-shaped puncturing mechanism was inserted into the cyst. The contents of the cyst—including cystic fluid, germinative membrane, numerous brood capsules, scolices, and daughter cysts of variable size—were then aspirated using suction tubing (Figs. 3 and 4). After the cystic contents were totally evacuated, 20% hypertonic sodium chloride solution was instilled into the cystic cavity, and irrigation was repeated. After an additional 10-minute interval, all remaining contents were once again evacuated by suction. This procedure is known as “second inactivation.” Finally, if the cyst was localized favorably (superficial and lateral or anteriorly), the cystic wall was partially removed with curved scissors or hook. The scope was the reinserted to explore for potential bleeding, biliary openings, and retained daughter cysts (Fig. 5). Small biliary communications were seen in 4 patients and were clipped with a regular 10-mm clip. Minor bleeding was found in 6 patients and was coagulated using electro-
Fig. 3. Ten-millimeter suction tip with a sharp-shaped puncturing mechanism.
W. Chen and L. Xusheng / The American Journal of Surgery 194 (2007) 243–247
Fig. 4. The contents of the cyst were aspirated using suction tubing.
cautery. Drainage was performed by placing a suction drain inside the cyst cavity in all patients (Fig. 6). Drainage tubes were removed within 2 to 6 days depending on the amount and characteristics of drainage. After the drainage tube was removed, if there was no evidence of bile leakage or major ascites, the patient was discharged. All of the patients were examined with abdominal ultrasonography before removal of the drains. A 3-month course of albendazole was administered after surgery in all patients. At 6 months, the patients were evaluated with either abdominal ultrasonography or CAT. The patients were then followed-up annually. Results A total of 76 echinococcus cysts were treated. Forty-nine (62.50%) patients had 65 cysts located in the right lobe of the liver, and 27 patients (37.50%) had 39 cysts located in the left lobe of the liver. Their distribution in 76 patients is shown in Fig. 7. There were 9 complicated cysts (Fig. 8). Cysts were solitary in 41 (53.95%) and multiple in 35
Fig. 5. The telescope was inserted into the cystic cavity to explore for potential bleeding, biliary openings, and retained daughter cysts.
245
Fig. 6. Drainage was performed by placing a suction drain inside the cyst cavity.
(46.05%) patients. Cyst size ranged from 2 to 30 cm in diameter (mean 10.5). Operating time (mean ⫾ SD) was 81 ⫾ 9 minutes (range 40 –120). Postoperative complications occurred in 5 patients, and overall morbidity was 6.58%. Complications are listed in Fig. 9. Port-side infections occurred in 2 patients, and biliary fistula occurred in 3 patients. No patients appeared to have pulmonary complications. Out of the cases that were complicated by biliary fistulas, the first 2 patients had a low-output biliary fistula (100 mL/d) and were observed conservatively. The fistulas closed 8 to 13 days after surgery. Although no sign of biliary communication was seen in the third patient during surgery, a high-output biliary fistula (750 mL/d) developed after surgery. The patient was discharged on the postoperative day 14, and the fistula closed in 53 days. For evaluation of recurrence, 68 patients (89.74%) were followed-up for a mean of 14 months (range 6 –38). Because their addresses had changed, 8 patients (10.26%) were lost to follow-up. Recurrence rate was evaluated with the following: symptoms, physical examination, ultrasound, CAT, and serologic tests. Ultrasound findings were 82% accurate, but 100% diagnostic accuracy was achieved with serologic tests and CAT. No recurrence was found after laparoscopic surgery in any of the patients studied. Mean postoperative hospital stay was 7.6 ⫾ 1.0 days (range 6 –15).
Fig. 7. Localization of cysts.
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W. Chen and L. Xusheng / The American Journal of Surgery 194 (2007) 243–247
Fig. 8. Distribution of complicated cysts.
Comments Hydatid disease of the liver (E granulosus) is a benign disease curable by conservative surgical procedures in a high percentage of cases. Removal of the parasite is an operative step common to all techniques. The infection should be suspected in patients who reside in rural areas and who present with abdominal pain and hepatomegaly or a palpable hepatic mass. Preoperative laboratory tests should be limited because they consume far more time than diagnostic imaging techniques. Ultrasound or CAT should be performed immediately in the evaluation process because both are fast, are noninvasive, and have high diagnostic accuracy. In primary echinococcosis, larval cysts may develop in every organ. In general, hepatic hydatid cysts are single, uncomplicated, and located in the right lobe of the liver [8 –10]. Some patients can have life-threatening complications, such as anaphylactic shock, rupture into the biliary tree and abdominal cavity, cyst infection, and, eventually, replacement of liver parenchyma. Surgery still remains the primary treatment of choice in the management of hydatid disease [1,11]. Although albendazole drugs have been used in patients, their clinical efficacy is not satisfactory. Teggi et al reported successful treatment in 49.3%, partially successful treatment in 13.1%, improvement in 5.9%, and failed treatment in 31.5% of patients treated with albendazole [12]. Several procedures, ranging from simple puncture to liver resection and transplantation, have been described for the treatment of hepatic echinococcal cyst. Although the most commonly used technique is total or partial pericystectomy, many debatable results have been reported in relation to surgical treatment of the cystic cavity. Some investigators prefer radical operations, such as hepatectomy, resection of the cyst, or pericystectomy [13,14]. However, such operations have high morbidity and mortality rates. We have used laparoscopic surgical techniques for the treatment of liver hydatid cyst since 2000. To our knowledge, this is one of the largest laparoscopic series reported in the literature. Laparoscopic surgical techniques have provided us with new methods for the treatment of patients with hepatic hydatid cyst. Laparoscopic treatment has many merits: it is minimally invasive; it requires less analgesia; and it involves a rapid recovery period and overall shorter hospital stay. This approach helps detect small bile openings, bleeding sources, and inactivation of scolices; prevents spillage; eliminates cystic contents (including daughter
cysts); and manages the residual cavity. In the event that cysts were located in subsegments VI and VII, we would not consider this lateral position safe for laparoscopic access. In the past, a major disadvantage of laparoscopy was lack of preventative measures with regard to spillage, especially under abdominal pressures induced by pneumoperitoneum [15–17]. However, in our laparoscopic techniques, intraabdominal spillage is prevented by isolating the cyst with 2 to 4 pieces of gauze soaked with hydrogen peroxide. The technique is easy to master and safe to perform. Second inactivation is an important procedure and is necessary because primary inactivation with 20% hypertonic sodium chloride solution does not ensure the inactivation or clearance of scolices. Therefore, the second inactivation makes up for any missed parasites from the primary inactivation. Another important issue in laparoscopic hydatid cyst surgery is removal of the germinative membrane and daughter cysts. For this purpose, we use a 10-mm suction catheter. In addition, good lighting and enlargement of the laparoscopic image enabled us to directly observe the entire cystic cavity. This procedure has proved to be effective in decreasing postoperative complications as well as recurrence. In this study, postoperative complications occurred in 5 patients, and overall morbidity was 6.58%. Postoperative morbidity in laparoscopic studies ranges from 8% to 25% [18,19]. Nevertheless, complications and morbidity in open surgery ranges from 12% to 63% [20]. Yagci et al noted biliary leakage in 2 of 355 patients after laparoscopic treatment for hydatid disease of the liver [21]. The recurrence rate is between 3% and 10% after open surgery for patients with hepatic hydatid cyst [21–23]. In our laparoscopic series and follow-up, we had a 0% recurrence rate. Drainage procedures are necessary in patients who have undergone laparoscopic treatment of hydatid cyst. In our experience, in the group treated by drainage, tube drainage of the cystic cavity decreased postoperative morbidity in both patients with complicated and those with noncomplicated cysts. Drainage procedures prevent various postoperative complications, such as hepatic abscess, biliary fistulas, biliary peritonitis, etc. However, Demirci et al [10] reported higher morbidity rates for patients with complicated cysts treated using drainage procedures. As a result of this study, we conclude, as have many investigators, that the preferred approach in the treatment of patients with liver hydatid cyst is laparoscopic surgery because it results in low morbidity and acceptable recurrence rates. This technique is easy to master. As long as preoperative preparation is adequate, laparoscopic surgical tech-
Fig. 9. Postoperative complications.
W. Chen and L. Xusheng / The American Journal of Surgery 194 (2007) 243–247
niques could be safe and feasible options in the treatment of patients with hepatic hydatid cyst. References [1] Dawson JL, Stamatakis JD, Stringer MD, Williams R. Surgical treatment of hepatic hydatid disease. Br J Surg 1988;75:946–50. [2] Rormero-Torres R, Campbell JR. An interpretative review of the surgical treatment of hydatid disease. Surg Gynecol Obstet 1965;121:851– 64. [3] Xu M. Hydatid disease. Sinkiang People’s Publishing Company; 1983:10 –74. [4] Barros JL. Hydatid disease of the liver. Am J Surg 1977;597– 600. [5] Ammann RW, Eckert J. Cestodes: Echinococcus. Gastroenterol Clin North Am 1996;25:655– 89. [6] Mentes A. Hydatid liver disease: a perspective in treatment. Dig Dis 1994;12:150 – 60. [7] Todorov T, Vutova K, Mechkov G, et al. Chemotherapy of human cystic echinococcosis: comparative efficacy of mebendazole and albendazole. Ann Trop Med Parasitol 1992;86:59 – 66. [8] Yılmaz E, Gokok N. Hydatid disease of the liver: current surgical management. Br J Clin Pract 1990;44:612–5. [9] Safioleas M, Misiakos E, Mann C, et al. Diagnostic evaluation and surgical management of hydatid disease of the liver. World J Surg 1994;18:859 – 65. [10] Demirci S, Eraslan S, Anadol E, et al. Comparison of the results of different surgical techniques in the management of hydatid cysts of the liver. World J Surg 1989;13:88 –91. [11] Sayek I, Yalıin R, Sanac Y. Surgical treatment of hydatid disease of the liver. Arch Surg 1980;115:847–500. [12] Teggi A, Lastilla MG, De Rosa F. Therapy of human hydatid disease with mebendazole and albendazole. Antimicrob Agents Chemother 1993;37:1679 – 84.
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[13] Belli L, Favero E, Marni A, et al. Resection versus pericystectomy in the treatment of hydatidosis of the liver. Am J Surg 1983;145: 239 – 42. [14] Belli L, Aseni P, Rondinara GF, et al. Improved results with pericystecromy in normorhermic ischemia for hepatic hydatidosis. Surg Gynecol Obstet 1986;163:127–32. [15] Terblanche J, Krige JEJ. Hepatic echinococcosis. In: Cameron JL, editor. Current surgical therapy. 6th ed. London, UK: Mosby; 1998: 326 –30. [16] Klingler PJ, Gadenstatter M, Schmid T, et al. Treatment of hepatic cysts in the era of laparoscopic surgery. Br J Surg 1997;84:438 – 44. [17] Iskender S. Diagnosis and treatment of uncomplicated hydatid cyst of the liver. World J Surg 2001;25:21–7. [18] Alper A, Emre A, Hazar H, et al. Laparoscopic surgery of hydatid disease: initial results and early follow-up of 16 patients. World J Surg 1995;19:725– 8. [19] Khoury G, Jabbour-Khoury S, Bikhazi K. Results of laparoscopic treatment of hydatid cysts of the liver. Surg Endosc 1996;10:57–9. [20] Günay K, Taviloglu K, Berber E, et al. Traumatic rupture of hydatid cysts: 12-year experience from an endemic region. J Trauma 1999; 46:164 –7. [21] Yagci G, Ustunsoz B, Kaymakcioglu N, et al. Results of surgical, laparoscopic, and percutaneous treatment for hydatid disease of the liver: 10 years experience with 355 patients. World J Surg 2005; 29(12):1670 –9. [22] Demirci S, Eraslan S, Anado E, et al. Comparison of the results of different surgical techniques in the management of hydatid cysts of the liver. World J Surg 1989;13:88 –91. [23] Turkcapar AG, Ersoz S, Gungor C, et al. Surgical treatment of hepatic hydatidosis combined with preoperative treatment with albendazole. Eur J Surg 1997;163:923– 8.
Laparoscopy
Laparoscopic surgical techniques in patients with hepatic hydatid cyst Wang Chen, B.A.*, Li Xusheng, B.A. No 80, Cuiyinmen, Linxia Rd, Chengguanqu, Centre of Laparoscopic Surgery, Second Hospital, Lanzhou University, Gansu Province, PRC 730030 Manuscript received April 19, 2006; revised manuscript November 14, 2006
Abstract Objective: The aim of this study was to describe in detail the laparoscopic treatment of patients with liver hydatid cyst. Method: Seventy-six consecutive patients with 104 liver hydatid cysts were considered for laparoscopic treatment from October 2000 to October 2005. Results: A laparoscopic surgical technique was used in all cases. The method involved treatment of the residual pericystic cavity and removal of the contents of the cyst. The operating time (mean ⫾ SD) was 81 ⫾ 9 minutes (range 40 –120). Complications were observed in 5 patients (6.58%) after surgery. Sixty-eight patients (89.47%) were followed-up for a mean of 14 months (range 6 –38). No recurrence was found in any of the cases. The mean postoperative hospital stay was 7.6 ⫾ 1.0 days (range 6 –15). Conclusions: This laparoscopic hepatic hydatid surgical technique is a safe and effective method of treatment in selected patients. It can be a useful alternative for treating patients with liver hydatidosis. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Hepatic hydatid cyst; Laparoscopic surgery; Treatment
Hydatid disease is a parasitic infection carried by the larvae of Echinococcus granulosus, which is a small tapeworm [1,2]. Man acquires the disease by ingesting parasitic eggs, which develop into hydatid cysts, usually in the liver or lung and less commonly in other organs; the most common site of infection is the liver, with an infection rate of 50% to approximately 70% [3,4]. Human infection is acquired by ingesting parasite eggs from infected animals. E granulosus causes cystic echinococcosis in humans, a condition that is found throughout the world and is endemic in large sheep-raising areas in Europe, Asia, the Mediterranean, South America, and northern Kenya [5]. With immigration, the prevalence of the disease has increased in Europe, North America, and particularly in northwestern China. Benzimidazole compounds have recently been favored for medical treatment of the disease, but surgery is still the mainstay of treatment despite advances in medical treatment and interventional radiologic techniques [6,7]. Laparoscopic surgery is a new therapeutic method for the treatment of hepatic echinococcosis. However, some controversy exists as to the selection of laparoscopic surgical procedures for
* Corresponding author. Tel.: ⫹011-00869318469898; fax: ⫹01100869318469898. E-mail address: [email protected]
hepatic hydatid cyst. The aim of this study was to describe laparoscopic surgical techniques in the treatment of patients with hepatic echinococcosis. Patients and Methods Seventy-six patients with 104 cysts were considered for laparoscopic management at the Centre of Laparoscopic Surgery, Second Hospital, Lanzhou University, between October 2000 and October 2005. There were 52 (68.42%) male and 24 (31.58%) female patients, with a mean age of 38 years (range 21– 67). Most of them came from rural areas and worked in farms or came into contact with domestic animals. Four patients (5.26%) had previously undergone ⱖ1 operation for hydatid disease of the liver. Seventy-six patients with hydatid cyst in the liver were described according to sex, age, cyst size and number, reoperation, and complications (Table 1). Preoperative radiologic studies consisted of abdominal computed axial tomography (CAT; all patients) and ultrasonography. Hepatic infestation with E granulosus was confirmed histologically in all patients. Several main indexes—such as postoperative complications, hospital stay, and recurrence rate of the disease— were monitored in those patients treated using laparoscopic surgical techniques. Patients were contacted to attend every 6 months, at which time clinical examination, computed
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.11.033
244
W. Chen and L. Xusheng / The American Journal of Surgery 194 (2007) 243–247
Table 1 Main patient characteristics N Mean age in years (range) Male Female Mean diameter of cysts (cm) Cases with reoperation Cyst number Complicated cysts
76 38 (21–67) 52 24 10.5 4 104 9
tomography, ultrasonography, and serologic tests were performed. Surgical techniques In all 76 patients, treatment of the residual pericystic cavity with laparoscopic surgery was performed. Patients received oral albendazole (10 mg/kg) for 5 days before surgery and continued albendazole treatment for a further 3 months after surgery. All patients received a single dose of 3 g caefotaxime during surgery. Patients underwent endotracheal general anesthesia and were placed in a supine position on the operating table. The surgeon stood on the appropriate left or right side of the patient (in keeping with the location of the cyst), and the first assistant was positioned on the opposite side. After pneumoperitoneum was established, the first 10-mm trocar was inserted infraumbilically. Intraabdominal pressure was maintained at 12 to 13 mm Hg. Exposure of the hepatic hydatid cyst was obtained through a 30° laparoscope. Laparoscopic ultrasonography was used in selected cases to localize the cyst and to determine its relationship with major vascular structures. The exact position of hydatid cyst was exposed (Fig. 1). Other puncture points were chosen according to the exact position of the cyst in the liver. After routine exploration, a second 10-mm trocar was inserted from a point as close as possible to the cyst. Using this trocar, 2 to 4 pieces of gauze soaked with hydrogen peroxide were introduced into the abdominal cavity and placed
Fig. 1. Exact position of exposed hydatid cyst.
Fig. 2. Two to 4 pieces of gauze with hydrogen peroxide were introduced into the abdominal cavity and placed around the cyst.
around the cyst (Fig. 2). The purpose of this was to prevent the spread of parasites and leakage of the hydatid fluid. A 20% hypertonic sodium chloride solution, 50 to 150 mL according to the size of the hydatid cyst, was injected into the cystic cavity. This procedure is known as “primary inactivation.” After a 10-minute waiting period to inactivate the cyst contents, a 10-mm suction tip with a sharp-shaped puncturing mechanism was inserted into the cyst. The contents of the cyst—including cystic fluid, germinative membrane, numerous brood capsules, scolices, and daughter cysts of variable size—were then aspirated using suction tubing (Figs. 3 and 4). After the cystic contents were totally evacuated, 20% hypertonic sodium chloride solution was instilled into the cystic cavity, and irrigation was repeated. After an additional 10-minute interval, all remaining contents were once again evacuated by suction. This procedure is known as “second inactivation.” Finally, if the cyst was localized favorably (superficial and lateral or anteriorly), the cystic wall was partially removed with curved scissors or hook. The scope was the reinserted to explore for potential bleeding, biliary openings, and retained daughter cysts (Fig. 5). Small biliary communications were seen in 4 patients and were clipped with a regular 10-mm clip. Minor bleeding was found in 6 patients and was coagulated using electro-
Fig. 3. Ten-millimeter suction tip with a sharp-shaped puncturing mechanism.
W. Chen and L. Xusheng / The American Journal of Surgery 194 (2007) 243–247
Fig. 4. The contents of the cyst were aspirated using suction tubing.
cautery. Drainage was performed by placing a suction drain inside the cyst cavity in all patients (Fig. 6). Drainage tubes were removed within 2 to 6 days depending on the amount and characteristics of drainage. After the drainage tube was removed, if there was no evidence of bile leakage or major ascites, the patient was discharged. All of the patients were examined with abdominal ultrasonography before removal of the drains. A 3-month course of albendazole was administered after surgery in all patients. At 6 months, the patients were evaluated with either abdominal ultrasonography or CAT. The patients were then followed-up annually. Results A total of 76 echinococcus cysts were treated. Forty-nine (62.50%) patients had 65 cysts located in the right lobe of the liver, and 27 patients (37.50%) had 39 cysts located in the left lobe of the liver. Their distribution in 76 patients is shown in Fig. 7. There were 9 complicated cysts (Fig. 8). Cysts were solitary in 41 (53.95%) and multiple in 35
Fig. 5. The telescope was inserted into the cystic cavity to explore for potential bleeding, biliary openings, and retained daughter cysts.
245
Fig. 6. Drainage was performed by placing a suction drain inside the cyst cavity.
(46.05%) patients. Cyst size ranged from 2 to 30 cm in diameter (mean 10.5). Operating time (mean ⫾ SD) was 81 ⫾ 9 minutes (range 40 –120). Postoperative complications occurred in 5 patients, and overall morbidity was 6.58%. Complications are listed in Fig. 9. Port-side infections occurred in 2 patients, and biliary fistula occurred in 3 patients. No patients appeared to have pulmonary complications. Out of the cases that were complicated by biliary fistulas, the first 2 patients had a low-output biliary fistula (100 mL/d) and were observed conservatively. The fistulas closed 8 to 13 days after surgery. Although no sign of biliary communication was seen in the third patient during surgery, a high-output biliary fistula (750 mL/d) developed after surgery. The patient was discharged on the postoperative day 14, and the fistula closed in 53 days. For evaluation of recurrence, 68 patients (89.74%) were followed-up for a mean of 14 months (range 6 –38). Because their addresses had changed, 8 patients (10.26%) were lost to follow-up. Recurrence rate was evaluated with the following: symptoms, physical examination, ultrasound, CAT, and serologic tests. Ultrasound findings were 82% accurate, but 100% diagnostic accuracy was achieved with serologic tests and CAT. No recurrence was found after laparoscopic surgery in any of the patients studied. Mean postoperative hospital stay was 7.6 ⫾ 1.0 days (range 6 –15).
Fig. 7. Localization of cysts.
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W. Chen and L. Xusheng / The American Journal of Surgery 194 (2007) 243–247
Fig. 8. Distribution of complicated cysts.
Comments Hydatid disease of the liver (E granulosus) is a benign disease curable by conservative surgical procedures in a high percentage of cases. Removal of the parasite is an operative step common to all techniques. The infection should be suspected in patients who reside in rural areas and who present with abdominal pain and hepatomegaly or a palpable hepatic mass. Preoperative laboratory tests should be limited because they consume far more time than diagnostic imaging techniques. Ultrasound or CAT should be performed immediately in the evaluation process because both are fast, are noninvasive, and have high diagnostic accuracy. In primary echinococcosis, larval cysts may develop in every organ. In general, hepatic hydatid cysts are single, uncomplicated, and located in the right lobe of the liver [8 –10]. Some patients can have life-threatening complications, such as anaphylactic shock, rupture into the biliary tree and abdominal cavity, cyst infection, and, eventually, replacement of liver parenchyma. Surgery still remains the primary treatment of choice in the management of hydatid disease [1,11]. Although albendazole drugs have been used in patients, their clinical efficacy is not satisfactory. Teggi et al reported successful treatment in 49.3%, partially successful treatment in 13.1%, improvement in 5.9%, and failed treatment in 31.5% of patients treated with albendazole [12]. Several procedures, ranging from simple puncture to liver resection and transplantation, have been described for the treatment of hepatic echinococcal cyst. Although the most commonly used technique is total or partial pericystectomy, many debatable results have been reported in relation to surgical treatment of the cystic cavity. Some investigators prefer radical operations, such as hepatectomy, resection of the cyst, or pericystectomy [13,14]. However, such operations have high morbidity and mortality rates. We have used laparoscopic surgical techniques for the treatment of liver hydatid cyst since 2000. To our knowledge, this is one of the largest laparoscopic series reported in the literature. Laparoscopic surgical techniques have provided us with new methods for the treatment of patients with hepatic hydatid cyst. Laparoscopic treatment has many merits: it is minimally invasive; it requires less analgesia; and it involves a rapid recovery period and overall shorter hospital stay. This approach helps detect small bile openings, bleeding sources, and inactivation of scolices; prevents spillage; eliminates cystic contents (including daughter
cysts); and manages the residual cavity. In the event that cysts were located in subsegments VI and VII, we would not consider this lateral position safe for laparoscopic access. In the past, a major disadvantage of laparoscopy was lack of preventative measures with regard to spillage, especially under abdominal pressures induced by pneumoperitoneum [15–17]. However, in our laparoscopic techniques, intraabdominal spillage is prevented by isolating the cyst with 2 to 4 pieces of gauze soaked with hydrogen peroxide. The technique is easy to master and safe to perform. Second inactivation is an important procedure and is necessary because primary inactivation with 20% hypertonic sodium chloride solution does not ensure the inactivation or clearance of scolices. Therefore, the second inactivation makes up for any missed parasites from the primary inactivation. Another important issue in laparoscopic hydatid cyst surgery is removal of the germinative membrane and daughter cysts. For this purpose, we use a 10-mm suction catheter. In addition, good lighting and enlargement of the laparoscopic image enabled us to directly observe the entire cystic cavity. This procedure has proved to be effective in decreasing postoperative complications as well as recurrence. In this study, postoperative complications occurred in 5 patients, and overall morbidity was 6.58%. Postoperative morbidity in laparoscopic studies ranges from 8% to 25% [18,19]. Nevertheless, complications and morbidity in open surgery ranges from 12% to 63% [20]. Yagci et al noted biliary leakage in 2 of 355 patients after laparoscopic treatment for hydatid disease of the liver [21]. The recurrence rate is between 3% and 10% after open surgery for patients with hepatic hydatid cyst [21–23]. In our laparoscopic series and follow-up, we had a 0% recurrence rate. Drainage procedures are necessary in patients who have undergone laparoscopic treatment of hydatid cyst. In our experience, in the group treated by drainage, tube drainage of the cystic cavity decreased postoperative morbidity in both patients with complicated and those with noncomplicated cysts. Drainage procedures prevent various postoperative complications, such as hepatic abscess, biliary fistulas, biliary peritonitis, etc. However, Demirci et al [10] reported higher morbidity rates for patients with complicated cysts treated using drainage procedures. As a result of this study, we conclude, as have many investigators, that the preferred approach in the treatment of patients with liver hydatid cyst is laparoscopic surgery because it results in low morbidity and acceptable recurrence rates. This technique is easy to master. As long as preoperative preparation is adequate, laparoscopic surgical tech-
Fig. 9. Postoperative complications.
W. Chen and L. Xusheng / The American Journal of Surgery 194 (2007) 243–247
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