- Email: [email protected]
Organ-sparing surgical treatment of giant hepatic hydatid cysts
The American Journal of Surgery 187 (2004) 288 –290
How I do it
Organ-sparing surgical treatment of giant hepatic hydatid cysts Julian E. Losanoff, M.D., Bruce W. Richman, M.A., James W. Jones, M.D., Ph.D.* Department of Surgery, M580 Health Sciences Center, University of Missouri-Columbia School of Medicine, One Hospital Dr., Columbia, MO 65212, USA Manuscript received September 20, 2002; revised manuscript January 14, 2003
Abstract Background: Excision of giant hepatic hydatid cysts may be associated with loss of hepatic tissue. We describe a method for obliterating spacious residual cavities that promotes salvage of healthy liver parenchyma. Methods: After simple cystectomy, the residual cavity is obliterated by manual compression of the healthy liver parenchyma from the left and right toward the midline of the cavity. While compression is maintained, the approximated edges of the cyst’s fibrous capsule are closed with mattress sutures. Omentoplasty or gelatine sponges are used to fill the dead space prior to suturing of the fibrous capsule. Results: The method was used in 8 patients between 1993 and 2000. No sepsis, postoperative bile leak, or other complications occurred. No long-term adverse effects were found. Conclusions: This method is simple and effective for obliteration of extremely large residual cavities after cystectomy for liver hydatidosis. It may be used safely in selected patients. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Echinococcosis; Surgery; Residual cavity
A variety of techniques has been recommended for managing the residual cavity after cystectomy. Selection is typically based on the cyst’s size, location, and surgeon’s personal preference. Surgeons occasionally see giant hydatid cysts which occupy substantial parts of the liver and displace and separate adjacent segments or even lobes. They represent special situations in which small streaks of healthy liver parenchyma connect otherwise preserved liver parts. Streaks at the cyst’s bottom may encompass the vena cava or other important vascular or biliary structures that emerge from the hepatic hilum, traverse the area of the cyst, and supply adjacent areas. We describe a method for managing the residual cavity after removal of such difficult hydatid cysts.
Technique The laparotomy incision and operative field are carefully isolated with abdominal packs soaked in 20% saline. The hepatic diaphragmatic attachments are dissected, facilitating
mobilization of the liver. Each hydatid cyst is aspirated through its most prominent part using a blunted spinal needle. The cavity is filled with 20% saline for 10 to 15 minutes, aspirated again, and then opened between stay sutures through a vertical 10 to 12 cm incision (Fig. 1). The cyst content is evacuated and the cavity inspected for intramural daughter cysts and biliary communications. Intramural cysts are managed with cystectomy, and biliary communications with direct suture. The cavity is then disinfected with Povidone iodine and obliterated manually by compressing the surrounding healthy parenchyma from the left and right toward the cavity’s midline. While compression is maintained, the cyst edges are sutured together using generous mattress sutures passed through the fibrous capsule’s cranial, anterior, and ventral aspects (Fig. 2). Significant dead spaces are filled with pedicled omentum. If omentum is not available, gelatin sponge is used prior to suture. A prophylactic large-caliber passive tube drain is placed in contact with the inferior liver surface and exteriorized dependently and laterally. The abdominal wall is closed in layers.
Results * Corresponding author. Tel.: ⫹1-573-882-4158; fax: ⫹1-573-8844585. E-mail address: [email protected]
The method was used between 1993 and 2000 in 6 patients with extremely large liver hydatid cysts. Patient
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.11.026
J.E. Losanoff et al. / The American Journal of Surgery 187 (2004) 288 –290
Fig. 1. Preoperative computed tomography scan showing large hydatid cysts of the liver.
selection was based on the presence of small streaks of liver parenchyma containing vital vascular and biliary tributaries displaced by the cysts and supplying healthy liver parenchyma lateral to the hydatid growths (Fig. 1). The patients were aged 19 to 68 years (mean 37); 4 (67%) were female. Four patients had single cysts (50% located in the left lobe), and there were two cysts each located in the right and left lobes, respectively, in each of the remaining patients. All patients were treated with Albendazole (Eskazole; SmithKline Beecham, London, United Kingdom) at doses of 10 to 15 mg/kg daily in two divided doses for two preoperative and one postoperative 1-month courses separated by 14-day intervals in accordance with the World Health Organization guidelines [1]. Surgery proceeded through median laparotomy. The average cyst volume was 588 mL (range 450 to 700 mL). Inspection of the cyst’s inner surfaces revealed no intramural daughter cysts and single cyst-biliary communications in 4 patients that were closed with direct suture using 4-0 Vicryl (Ethicon, Somerville, New Jersey). None of the patients had fibrotic liver parenchyma outside the area of the cyst. The residual cavities were managed with the above described suture technique using no. 2 multifilamented Vicryl. The large suture size was presumed to avoid sutures cutting through the pericyst tissue. The remaining dead
Fig. 2. Postoperative computed tomography scan 3 months postoperatively showing scar tissue (A) replacing the residual defect.
289
space was visually assessed and found to be significant in 7 cysts (88%) after the remaining healthy liver parenchyma was compressed toward the midline. The dead space was filled with gelatin sponge alone in 3 cysts (38%), omentum alone in 3, and combined gelatin sponge and omentum in 1 cyst. No prophylactic antibiotics were used. The postoperative management was routine and included early ambulation and enteral nutrition. No antibiotics were used. There was no hepatic necrosis, bile leakage, intraabdominal sepsis, or other surgical morbidity. The abdominal drains were removed in the absence of effluent, typically between the second and fourth postoperative days. Follow-up included clinical and laboratory examinations, ultrasonography, and computed tomography performed at 1-month intervals for the first 3 months, and annually thereafter (Fig. 2). Negligible residual cavities were initially observed in all patients, but disappeared by the end of the second postoperative month. No additional pathology was detected.
Comments Residual cavities after liver hydatid cystectomy can be managed by suture obliteration [2], omentoplasty [3], introflexion [4], double breasting [5], simple closure [6], deroofing [7], and tube drainage [8]. None of these methods is universally applicable, however [2– 8]. Each has been proven effective in a large number of patients, but some limitations apply to extremely large hydatid cysts. Cystectomy is considered the least traumatic method for removal of hepatic hydatid cysts [2– 8], but there is typically a large residual cavity that can lead to a number of lifethreatening complications such as suppuration, recurrence, and biliary fistula. Closure was difficult in all our patients because the cavities were large, extended deep within the organ, and were surrounded by relatively unyielding hepatic parenchyma. The cavities bordered vital vascular and biliary structures, the precise localization of which was difficult because of severe scarring and altered anatomy. Pericystectomy and hepatic resection were considered as alternatives to cystectomy to negotiate these problems. Pericystectomy was ultimately considered to be extremely dangerous because there was little if any healthy liver parenchyma through which to dissect the cyst’s fibrous capsule [1–7]. Hepatic resection would have removed a considerable amount of healthy tissue distal to the resection line, with the risk of hepatic failure, severe bleeding, and biliary fistula [9]. Pericystectomy and hepatic resection are typically considered too radical for echinococcosis, a benign disease [2–9]. Obliteration of the cavity with sutures (capitonnage) risks injury to deeply located blood vessels and biliary ducts when sutures are passed from the more superficial layers to the base of the cyst [2,10]. We concluded that this method as well as introflexion, double breasting, and simple clo-
290
J.E. Losanoff et al. / The American Journal of Surgery 187 (2004) 288 –290
sures were all inappropriate for our patients because of the small amount of endogenous pericystic tissue and large residual cavities, with the potential of considerable dead space in the depth of the cavity and increased infection risk. Deroofing was considered an option, too, but was abandoned because of the residual cavities’ depth and literature indicating that the method may produce intestinal entrapment in the remaining cavity [4]. Simple tube drainage was not used because of the high reported incidence of iatrogenic external biliary fistulas [3,11]. Omentoplasty has reportedly been inapplicable in extremely large or infected cysts [8,11,12] but the method effectively deals with small cavities and expected bile leaks [12]. It is especially useful in rigid, calcified defects, and to close cystobiliary communications [12]. We used the method alone and in combination with gelatin sponge in patients with available omentum. The pedicled graft was used to fill the larger cavity in patients with more than one cyst. Extensive mobilization of the liver and the small amount of healthy parenchyma surrounding our patients’ cysts were beneficial because they permitted increased liver mobility and atraumatic tissue approximation. A mechanically and geometrically sound obliteration of the residual cavities resulted, as demonstrated by long-term radiographic followup. We used gelatin sponge because the material promotes fibroplasia, aids cavity obliteration, is fully absorbable, and does not precipitate foreign body reactions or become a nidus of infection [13]. The literature and our preliminary experience suggest that this method of modified cavity obliteration can be combined with omentoplasty [3,11–13], but this awaits a larger trial. The described method represents a variant of capitonnage, with all sutures passed through superficial rather than deep anatomic layers bordering the residual cavity. The fibrous capsule was left in situ and only its peripheral part was used for closure, thereby avoiding ischemia and necrosis of surrounding liver tissue. Our initial good results sug-
gest that the technique might be considered a viable alternative to other, higher risk methods when surgeons are confronted with extremely large hydatid cysts of the liver. It may be used in selected patients who present with extremely large hydatid cysts, and it promotes salvage of healthy liver parenchyma. References [1] Saimot AG. Medical treatment of liver hydatidosis. World J Surg 2001;25:15–20. [2] Sayek I, Onat D. Diagnosis and treatment of uncomplicated hydatid cyst of the liver. World J Surg 2001;25:21–7. [3] Koksal N, Muftuoglu T, Gunerhan Y, et al. Management of intrabiliary ruptured hydatid disease of the liver. Hepato-Gastroenterology 2001;48:1094 – 6. [4] Kayaalp C, Sengul N, Akoglu M. Importance of cyst content in hydatid liver surgery. Arch Surg 2002;137:159 – 63. [5] Shreevathsa MR, John AK. Double breasting technique for residual cavity in hepatic hydatid. J R Coll Surg Edinb 1997;42:244 –5. [6] Safioleas M, Misiakos EP, Kakisis J, et al. Surgical treatment of human echinococcosis. Int Surg 2000;85:358 – 65. [7] Vagianos CE, Karavias DD, Kakkos SK, et al. Conservative surgery in the treatment of hepatic hydatidosis. Eur J Surg 1995;161:415–20. [8] Kama NA, Sahin M, Gocmen E, et al. The results of surgical techniques in hepatic hydatidosis: treatment with drainage versus treatment without drainage—a 6-year experience. J R Coll Surg Edinb 1998;43:254 – 6. [9] Cirenei A, Bertoldi I. Evolution of surgery for liver hydatidosis from 1950 to today: analysis of a personal experience. World J Surg 2001;25:87–92. [10] Gunay K, Tavioglu K, Berber E, Ertekin C. Traumatic rupture of hydatid cysts: a 12-year experience from an endemic region. J Trauma 1999;46:164 –7. [11] Zaouche A, Haouet K, Jouini M, et al. Management of liver hydatid cysts with a large biliocystic fistula: multicenter retrospective study. World J Surg 2001;25:28 –39. [12] Demirbilek S, Sander S, Atayurt HF, Aydin G. Hydatid disease of the liver in childhood: the success of medical therapy and surgical alternatives. Ped Surg Int 2001;17:373–7. [13] Kjossev KT, Losanoff JE. Surgery for deeply located hydatid cysts of the liver: a simple alternative. Hepato Pancreat Bil Surg 2000;11: 307–10.
How I do it
Organ-sparing surgical treatment of giant hepatic hydatid cysts Julian E. Losanoff, M.D., Bruce W. Richman, M.A., James W. Jones, M.D., Ph.D.* Department of Surgery, M580 Health Sciences Center, University of Missouri-Columbia School of Medicine, One Hospital Dr., Columbia, MO 65212, USA Manuscript received September 20, 2002; revised manuscript January 14, 2003
Abstract Background: Excision of giant hepatic hydatid cysts may be associated with loss of hepatic tissue. We describe a method for obliterating spacious residual cavities that promotes salvage of healthy liver parenchyma. Methods: After simple cystectomy, the residual cavity is obliterated by manual compression of the healthy liver parenchyma from the left and right toward the midline of the cavity. While compression is maintained, the approximated edges of the cyst’s fibrous capsule are closed with mattress sutures. Omentoplasty or gelatine sponges are used to fill the dead space prior to suturing of the fibrous capsule. Results: The method was used in 8 patients between 1993 and 2000. No sepsis, postoperative bile leak, or other complications occurred. No long-term adverse effects were found. Conclusions: This method is simple and effective for obliteration of extremely large residual cavities after cystectomy for liver hydatidosis. It may be used safely in selected patients. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Echinococcosis; Surgery; Residual cavity
A variety of techniques has been recommended for managing the residual cavity after cystectomy. Selection is typically based on the cyst’s size, location, and surgeon’s personal preference. Surgeons occasionally see giant hydatid cysts which occupy substantial parts of the liver and displace and separate adjacent segments or even lobes. They represent special situations in which small streaks of healthy liver parenchyma connect otherwise preserved liver parts. Streaks at the cyst’s bottom may encompass the vena cava or other important vascular or biliary structures that emerge from the hepatic hilum, traverse the area of the cyst, and supply adjacent areas. We describe a method for managing the residual cavity after removal of such difficult hydatid cysts.
Technique The laparotomy incision and operative field are carefully isolated with abdominal packs soaked in 20% saline. The hepatic diaphragmatic attachments are dissected, facilitating
mobilization of the liver. Each hydatid cyst is aspirated through its most prominent part using a blunted spinal needle. The cavity is filled with 20% saline for 10 to 15 minutes, aspirated again, and then opened between stay sutures through a vertical 10 to 12 cm incision (Fig. 1). The cyst content is evacuated and the cavity inspected for intramural daughter cysts and biliary communications. Intramural cysts are managed with cystectomy, and biliary communications with direct suture. The cavity is then disinfected with Povidone iodine and obliterated manually by compressing the surrounding healthy parenchyma from the left and right toward the cavity’s midline. While compression is maintained, the cyst edges are sutured together using generous mattress sutures passed through the fibrous capsule’s cranial, anterior, and ventral aspects (Fig. 2). Significant dead spaces are filled with pedicled omentum. If omentum is not available, gelatin sponge is used prior to suture. A prophylactic large-caliber passive tube drain is placed in contact with the inferior liver surface and exteriorized dependently and laterally. The abdominal wall is closed in layers.
Results * Corresponding author. Tel.: ⫹1-573-882-4158; fax: ⫹1-573-8844585. E-mail address: [email protected]
The method was used between 1993 and 2000 in 6 patients with extremely large liver hydatid cysts. Patient
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.11.026
J.E. Losanoff et al. / The American Journal of Surgery 187 (2004) 288 –290
Fig. 1. Preoperative computed tomography scan showing large hydatid cysts of the liver.
selection was based on the presence of small streaks of liver parenchyma containing vital vascular and biliary tributaries displaced by the cysts and supplying healthy liver parenchyma lateral to the hydatid growths (Fig. 1). The patients were aged 19 to 68 years (mean 37); 4 (67%) were female. Four patients had single cysts (50% located in the left lobe), and there were two cysts each located in the right and left lobes, respectively, in each of the remaining patients. All patients were treated with Albendazole (Eskazole; SmithKline Beecham, London, United Kingdom) at doses of 10 to 15 mg/kg daily in two divided doses for two preoperative and one postoperative 1-month courses separated by 14-day intervals in accordance with the World Health Organization guidelines [1]. Surgery proceeded through median laparotomy. The average cyst volume was 588 mL (range 450 to 700 mL). Inspection of the cyst’s inner surfaces revealed no intramural daughter cysts and single cyst-biliary communications in 4 patients that were closed with direct suture using 4-0 Vicryl (Ethicon, Somerville, New Jersey). None of the patients had fibrotic liver parenchyma outside the area of the cyst. The residual cavities were managed with the above described suture technique using no. 2 multifilamented Vicryl. The large suture size was presumed to avoid sutures cutting through the pericyst tissue. The remaining dead
Fig. 2. Postoperative computed tomography scan 3 months postoperatively showing scar tissue (A) replacing the residual defect.
289
space was visually assessed and found to be significant in 7 cysts (88%) after the remaining healthy liver parenchyma was compressed toward the midline. The dead space was filled with gelatin sponge alone in 3 cysts (38%), omentum alone in 3, and combined gelatin sponge and omentum in 1 cyst. No prophylactic antibiotics were used. The postoperative management was routine and included early ambulation and enteral nutrition. No antibiotics were used. There was no hepatic necrosis, bile leakage, intraabdominal sepsis, or other surgical morbidity. The abdominal drains were removed in the absence of effluent, typically between the second and fourth postoperative days. Follow-up included clinical and laboratory examinations, ultrasonography, and computed tomography performed at 1-month intervals for the first 3 months, and annually thereafter (Fig. 2). Negligible residual cavities were initially observed in all patients, but disappeared by the end of the second postoperative month. No additional pathology was detected.
Comments Residual cavities after liver hydatid cystectomy can be managed by suture obliteration [2], omentoplasty [3], introflexion [4], double breasting [5], simple closure [6], deroofing [7], and tube drainage [8]. None of these methods is universally applicable, however [2– 8]. Each has been proven effective in a large number of patients, but some limitations apply to extremely large hydatid cysts. Cystectomy is considered the least traumatic method for removal of hepatic hydatid cysts [2– 8], but there is typically a large residual cavity that can lead to a number of lifethreatening complications such as suppuration, recurrence, and biliary fistula. Closure was difficult in all our patients because the cavities were large, extended deep within the organ, and were surrounded by relatively unyielding hepatic parenchyma. The cavities bordered vital vascular and biliary structures, the precise localization of which was difficult because of severe scarring and altered anatomy. Pericystectomy and hepatic resection were considered as alternatives to cystectomy to negotiate these problems. Pericystectomy was ultimately considered to be extremely dangerous because there was little if any healthy liver parenchyma through which to dissect the cyst’s fibrous capsule [1–7]. Hepatic resection would have removed a considerable amount of healthy tissue distal to the resection line, with the risk of hepatic failure, severe bleeding, and biliary fistula [9]. Pericystectomy and hepatic resection are typically considered too radical for echinococcosis, a benign disease [2–9]. Obliteration of the cavity with sutures (capitonnage) risks injury to deeply located blood vessels and biliary ducts when sutures are passed from the more superficial layers to the base of the cyst [2,10]. We concluded that this method as well as introflexion, double breasting, and simple clo-
290
J.E. Losanoff et al. / The American Journal of Surgery 187 (2004) 288 –290
sures were all inappropriate for our patients because of the small amount of endogenous pericystic tissue and large residual cavities, with the potential of considerable dead space in the depth of the cavity and increased infection risk. Deroofing was considered an option, too, but was abandoned because of the residual cavities’ depth and literature indicating that the method may produce intestinal entrapment in the remaining cavity [4]. Simple tube drainage was not used because of the high reported incidence of iatrogenic external biliary fistulas [3,11]. Omentoplasty has reportedly been inapplicable in extremely large or infected cysts [8,11,12] but the method effectively deals with small cavities and expected bile leaks [12]. It is especially useful in rigid, calcified defects, and to close cystobiliary communications [12]. We used the method alone and in combination with gelatin sponge in patients with available omentum. The pedicled graft was used to fill the larger cavity in patients with more than one cyst. Extensive mobilization of the liver and the small amount of healthy parenchyma surrounding our patients’ cysts were beneficial because they permitted increased liver mobility and atraumatic tissue approximation. A mechanically and geometrically sound obliteration of the residual cavities resulted, as demonstrated by long-term radiographic followup. We used gelatin sponge because the material promotes fibroplasia, aids cavity obliteration, is fully absorbable, and does not precipitate foreign body reactions or become a nidus of infection [13]. The literature and our preliminary experience suggest that this method of modified cavity obliteration can be combined with omentoplasty [3,11–13], but this awaits a larger trial. The described method represents a variant of capitonnage, with all sutures passed through superficial rather than deep anatomic layers bordering the residual cavity. The fibrous capsule was left in situ and only its peripheral part was used for closure, thereby avoiding ischemia and necrosis of surrounding liver tissue. Our initial good results sug-
gest that the technique might be considered a viable alternative to other, higher risk methods when surgeons are confronted with extremely large hydatid cysts of the liver. It may be used in selected patients who present with extremely large hydatid cysts, and it promotes salvage of healthy liver parenchyma. References [1] Saimot AG. Medical treatment of liver hydatidosis. World J Surg 2001;25:15–20. [2] Sayek I, Onat D. Diagnosis and treatment of uncomplicated hydatid cyst of the liver. World J Surg 2001;25:21–7. [3] Koksal N, Muftuoglu T, Gunerhan Y, et al. Management of intrabiliary ruptured hydatid disease of the liver. Hepato-Gastroenterology 2001;48:1094 – 6. [4] Kayaalp C, Sengul N, Akoglu M. Importance of cyst content in hydatid liver surgery. Arch Surg 2002;137:159 – 63. [5] Shreevathsa MR, John AK. Double breasting technique for residual cavity in hepatic hydatid. J R Coll Surg Edinb 1997;42:244 –5. [6] Safioleas M, Misiakos EP, Kakisis J, et al. Surgical treatment of human echinococcosis. Int Surg 2000;85:358 – 65. [7] Vagianos CE, Karavias DD, Kakkos SK, et al. Conservative surgery in the treatment of hepatic hydatidosis. Eur J Surg 1995;161:415–20. [8] Kama NA, Sahin M, Gocmen E, et al. The results of surgical techniques in hepatic hydatidosis: treatment with drainage versus treatment without drainage—a 6-year experience. J R Coll Surg Edinb 1998;43:254 – 6. [9] Cirenei A, Bertoldi I. Evolution of surgery for liver hydatidosis from 1950 to today: analysis of a personal experience. World J Surg 2001;25:87–92. [10] Gunay K, Tavioglu K, Berber E, Ertekin C. Traumatic rupture of hydatid cysts: a 12-year experience from an endemic region. J Trauma 1999;46:164 –7. [11] Zaouche A, Haouet K, Jouini M, et al. Management of liver hydatid cysts with a large biliocystic fistula: multicenter retrospective study. World J Surg 2001;25:28 –39. [12] Demirbilek S, Sander S, Atayurt HF, Aydin G. Hydatid disease of the liver in childhood: the success of medical therapy and surgical alternatives. Ped Surg Int 2001;17:373–7. [13] Kjossev KT, Losanoff JE. Surgery for deeply located hydatid cysts of the liver: a simple alternative. Hepato Pancreat Bil Surg 2000;11: 307–10.