management of hydatid cyst of liver

1. Hydatid cyst of liver
Dr Shambhavi Sharma
MS resident , 1ST Year
Moderator
Dr Surendra Shah
Assistant professor

2. Causative agents
Zoonotic disease caused by
metacystodes of echinococcus spp.
Incidence :< 1-200 per 100,000 in
endemic areas
• E. granulosus
• E. multilocularis
• E. vogeli
• E. oligarthrus
Common

3. Lifecycle

4. Layers of hydatid cyst

5. Natural history
E.Granulossus
Growth phase :
Cysts may continue growing (10 to 50 mm per year),
persist with no change,
rupture spontaneously
Phase of involution and calcification
Calcification occurs in 5-10 years and resolve completely
E.Multilocularis :
– more than 90 percent of patients will die within 10 years of the
onset of clinical symptoms
– virtually 100 percent will die by 15 years

6. Liver involvement
• Right lobe affected in 60 to
85%
• unusual before the cyst has
reached at least 10 cm in
diameter
• Most frequent sign
hepatomegaly/palpable mass

7. Clinical features
• Abdominal pain, dyspepsia, and vomiting.
• Jaundice and fever about 8% of patients
• Bacterial superinfection ,present like a pyogenic abscess
• Rupture of the cyst into the biliary tree
• Free ruptures can result in disseminated echinococcosis and a
potentially fatal anaphylactic reaction.

8. Investigations
CBC :
– leukocytosis (suggests infection)
– Eosinophilia is present in 15%
LFT :
increased bilirubin , S. ALP (biliary communication)

9. Serodiagnostic tests

10. Imaging
Abdominal X-ray
– Limited value
– In endemic areas, elevation of the right
hemidiaphragm in an otherwise healthy,
asymptomatic patient is highly indicative of
liver hydatidosis
– Sometimes streaklike or round
calcification of a senile hydatid cyst.

11. Ultrasonography
diagnostic accuracy of 90%

13. Computed Tomographic scan
• Highest sensitivity of imaging of the cyst (98%)
• detect the number, size, and location, of the cysts
• complications such as infection, and intrabiliary rupture
• Detect recurrance and monitor lesions during therapy
• Exogenous cyst
imperative for operative management, especially when a
laparoscopic approach is planned

15. Other modalities
MRI
– Subhepatic HC
– Disseminated HC
– Extraabdminal location
MRCP : Cystobiliary
communication
ERCP
– Diagnostic : MRCP not
available
– Therapeutic : papillotomy
for hydatid material in
CBD or f/s/o cholangitis

16. Treatment
Options:
– Medical
– Percutaneous
– Endoscopic
– Surgical

17. TREATMENT GUIDE

18. Medical treatment
Agent : Albendazole (10-15 mg/kg/day)
MOA :
inhibit the uptake of glucose by the parasite and inhibit production
of adenosine triphosphate
Indications:
– inoperable cysts (because of location or medical condition)
– patients with cysts in 2 or more organs
– CE1,CE3
– Cyst in deep liver parenchyma
– Combination with surgery
– Prevention and management of secondary hydatid cyst

19. Mebendazole
(3-6 months orally in dosages of 40-50 mg/kg/d)
Praziquantel : (40mg/kg/week)
– Used in combination with albendazole to improve
proctoscolicidal effects
– prevent secondary implantation of spilled protoscoleces

20. Treatment duration
1.Perioperative drug therapy :
Initiated at least 4 days prior to surgery and atleast 30 days
postperatively
continued for 3-6 months for patients with incompletely
resected CE, spillage during surgery or PAIR, and
metastatic lesions
2.Primary Treatment
continuous 3-6 months without interruption for inoperable cysts
• Albendazole is poorly absorbed and should be ingested with
food, ideally with a fatty meal to increase bioavailability

21. Expected outcome
• 30-70%improvement
• 10-30% cure
• 20-30% treatment failure
• Relapse rate : 3%-30%
• Within 2 years of treament
Contraindications:
– Early pregnancy
– Bone marrow
suppression
– Chronic hepatic
disease

22. PAIR (Puncture, Aspiration, Injection, Re-
aspiration)

23. Procedure
1. Prophylaxis with albendazole
2. Puncture and parasitological examination (if possible) non
dependent wall
3. Aspiration of cystic fluid 30-40% of cyst volume
4. Test for bilirubin in cyst fluid
5. If bilirubin present: →→ →→ stop procedure
6. If no bilirubin present: →→ →→ aspirate all cystic fluid
7. Injection of proctoscolicidal agent
8. Re aspiration after 15-20 min
9. Sclerosing agent ( alcohol )

24. Scolicidal agents
• 20% NaCl
• 95% Alcohol
• 10% povidone iodine
• 5% chlorhexidine gluconate
• 10% formalin
• Contact time : 10-15min

25. Catheterization
If cyst diameter is > 6 cm
– Drainage catheter left temporily and free darinage for
24 hours
– Cystogram
– Sclerosing agent injected
Outcome
– Heterogeneous pattern 2-4 months
– Pseudotumor 4-8 months
– Cyst obliteration by 9-12 months

26. Contraindications
• Cyst with nondrainable solid material or echogenic foci
• Superficial cyst at risk of rupture into the abdominal
cavity
• Cyst that has ruptured into the peritoneum
• Cyst with biliary communication
• Inactive or calcified cyst

27. SURGICAL TREATMENT
Indications:
WHO
– Large liver cysts with multiple daughter cysts > 10 cm
– superficially located single liver cysts that may
rupture(traumatically or spontaneously)
– liver cysts with biliary tree communication or pressure
effects on vital organs or structures
– infected

28. Contraindications:
– General contraindications to surgical procedures
(eg, extremes of age, pregnancy, severe preexisting medical
conditions)
– multiple cysts in multiple organs
– cysts that are difficult to access

29. PRINCIPLES OF HYDATID SURGERY
1) Total removal of all infective components of the cysts
2) The avoidance of spillage of cyst contents at time of
surgery
3) Management of communication between cyst and
adjacent structures
4) Management of the residual cavity
5) Minimize risks of operation
divided into two large groups
• conservative group
• radical group

30. Laparsocopic vs open
Laparoscopic :
– May be associated with increased risk of spillage due to
elevated intraabdominal pressures caused by
pneumoperitoneum
– Most successful in anteriorly located hepatic cysts
Exclusion criteria :
Deep intraparenchymal cysts
Posterior cysts situated close to the vena cava
Presence of more than three cysts with calcified walls
Septic patients

31. Conservative techniques
partial cystopericystectomy
Aspiration of the cyst, instillation of scolicidal agents and evacuation of
the cyst contents and leaving the pericyst

32. Management of residual cavity
Omentoplasty

33. Radical surgical procedures
Pericystectomy ( aka radical
cystectomy/total
cystectomy/cystopericystecto
my)
Techniques
1. Closed:
Complete removal of cyst without
opening it
2. Open :
– large cyst
– Rupture and spillage have
occurred

34. Radical surgical procedures
3. Near total cystectomy
4. Subadventitial cystectomy
5. Hepatic resections
• surgical therapy for E. multilocularis as the disease
is infiltrative and disease margin is ill defined
• considerable morbidity and mortality from resection
• Risk vs benefit

35. Management of cystobiliary
communication
Identification
Preoperative :
LFT
ERCP/MRCP
Intraoperative
Ultrasound

36. 1.Direct suture:
<5 mm communication
– omental patch
2.Internal drainage technique
– Transduodenal sphincteroplasty
– Endoscopic papilotomy

37. 3. External drainage
– Bipolar drainage
– Cystobiliary disconnection
4.Reconstruction
– Hilar cyst
– Pericystojejunostomy
– Hepaticojejunostomy

38. COMPLICATIONS OF SURGERY

39. Follow up
• Laboratory tests:
Patients on albendazole
– liver enzyme evaluation performed at 1 month interval
for 3 months
ELISA or indirect hemagglutination tests
– Decrease by 3 months
– May be negative after 1-2 years

40. SUMMARY

41. Thank you

42. References
Fisher’s Mastery of Surgery ,volume 1, seventh
edition