Echinococcus granulosus is a parasitic tapeworm that causes hydatid disease (hydatidosis) in humans. Its life cycle involves carnivores as definitive hosts and herbivores as intermediate hosts. Humans can be infected by ingesting E. granulosus eggs from a definitive host. The larvae develop into hydatid cysts, most commonly in the liver. Hydatid cysts can cause symptoms from pressure or complications like rupture. Diagnosis involves imaging and serology. Treatment depends on cyst type and complications but may include surgery, percutaneous drainage, or antiparasitic drugs.

1. Hydatid disease of
the liver
‫طارق‬‫المنيزل‬
‫مستشار‬‫الكبد‬ ‫وزراعة‬ ‫جراحة‬
HPB and liver transplant surgeon
Tariq Almunaizel

2. parasites
endoparasites
Metazoa
(helminths)
Protzoa
Ectoparsites
Arthropds
Kingdom
Subkingdom

3. Metazoa
(helminths)
Nemathelminthes
(nematodes)
Platyhelminthes
(flatworms)
CestodeTrematode
Subkingdom
Phylum
Class

4. Echinococcus:
Is a small endoparasitic flatworm belong to the class Cestoda.
An adult Echinococcus is only a few millimeters long (rarely more
than 7 mm) and usually has no more than six segments.
Like all tapeworms, Echinococcus has no gut and all metabolic
activities takes place across the syncytial outer covering, the
tegument.

5. The adult Echinococcus formed of:
1- The head (scolex):
Which has four muscular suckers and two
rows of hooks on the rostellum.
Suckers and hooks:
used to attach the worm to the intestinal villi.
Rostellum:
Is embedded deep into the villi at the crypts or Lieberkühn to
absorb nutrition.
(Firm attachment of the head in the villi stimulate the proglotide
segmentation and differentiation. )

6. 2- The body (or strobila):
Which is segmented and consists of a number of reproductive
units (proglotids), which may vary in number from 2-6:
• Immature proglotide:
Contain a germinal mass.
• Mature proglotide:
Contain male and female sexual organs (hermaphrodite)
for sexual reproduction (self-fertilization).
• Gravid proglotide:
contain eggs (range from 100-1500) .

7. Cestode (adult
worm )
eggs
(oncospheres)
Metacestode
(hydatid cyst)
protoscolece
Carnivorous (definitive host)
Herbivorous (intermediate host)
Omnivorous
(intermediate host)
Or dead end hosteggs (oncospheres)protoscoleces
Typically Echinococcus require 2 mammalian hosts to complete its life cycle:
• carnivorous (definitive host):
In which the adult Cestode develops in the small intestine
• Herbivorous or omnivorous (intermediate host):
In which the Metacestodes develops in the viscera.

8. Life cycle of the echinococcus
1- Carnivorous feed on slaughtered sheep infected with meatcestodes ( hydatid cyst contain brood
capsules which contain viable protoscoleces) .

9. Protoscoleces
2- Protoscoleces released from the brood capsule and reach
the carnivorous intestine.

10. 3-Protoscoleces is attached immediately to the mucosal surface in the crypts of Lieberkühn to
avoid being swept out by the small intestine.
4-Protoscoleces growth and differentiation into adult worm begins once attachment into the
mucosal surface in the crypts of Lieberkühn completed.

11. 5-After maturation of the adult worm, the gravid proglotide detached (apolysis) from the adult worm and
disintegrate to release the eggs in the feces of the canine and contaminate its body , water and grace .
6-The eggs are formed of :
 Egg shell (embyrophore):
which is resistant to the environmental factors to protect the embryo for several months.
 The embryo ( oncosphere or hexacanth).

12. When the eggs are ingested by the intermediate host the embryophore is disaggregated at the host
stomach and intestine and releases the onchosphere and result in its activation.
The liberated, activated oncosphere poses 3 pairs of hooks which enable it to attach to the jejunal and
proximal ileal mucosa, using the hooks and its muscle it penetrate the epithelium to reach the portal
system or lymphatics to their final destinations.
Once the oncosphere reaches its predilection site the larval stage begin , by degeneration of its hooks
and muscles, vesiculation and central cavity formation which is filled with fluid , creating a metacestode
(hydatid cyst) .
Embryophore
Oncosphere

13. During the maturation of the metacestodes , and inner nucleated cellular layer (germinal layer) is formed ,
which secret an acellular glycopotenaceous layer (laminated layer) that provide protection to the germinal
layer by modulation the host-parasite interface ( by offering an immunologically inert barrier against host
immune system , enzymes, bile and bacteria).
The germinal layer and the laminated layer both form the endocyst of the hydatid cyst .
As a host reaction an adventitial layer formed of inflammatory and fibrous tissue around the cyst called the
pericyst ( or ectocyst).

14. Endocyst of the hydatid cyst:
• The cellular germinal layer start budding into its cavity forming the
brood capsules ( which is an inward invagination of the germinal
layer) . within these brood capsules asexual reproduction begins to
form protoscoleces ( which is the future worms when its ingested by
the definitive hosts).
• Brood capsules may stay attached to the germinal layer and contain
1000s of protoscoleces or detached forming daughter cysts ( detached
Brood capsules ).
• In 16-65% of the cases the Brood capsules Vesiculate through the
laminated layer when there is a small leak or defect (or commonly in
echinococcus Multilocularis) forming exogenous daughter cyst
(“satellite” hydatid cyst ), which also can metastasizes to distance
organs through the blood and lymphatic system
Protoscoleces

15. Pericyst ( or Ectocyst):
• This thick fibrous layer is present in hydatid cysts in the liver and spleen
but is absent in pulmonary and brain hydatid cysts.
• Vascular structures and bile ducts in the adventitial layer remain intact
and patent despite enlargement of the cyst and may result in
postoperative bleeding or bile leaks after partial pericystic resection.
• The blood supply of the adventitial layer is abundant and results in the
appearance of a hypervascular rim or halo around the cystic cavity on
computed tomography (CT) scans after contrast injection.
• No clear cleavage planes are apparent between the adventitial layer and
the surrounding normal liver tissue, and the cyst is not separable from
the surrounding parenchyma.
• With time, the adventitial layer may calcify, either partially or totally

16. Ruptured cyst In definitive host
Protoscoleces
Metacestodes
(hydatid cyst)
Cestode
(adult worm)
Rupture of the metacestodes ( hydatid cyst ) may release the
protoscoleces within the peritoneal cavity . Protoscoleces have the
capability to grow in a revers direction to from a new metacestodes
( hydatid cyst)

18. At present, 4 species of Echinococcus are recognized:
1. Echinococcus granulosus.
2. E. multilocularis.
3. E. oligarthrus.
4. E. vogeli.
Echinococcosis is a zoonotic infection caused by adult worm stages of cestodes.
Hyditosis is a zoonotic infection caused by larval (metacestode) stages of cestodes

19. Echinococcus granulosus
Introduction:
• Echinococcus granulosus is the most common cause of Hydatid
Disease (HD).
• Human infection caused by the larval stage of the cestode.
• Humans are accidental hosts and play little part in the transmission
of the disease, making them so-called “dead-end hosts.”
• HD is not transmitted from human to human.
• The liver is the most commonly involved organ in 2/3 of patients,
especially in segments VII and VIII.

20. Epidymiology:
• E. granulosus is present worldwide, affecting 2-3 million people.
• Its endemic in many Mediterranean countries, the Middle and Far East, and South and
East Africa. The endemy is also high in Northeast Africa, South America, and Eurasia.

21. Human infection results from:
• Eating raw vegetables infected by the feces of dogs.
• by direct contact with dogs, mostly through the close contact of children with their pets.
• Some professions are particularly exposed:
o workers in slaughterhouses.
o Veterinary.
o stock breeders.
o Shepherds.
o Tanners and butchers.

22. DIAGNOSIS:
The diagnosis of a hydatid cyst is based on:
• A past history of hydatic disease.
• Imaging.
• Serology.
• high index of suspicion in at-risk populations.
The presence on cytology or histology of hydatid material or scolices in the cyst fluid confirms the
diagnosis.

23. Symptoms :
The symptoms of hydatid cyst are not specific.
1. They are related to pressure syndrome secondary to the size of the cyst. The expansion of
larger cysts or the inflammatory reaction around a cyst, causing irritation of the adjacent
parietal peritoneum, may cause moderate pain in the right upper quadrant or in the lower
chest.
2. or related to a complication, usually an infected or ruptured cyst (presented as acute
abdominal pain, urticaria, bronchospasm or anaphylactic shock).
3. In most cases, the diagnosis is incidental , when ultrasonography or a CT scan is indicated for
abdominal pain or for abnormal LFT.
4. rare clinical presentations :
 biliary colic, jaundice, or cholangitis from endobiliary rupture.
 Bronchobilia resulting from a hepatobronchial fistula.
 ascites resulting from pressure on hepatic veins or IVC or both (Budd-Chiari syndrome).

24. Laboratory Tests
Liver Function Tests
No conventional liver function tests were validated as specific during the consensus conference to support the
diagnosis (Brunetti et al, 2010).
Cholestatic enzymes, such as ALP and GGT, can be mildly elevated in about one third of patients, especially in
patients with biliary compression.
Elevated bilirubin levels (>17 μmol/L) with elevated alkaline phosphatase and GGT levels are highly suggestive of
cystobiliary communication.
Serology
Serologic tests in HD are used for the:
• differential diagnosis of a cystic liver mass.
• epidemiologic surveillance.
• post-treatment follow-up.

25. Radiology
Gharbi WHO
I CE 1 Univesicular anechoic cystic lesion with double line sign. Active
III CE 2 Multiseptated “ Rosset-like ” or Honey-comb cyst. Active
II CE 3a Detached laminated membrane, water-lily sign Transitional
III CE 3b Cysts with daughter cysts in a solid components. Transitional
IV CE 4 Cysts that contain both cystic and solid components without
visible daughter cysts
Inactive
V CE5 Solid cyst with calcified wall. Inactive
CTMRUS
Who CE 1 CE 2 CE 3a CE 3b CE 4 CE 5
Gharbi I III II III IV V

26. COMPLICATIONS OF HYDATID CYSTS:
Compression:
Depending on the location and size, large cysts can cause compression of the:
Bile ducts …. Obstructive jaundice.
The hepatic veins and or IVC ….a Budd-Chiari syndrome.
Portal vein …. presinusoidal portal hypertension.

27. Cyst Infection:
hydatid cysts may become infected after an episode of bacteremia or via a communication with the bile ducts.
Presentation is similar to a pyogenic liver abscess, with right upper quadrant pain, high fever, rigors,
leukocytosis.

28. Rupture Into the Biliary Tract:
The most common complication of liver hydatid cysts (incidence of cystobiliary communications range from 1% to
42%.).
Cystobiliary communications (fistulae) that occur after rupture of a cyst into the bile ducts can be:
1. Minor cystobiliary fistulae (when the size of intrabiliary rupture is lesser than 5 mm) are usually
asymptomatic and rarely cystic material found in the bile duct and its revealed postoperatively by the
presence of a bile leak.
2. Major cystobiliary fistulae (when the size of intrabiliary rupture is greater than 5 mm). Communications
may cause daughter cysts to enter the bile duct and cause obstructive jaundice and cholangitis. its
incidence is 5% to 10%.
predictor for the presence of intrabiliary rupture:
• age.
• Jaundice.
• past history of hydatidosis.
• preoperative level of γ-glutamyl transferase (GGT).
• location near the hilum.
• Cyst diameter greater than 10 cm.

30. Rupture Into the Bronchial Tree
hydatid cysts of the posterior and upper segments of the liver (IVa, VII, and VIII) may erode the diaphragm.
Result in biliary-pleural fistula (rare), or biliary-bronchial fistula (commonly).
biliary-pleural fistula
biliary-bronchial fistula

31. Rupture Into the Peritoneum
The main cause of peritoneal involvement is the
intraperitoneal rupture of a hydatid cyst.
This complication is rare, even in endemic regions, with an
incidence ranging from 1% to 8% . It may occur
spontaneously or after a traumatic injury.
Although this complication may be totally silent,
abdominal pain, nausea, vomiting, and urticaria are the
most common symptoms.
Acute abdominal signs, such as guarding, rebound, and
tenderness, are generally present.
Systemic anaphylactic reactions have been reported in
1%.

32. Rupture Into Other Cavities or Organs
Rupture into the gastrointestinal tract that involves the stomach and the duodenum has been reported
(Diez Valladares et al, 1998).
Isolated cases of rupture of liver hydatid cysts into the pericardium (Thameur et al, 2001) and into large
vessels, including the inferior vena cava, have also been described.

33. TREATMENT INDICATIONS AND METHODS
The objectives of the ideal treatment are threefold:
1. Removal of the entire parasite.
2. Removal of the residual cavity.
3. The identification and treatment of biliary fistula.
Three treatment options are currently available:
1. Surgery (Conservative or Radical surgery).
2. Percutaneous Treatments (PAIR or PIAR Catheterization and PEVAC).
3. Antiparasitic medical treatment with benzimidazoles (BMZs).

34. Radical surgery, is the only treatment that reaches the three
objectives of the ideal treatment, and it’s the most efficient
treatment.
Conservative surgery, Percutaneous and medical treatments
represent alternatives to Radical surgery. Indeed, these
treatments:
• Do not treat possible exogenous daughter cysts(ranging
from 16% to 65%).
• Do not treat biliary fistula.

35. Indications for treatment:
There is no clear consensus about the treatment of CE (cystic echinococcosis).
Based on the 2010 expert consensus of Brunetti and colleagues, indications are summarized below
according to the WHO-IWGE US guidelines
Surgery Percutaneous Medical (BMZ)
Indications
 Large CE2-CE3b cysts with multiple
daughter vesicles.
 Single superficial liver cysts (CE1-
CE3a).
 Any Complicated cysts.
 CE1 & CE3a > 5 cm
 Inoperable patients
 Refuse surgery
 Relapse after surgery
 Failure to respond to BMZ alone
 CE1 & CE3a < 5 cm
 Inoperable patients
 Refuse surgery
 To Prevent recurrence
following surgery or PAIR
 Multiple cysts in >2 organs
 Peritoneal cysts
Contraindications
 Uncomplicated CE4 and CE5
 Very small cysts
 Uncomplicated CE4 and CE5
 CE2
 CE3b
 Biliary fistulae
 Uncomplicated CE4 and CE5
 Pregnancy
 Alone if cyst > 10 cm
 Cysts at risk of rupture
 Chronic hepatic disease
 Bone marrow depression

36. Medical Treatment:
• Antiparasitic treatment is based on Benzoimidazole drugs (BMZs).
• BMZs (Mebendazole [MBZ] and Albendazole [ABZ]) kills the parasite by impairing its
glucose uptake.
• MBZ was introduced first, but ABZ became the drug of choice because of its superior
absorption in the gastrointestinal tract and better clinical results.
• ABZ should be administered in a dose of 10-15 mg/kg twice daily with a fat-rich meal to
increase its bioavailability; and without medication that reduces gastric acidity.

37. Adverse events of BMZ including:
• headache, nausea, anorexia, vomiting, abdominal pain, and itching (have been
reported in 5% to 10% of patients).
• In the first weeks of treatment, a transient increase in liver enzymes may occur,
and leukopenia is rare.
• Complete hair loss, which is reversible when ABZ is stopped, may also occur.

38. There are four objectives with medical treatment:
1. definite cure: univesicular cysts (CE1) requires a 3 to 6 month course, which can achieve an 80%
success rate with a 25% relapse rate
2. a reduction in cyst viability: can be achieved in multivesicular cysts
3. preoperative treatment: in univesicular cysts when percutaneous or elective surgery is planned
4. perioperative prophylaxis:
(No published data are available on the efficacy of perioperative prophylaxis, it is generally advised that
ABZ is given for) :
• 1 week before the procedure.
• 3 to 8 weeks for uncomplicated cases (posttreatment prophylaxis (surgical or percutaneous)).
• 3 to 6 months of treatment is advised in complicated cases with a higher risk of spillage of cyst
contents.

39. Most relapses occur within 2 years after cessation of treatment, but more prolonged monitoring has shown
that a significant number of relapses occur 2 to 8 years after completing initial treatment.
Factors that influence the efficacy of BMZs:
 Young cysts without pericystic fibrosis are more sensitive to drugs than thick cysts.
 It is less effective in daughter cysts within a mother cyst and in cysts with infection or a biliary communication.
 Small cysts (<8 cm) and secondary cysts are mostly sensitive to BMZs.
 More effective in young patients.

40. Percutaneous Treatments (PT):
PTs can broadly be divided into:
1) those aiming at the destruction of the germinal layer (PAIR).
2) those aiming at the evacuation of the enrire endocyst (also known as modified catheterization
techniques and percutaneous evacuation of cyst content (PEVAC).
They represent a safe and valid alternative to surgery, and have gained recognition because of
their feasibility, low cost, with a low morbidity (4.1%) and mortality (0.08%).
The major risk is spillage of hydatid fluid during the placement of the needle.
With US or CT guidance, the position of the needle can be precisely monitored, and a transhepatic
approach to the cyst, rather than a direct transperitoneal approach used to minimize the
possibility of spillage.

41. Complications of PAIR:
• Currently, urticaria, itching, and hypotension are the main minor complications that may occur during or
several hours after the procedure; these can be treated with antihistamines.
• In some patients, fever (>38.5° C) may occur, but this generally resolves spontaneously.
• Cavity complications, such as biliary fistula and infections, have been reported in 10% of patients.
Limitation of PAIR :
• In these methods, the daughter cysts and laminated membranes remain inside the cavity, and each
daughter cyst must be punctured separately, which is difficult and may be dangerous for the patient.
• Aspiration is contraindicated in cysts that are inaccessible to puncture, in cysts in which puncture may
damage important vascular structures, and in peripheral cysts that do not have a sufficient layer of
hepatic tissue to permit safe transhepatic puncture.
• PT is contraindicated in liver hydatid cysts that have ruptured into the bile ducts, peritoneum, or the
pleural space.

42. PAIR (Puncture, Aspiration of Cyst Content, Injection of Protoscolicidal Solution, and Reaspiration of the Fluid):
Historically, the PAIR technique was described by Ben Amor and associates in Tunisia (1986), first developed in
sheep, and then successfully used in humans.
PAIR is indicated for:
• large (>5 cm) CE1 and CE3a cysts.
• inoperable patients.
• those who refuse surgery.
• in cases of relapse after surgery or failure to respond to medical treatment alone.
Procedure:
• Patients are given ABZ before and after the procedure for prophylaxis.
• Under local anesthesia, a fine needle is inserted into the cystic cavity through normal liver tissue with US or CT
guidance.
• As much fluid as possible is aspirated and, on completion, a protoscolicidal agent is injected into the cavity.
• After 15 minutes, as much fluid as possible is reaspirated, and the needle is withdrawn.
• Direct microscopic examination of the aspirated fluid is used to identify protoscolices.
The most characteristic sonographic signs of involution at follow-up are:
• heterogeneous reflections of cyst content (3 months).
• obliteration and pseudotumor appearance (5 months).
• loss of echogenicity and disappearance of the cyst (9 months).

43. PAIR Catheterization
similar to the PAIR technique but a catheter is placed into the cavity by the
Seldinger technique and left to facilitate drainage for 24 hours.
If there is no bile drainage within 24 hours, it is accepted that there is no
communication between the biliary system and the cavity, which is also confirmed
by obtaining a cystogram under fluoroscopic guidance.
If the amount of drainage in 24 hours is less than 10 mL, absolute alcohol (95%) is
injected into the cavity (approximately 25% to 35% of the volume); after waiting 20
minutes, all the fluid is reaspirated and the catheter is withdrawn.
If the amount of drainage in 24 hours is more than 10 mL or contains bile, the
catheter is kept in place until the daily amount of drainage decreases to less than
10 mL and no bile, cystogram is performed and sclerosis are performed as already
mentioned.

44. Percutaneous Evacuation of Cyst Content (PEVAC)
Saremi and McNamara (1995) developed this alternative method.
The first session:
As in the PAIR catheterization technique, the cyst is first aspirated as much as possible, and the
catheter is left in place for drainage.
In the second session:
the catheter is replaced with a 14- to 18-Fr stiff sheath. A suction catheter is introduced into
the cyst cavity through the sheath. The cyst contents are evacuated by applying suction and
directing the catheter toward the daughter cysts, endocyst, and undrainable material.
A special cutting instrument is used to fragment and evacuate daughter cysts and laminated
membrane while the cavity is continuously irrigated with a protoscolicidal solution(only if no
cystobiliary fistula was present). After removal of the sheath, a catheter of the same size as
the sheath is placed into the cavity.
similar to the PAIR catheterization technique, In the absence of cystobiliary fistula or any
discharge, the catheter is removed.
If cystobiliary fistula or any discharge present, the catheter is removed only after complete
cyst collapse and closure of the cystobiliary fistula , which may be facilitated by endoprosthesis
or sphincterotomy.

45. Surgery
Common Principles of Surgery:
Prevention of Intraoperative Spillage
Any effort made to avoid fluid spillage is recommended, including protection of peritoneal tissues and organs
with protoscolicide-soaked surgical drapes and soft injection without any pressure of protoscolicide into the cyst
before opening.
The protoscolicides are:
Albendazole.
chlorhexidine gluconate (Chx-Glu)(0.04%).
1.5% cetrimide-0.15% chlorhexidine (Savlon)
honey(10%).
hypertonic saline(20%).
silver nitrate (20%).
Cetrimide (0.5–1%).
ethyl alcohol(95%).
hydrogen peroxide (3%).
povidone-iodine (10%).
Warm water.

46. Approach
Open Approach or Laparoscopy approach .
The surgical incision depends on the:
• Location.
• Size.
• number of cysts in the liver.
• The presence of extrahepatic intraabdominal cysts.
Right subcostal incision with proximal midline extension or a bilateral subcostal incision will give adequate
exposure to all liver hydatid cysts.
Midline laparotomy is preferred in patients who have cysts in the left lobe of the liver and in those who have
abdominal hydatidosis.
thoracoabdominal incisions used only for, combined right lung and liver hydatid cysts.

47. Types of surgery:
1- Conservative Surgery: • Partial Pericystectomy
2- Radical Surgery: • Total Pericystectomy
• Liver Resection

48. Conservative Surgery
also called closed cystectomy or cyst unroofing or partial pericystectomy, is more simple and safe
than radical surgery.
This procedure is especially suited for endemic areas where the operations are performed by
general surgeons.
No special equipment is required, and liver tissue is neither entered nor resected.
However, the risk of secondary echinococcosis from protoscolex dissemination is higher than
with total pericystectomy, and hepatic resection.
Cystectomy consists of:
(1) punction aspiration.
(2) injection (if no contraindication).
(3) hydatidectomy (removing its contents: daughter cysts, laminated and germinal layers).
(4) unroofing (removing the portion that protrudes the liver surface: adventitia layer and thinned-
out liver).

49. Cystectomy consists of:
(1) punction aspiration.
(2) injection (if no contraindication).
(3) hydatidectomy (removing its contents: daughter cysts, laminated and germinal layers).
(4) unroofing (removing the portion that protrudes the liver surface: adventitia layer and thinned-
out liver).

50. Intraoperative Management of Biliary-Cyst Communication
• Perioperatively, careful inspection for cyst-biliary communications should be done from a wide opening in
the pericyst and should be confirmed by leaving a dry pad on the inner surface of the cyst and applying
gentle pressure on the gallbladder.
• In cases of suspected biliary-cyst communication, intraoperative cholangiography is preferable to identify
the communication site.
• After excision of the cyst, a methylene blue test through a transcystic duct tube is helpful in identifying
small, overlooked biliary communications or leaks. Any obvious biliary orifices should be sutured to
prevent postoperative biliary leakage, fistula, and cavity infections.
• On rare occasions, cyst communications involving a large duct may need drainage with a Roux-
en-Y hepaticojejunostomy and even more rarely a liver resection

51. Management of the Residual Cavity
Although a variety of techniques have been described to prevent complications related to the residual cavity,
depending on its size and shape and site, the safest way is to perform an omentoplasty. The omentum is
mobilized from the transverse colon with sufficient mobility to pack the cavity and obliterate the dead space,
and it is sutured to tether the omentum in place If the cavity has a large volume, a temporary drain is placed
into the cavity alongside the omentum. the tubes are removed as soon as drainage ceases. Omentum has a
natural absorptive capacity that decreases the risk of infection and minimizes fistula formation.

52. Postoperative Complications
Biliary Fistula
The incidence of biliary fistula after hydatid liver surgery varies from 1% to 10%.
Endoscopic treatment is the main approach, and the aim of endoscopic drainage for biliary
fistulas is to reduce the bilioduodenal pressure difference to zero.
The optimal endoscopic approach for managing external biliary fistulae resulting from hydatid
liver disease has not been established and include:
• Sphincterotomy alone.
• Stent.
• nasobiliary drain placement alone.
• combination of sphincterotomy and stenting or nasobiliary drainage.
The overall success rate is 83.3% to 100%.
Although closure time has been reported to be as short as 2 to 6 days (the average 2 to 4
weeks).

53. Biliary Stricture
• Postoperative biliary strictures are uncommon.
• The most dramatic form is caustic sclerosing cholangitis: Diffuse caustic
sclerosing cholangitis may result in secondary biliary cirrhosis, portal
hypertension, and liver decompensation with ascites and bleeding esophageal
varices, which may ultimately require liver transplantation.
• Minor passage of the scolicidal solution may cause a localized biliary stricture,
which may be asymptomatic if the bile duct confluence is not involved.
• A bile duct stricture at the biliary confluence may result from a large biliary
fistula treated by conservative surgery. Surgical repair is usually not feasible,
but long-term endoscopic stenting is a safe and effective method in these
patients.

54. Recurrence
• Recurrent disease is defined as the appearance of new active cysts after therapy of
intrahepatic or extrahepatic disease.
• recurrence rates ranging from 0% to 34.4%.
• Failure to achieve permanent control of the primarily treated cyst is considered local
recurrence.
• the appearance of new cysts in the peritoneal cavity is regarded as disseminated disease.
• Intraoperative spillage of cyst contents, lead to recurrence.

55. Predictive factors of recurrence:
1. laparoscopic approach is a predictive factor of both hepatic and peritoneal recurrence,
because of the risk of spillage of hydatic material and peritoneal contamination.
2. cysts larger than 7 cm.
3. history of liver hydatic cysts.
4. number of cysts in the liver.
5. reduced effect of protoscolicidal agents
6. residual cyst content, and overlooked cysts
7. the surgeon’s degree of practice and experience is one of the most important elements to
successful treatment of liver hydatic cysts.

56. Follow up :
• All patients initially require close follow-up at 6 month intervals.
• Evaluation should include radiologic and serologic studies; the complement fixation test,
immunoelectrophoresis, counterimmunoelectrophoresis, ELISA, and blotting are used to
detect recurrences.
• Even with complete removal of disease, blood titers may decrease slowly during months to
years; therefore a positive serologic test during follow-up is not diagnostic of recurrence but a
rising titer is.

57. Radical Surgery
Parasitic material should be removed as much as possible. However, the more radical the
intervention, the higher the operative risk, but with the likelihood of fewer relapses, approx-
imately 1% and vice versa.

58. Pericystectomy
Also called radical cystectomy or total pericystectomy:
involves complete removal of the hydatid cyst. By creating a surgical plane just outside the
pericyst layer without opening the cyst, the parasite and the adventitial layer are excised en bloc.
No clear anatomic plane exists.
The Cavitron ultrasonic aspirator (CUSA) maybe used to isolate the vessels and biliary ducts that
are deviated and compressed by the cyst.
The aspirator should be used away from the pericyst to avoid fracture of the cyst, which can be
responsible for spillage of the cyst contents.
Pericystectomy must be avoided for a cyst impinging on the major hepatic veins, IVC, or the liver
hilum.

59. On occasion, the surgeon may need to use a hybrid technique that uses both
cystectomy with evacuation of hydatid contents and partial pericystectomy to resect
peripheral liver parenchyma.

60. Liver Resection (LR)
The indications for formal liver resection (LR) for liver hydatic cysts are infrequent.
Indications for LR:
 LR is the only surgical therapy for E. multilocularis, but it is inappropriately radical for E. granulosus.
 when the remaining parenchyma of a liver lobe is atrophic as a result of biliary obstruction, or when a
large bile leak cannot be safely managed with a Roux loop.
 for peripherally placed cysts, usually in the left lateral segment.
 for pedunculated lesions.
 for extrahepatic intraabdominal cysts.
Liver surgery for HD is predominantly performed by general surgeons whose resources are frequently
limited. Surgeons who do not have extensive training and experience in LR should not be tempted to
resect for HD.

61. Thank you