Uploaded byDr. ZAHID IQBAL MIR
HYDATID CYST.04
The document discusses the management of liver hydatid disease, focusing on various treatment approaches including antiparasitic therapy, percutaneous management, and surgical options. It outlines the indications for each treatment, considerations for adjunctive therapies, and the importance of postoperative monitoring for potential complications. Additionally, it details the stages of cyst development and the appropriate interventions based on cyst size and characteristics, highlighting the complexities and challenges involved in managing this condition.
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HYDATID CYST.04
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- 2. MANAGEMENT APPROACH ANTIPARASITICAPPROACH CYSTMANAGEMENT SURGERY PERCUTANEOUS Whetherthe patient is treated only medically or in combination with surgery will depend upon the clinical group (which gives an idea as to the activity of the disease), thenumberof cysts andtheir anatomicalposition. DEFINITIVE ADJUNCTIVE PAIR & MODIFICATIONS
- 3. ANTIPARASITICTHERAPY üFor definitive treatmentor adjunctive to surgery or PAIR üAlbendazole - primary drug • poorly absorbed • Ingested with fatty meal • 15 mg/kg/day, divided into two doses, to maximum 400 mg orally twice daily üMebendazole (40-50mg/kg/day in three divided doses) üPraziquantel (40 mg/Kg/wk)
- 4. DEFINITIVETREATMENT • Initial managementwith drug treatment alone - CE1 and CE3a cysts (<5 cm) Optimalduration–uncertain;1-3monthsmaybeappropriate,(up to6months) • Other indications: ümultiplelivercysts <5cm ücysts deep in liver parenchyma that are not amenable to percutaneous treatment, üperitonealcysts.
- 5. ADJUNCTIVETHERAPY • Adjunctive tosurgery and percutaneous treatment. • Perioperative therapy reduces the risk of recurrent disease by inactivating protoscolices and softens the cyst, facilitating removal. Theoptimaldurationof treatment- Uncertain ØAt least 7 days ( WHO :4-30days) prior to surgery and should be continued for at least 1 month (albendazole) or3months(mebendazole)followingsurgery. • For spontaneous cyst rupture
- 6. MONITORING : CBC, LFT( twice weekly X 3 months f/b monthly ) Adverse effects of Albendazole üReversiblehepatotoxicity(1to5%) üCytopenia(<1%) üalopecia(<1%) üIncreased levels of aminotransferases ( 5X upper limit – Alternativetreatment) üAgranulocytosis üDizziness,headache,vomiting,andrash • Albendazole -avoided during pregnancy – risk of potential teratogenicity
- 7. PERCUTANEOUSMANAGEMENT • CE1andCE3a • Cysts- difficult to drain or tendtorelapseafterPAIR • CE2andCE3bcysts Destroy the germinal layer with scolicidal agents — PAIR Evacuatingtheentire cyst with large bore catheter.
- 8. PAIR • Less invasive(diagnosticandtherapeutic) • Cure rate among appropriately selected patients >95 % • Presence of daughter cysts - precludes use of PAIR for definitive management • dogmatically contraindicated for fear of spillage, dissemination, and life-threatening anaphylactic reaction. AJRAmJRoentgenol.1999;172(1):91 ActaTrop.1997;64(1-2):95 ClinInfectDis.1995;21(6):1372.
- 9. TECHNIQUE • Ultrasound orCT guidance • Puncture Aspiration (fluid evaluation for protoscolices) Injection of the protoscolicidal agent. Reaspiration (after at least 10 to 15 minutes) Before injection of protoscolicidal agent, a radio opaque contrast is injected to seecavity &CBC Protoscolices in the reaspirated fluid should prompt repeat protoscolicidal injection • Adjunctive drug therapy - at least 4 hours prior to PAIR Albendazole continued for 1 month & mebendazole for 3 months after the procedure
- 10. Indications ü Inoperable patient üRefusessurgery ü For primary treatment of CE1 and CE3a , following relapse after medical therapy or surgery ü Infectedcysts ü Multiple cysts of > 5cm in differentliversegments ü Pregnant women ( except earlypregnancy) ü Children<3years Contraindications ü Nondrainable material or echogenicfoci ü Superficial cyst at risk of rupture ü Rupturedintoperitoneum ü CystwithCBC ü Inactiveorcalcifiedcyst ü Multiplesepta/divisions ü inaccessiblecysts ü Mostcystsinlung,bone
- 11. RISKS OFPAIR • Spillageof contents • Chemical sclerosing cholangitis • Biliary fistula (6%) • Local recurrence (3%) • Bleeding and infection (4%) • Fever and urticaria (11-13%) • Anaphylaxis - reduced with fine needles and catheters and advances in imaging (0.5%) Endoscopy can be useful both before and after PAIR to evaluate for cyst communication with the biliary tree
- 12. PROTOSCOLICIDALAGENTS AGENTS CONC. DURATION HYPERTONICSALINE 5% 180 min HYPERTONIC SALINE 10% 30min HYPERTONIC SALINE 15,20,30% 10 min ALCOHOL 70% 10 min POVIDONE IODINE 10% 10min FORMALIN 10% 10min CHLOROHEXIDINE GLUCONATE 5% 10min CETAVALON - 5min CEVALAX - 5min HYDROGEN PEROXIDE 3% 10 min Complications: • acute toxic reaction • anaphylaxis • hypernatremia • air embolism • metabolic acidosis • Unconsciousness coma, and death • peritoneal adhesions • methemoglobinemia • caustic sclerosing cholangitis( formalin)
- 13. PAIRmodifications Ø Complicatedcysts,Cysts withmanydaughtercysts,Largevolume cysts 1.Pair catheterisation technique 2. D-PAI (double-puncture, aspiration, and injection) technique 3. Percutaneous evacuation of cyst content (PEVAC) technique 4. Modified catheter aspiration technique (MoCAT) Heterogeneouspattern -in2to4months Pseudotumor–in 4to8months Cystobliteration-in9to12months. AFTERPAIR USG
- 14. Adjunctive therapy The optimalduration of treatment- Uncertain Ø At least 7 days ( WHO :4- 30days) prior to surgery and should be continued for at least 1 month (albendazole) or 3 months (mebendazole) following surgery. SURGERY-indications üComplicated cysts üNot suitable for percutaneous treatment (CE2 and CE3b) üp >10 cm, üsuperficial cyst at risk of rupture üExtrahepatic disease (lung, bone, brain, kidney etc.) üPercutaneous treatment not available. SURGERY–goldstandard
- 15. OPENSURGERY Rationale for surgicalmanagement • surgery - most effective treatment applicable to all cysts, • Removes parasite • Manages CBC • Manages the cystic cavity (conservative surgery) • Acceptable morbidity and mortality rate • Low recurrence rate. CONSERVATIVE PROCEDURE RADICAL PROCEDURE
- 16. Conservativesurgicalprocedures Partial pericystectomy Rationale • Allcysts can be treated • Safely by general surgeons, HPB surgeon– not necessary • Parenchyma is not entered • No special equipment • Applicable to multiple B/L cysts • Morbidity, mortality, and recurrence rates are acceptable • Cost effective • T issue sparing(important in endemic areas)
- 17. ØGoals üSafe & completeexposure of cyst üSafe decompression of cyst üSafe evacuation of cyst contents üSterilisation of cyst üManagement of CBC ( cystobiliary communication) if present üManagement of remaining cyst cavity
- 18. Technique Surgicalapproach-individualized • If feasible-removaloftheintactcyst •If not feasible - protoscolicidal agent injected into the cyst & surgical field should be protected with pads soaked in protoscolicidalagentsbeforeremoval “walledoff” Or Cyst opened and sterilized with protoscolicidal agents, followed by evacuationofcystcontentsandremovalofthepericystictissue. • If spillage - peritoneum washed with hypertonic saline & albendazole (3 to 6 months) and a brief course of praziquantel(7days)
- 19. MANAGEMENTOFRESIDUALCYSTCAVITY Partial cystopericystectomy -redundant portion of the pericyst is resected, residual cavity is left behind Subtotal pericystectomy - most of the pericyst is resected A. The pericyst cavity left open after oversewing the rim - small, shallow cyst B. Simple closure of the cyst cavity filled with saline. C. Introflexion (infolding) of the rim of the pericyst cavity
- 20. D. Flattening therim of the pericyst in shallow cysts E.Capitonnage F. Omentoplasty ( anterior , posterior ) Other procedures: Simple cyst closure, Marsupilastion, External tube drainage, Partial capitonnage + Omentoplasty, Roux-en Y cystojejunostomy (rare) , Myoplasty
- 22. MANAGEMENTOFCBC • Suture (simplesuture, suture with T-tube CBD drainage, intralameral pericystectomy, and capitonnage) • Internal drainage procedures (biliodigestive bypass, transduodenal sphincterotomy, internal transfistular drainage +/- transduodenal sphincteroplasty) • External drainage procedures (bipolar drainage, cystobiliary disconnection) • Reconstructive procedures ( pericystojejunostomy, intracavitary biliodigestive bypass, or bile duct repair) • liver resection number, type, site, size of the orifice, involved bile duct, patient status, condition of liver & expertise of the surgeon.
- 23. Radicalsurgicalprocedures • Open /closedcystectomy • Total pericystectomy • Near total cystectomy • Sub-adventitial cystectomy • Completion & total cystectopericystectomy • Liver resection (anatomical / non-anatomical) Rationale • totalremovalofthecystandexocysts–lowestrecurrence • Chemotherapy- unnecessary • Biliaryfistulaandcavity-relatedcomplications- low • Calcifiedcystscanberemoved • Experthands- mortalityandmorbidity(low)
- 24. Hepatectomy - theen bloc resection of the echinococcal cyst along with part of the normal liver parenchyma. Total cystectomy - resection of the adventitial layer , laminated layer, & germinal layer Sub-total cystectomy - partial resection of the adventitial layer & total resection of laminated layer, & germinal layer Schematicstructureoftheechinococcalcystanddifferentapproachesforsurgicalremoval
- 25. LAPROSCOPICSURGERY Ø Laparoscopic marsupialisationof the cyst (de-roofing) - removal of cyst containing the endocyst along with daughtercysts Ø Cysto pericystectomy removing entire cystintact(small,superficial,inleftlobe) ü increasedriskofspillage(pneumoperitoneum) ü successfulinthesettingofanteriorlylocatedcysts Ø Exclusioncriteria • Deepintraparenchymalcysts • Posterior cysts (close to vena cava) • >3cyst • Calcifiedwalls
- 27. WHO STAGE SIZE PREFERRED TREATMENT ALTERNATE TREATMENT STAGECE1 <5cm ALBENDAZOLE ALONE PAIR >5cm ALBENDAZOLE + PAIR PAIR STAGE CE2 Any ALBENDAZOLE + EITHER MODIFIED CATHETERISATION OR SURGERY MODIFIED CATHETERISATION STAGE CE3a <5cm ALBENDAZOLE ALONE PAIR >5cm ALBENDAZOLE + PAIR PAIR STAGE CE3b Any ALBENDAZOLE + EITHER MODIFIED CATHETERISATION OR SURGERY MODIFIED CATHETERISATION STAGE CE4 Any OBSERVATION - STAGE CE5 Any OBSERVATION - Summary - CE
- 28. AE Stratify according toFDG-PET/ MRI Findings Metabolically active AE (MAAE) Complete resection of AE lesion Possible Impossible Surgery +ABZ Metabolically Inactive (MIAE) Wait and watch Signs of activity No signs of activity ABZ Yearly Follow up PET-CT Serology negative for 2 years Stop ABZ Vascular complications ABZ Biliary complications Bacterial infection Surgery ERCP and stenting Drainage
- 29. POSTOPERATIVECOMPLICATIONS • Obstructive jaundice(echinococcal remnants in the biliary tree) • Development of an external biliary fistula (2-4 weeks postop.) • Sphincter of Oddi stenosis • bile duct stricture • sclerosing cholangitis (formalin) • secondary infection of cyst cavity • intraabdominal abscess • spillage of cyst contents leading to secondary echinococcosis and/or anaphylaxis.
- 30. Patientswithbiliarycomplications- ERCP • Obstructivejaundice - Sphincterotomy - removal of cysts and membranes • Cholangitis - Nasobiliary drain - extraction of hydatid cysts and membranes (with or without sphincterotomy) • External biliary fistula - endoscopic biliary stenting ( 4- 6 weeks) ; sphincterotomy • Sphincter of Oddi stenosis - sphincterotomy. • Bile duct stricture - ERCP with balloon dilation and placement of a temporary biliary stent
- 31. OUTCOME Varies with stageof disease 1. Cysts may continue growing (1 to 50 mm per year) 2. persist with no change, 3. rupture spontaneously, 4. resolve completely. 5. Calcification •usually 5 to 10 years to develop •most commonly with hepatic cysts (rarely with pulmonary or bone cysts) •Total calcification of cyst wall- cyst may be nonviable.
- 32. FOLLOWUP • Cystic echinococcosiscan relapse years after treatment. • Must be individualized according to patient and available resources. • Ultrasound or other imaging (CT or MRI) at 3-6 month intervals until stable, followed by yearly • Follow up up to 5 years , if radiographic findings are stable at 12, 24, and 36 months – upto 3 years IMAGING
- 33. Effective therapy •Complete disappearance •Reductionin size and volume •Increase in proportion of solid component •Thickening and irregularity of the wall •In multivesicular cysts, reduction in size / no. of daughter cysts Relapse Development of new cysts, Increase in cyst size or volume Increase in liquid component of the cyst.
- 34. SEROLOGY • Increase intitre in the majority within the first 3 months after surgery • Specific IgG ELISA - most sensitive measure of response to treatment • All serologic tests - decreasing titers from 3 months after surgery in patients without relapse.
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