The document provides an in-depth discussion on liver cysts, including their classification, types, and personal case studies dealing with hydatid cysts. It covers salient features, complications, and recent advances in treatment options while emphasizing the need for standardized approaches. Key points highlighted include the challenges in diagnosis and management as well as the incidence of various types of cysts across different specialties.

1. LIVER CYSTS
Prof.Dr.U.Murali.M.S;MBA
Dept.Of Surgery
D Y Patil Medical College
Mauritius.

2. “ Is Life worth living ?
It all depends on the Liver ! ”
- William James
(1842-1910 )

3. Contents of Discussion
 Facts & Salient Features – Liver Cysts
 My Personal Experience – Hydatid Cyst
 Around Each Dept – Interesting case reports
 Recent Advances
 Key points

4. Salient Features
 Anatomy – Segmental Anatomy
 Common – Rt side – “stream-line”
 Segment – VII - common
 Hepatomegaly – Sign – U.problem
 Cysts > 10cm – CB communication
 Most series in the literature are relatively
small, reporting fewer than 50 patients each.

5. Couinaud Classification
•Divides the liver into 8 functionally independent segments.
•Each segment has its own vascular inflow, outflow and biliary drainage

6. Facts & Features
 Hepatic cyst – Simple cyst
 Asymptomatic (78%) & Incidentally found
 5th – 7th Decade
 Cong – F / Acq – M ( F>M )
 10-18% - Develop symptoms - nonspecific
 True cysts – arise - HT

7. D/D – Cystic Liver Lesions
Infectious
 Parasitic
Hydatid cyst
Amoebic abscess
 Non-Parasitic
Pyogenic abscess
Fungi abscess
Non- Infectious
Cystic Component
 Simple cyst
 PCLD
 Cystadenoma
 Cystic metastasis
 Peribiliary cyst
 Caroli’s disease

8. D/D – Cystic Liver Lesions - contd
Partially Cystic component
 HCC
 Giant Haemangioma
 Embryonal sarcoma
 Hepatic Foregut cyst
 Pseudocyst
 PT-Hematoma
 Biloma
 Cholangiocarcinoma

9. F & F - contd
 Rare – 30 yrs ago
 Incidence – 3-5% (u/s) / 18% (CT)
 Giant Hepatic cyst – 26x24cm / 7 L
 Rate of growth – 1-5cm / yr
 Recurrence – varies – PA -100%/Lap-20%
 Recurrence occur – 3-5yrs ( 28.3% )

10. F & F - contd
 Hydatid cyst > E.histolytica
 Disease – worldwide
 Endemic – M/ME/I/SA/C
 Eradicated - Iceland
 Annual incidence – 1-220/100,000
 New era – Mgt on HC
 Lge & recur – Rt.post.lobe
 Recurrence – 2.2-22%

11. Giant Hepatic Cyst – 26x24cm

12. Personal Experience
 Case 1 – Hydatid Cyst – Liver
 Case 2 – Recurrent Hydatid - Abdomen

13. Case – 1 (Hydatid – Liver )
 55 yrs
 Pain Abd / Swelling – 1 mth
 No LOW / Fever
 P/A – Hepatomegaly
 CBC – WNL
 CT Scan – Hydatid Cyst

14. De-roofing / Omentoplasty
 Cyst identified
 Aspiration
 De-roofing
 Omentoplasty
 Fragments

15. Case – 2 (Hydatid – Abdomen )
 29 yrs
 Pain Abd / Swelling – 6 mths
 UW – CA – 3 yrs Back
 P/A – Liver + / + masses abd
 CBC – WNL
 CT Scan – Hydatid Cyst
Multiple Liver & Mes.

18. Around the Depts -

19. Anaesthesia
 62 - admitted – removal – hydatid cyst liver
 IO – hypotension / tachycardia & ST segment
elevation
 No erythema / bronchospasm / desaturation
 Anas. Agents stopped – O2 – increased
 View- recr.hypotension – shifted –ICU
 Acute MI – ruled out – resusitated
 Anaphylaxis – well managed

20. Anaesthesia
 Stabilized – back – cyst removed
 HPE – confirmed
 Conclusion –
 Atypical IO Anaphylactic shock with ECG changes
sec – non- ruptured hapatic hydatid cyst.
( Anaphylaxis sec – non-ruptured cyst – uncommon )

21. Dermatology
 21 yrs - 3mths - urticaria
 Trt – Ah b/d – OP
 Lost wt 4-5kg – 6mths
 C/E – WNL
 Lab – WBC ↑ / ESR – 45mm/hr / CRP-14.3mg/dl
 Chest X-ray – Cavity – upper lobes
 AFB – Sputum +ve
 Other parameters - WNL

22. Dermatology
 ATT – Started
(a)
 Post Att – Wt + But UC contd-
 Rpt X-ray – No lesions
(b)

23. Dermatology
 Further tracing - etiology – U/S abd
 U/S – 55X52mm mature HC – Rt lobe
 Ref – Gastro dept.
 CT/HIAA – confirmed / Alb - started
 PCA – after 1 wk – POP – discharged
 7hr later – A/E – gen.pruritis / uc / ang face/
hands / dyspnoea / cyanosis
 Emerg trt – Stabilised
 Discharged

24. Late onset Anaphylaxis – HC case
with chronic urticaria
 First manifestation – CSU - Endemic
 CU - > 6 wks
 Type I sens – urt. Symp.
 PCA – Obs – 1 day
 Etiol – CSU
 Late – onset

25. Gynaecology
 27 - G2/P1 – H/O – LSCS
 30 wk preg – admitted
 C/O epi & Rt.up.qdt.pain
 C/E – vitals stable / tend – Rt.up.qdt.
 U/S – 14X10cm cyst – 7s & 7x5cm – 6s
 30 wk fetus – noted
 IHA test & ELISA – confirmed
 Ref – GS

26. Gynaecology
 Cons.trt – Alb – 400mg b/d
 Surg – avoided
 38 wks – delivered – 3kg baby – LSCS
 Surg – PP – 6wks later
Conclusion
 Incidence – 1/20000 – 1/30000
 No standardized trt – Med / PAIR / Surg

27. Medicine
 30 yr – ref – A/E
 Ex.Angina / Hptysis / Short.breath
 C/E – Healthy / CVS& RS – WNL
 ECG – ST↓ / T ↓ – Leads – v5&v6
 U/S – Interventricular cyst
 Echo – 4.9x4.7cm cyst – IVS
 Chest X-ray – 2 cyst – PC
 CT – Not done

28. Cardiac HD
III - world
*Cardiac Ecchinococcosis -
rare disease.
*Its incidence varies from
0.02-2%.
*Commonly seen in the left
ventricle arising from the
subepicardial region.
Asp.
/Cyst.pericystectomy
Thoracotomy -
recovered

29. Orthopedics
 50 yr – pain & swelling – Lt – thigh
 Needle biopsy – 6 yrs back
 HPE – HC – Lt femur
 Surg – adv – pt – refused / Trt – cons.
 L/E Lge immobile / painless mass – AL surf
lt.thigh & limping with pain
 Lab – WNL / U/S – abd & CT – thorax - N
 Plain X-ray & MRI – HC

31. Orthopedics
 Surg – Debridement
 E-O portion of the cyst was dissected and excised
10 minutes after injection of 50 mL 10% povidone-iodine
solution into the cyst
 Lt k.jt was opened .Intercondylar notch was drilled
upto distal femoral metaphysis. An 8 mm ET tube
was inserted into the intercondylar notch, and its
cuff has been inflated to prevent any leakage.

32. Orthopedics
 P-iodine soln. was injected - intubation tube into
the medullary cavity. After 10 mts, all daughter
vesicles and germinative membranes aspirated
safely from the distal end through the intubation
tube, which has been placed previously, while
aspirating simultaneous drilling and broaching the
medullary cavity of the left femur from proximal to
distal was performed.

33. Orthopedics
 Drains were removed - 3rd POD. HPE - was
reported as echinococcal hydatid cysts of femur.
Pt – discharged with crutches.
 10 days - discharge, the patient came back with a
spontaneous pathological fracture of the left femur
Thorough debridement – done. NEO hydatid
disease was observed intraoperatively.

34. Orthopedics
 The IMC was filled with vancomycin beads
& closed, and the patient was put into skeletal
traction from tuberosity of tibia.
 When the infection has ceased, the pathological
fracture has been treated using a custom-made
interlocking intramedullary nail.

35. HD - Femur with an Extraosseous Extent
-pathological Fracture
 Bone hydatidosis is about 1–2.5% of all human
hydatid disease
 Spine is the most common location (50%)
 D/D – Bone tumors & TB / Fungal
 Bone hydatidosis - often asymptomatic & is
usually detected only after a pathologic fracture,
secondary infection, or neurovascular symptoms
caused by compression

36. HD - Femur with an Extraosseous Extent
-pathological Fracture
 The forming defect after curettage or excision is
a major problem. The dead space can be filled
with bone grafts, bone cement, or
endoprostheses.
 Bone grafts can be invaded by the parasites,
and recurrence is often common.
 A stepped surgical care should be planned.

37. Paediatrics
 6 yr boy – attended – AE
 Prod.cough / dyspnoea
 P/H – LOA & weakness
 C/E - ↓ air entry Rt + wheeze
 Trt – Bdtrs. – no response
 Chest X-ray – cyst – middle lobe - Rt
 CECT – “ Warerlilly sign ” + pleural eff.
 Trt – Alb + Radical cystectomy
 Fully recovered

38. Waterlilly
sign
Endocyst collapses &
Floats – cystic fluid

39. Radiology – Learning points
 Radiological findings in ruptured pulmonary
hydatid cyst can frequently be non-specific.
 Radiologically it often mimics non-resolving
pneumonia & lung mass.
 “Sign soups” - follows

49. Recent Advances
 Lap. Liver Surgeries – World wide
 PHS ( Palanivelu Hydatid System ) - India
 PEVAC ( Percutaneous evacuation of cyst
content )
 PAI ( Percutaneous aspiration & Injection )
↓ LA – Inj. Alb. – form dissolved in
normal saline ↓ U/S guidance - Turkey

50. Recent Advances
 Micro chinese therapy
 B- ultrasonic guided RFA ↓ L.A – China
 Inj.Lanreotide I.M – Reduces the volume of
Polycystic liver disease - Netherlands
 EG -95 Recombinant vaccine – Hydatid Disease
 Amoebiasis vaccine – under trial
 Liver Care Foundation - India

51. Key points
 Most app. Method – Lack consensus
 Scolicidal Agents – No consensus
 Recurrence disease – 5 yrs
 Hydatid disease – Diverse forms
 Serodiagnostic test – High sens & spec
 Clinically – Difficult – Complicated cysts
 CEUS – Acc. excludes cystic neoplasms.