Role of interventional radiology in the management of hepatic hydatid disease.

The obliteration of the cyst cavity after evacuation is a controversial procedure in hepatic hydatid disease. There is no ideal surgical technique which can be used in all hydatid cyst cavities. Since 1989 we have been using a new technique, which we call overlapping, in the treatment of suitable cases of hepatic hydatid cyst cavities. The technique depends on the obliteration of the cavity without drainage. After evacuating the hydatid material from the cavity, instillation of the cystic cavity is performed with scolecidal agent (silver nitrate solution, 0.5%). The cavity is opened along its long axis. The pericyst is prepared, and the upper edge is sutured to the bottom of the cavity with absorbable stitch (modified external collapse). Before doing this, if there is no possibility of operative ultrasonography, the cavity is punctured with a fine needle to evaluate any dangerous areas. Then the other edge of the pericyst is laid down beside the collapsed one and sutured to the former with the same technique. The term “overlapping” stems from this second procedure. During the operation, we decide which pericyst will collapse and which one will overlap. Before overlapping, openings between the cavity and biliary tree should be found and if there are any, they should be secured. In cases of large and multiple openings, T-tube choledochostomy is necessary. We applied overlapping to 31 of 43 hepatic hydatid cysts (ranging from 5 to 17 cm in diameter, with a mean of 12 cm) in 19 patients. Twenty-four of 31 cysts had partial pericystectomy before overlapping. Three cystic cavities were connected to the biliary tree. Because of a large connection, T-tube choledochostomy was added in one case. We have not seen any complications, either infection or biliary fistula. The results of the obliteration of cavities were excellent in 15 cysts. There were no residual cavities

Most cases of hepatic hydatid disease exhibit uncomplicated clinical course and management. However, the diagnosis and management of complicated hepatic hydatid disease is a special issue. One of the most common and serious complications of hepatic hydatid disease is the rupture of the cyst into intrahepatic bile ducts. The clinical appearance of intrabiliary rupture can range from asymptomatic to jaundice, cholecystitis, cholangitis, liver abscess, pancreatitis and septicemia. Current treatments for major ruptures can result in high morbidity and mortality rates. Furthermore, ruptures that cannot be diagnosed preoperatively can induce complications such as biliary fistulae, biloma, cavitary infection and obstructive jaundice. In the past, these complications were diagnosed and treated by surgical methods. Currently, complications in both the pre- and postoperative periods are diagnosed and treated by non-invasive or minimally invasive methods. In clinical practice, endoscopic retrograde cholangiopancreatography (ERCP) is indicated for patients with preoperative frank intrabiliary rupture in which hydatid elements are clearly seen in the bile ducts, or for biliary adverse events after surgery, including persistent biliary fistulae and jaundice. However, controversy concerning routine preoperative ERCP and prophylactic endoscopic sphincterotomy in patients suspected of having minor cystobiliary communications still remains. In this article, the role of ERCP in the diagnosis and management of hepatic hydatid disease during the pre- and postoperative periods is reviewed.

Sir, Povidone-iodine (PI) is an antiseptic solution consisting of polyvinylpyrrolidone with water and iodine (available iodine 1%). The 10% solution has been used effectively as a scolicidal agent for hydatid cysts. We hereby discuss the case of a child posted for laparoscopic removal of hepatic and renal hydatid cysts, who developed metabolic acidosis with acute renal failure. A 10-year-old child (weight 26 kg) presented with history of pain in epigastrium. Pain was dull, mild to moderate, and there was no radiation. Systemic examination revealed hepatomegaly. Computed tomography scan abdomen revealed well-defined cystic lesion of 12.5 × 8.5 × 11.4 cm in the left lobe of liver extending to lesser sac and perihepatic area along with small cysts in right kidney. Routine blood investigations and liver function tests were normal. Anti-Echinococcus IgG antibody was positive by Enzyme Linked Immunosorbent Assay. Diagnosis of hydatid cyst of liver and kidney was made, and the child was posted for elective laparoscopic removal of hepatic and renal cysts. Baseline haemodynamic parameters were normal for age. Inhalational induction performed with sevoflurane (8%) in oxygen. After administering fentanyl (60 μg) and vecuronium (3 mg), trachea was intubated. A total of 2.5 L of 10% PI (Microwin®10% w/v) was injected into hepatic hydatid cyst. An hour into the procedure, suddenly heart rate increased from 110 to 180/min along with hypercarbia (end-tidal CO255mmHg) and hyperthermia (from 35.1 to 37.4°C). Injection paracetamol (500 mg) and a bolus (0.5 L) of normal saline were infused. An arterial blood gas analysis showed pH 7.14, pCO236.5 mmHg, pO2135 mmHg, SO297.7%, K+7.4 mmol/L, Na+127 mmol/L, Ca+0.81 mmol/L, Cl − 249 mmol/L, lactate 4.3 mmol/L, base deficit - 15 mmol/L, HCO312.7 mmol/L with Hb of 16 gm%. Blood pressure and airway pressures were normal. Urine output decreased and did not improve after first fluid bolus so a further fluid bolus of 0.5 L of balanced salt solution (sterofundin®) and injection frusemide 15 mg intravenous (IV) were administered. Urine output improved and presumptive diagnosis of anaphylaxis due to systemic entry of hydatid cyst fluid was suspected. Injection hydrocortisone and pheniramine maleate were administered. Patient was shifted to intensive care unit (ICU). Investigations revealed haemoglobin 17 g/dL, leukocyte count 49.6 × 103/μL, serum creatinine 0.9 mg/dL, serum albumin 1.9 g/dL, and potassium 5.2 mEq/L in the immediate post-operative period. Liver, renal, and thyroid function tests were in normal range. Severe metabolic acidosis persisted and thus plan for haemodialysis was made. Tachycardia was fluid responsive and Sterofundin®100 ml/h, albumin (20%) 25 ml/h and hydrocortisone 6 mg/h were started. Bedside echocardiography revealed good cardiac contractility, under filled heart chambers and inferior vena cava diameter of 0.4 – 0.8 cm with collapsibility. After 3–4 h of initiation of haemodialysis, acidosis was corrected and heart rate settled. On post-operative day 1, the patient was fully awake and obeying commands. Trachea was extubated after completion of dialysis. Hydrocortisone infusion was tapered and stopped. Patient was kept for another 2 days in ICU for observation before shifting to ward. In its complexed form (i.e. PI), iodine vapour pressure is reduced essentially to zero, and it becomes soluble in water. The available iodine is released at very slow rate from the complex, prolonging germicidal action of free iodine. Povidone-iodine is highly nephrotoxic and due to its renal elimination, iodine intoxication can result in lethal vicious cycle and anuria.[1] Clinically, patients with PI intoxication can present with hypotension, nausea, vomiting, acute renal failure, hypothyroidism, confusion, metabolic acidosis, seizures, blindness, fever, rash, uterine infarction, elevated hepatic enzymes and iodine-induced haemolysis with decreased serum haptoglobin and lactate dehydrogenase levels.[1] Serum iodine levels could not be done as this analysis was not available in our hospital. Labbe et al. reported a case where abnormalities of cardiac conduction, lactic acidosis, acute renal failure, hypocalcaemia and thyroid dysfunction were features of intoxication.[2] In another case report of iodine toxicity in a child with mediastinitis, after median sternotomy, continuous PI irrigation was carried out and the child died due to its toxicity.[3] Iodinated contrast medium (IV) can cause contrast-induced acute kidney injury, but even with non-intravascular use of iodinated compounds, iodine absorption through mucosal, burned skin or interstitial tissues, can cause nephrotoxicity.[4] Early implementation of renal replacement therapy can be lifesaving.

Muscular hydatid cyst in Iran: A case report

To determine the outcome of laparoscopic management of hepatic hydatid disease in terms of complications. Case series. Surgical C Unit, Khyber Teaching Hospital, Peshawar, from February 2007 to March 2010. All patients with 3 or less hepatic hydatid cysts who underwent laparoscopic treatment for hepatic hydatid cyst disease were included during the study period. Laparoscopic aspiration, unroofing and evacuation of the hepatic hydatid cysts was done. Clinicopathologic features, operative time, conversion to laparotomy, morbidity, mortality and recurrence rates were analysed. Forty three patients had laparoscopic treatment for hepatic hydatid cysts. Females were 27 (62.79%) and males were 16 (37.20%). Mean age of patients was 38.6 ± 14.03 years (range 15-64 years). Pain was the commonest presentation occurring in 34 (79.06%) and mass in 9 (20.93%). Hepatic hydatid cysts were successfully treated laparoscopically in 40 patients. Open surgery conversion was needed in 3 (6.97%) due to inadequate access. The mean duration of surgery was 46.27 ± 13.84 minutes. Complications included port-site infection in 3 (6.97%), bile leak in 4 (9.30%) and recurrence in 2 (4.65%) cases; there was no mortality in the series. Laparoscopic hepatic hydatid cyst surgery was a safe and effective method in selected patients.

Hydatid disease of the liver, and its complications, causes serious morbidity and mortality. We evaluated the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatic hydatid disease. This retrospective analysis includes 28 patients with hepatic hydatid disease who underwent ERCP. ERCP was performed preoperatively in 11 patients, for acute cholangitis (n =7), acute pancreatitis (n = 1) and right upper quadrant pain (n = 3), and in eight asymptomatic cases to search for fistulae between the cyst and the biliary tree. In a further nine patients ERCP was performed for early (< 30 days; n = 7) and late (n = 2) postoperative biliopancreatic problems. In all seven patients with cholangitis preoperative ERCP with EST and ductal clearance of daughter cysts and debris led to substantial clinical improvement, including four acutely ill elderly patients who stabilized and were later able to undergo surgery. EST in two of the three patients with pain who had papillary stenosis led to resolution of the abdominal pain. Six of the seven postoperative fistulae could be successfully treated endoscopically using EST. This study demonstrates the usefulness of ERCP in symptomatic patients with hepatic hydatid cysts; EST enables clearance of the common bile duct and allows healing of postoperative fistulae in the majority of patients. We do not, however, recommend performing routine preoperative ERCP in asymptomatic patients with the disease.

Hepatic hydatid cyst ruptured into the biliary tract: about 2 cases

Background: Hepatic hydatid cysts, caused by the larval stage of Echinococcus granulosus, are a significant health concern in regions where livestock farming and animal-human interactions are prevalent. The liver is the most commonly affected organ, and while cysts may remain asymptomatic for years, complications such as cystobilliary communication (CBC) can lead to jaundice, cholangitis, and biliary obstruction. Effective management strategies are essential to mitigate these complications and improve patient outcomes. Objective: To evaluate the management strategies for hepatic hydatid cysts with cystobilliary communication and determine the effectiveness of surgical and medical approaches. Methods: This observational study was conducted at Bolan Medical College, Quetta, from January to July 2024, involving 85 patients diagnosed with hepatic hydatid cysts and CBC. Inclusion criteria were confirmed cases of hepatic hydatid cysts with CBC, identified via ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI). Patients with previous hydatid surgery, other liver pathologies, or age under 18 were excluded. Data collection included demographic details, clinical symptoms, comorbidities, and imaging findings. Patients were categorized into surgical and medical treatment groups. Surgical procedures included cystectomy and partial hepatectomy, while medical management comprised albendazole or mebendazole. Patients were followed for three months to assess outcomes, symptom resolution, and recurrence. Results: The study included 85 patients, with a mean age of 47.3 ± 12.6 years (range: 18–78). Males constituted 55.3%, and females 44.7%. Comorbidities were present in 35.3% of patients, including hypertension (15.3%), diabetes mellitus (10.6%), and chronic liver disease (4.7%). Jaundice (61.2%), abdominal pain (56.5%), and elevated liver enzymes (78.8%) were the most common symptoms. Cysts were predominantly located in the right lobe (88.2%), with minor CBC observed in 44.7%, moderate CBC in 38.8%, and severe CBC in 16.5% of patients. Surgical treatment was administered to 64.7% of patients, with cystectomy being the most frequent procedure (58.2%). Symptom resolution rates were significantly higher in the surgical group compared to the medical group. Recurrence rates were lower in the surgical group (3.6%) compared to the medical group (6.7%). Conclusion: Surgical management, particularly cystectomy, demonstrated superior outcomes for hepatic hydatid cysts complicated by CBC, achieving higher symptom resolution and lower recurrence rates than medical management. The degree of CBC influenced treatment outcomes, underscoring the importance of individualized management strategies.

Primary hydatid cyst of pancreas: Case report and review of literature

Echinococcosis, or hydatid disease, is a zoonotic parasitic infection caused by the larval stage of Echinococcus granulosus Although the liver and lungs are the most commonly affected organs, primary isolated splenic hydatid cysts are rare, accounting for less than 2% of all cases even in endemic regions. Diagnosis can be challenging due to non-specific clinical presentations.We report a female in her late 20s from Rampur district in Uttar Pradesh who presented with dull, intermittent pain in the left upper abdomen for 3 years. Imaging revealed a well-defined cystic lesion within the splenic parenchyma without involvement of other organs. Serological testing for hydatid disease using Echinococcus IgG ELISA was positive. The patient underwent laparoscopic splenectomy and histopathological examination confirmed the diagnosis of a hydatid cyst. Postoperative complications, including bilateral pleural effusion, pancreatic fistula and surgical site infection, were managed conservatively. The patient recovered well and remained asymptomatic at the 12-month follow-up with no evidence of recurrence on imaging.Primary isolated splenic hydatid cyst is an uncommon manifestation of echinococcosis and should be considered in the differential diagnosis of cystic splenic lesions, particularly in patients from endemic regions. Imaging, serological testing and histopathological evaluation are key to establishing the diagnosis. Splenectomy remains the treatment of choice.

The role of diffusion-weighted magnetic resonance imaging in the classification of hepatic hydatid cysts

Hydatid disease, caused by the larval stage of Echinococcus granulosus, is a significant zoonotic infection predominantly affecting the liver and lungs. While hydatid cysts are commonly found in internal organs, cases in the axillary region are rare. We report a unique case of a 52-year-old female patient presenting with a painless left axillary swelling for two years. Physical examination revealed a firm, mobile mass measuring 10×5cm, with no associated lymphadenopathy. Laboratory tests indicated normal results, while ultrasound imaging confirmed a thick-walled cystic lesion. The patient underwent total cystectomy under general anesthesia, and histopathological analysis confirmed the diagnosis of a hydatid cyst. Hydatid cysts typically originate in the liver or lungs, with axillary primary cysts being rarely documented, with less than 20 prior cases in English literature. The mechanism for larvae migration to the axillary region remains unclear. The patient exhibited a mobile, asymptomatic mass, and imaging studies were crucial for diagnosis, emphasizing that differential diagnoses should include various axillary masses such as lymphadenitis or neoplasms. This case highlights the need for awareness of axillary hydatid cysts in endemic regions, which may be misdiagnosed due to their rarity. Prompt diagnosis and individualized treatment, including total cystectomy and adjunctive medical therapy with albendazole, are critical to prevent complications and recurrence of hydatid disease.

The deceptive cysts of echinococcus granulosus in the thigh: A case series and review of diagnostic and management challenges.

Echinococcosis (hydatid disease) is a zoonosis caused by the larval stage of Echinococcus granulosus. About seventy-five per cent of all hydatid cysts are found in the liver. Surgical management of hepatic hydatid cyst includes neutralization of the parasite, evacuation of cyst, removal of germinal lining and management of the residual cavity. Our study focussed on the management of the residual cavity in patients with cystobiliary communications. We divided the patients into two groups of 40 patients each. In both the groups the cystobiliary communications were ligated using sutures. After closing the cystobiliary communications, the residual cavity was left to drain externally using a polyvinyl chloride tube in group 1 whereas either capitonnage or omentoplasty was done in group 2. The results were studied in terms of the postoperative complications, mortality and hospital stay. In the patients managed by external tube drainage, average hospital stay was 6.95 ± 0.93 days while as patients in group 2 had an average post operative stay of 4.54 ± 0.76 days (p value = 0.0001). Bile leak was seen in 6 (15%) patients in group 1, while as only 1(2.5%) patient from group 2 developed an intra-abdominal bile collection. Wound infection and deep vein thrombosis was seen in one patient each in group 1, whereas no such complication was seen in group 2. One (2.5%) patient from each group had a recurrence of the disease during follow-up.

Hydatid pulmonary embolism is an uncommon condition resulting from the rupture of a hydatid heart cyst or the opening of a visceral hydatid cyst into the venous circulation. We report a rare case with multiple intra-arterial pulmonary hydatid cyst emboli originating from a hepatic hydatid cyst ruptured into the hepatic segment of the inferior vena cava. We present the ultrasonography findings of hepatic hydatid cyst and multidetector computed tomography pulmonary angiography images demonstrating both multiple hydatid cyst emboli and their hepatic origin.