Pattern of Relapse in Hepatic Hydatidosis: Analysis of 238 Cases in a Single Hospital.

INTRODUCTION: Hydatidosis is a chronic disease that is endemic and prevalent in certain regions of the world. Surgical treatment is the best option, although its main problem is that there is a high rate of recurrence. The objective of the present study was to assess its therapeutic management and the factors related to its postoperative morbidity and relapse. MATERIAL AND METHODS: A descriptive and retrospective study was made of 238 patients with hepatic hydatidosis operated from January 2006 to December 2017 at our center. An analysis was made of the variables associated with postoperative morbidity and relapse, and of the temporal pattern of that relapse. RESULTS: Out of 238 patients, radical surgery was performed in 132 (55.5%) and partial cystectomy in 106 of them (44.3%). The postoperative morbidity was 42% (100/238) and the relapse rate was 7.2% (17/238). The factors associated with greater postoperative morbidity were partial cystectomy (OR, 2.83 (1.47-5.43); p = 0.002), ≥ 2 cysts (OR, 3.22 (1.51-6.86); p = 0.002), and biliary fistula (OR, 4.34 (2.11-8.91); p < 0.0001); and those associated with higher relapse rate were history of hydatidosis (OR, 4.98 (1.76-14.11); p = 0.003) and ≥ 2 cysts (OR, 3.23 (1.14-9.11); p = 0.027). The first relapses appeared after 14 months, with the greatest incidence between 14 and 36 months. CONCLUSIONS: The surgical procedure applied is associated with morbidity but not with that of relapse. The observed relapse pattern demonstrates the need to maintain long-term follow-up, but with no follow-up being necessary in the first year. Broader multicenter and prospective studies are needed to establish more precise recommendations.

Histopathological Aspects Described in Patients with Hepatic Hydatidosis.

INTRODUCTION: Hydatidosis is a parasitic disease with tumour-like development of a cystic mass. This has specific endemic areas, Romania being amongst them. Our hospital has national addressability and the collaboration between the Departments of Parasitology, General Surgery and Pathology ensures optimal multidisciplinary approach to cases of therapeutic and diagnostic standpoint. The study aims to test the hypothesis that the gallbladder is a hydatid reservoir, to identify signs of biliary fistulas in the pericyst and liver parenchyma; to identify inflammation elements in the pericyst and the gallbladder. MATERIAL AND METHODS: The study is a retrospective observational one, carried out between 2011-2014, on a total of 35 patients operated for hepatic hydatidosis in the General Surgery Department of "Colentina" Clinical Hospital. All the selected patients had sent to the Pathology Department: gallbladder, cyst and pericyst. Statistical analysis of the data was performed using SPSS package Statistics 19. RESULTS: The main results of the study revealed no evidence to confirm the hypothesis that the gallbladder is a hydatid reservoir. Out of the 35 cases, in 16 we observed the tendency to include hepatic biliary ducts in the pericyst or the formation of new canals which lead to the formation of biliary fistulas. Using immunohistochemical techniques with mark of CK19 (cytokeratin 19), have been observed the pattern of fistulization and modification of local architecture through the formation of the pericyst, in 16/35 (45.7%) of cases. CONCLUSION: Although it is a benign pathology, the evolution of hepatic hydatidosis can lead to severe complications and a low quality of life for the patient, both before and after surgery. Better knowledge of the pathology behind the local evolution of the disease can influence the therapeutic approach.

Endoscopic retrograde cholangiopancreatography in hepatic alveolar echinococcosis.

BACKGROUND AND AIM: Hepatic alveolar echinococcosis (HAE) involves both the vascular and biliary structures of the liver. Endoscopic retrograde cholangiopancreatography (ERCP) is said to be an alternative for the diagnosis and treatment of biliary complications of HAE. We present here our experience with ERCP in HAE. METHODS: We followed 13 patients who underwent ERCP for the treatment of biliary complications of HAE in the endoscopy unit of our clinic at Ataturk University School of Medicine, Erzurum between January 2002 and June 2008. RESULTS: Eight men and five women were followed up. Mean age was 43.2 (24-64 years). All patients had non-resectable HAE. Indications for ERCP were biliary fistula in seven patients, obstructive jaundice in five patients and cholangitis in one patient. Endoscopic sphincterotomy (ES) was carried out in 12 patients, and in one patient with biliary leakage, a stent was inserted into the right hepatic branch. ERCP findings were dilated common bile duct, irregular narrowing and distortion of the common bile duct and common hepatic duct, communication with the cystic cavity or biliocutaneous fistula and complete disappearance of the biliary tree above the level of the common hepatic duct or hepatic bifurcation. In patients with biliary leakage, biliary drainage decreased only in two patients after ERCP and in patients with obstructive jaundice, the high bilirubin levels decreased in only one patient. CONCLUSION: ERCP showed structural changes of the external biliary tract and ES has a limited effect on these changes and stents can be used in selected cases.

Satellite cysts and biliary fistulas in hydatid liver disease. A retrospective study of 17 liver resections.

In Switzerland, the preferred mode of treatment for hydatid liver disease caused by Echinococcus granulosus is surgery, giving us the opportunity for a retrospective histopathologic study of 17 consecutive liver resections. We focused on the occurrence of satellite cysts and of biliary fistulas and their effects on bile ducts. Of 17 patients, 6 (35%) had one or more satellite cysts, to be distinguished from internal daughter cysts. Small areas of fibrinoid necrosis within the fibrous pericyst, a surprisingly constant histologic finding, offer a simple explanation for the occurrence of such satellite cysts as well as for the development of biliary fistulas. Large fistulas with gross drainage of cyst contents into bile ducts were present in 5 patients (30%). The accompanying cholangitis was distinctly granulomatous in 2 of them, an observation rarely mentioned in the literature. All 5 patients with large fistulas also had chronic sclerosing cholangitis and dilatation of smaller bile ducts, in all probability the result of chronic cyst fluid leakage through preexisting, clinically silent smaller fistulas. Dilatation of small bile ducts is rightly considered a precursor sign for large fistulas. Awareness of the histopathology of these complications facilitates the interpretation of ultrasound and radiologic imaging, sheds light on their pathogenesis, and may influence the choice of treatment.

MR imaging for diagnosing cysto-biliary fistulas in cystic echinococcosis.

OBJECTIVE: To evaluate the sensitivity and specificity of magnetic resonance imaging (MR imaging) including MR cholangiography for the identification of cysto-biliary fistulas in patients with hepatic hydatid disease. PATIENTS AND METHODS: Retrospective analysis of 3 groups of patients (20 patients with 51 echinococcal cysts) in a cohort of 103 patients with cystic echinococcosis with different pretest probabilities for cysto-biliary fistulas. Patients who had MR imaging/MR cholangiography with symptoms and signs of biliary obstruction (5 patients with 16 cysts, group I), before surgery for other reasons than biliary obstruction (9 patients with 14 cysts, group II) and for cyst staging (6 patients with 21 cysts, group III). All MR images were evaluated before surgery for the presence of cyst wall defects and hydatid debris in bile ducts. In groups I and II MR results were compared with surgical, parasitological, and biochemical findings of each individual cyst. RESULTS: Based on direct (i.e. defects in the cyst wall and continuity of dilated biliary ducts into adjacent cysts), and indirect MR imaging/MR cholangiography imaging signs (i.e. intraluminal debris) our best estimate of sensitivity and specificity (stage-specific, WHO type CE3 and CE4) for cysto-biliary fistulas was 75% and 95%, respectively. CONCLUSIONS: MR imaging with MR cholangiography is a valuable non-invasive imaging technique to assess the risk of cysto-biliary fistula-related complications and for planning of surgery.

[Management of biliary fistulas in surgery for hepatic hydatid cyst]. / Managementul fistulelor biliare în chirurgia chistului hidatic hepatic.

One of the most important problems of the surgical treatment of the hydatid disease of the liver is the remaining cavity of the cyst. Its evolution is mainly decided by the existence and the debit of a biliary fistula. During 10 years (1997-2006), 138 patients with 166 hydatid cysts of the liver were admitted and operated in our clinic. Among them, 57 cysts had a biliary fistula, found during the operation, while in 11 other patients the fistula became obvious 1 or 2 days after the procedure. The incidence of biliary fistulas (68 of 166 cases, which means 41%) is higher, due to the location of the cysts, mainly in the central parts of the liver. There were 44 (65%) low debit fistulas and 24 (35%) high debit fistulas. Our surgical attitude regarding the cavities with biliary fistulas has considerably changed; while between 1997-2000 an anastomosis with a Y or Omega jejunal loop was the most frequent technique, nowadays we use the external drainage of the cavity, associated to endoscopic sphincterotomy, for fistulas with large volumes (more than 300 ml/day) and/or persistent. Whenever it is possible, we practice the direct suture of the biliary fistula.

The usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae.

Hydatid disease is an important health problem in areas where it is endemic. There are several therapeutic modalities, the most important being surgery, antibiotherapy, and percutaneous treatment. In recent years percutaneous treatment has become popular, and for this method or surgery it is sometimes lifesaving to know the relation between the biliary ducts and the cyst cavity. The aim of this study was to examine the usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae before percutaneous or surgical treatment. A total of 72 patients diagnosed with hepatic hydatid disease via ultrasound and serologic tests were enrolled in the study. Endoscopic retrograde cholangiopancreatography was successfully performed in all patients. (99m)Tc-labeled albumin macroaggregates also were injected into cysts at a dose of 1.5-2 mCi just before the treatment. All but three patients were treated percutaneously. Scintigraphy of abdominal and thoracic areas was performed with a GE Starcam 3200 XC/T gamma camera at 30 and 120 min after Tc-labeled albumin macroaggregate injections. Endoscopic retrograde cholangiopancreatography revealed communications between biliary ducts and cyst cavities in nine patients (12.5%). However, (99m)Tc-labeled albumin macroaggregates showed not only leakage into the systemic circulation in nine patients but also into the biliary ducts in two (15.4%). In one patient, mild acute pancreatitis occurred as a complication of endoscopic retrograde cholangiopancreatography. No complications of (99m)Tc-labeled albumin macroaggregates injection were seen. Three patients were surgically treated because of clinically manifested cystobiliary fistulae. We conclude that endoscopic retrograde cholangiopancreatography is a gold standard technique for the diagnosis of communication between the biliary duct and the cyst cavity, and (99m)Tc-labeled albumin macroaggregate injection is useful for revealing leakage into the systemic circulation. The diagnosis of biliary fistulae before percutaneous treatment of hydatid disease may enable planning of the optimal therapy.

Treatment of hydatid bronchobiliary fistulas: 30 years of experience.

BACKGROUND: Bronchobiliary fistula (BBF) is an uncommon but severe complication of hydatid disease of the liver. Operation is considered the treatment of choice but the most appropriate operation is uncertain. The aim of this study was to evaluate the early and long-term outcomes following different surgical procedures. METHODS: A retrospective evaluation of 31 patients with BBF was performed. Surgical access consisted of laparotomy, thoracotomy or a thoracoabdominal (TA) incision. Surgical procedures for the treatment of the cyst were classified as conservative or radical. RESULTS: Radical treatment including lung resection and pericystectomy was performed in all patients in whom the surgical exposure was obtained by either thoracotomy or TA. Of the patients treated by laparotomy, two had a pericystectomy, and four had drainage of the cyst. There were two deaths among the seven thoracotomy patients and one among the 18 TA patients. Pleural effusion was observed in six of the TA, two of the thoracotomy, and three of the laparotomy patients. Biliary fistula occurred in two of the five thoracotomy patients surviving operation and in two laparotomy patients (2/6). Progression of the lung disease was observed in four laparotomy patients and in one thoracotomy patient. CONCLUSIONS: The better outcome achieved in TA patients is the result of the simultaneous radical treatment of all the pathological aspects of BBF.

[Analysis on the anatomic features of 47 cases of hepatic hydatidosis complicated with biliary fistula].

OBJECTIVE: To propose a criterion and its significance of clinical classification of hepatic hydatidosis complicated with biliary fistula. METHODS: 47 hepatic hydatidosis with biliary fistula cases who were given a subadventitial pericystectomy were observed from 2000 to 2005 in a retrospective study. The methods included observation of the different anatomic features of hepatic hydatidosis complicated with biliary fistula during the surgical operation and evaluation of the curative effect. RESULTS: All the 47 patients recuperated successfully and had no complication. Based on the anatomic features of hepatic hydatidosis complicated with biliary fistula, a criterion on clinical classification was proposed as three types: tangential, transfixional and terminal types. CONCLUSIONS: Hepatic hydatidosis complicated with biliary fistula can be classified as three types according to its anatomic features.

Intrabiliary rupture: an algorithm in the treatment of controversial complication of hepatic hydatidosis.

AIM: Intrabiliary rupture (IBR) is a common and serious complication of hepatic hydatid cyst. The incidence varies from 1% to 25%. The treatment of IBR is still controversial. We aimed to design an algorithm for the treatment of hepatic hydatidosis with IBR by reviewing our cases. METHODS: Eight cases of IBR were analyzed retrospectively. Patients were evaluated according to age, sex, clinical findings, cyst number and stage, abdominal ultrasonography and CT-scan, surgical methods, complications, results and coincidental diseases. RESULTS: Female/male ratio was 1/7. Mean age was 52.12+/-18.26 years (range 24-69 years). Right upper quadrant pain, flatulence, palpable hepatic mass were symptoms common in all patients. Cholestatic jaundice was found in four cases. In all patients, cyst evacuation and omentoplasty were performed, followed by either choledochoduodenostomy, T-tube drainage, intracavitary suturing of the orifice, two cases in each. Whereas in two patients diagnosed post-operatively percutaneous drainage of biliary collection or ERCP and sphincteroplasty were added. Morbidity and hospital stay were higher in these cases. CONCLUSION: When the diagnosis of IBR can be done pre- or intra-operatively, morbidity decreases. If a biliary fistula is seen post-operatively, endoscopic procedures such as ERCP, sphincteroplasty or nasobiliary drainage can be applied.

Bronchobiliary fistulae due to echinococcosis.

OBJECTIVE: A bronchobiliary fistula (BBF) is a rare complication of echinococcosis due to rupture of hydatid cysts located at the upper surface of the liver to the bronchial tree. We present our experience in treating this uncommon and dangerous entity. MATERIAL: During the last 20 years, 21 patients, ten men and 11 women ranging in age from 26 to 83 years with a BBF were treated in our department. They presented dyspnea, biloptysis, cough or fever. Diagnostic imaging studies have been very helpful in identifying the communication and in delineating its location. The disease was limited to the liver in 11 cases, whereas in the rest ten cases, both liver and lung were involved. RESULTS: Right thoracotomy was the approach of choice. Our strategy consisted of adequate evacuation of the intrahepatic cysts, obliteration of the cyst space, freeing the adherent lung, dissection and closure of the BBF. Two deaths occurred due to anaphylactic shock and cardiac insufficiency. Follow up at 7-12 years did not reveal any recurrence. CONCLUSION: Although the incidence of echinococcosis has been decreased, the BBF still remains a serious complication with a high morbidity and mortality. Early diagnosis and management of septic associated complications are essential.

[Hydatid cysts of the liver opening in the biliary tract. Report of 64 cases]. / Les kystes hydatiques du foie rompus dans les voies biliaires. A propos de 64 cas.

STUDY AIM: The aim of this retrospective study was to report a series of patients with hydatid cyst opened in the biliary tract, who were operated in Morocco. PATIENTS AND METHOD: From 1991 to 1998, among 250 hydatid cysts of the liver operated in the same center, 64 were in communication with the biliary tract (25%). There were 39 men and 25 women. The mean age was 34.2 years (range: 6-60). The revealing symptoms were abdominal pain, jaundice or cholangitis, but the biliary fistula was asymptomatic in more than 50% of the patients. The hydatid cysts were recognized by ultrasonography in all the patients but the biliary fistula was only suspected in 17 patients. The surgical procedure included drainage and sterilization of the cyst, resection of the protruding wall of the cyst (84.4%), unblockage of the main hepatic duct (n = 21) associated with a Kehr drainage, and treatment of the bilio-cystic fistula with suture (n = 23) or double side drainage (n = 24) or cystobiliary disconnection (n = 15). RESULTS: There were two postoperative deaths due to septic shock (n = 1) and encephalopathy secondary to a biliary cirrhosis (n = 1). The morbidity rate was 25%. Among complications, there were four subphrenic abscesses, four prolonged biliary leakages and two intestinal obstructions. The main hospital stay was 20 days. CONCLUSION: The opening of hyatid cysts of the liver into the biliary tract may be silent or revealed by biliary symptoms. The results of this series favour a conservative procedure, including resection of the protruding wall of the cyst and cysto-biliary disconnection, in spite of a high morbidity rate and a long hospital stay.

[Serous fibrinous pleurisy disclosing hydatid cyst of the liver fistulizing into the pleura]. / Pleurésie séro-fibrineuse révélatrice d'un kyste hydatique du foie fistulisé dans la plèvre.

Hydatic cyst of the liver remains a serious public health problem in Morocco and several other Mediterranean countries. This benign affection can cause serious sometimes fatal complications such as cyst rupture into the biliary ducts or the thorax. We present the case of a patient with serofibrous pleurisy and recall the often late diagnosis of hydatic cyst. Biliary pleural fistulization is a rare but serious complication.

The rupture of hepatic hydatid disease into the right hepatic vein and bile ducts: a case report.

Echinococcus granulosus and Echinococcus multilocularis cause liver hydatid disease. One of its most common complications is rupture into the bile ducts; however, penetration of a cyst into a vessel is a very rare complication. We detected a defect (2 x 1 cm) on the wall of the right hepatic vein, in addition to three distinctive ruptures into the bile ducts, in our case. For systemic hypotension due to a bleeding during operation and to repair the vessel wall defect, an urgent right thoracotomy followed by a radial phrenotomy was needed. We were able to reach the operation site easily and repaired the vessel wall with polypropylene suture. Because of the occurrence of these two complications together and the difficulties of the operation, we decided to report this case.