Hydatid cyst of the liver: spontaneous rupture with peritoneal and thoracic involvement. Report of a case.

Hydatidosis due to Echinococcus granulosus is an endemic parasitic disease in Mediterranean countries. The most frequent anatomical locations are the liver and lung and the most significant complication of liver hydatidosis is rupture into the biliary tract. Spontaneous rupture into the free peritoneal cavity associated with thoracic involvement is an unusual complication accompanied by a high mortality rate. An isolated abdominal approach is necessary when peritoneal cavity drainage is required and may be sufficient in cases of contamination of the pleural cavity by scolices without suppurative involvement. An unusual case of spontaneous rupture of a hydatid cyst of the liver into the free peritoneal cavity associated with diaphragmatic and pleural involvement is reported. This complication requires immediate surgical treatment consisting in a combined thoracic and abdominal approach. The isolated abdominal approach not requiring thoracotomy may be satisfactory if there is no intrathoracic damage due to the chronic presence of scolices. Intrabdominal and intrathoracic cyst rupture still remains a serious complication because of the complexity of the lesions which are often difficult to treat in a one-stage operation. The mortality remains high in various series.

Radiofrequency-assisted liver resection.

Radiofrequency (RF)-assisted thermal ablation has been used with increasing frequency for unresectable hepatic tumors. This new approach employs RF energy to coagulate the liver at the hepatic resection line after which hepatic resection is performed with the use of a common scalpel. This procedure was used in three patients with hepatocellular carcinoma and in five patients with colorectal metastasis to the liver. These eight patients underwent a total of two left bisegmentectomies, three segmentectomies, and seven wedge resections. Mean operative time was 220 minutes. A mean of 78 sessions of RF-assisted ablation were required for these resections. Mean blood loss was 46 ml; no device other than RF ablation was required to obtain hemostasis. None of the patients needed a blood transfusion. Preoperative hemoglobin was 12.8 gm/dl and postoperative hemoglobin was 11.3 gm/dl. There were no perioperative deaths. Postoperative complications occurred in two patients: a liver abscess in one and heart failure in the other. The mean hospital stay was 9.4 days. This new approach, integrated with other techniques, reduces blood loss and coagulates the margins of resection during liver surgery. This new technique has two limitations: (1) it cannot be applied near main portal pedicles, and (2) it requires a long operative time. The best indication for this technique is when segmentectomy is required in patients with cirrhosis. Its role in major hepatic resections has yet to be determined. Further progress in the development of thermal ablation techniques and experience gained during the learning curve should help reduce the operative time, thereby improving the safety and efficacy of this procedure.