Hydatid disease of the liver – Surgical treatment

A. C. Liatas, Th. Liakakos, J. Koufopoulos, S. Kundurakis, J. Kontojiannis, P. Ketsegis,

E. Issaris, S. Dendrinos.

From The 2nd Department of Surgery of The District General Hospital of Athens, Greece

This paper was presented in the 2nd Mediterranean Surgical Congress: Athens, 24th – 27th of June 1989

Hydatid disease is a parasitic infection caused by several species of the cestode echinococcus.

The most common form in Greece is Granulosus. Patients affected by the parasite are asymp-

tomatic for a long period of time. They usually seek medical care when their cysts have become

very large and a great amount of liver parenchyma has already been destroyed. We are report-

ing a 15 year experience with various surgical procedures employed to treat these patients.

Keywords: Hydatid disease of the liver, echinococcus Granulosus, surgical techniques used for

treatment of Hydatid disease of the liver, symptoms of hydatid disease of the liver, laboratory

tests investigating the hydatid disease of liver, imaging techniques for diagnosis of hydatid dis-

ease of the liver,

Material and Methods

Population: From 1973 to 1988, 90 patients with hy-

datid disease of the liver were treated surgically in the

2nd Surgical Department of the District General Hospital

of Athens (Table I)

Gender # of patients Age (mean)

Males 35 (38,8%) 15 – 99 (49,5%)

Females 55 (61,2%) 14 – 80 (51,2%)

Total 90 (100%) 14 – 99 (50,5%)

Table I

There were 35 male patients aged between 15

and 99 years ( X = 49,5 years) and 55 female

patients aging from 14 – 80 years ( X = 51,2

years).

Symptom or sign # of patients ( % )

Abdominal pain ± tenderness 68 75,5%

Hepatomegaly 51 56,6%

Abdominal mass 22 24,4%

Fever 20 24,4%

Jaundice 13 14,4%

Urticaria + anaphylaxis 7 7,7%

Asymptomatic 12 13%

Table II

Pain and tenderness were the most common

complaints (75,5%) followed by hepatomegaly, a

palpable abdominal mass, fever and jaundice

(Table II)

Nine patients had had a previous operation for hydatid disease before being referred to our de-

partment. Nine patients had an acute clinical presentation due to rupture of a hydatid cyst into

2nd Mediterranean Surgical Congress Athens, 24th – 27th of June 1989

Αναστάσιος Λιάτας MD. F.I.C.A. Διευθυντής Χειρουργός ΕΣΥ, Γ.Ν.Α "ΕΥΑΓΓΕΛΙΣΜΟΣ"

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the biliary ductal

system, the perito-

neal or plural cavi-

ties, or due to inter-

nal bleeding (Table

III)

Symptom or sign (on admission) # of patients ( % )

Acute abdomen 6 6,6%

Rupture into the biliary ductal system 4 4,4%

Rupture into the peritoneal cavity 2 2,2%

Internal bleeding 1 1,1%

Acute respiratory distress due to rupture into the plural cavity 3 3,3%

Table III

Table IV shows the results of full blood

count and liver function tests. A total eosi-

nophil count of more than 250 cells/mm3

was seen in 29% of patients. Elevation of

serum alkaline phosphatase was the second

most frequently observed abnormality seen

in 27% of patients. Leukocytosis and ele-

vated serum bilirubin level were present in 22% and 16,5% respectively.

Test Normal Elevated Sensitivity

Eosinophil count 65 19 29%

Alkaline phosphatase 40 15 27%

Leukocytosis 70 20 22%

Bilirubin 67 13 16,5%

Table IV

Serology and skin tests (Table V) were very

helpful in establishing the diagnosis of hydatid

disease. There has been a gradual adoption to

the most recently developed tests. Casoni skin

test was the only test performed in the early

patients and was positive in 45 out of 61 pa-

tients tested (sensitivity 74%) whereas the

passive haemaglutination test became available later and was positive in 26 out of 30 patients

(sensitivity 86,6%).

Casoni Passive haemaglutination

Normal 16 4

Abnormal 45 26

Not performed 29 60

Sensitivity 74% 86,6%

Table V

In order to establish the diagnosis,

four imaging techniques were used.

Calcification of the cyst shown in

plain abdominal x-rays was present

only in 18 patients (20%). The liver

nucleotide scanning demonstrated

“cold areas” in 13 out of 15 patients

tested. Ultrasonography of the liver

and CT scan demonstrated cystic

lesions in both intra- and extra-

hepatic locations with sensitivity 93,3% and 100% respectively (Table VI).

# of patients tested # positive Sensitivity

Plain abdominal-XRs

(calcification) 90 18 20%

Liver nucleotide scanning

(silent areas) 15 13 87%

Ultrasonography

(cysts) 30 28 93,3%

CT-Scan

(cysts) 29 29 100%

Table VI

2nd Mediterranean Surgical Congress Athens, 24th – 27th of June 1989

Αναστάσιος Λιάτας MD. F.I.C.A. Διευθυντής Χειρουργός ΕΣΥ, Γ.Ν.Α "ΕΥΑΓΓΕΛΙΣΜΟΣ"

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Location # of cysts Multiplicity

Right lobe 60 (66%) Single: 65 (72%)

Left lobe 18 (20%)

Both lobes 14 (14%) Multiple: 25 (28%)

Extrahepatic 11 (12%)

Biliary fistula 23 (25,5%)

Table VII

Cysts were found in the right lobe in 60 patients, in

the left lobe in 18 and in both lobes in 14 patients

(Table VII).

Cysts were single in 65 patients and multiple in 25.

Communication of the cyst with the biliary ductal

system was demonstrated in 23 cases. Eleven pa-

tients had extrahepatic cysts, one of whom had a

diffuse intraperitoneal echinococciasis.

Treatment

All patients were treated surgically. We performed 92 operations, 9 of which for a relapsed hy-

datid disease. The operative approach was through an abdominal incision in 84 patients (50 had

a right subcoastal, 28 a median and 6 a right paramedian). A thoracic approach was performed

in 7 and a combined thoraco-abdominal one in 1 patient. The decision was based on the loca-

tion of the hepatic cyst and the presence or absence of extra-hepatic disease. Radical operative

procedure was carried out in 11 patients (2 hemihepatectomies and 9 pericystectomies), Table

VIII.

Radical procedures n Conservative procedures n combination n

(n = 11) (n = 77) (n = 4)

Pericystectomy 9 Unroofing + omentoplasty + tube drainage 68 Pericystectomy + cyst resection 4

Hepatectomy 2 Simple drainage 5

Marsupialization 3

Open - close 1

Common bile duct exploration 23

Primary closure 2

Choledochoduodenostomies 3

T-tube drainage 18

Table VIII

Conservative surgical treatment was used in 77 patients and 4 patients underwent a combina-

tion of both techniques (pericystectomy and cystic resection).

The most frequent conservative procedure we performed was cystectomy with resection of the

prominent part of the pericyst (unroofing). Our goal mainly was to create a generous aperture

by removing the prominent part of the pericyst in order to minimize the depth of the residual

cavity and thus promoting its obliteration. Whenever possible an omental tag was placed into

the residual cavity and fastened in this position with absorbable sutures. One or more drains

were left in place. Twenty three common bile duct explorations were performed followed by its

primary closure (2 cases), choledochoduodenostomies (3 cases), or T-tube drainage (18 cases).

2nd Mediterranean Surgical Congress Athens, 24th – 27th of June 1989

Αναστάσιος Λιάτας MD. F.I.C.A. Διευθυντής Χειρουργός ΕΣΥ, Γ.Ν.Α "ΕΥΑΓΓΕΛΙΣΜΟΣ"

3/5 A C Liatas MD F.I.C.A. - Consultant Surgeon Athens General Hospital "EVAGELISMOS"

Rage of days X (Days) Postoperative hospitalization 4 - 32 14,5

T-tube left in place 8 - 23 12,8

Drains left in place 3 - 65 15,5

Table IX

The mean postoperative in hospital stay

was 14,5 days. The T-tubes were left in

place for about 12 days whereas the drain

tubes for about 15 days. A few patients

were discharged with the tube drains in

place (Table IX).

Postoperative complications are show in Table

X. There were no deaths. The most frequent

complication was wound infection, followed by

pulmonary complications. We had 7 biliary fis-

tulae, 5 of which were obliterated spontane-

ously in less than 2 months whereas the other

2 required surgical intervention.

Complications # of patients ( % )

Wound infection 19 21%

Pulmonary complications 11 12%

Biliary fistula 7 7,7%

Infection of residual cavity 5 5,5%

Intra-abdominal abscess 2 2%

Deaths - 0%

Table X

Recurrent symptomatic cysts that required reop-

eration developed in 4 patients (Table XI). # of patients ( % )

Available for follow up 51 56,6%

Recurrent disease

(from 11 months to 8 years) 6 7,1%

Table XI

In conclusion, we can say that surgical treatment of hepatic hydatid disease was aimed primar-

ily to the:

1. Eradication of the parasite

2. Prevention of complications

3. Obliteration of the residual cavity

In our opinion, the conservative surgical approach with which our patients were treated was

very close to the above goals.

1. We removed the scoleces, the daughter cysts and the germinal layer.

2. The unroofing of the pericyst in close proximity to the hepatic parenchyma created a

large aperture and thus significantly reduced the depth of the residual cavity promoting

its obliteration and diminishing the risk of postoperative infection, and

3. We avoided pericystectomy which is a major and time consuming procedure with a high

risk of biliary fistula formation.

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2nd Mediterranean Surgical Congress Athens, 24th – 27th of June 1989

Αναστάσιος Λιάτας MD. F.I.C.A. Διευθυντής Χειρουργός ΕΣΥ, Γ.Ν.Α "ΕΥΑΓΓΕΛΙΣΜΟΣ"

4/5 A C Liatas MD F.I.C.A. - Consultant Surgeon Athens General Hospital "EVAGELISMOS"

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2nd Mediterranean Surgical Congress Athens, 24th – 27th of June 1989

Αναστάσιος Λιάτας MD. F.I.C.A. Διευθυντής Χειρουργός ΕΣΥ, Γ.Ν.Α "ΕΥΑΓΓΕΛΙΣΜΟΣ"

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