The Ulster Medical Journal, Volume 71, No. 2, pp. 106-110, November 2002.

Management of symptomatic liver cystsA Pitale, A K Bohra, T Diamond

Accepted 29 May 2002

SUMMARY

Non-parasitic liver cysts are seen in up to 5% of the population. They become symptomatic whenthey are large and can cause pain, nausea, vomiting, early satiety and obstructive jaundice.Treatment modalities include percutaneous drainage, open deroofing, hepatic resection andlately, laparoscopic deroofing. We assessed our management of eleven symptomatic patients overthe last five years between May 1996 and August 2001. Two of these had mild symptoms and werekept under review. The remaining nine were treated surgically. Of these, eight were treated bylaparotomy and open deroofing with argon laser coagulation of the cut edges while one wastreated with left hepatic resection. Three of these had been previously treated with laparoscopicderoofing at other hospitals and had been referred after having developed recurrent symptomaticcysts. Two patients developed post-operative complications - bile leakage that resolved withconservative management. The patients were followed up for a median period of twelve monthsranging from 3-62 months. One patient died of liver failure 12 months after surgery. There wasno symptomatic recurrence. We conclude that open cyst deroofing gives marked symptomaticrelief with a very low complication rate. In today's era of laparoscopic surgery, it has a definiterole in the management of symptomatic liver cysts, more so in recurrent cysts followinglaparoscopic treatment.

INTRODUCTION

Non-parasitic liver cysts are seen in up to 5% ofthe population.' These usually tend to beasymptomatic. When the whole liver is involved,Polycystic Liver Disease (PCLD) is presumed toexist.2 Large cysts may cause symptoms,predominantly pain. Nausea, vomiting,obstructive jaundice and early satiety may becaused by the pressure effects of large cysts.3Different treatment modalities have been used.They include percutaneous drainage, openderoofing, laparoscopic deroofing and hepaticresection. This study assesses our managementof symptomatic liver cysts over the last fiveyears.METHODS

BetweenMay 1996 and August 200 1, nine patientsunderwent surgery for histologically proven non-parasitic cysts of the liver. Two patients withmild symptoms have not been operated on andhave been kept under review. Patients wereidentified from the hepatobiliary database andrecords were reviewed for clinical presentation,preoperative investigations, surgery and follow-

up. CT scanning was performed in all patients todetermine the extent of the disease and to helpexclude parasitic cysts. Of the nine patients whounderwent surgical treatment eight were treatedby laparotomy and open deroofing while one wastreated by left hepatic resection for extensiveinvolvement ofthe left lobe by a large multilocularcyst. The major aim of surgery was to remove asmuch of the cyst wall as possible to preventrecurrence. A CUSA (Cavitron Ultra SonicAspirator) was used for liver resection. Threepatients underwent synchronous cholecystectomyfor coexistent gallstones.RESULTS

Eleven patients with symptomatic cysts (9 women,2 men) with a median age of 55 years (age range49-81 yrs) were identified from the records. The

Mater Hospital Trust, Crumlin Road, Belfast BT14 6AB.

A Pitale, MBBS, MS, FRCS, Senior House OfficerA K Bohra, MBBS, MS, FRCS, Specialist RegistrarT Diamond, MD, FRCS, FRCSI, Consultant Surgeon

Correspondence to Mr Diamond

C The Ulster Medical Society, 2002.

Management of symptomatic liver cysts

TABLE

Demography, clinicalfeatures, procedure and outcome

Patient No. Age Presenting Previous Procedure Follow-up!Year/Sex Symptoms Treatment Results

Pain,Nausea

Pain

Pain,Nausea

Pain

Pain,Nausea &vomiting

Abdominaldistension

Pain,AbdominaldistensionPain

Abdominalwall/ veindistension+leg oedemadue to IVCobstruction

Nil

Nil

Open cystderoofing

Open cystderoofing

Nil

P.C.Aspiration,LaparoscopicderoofingLaparoscopicderoofing

PC. Aspiration,Laparoscopicderoofing

Nil

Nil

Nil

Open cystderoofing+Cholecyste-ctomy

Openderoofing

Open cystderoofing

Open cystderoofing+Cholecyste-ctomy

Left hepaticresection

Openderoofing+Cholecyste-ctomy

Open cystderoofing

3 monthsSymptomfree

60 monthsSymptomfree

47 monthsSymptomfree

22 monthsSymptomfree

62 monthsSymptomfree

10 monthsSymptomfree

62 monthsSymptomfree

10 monthsSymptomfree

12 monthsDied of liverfailure

Nil ConservativeManagementConservativeManagement

Nil

8 months

11 months

(P.C.: Per Cutaneous)

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1 80/F

2 55/F

3 49.5/F

4 81/m

5 53/F

6 78/F

7 61/F

8 49/F

9 51/F

10 54/F

11 69/F

Mild Pain

Mild Pain

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The Ulster Medical Journal

Fig 1. CT scan demonstrating multiple liver cysts in apatient with PCLD and one very large cyst.Surgical deroofing/cyst excision in such a patientachieves a very significant reduction on the masseffect and good symptom relief.

Fig 2. A large, centrally located cyst with vena cavalcompression and caval thrombosis.

main presenting complaints were pain (82%),abdominal distension (27.2%), nausea and/orvomiting (36.3%) (Table). Liver function testswere abnormal in 20% of patients. One patientwith PCLD presented following a road traffic

accident. She sustained a spinal fracture but alsodeveloped a large haemorrhage into a liver cyst(Fig. 1). One patient with a very large cystinvolving the right lobe and segment IV of theleft lobe developed a thrombosis in the inferiorvena cava (Fig. 2). One patient had polycysticliver disease and two had polycystic disease ofboth the liver and the kidneys. One patient withPCLD and mild symptoms has been treatedconservatively. Of the nine patients treatedsurgically, two had undergone previous repeatedaspirations followed by laparoscopic deroofingand one patient had undergone laparoscopicderoofing alone. These procedures had beencarried out at other hospitals and all three patientsdeveloped recurrent symptomatic cysts. Twopatients had a postoperative complication - bileleakage that resolved with conservativemanagement.

Patients have been followed up for a medianperiod of twelve months ranging from 3 - 62months. One patient with polycystic liver disease(PCLD) was admitted twelve months after surgerywith jaundice and deteriorating general healthand died of liver failure. There has been nosymptomatic recurrence of cysts in the otherpatients.

DISCUSSION

Simple liver cysts are thought to arise as acongenital aberration of bile duct development.The dominant cyst is usually accompanied byseveral smaller cysts. ' When however, the wholeliver is involved, PCLD is presumed to exist,which has a close association with polycysticdisease of the kidneys.2Liver cysts are normally asymptomatic and areusually detected incidentally during abdominalimaging. I Symptoms appear to be due to pressureeffects with pain as the predominant feature. Thestomach or duodenum may be compressed by theenlarged liver giving rise to nausea, vomiting andearly satiety.3It has been observed that symptomatic liver cystsoccur ten times more commonly in women,usually at age 50-60 years with pain as thepredominant symptom.' Our experience wassimilar with symptoms occurring more commonlyin women (4: 1) with an age range of 50-60 yearsand with pain as the predominant symptom. Mostsymptomatic liver cysts are benign but carcinomaarising in the wall of a cyst has been reported.4

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Management of symptomatic liver cysts 109

Different treatment modalities have been used.Percutaneous aspiration appears to be a simpleoption. It is, however, associated with a highrecurrence rate.5 Percutaneous aspiration withintroduction of sclerosing agents has shown goodressults.6-7 Larssen et al injected alcohol in tenpatients. There was reaccumulation of fluid ineight patients and this resolved over the next fewmonths with no need for further alcoholsclerotherapy.6 The rate of symptomaticrecurrence seems to be definitely reduced afterpercutaneous sclerotherapy.8

The technique of open cyst deroofing orfenestration was first described by Lin et al in1968.9 It has been recommended by several groupsand has been applied successfully for simple livercysts.'°011 We have found it to be particularlysuccessful when there are only one or severallarge cysts and a significant reduction in the'mass' effect of the cysts can be achieved. Formultiple smaller cysts (eg, 2-5 cms) as occursusually in PCLD, deroofing/fenestration is not aseffective, as the fibrous architecture of the liverand cysts remains intact and a significant reductionof the volume cannot be achieved. For thesepatients, resection is perhaps more appropriate.

More radical approaches like hepatic resectionhave been advocated for treatment of large cysts.It has been shown that hepatic resection is safeand effective and that symptomatic relief iscomplete and permanent except in cases ofdiffusepolycystic disease ofthe liver. '2Total cystectomyand liver transplantation have been advocated inPCLD. 13 14

Laparoscopic deroofing of the liver cysts wasfirst described in 199 1. 5 It has been advocated asthe treatment of choice.'6 Studies indicate thatlaparoscopic deroofing results in permanent curein the majority of cases.'7 Zacherl et al operatedon eleven patients and only one developedrecurrence.'7 Klingler et al have reviewed thestudies on laparoscopic treatment of liver cystsand pointed out that most studies have not quoteda recurrence rate. 18 They advocate that recurrenceshould be made the end point and have cautionedthat the general application of the minimallyinvasive technique should await a thoroughevaluation of the operative complications andoutcome in terms of cyst recurrence.'8 Certainly,in our series, one third ofthe patients who requiredsurgery had a previously failed laparoscopicprocedure.

In conclusion, in view of the above findings, withno recurrence, marked symptomatic improvementand minimal complications after open deroofing,we conclude that open deroofing of liver cystshas a definite role in the management of patientswith symptomatic liver cysts in this era oflaparoscopic surgery and more so in the treatmentof recurrent cysts after laparoscopic treatment.

REFERENCES

1. Caremani M, Vincenti A, Benci A, Sassoli S, TacconiD. Echographic epidemiology of non-parasitic hepaticcysts. J Clin Ultrasound 1996; 21(2): 115-8.

2. European PKD Consortium. The polycystic kidneydisease 1 gene encodes a 14kb transcript and lieswithin a duplicated region on chromosone 16. Cell1994; 77: 881-94.

3. Lai E C, Wong J. Symptomatic non-parasitic cysts ofthe liver. World J Surg 1990; 14(4): 452-6.

4. Kasai Y, Sasaki E, Tamaki A, Koshino I, KawanishiN, Hata Y. Carcinoma arising in the cyst of the liver;report of three cases. Jpn J Surg 1977; 7(2): 65-72.

5. Sanchez H, Gagner M, Rossi R L, Jenkins R L, LewisW D, Munson J L, et al. Surgical management ofnonparasitic cystic liver disease. Am J Surg 1991;161(1): 113-8.

6. Larssen T B, Viste A, Jensen D K, Sondenna K, Rokke0, Horn A. Single-session alcohol scierotherapy inbenign symptomatic hepatic cysts. Acta Radiol 1997;38(6): 993-7.

7. Polysalov V N, Oleshchuk N V. Puncture sclerosingtreatment ofnonparasitic liver cysts. Article in Russian.Vestn Khir Im I-I-Grekova 1997; 156(5): 78-80.

8. Montorsi M, Torzilli G, Fumagalli U, Bora s, RostaiR, De Simone M, et al. Percutaneous alcoholsclerotherapy of simple liver cysts. Results from amulticentre survey in Italy. HPB Surgery 1994; 8(2):89-94.

9. Lin T Y, Chen C C, Wang S M. Treatment of non-parasitic cystic disease of the liver: a new approach totherapy of the polycystic liver. Ann Surg 1968; 168(5):921-7.

10. Doty J E, Tompkins R K. Management of cysticdisease of the liver. Surg Clin North Am 1989; 69(2):285-95.

11. Edwards J D, Eckhauser F E, Knol J A, Strodel W E,Appelman H D. Optimizing surgical management ofsymptomatic solitary hepatic cysts. Am Surg 1987;53(9): 510-4.

12. Madariaga J R, Iwatsuki S, Starzi T E, Todo S, SelbyR, Zetti G. Hepatic resection for cystic lesions of theliver. Ann Surg 1993; 218(5): 610-4.

13. Que F, Nagorney D, Gross J B, Torres V E. Liverresection and cyst fenestration in the treatment ofsevere polycystic liver disease. Gastroenterology1995; 108(2): 487-4.

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14. Starzi T E, Reyes J, Tzakis A, Mieles L, Todo S,Gordon R. Liver transplantation for polycystic liverdisease. Arch Surg 1990; 125(5): 575-7.

15. Paterson-Brown S, Garden 0 J. Laser-assistedlaparoscopic excision of liver cyst. Br J Surg 1991;78(9): 1047.

16. Diez J, Decoud J, Gutierrez L, Suhl A, Merello J.Laparoscopic treatment of symptomatic cysts of theliver. Br J Surg 1998; 85(1): 25-7.

17. Zacherl J, Scheuba C, Imhof M, Jakesz R, Fugger R.Long-term results after laparoscopic unroofing ofsolitary symptomatic congenital liver cysts. SurgEndosc 2000; 14(1): 59-62.

18. Klingler P J, Gadenstatter M, Schmid T, Bodner E,Schwelberger H G. Treatment of hepatic cysts in theera of laparoscopic surgery. Br J Surg 1997; 84(4):438-44.

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