|Year : 2017 | Volume
| Issue : 1 | Page : 35-39
Laparoscopic management of parasitic liver cysts: A retrospective, comparative study
Hossam Eldeen Mohamed Soliman, Hany Abdelmeged Shoreem, Osama Hegazy Abdelsallam, Sherief Mohamed Saleh, Mohamed Taha Badawey, Ahmed Nabil Sallam, Islam Ali Ayoub, Emad Hamdy Gad, Taha Eid Yaseen, Hazem Zakaria Lasheen, Maher Ali Osman, Amro Mostafa Aziz, Ibrahim Abdelkader Salama, Tarek Mohamed Ibrahim, Khaled Aly Abuellella
Department of Hepatobiliary Surgery, National Liver Institute, Menoufia University, Al Minufya, Egypt
|Date of Web Publication||12-Apr-2017|
Hossam Eldeen Mohamed Soliman
3029 Elhadaba Elwosta, El Mokatam Cairo
Source of Support: None, Conflict of Interest: None
Introduction: Parasitic liver cysts are common in many areas of the world. In our country, hydatid disease is the commonest to cause cystic lesions. We reviewed our data to compare and analyze the outcome of laparoscopic management of these patients. This paper assesses the feasibility and safety of laparoscopic management of hepatic hydatid disease in a tertiary center in Egypt.
Materials and Methods: We retrospectively reviewed our operative and inpatient data at the National liver institute, Menoufia university, Egypt for clinical and operative, postoperative details patients with preoperative diagnoses of a hepatic hydatid disease starting from June 2012 to June 2015.
Results: 47 patients had operative management for hepatic hydatid cystic lesions. Twenty seven patients had laparoscopic management and 20 patients were managed through open procedures. Operative procedure included endocystectomy in all laparoscopic cases and while three of the open group had liver resection in addition. Hospital stay was at a mean of 3 days for lap cases and 6 cases for open group. Complications included one cases of bile leak and minor wound infections in the open group. While there were no complications in in the lap group. Follow up showed occurrence of recurrence in two of the open group only.
Conclusions: With conventional laparoscopic instruments, the laparoscopic approach in the management of hepatic hydatid cysts is safe and feasible even. It showed shorter operative time and hospital stay with relatively decreased postoperative complication rate.
Keywords: Hydatid, laparoscopic, liver, surgery
|How to cite this article:|
Soliman HE, Shoreem HA, Abdelsallam OH, Saleh SM, Badawey MT, Sallam AN, Ayoub IA, Gad EH, Yaseen TE, Lasheen HZ, Osman MA, Aziz AM, Salama IA, Ibrahim TM, Abuellella KA. Laparoscopic management of parasitic liver cysts: A retrospective, comparative study. Saudi Surg J 2017;5:35-9
|How to cite this URL:|
Soliman HE, Shoreem HA, Abdelsallam OH, Saleh SM, Badawey MT, Sallam AN, Ayoub IA, Gad EH, Yaseen TE, Lasheen HZ, Osman MA, Aziz AM, Salama IA, Ibrahim TM, Abuellella KA. Laparoscopic management of parasitic liver cysts: A retrospective, comparative study. Saudi Surg J [serial online] 2017 [cited 2017 Jun 27];5:35-9. Available from: http://www.saudisurgj.org/text.asp?2017/5/1/35/204414
| Introduction|| |
Hydatid disease is a parasitic disease with a wide range of distribution. It is endemic in many areas such as Middle East, South America, New Zealand, and Turkey. It is more common where farming is the basic occupation of the population.
Hydatid disease must be treated once it is diagnosed. Although there are alternative treatment modalities such as medical therapy and percutaneous aspiration of simple hydatid cyst, surgical treatment remains the first-line treatment, particularly for complicated cysts providing similar results regarding complications.,,,,,,,,
Despite growing interest in the nonsurgical techniques, a variety of surgical procedures have been described using conventional open techniques, including pericystectomy, unroofing the cyst with omentoplasty, marsupialization, and liver resection.,,,
The first laparoscopic treatment attempts were made in 1992. Over the last two decades, laparoscopic approaches for the treatment of hydatid cysts have gained increasing popularity. So far, the controversies regarding the role of laparoscopy in the management of hydatid disease have not been resolved.
This comparative study analyzes and compares the results of both open and laparoscopic treatment of hepatic hydatid cyst. These surgical approaches were investigated, especially for the safety and feasibility of the laparoscopic approach.
| Subjects and Methods|| |
This study included the retrospective analysis of the data of patients who were diagnosed to have liver hydatid cyst and managed surgically during June 2012–June 2015 at the National Liver Institute (NLI), Menoufia University, Egypt. This study followed our institutional guidelines and was approved by the Ethical Committee.
The diagnosis of echinococcal cysts was based on patient's history, physical examination, serological testing, and ultrasound and computed tomography scan.
In NLI protocol of management, preoperative medical treatment with albendazole at a dose of 10–15 mg/kg was given for all cases that scheduled for surgery 1 month before surgery and continued at least 3 months following surgery.
Data collection included patient's demographic characteristics, presenting signs and symptoms, clinical findings, features of hydatid cysts, surgical procedure, and postoperative outcomes including morbidities and mortalities. Patients were divided into two groups regarding surgical approach: Group A – conventional open surgery and Group B – laparoscopic surgery. Magnetic resonance cholangiopancreatography was performed to exclude biliary communication if suspected.
Radical surgery referred to pericystectomy and liver resection, whereas conservative surgery involved the unroofing of the cyst and removal of the cyst content, together with partial cyst resection (endocystectomy).
Right subcostal laparotomy incision ± midline or left limb was used in most of the patients in the open group. In the laparoscopic cases, placement of at least four trocars was performed. In both types of surgical interventions, fluid in the cyst was aspirated using a needle until the tension of cyst disappeared, and then, injection of a hypertonic saline solution (3%) into the cyst was applied and kept in for 10 min to obtain scolocidal effect. In the laparoscopic cases, the endocysts were retrieved in a laparoscopic endobag or completely aspirated. The technique is shown in [Figure 1].
|Figure 1: (a) A cyst in segment VI of the liver. (b) Packing the field by soaked gauze. (c) Aspiration of the cyst. (d) Injection of 3% hypertonic saline. (e) Hypertonic saline is left for 10 min. (f) Opening and unroofing of the cyst. (g) Removal of the cyst wall in a bag. (h) Burning the wall with diathermy|
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Postoperative management and follow-up
All patients underwent clinical follow-up and daily monitoring until they were discharged from the hospital. The daily drain output, its consistency, and color were monitored. The patient outcomes include length of hospital stay, complications related to the procedure, and its management. A protocol of regular postoperative follow-up in outpatient clinic by ultrasonography and clinical examination for at least 6 months was adopted in NLI.
Statistical analysis was performed using SPSS version 20 (SPSS, Chicago, IL, USA). All continuous data were presented as means ± standard deviations. Statistical significance of the findings was analyzed using the two-tailed Student's t-test and Wilcoxon-related two-sample test. The Fisher's exact test was employed for testing the statistical significance of the association between two discrete variables, and Spearman's rank correlation was used. A P < 0.05 was considered statistically significant.
| Results|| |
Forty-seven patients were included in this study. The mean age was 36.62 ± 10 years (range: 4–67 years) and there were 29 males (61.7%) and 18 females (38.3%). Twenty patients were treated with the open surgical approach (Group A) and 27 with laparoscopic surgical procedures (Group B). The demographic characteristics and cyst features are shown in [Table 1].
Both groups were comparable in terms of cyst location, size, and type. Cyst location was right lobe in 61.7% of the patients and left lobe in 31.9% of the patients. The lesion was found bilaterally located in 3 patients (6.38%) only; four patients had an extrahepatic location, splenic in two cases and perihepatic cyst in another two cases. Clinical findings included dyspepsia (due to cyst pressure to stomach) (n = 10), abdominal pain (n = 31), and incidental diagnosis during abdominal radiological study (n = 6).
The selection criteria for laparoscopic approach were single, superficial, peripheral cysts without biliary communication or relation to big vessels. The surgical procedure was chosen based on the patients' comorbidities and the location and relations of the cyst with vascular and biliary structures, as well as the surgeon's preference and experience.
Operative procedures and complications are shown in [Table 2]. The surgical techniques included conservative approaches such as unroofing of the cystic cavity with drainage and pericystectomy procedure and radical resection surgery (one right hepatectomy, one nonanatomical resection, and one pericystectomy) [Figure 2],[Figure 3],[Figure 4]. Omentoplasty was added in 14 patients. Cholecystectomy was performed in eight patients (17%) due to concomitant cholelithiasis (n = 4) or a close relationship between hydatid cyst and gallbladder (n = 4). Splenectomy was performed in two patients due to splenic hydatid disease. One patient in the laparoscopic group had pericystectomy [Figure 5]. In the open group, two patients had perihepatic cysts and were completely excised. There was no operative mortality in both groups.
|Figure 2: A case of large cyst in the right lobe treated by non anatomical resection. (a) Computed tomography of right lobe cyst. (b) Operative picture. (c) Bed after resection|
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|Figure 3: Huge right lobe cyst treated by liver right hepatectomy. (a) Huge right lobe hydatid. (b) Right hepatectomy specimen. (c) Bed after resection|
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|Figure 4: The recurrent case treated by pericystectomy. (a) Pericystectomy of recurrent cyst. (b) Cross-section of the cyst|
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|Figure 5: Laparoscopic pericystectomy of a small cyst is simian immunodeficiency virus. (a) Computed tomography scan of left lobe hydatid cyst. (b) Laparoscopic pericystectomy|
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Both groups were comparable in terms of cyst location, size, and type. In patients in Group A, postoperative complications occurred in six patients (30%) and included one biliary leak, intra-abdominal fluid collection, and wound infection. Although it was lower in the laparoscopic group, there were no statistically significant differences between groups.
Operatively, three cysts in the open group had biliary communication. All were closed surgically without complications. Another patient had bile leak that was diagnosed in the postoperative period by to bile presence in the drain tube. This was treated conservatively as the amount of leak decreased gradually, with complete closure of the biliary fistula in 6 days. Ultrasound-guided percutaneous intervention aspiration and/or drainage were efficient in the management of the postoperative fluid collection in one case. No surgical interference was needed.
The mean follow-up period was 24.2 months (range, 6–42 months) for Group A and 28.4 months (range, 6–40 months) for Group B. There were two recurrences that were observed in the open group only. Overall recurrence rate was 3.6% during a median follow-up period of 28 months (range: 6–48 months). This recurrence was treated by medical treatment and one was successfully treated by pericystectomy [Figure 4].
| Discussion|| |
Although the possibilities for the treatment of hepatic echinococcosis have increased considerably in recent years (including medical treatment, percutaneous aspiration, or a combination of these two), surgery remains the mainstay and the best option for a complete cure for hydatid disease., The type of surgical approach depends on cystic features including size, complications, and surgeon's personal preferences. As the laparoscopic approach has been performed for numerous surgical procedures, it has also been popularized in the surgical treatment of hydatid cysts. Initially, however, laparoscopy was not quickly accepted or widely used in the treatment of hydatid disease due to the concern that the recurrence rate and the risk of intraperitoneal dissemination might be higher than with the conventional approach. In fact, the real risk of spillage is lower than might be expected and the short-term recurrence rate is higher in open surgery.,,, Another great advantage of laparoscopic treatment is that the laparoscope can be inserted into the cystic cavity, allowing its inspection ,
The advantages of laparoscopic approach as compared to open surgery include shorter hospital stay,,,,,, which we also encountered in our study, lower incidence of wound infection, and less postoperative pain.
A few disadvantages of the laparoscopic approach need to be considered. For example, laparoscopy still is limited in terms of major liver resection, closure of biliary communications, and achievement of anastomoses although, in recent years, an increasing number of authors have published promising results.,, We did not perform any hepatic resections anastomoses through laparoscopy. In addition, for the laparoscopic approach, it is believed that location is an important factor in selecting the patients, particularly anteriorly located cysts. However, a comparative study by Zaharie et al. showed that a laparoscopic approach is safe for the treatment of cysts in almost all segments. In this study, right lobe of the liver was found to have two-fold increased risk of hydatid disease. Similar results have also been available in previous reports.,, However, regarding anterior/posterior locations, there was found no difference in our study.
In this study, although the postoperative morbidity was found to be lower in the laparoscopic group, it was not statistically significant. The overall rate of biliary fistula is consistent with previous studies, reporting a rate ranging between 3% and 37%.,,, Although it was not statistically significant, postoperative biliary fistula rate was found lower in the laparoscopic group. This may be due to the fact that open surgery cysts were more complex and that laparoscopically treated cysts were smaller and located mostly peripherally including tertiary biliary ducts, which are prone to spontaneous closure.
In the present study, except for biliary fistula formation and recurrence, complications did not differ significantly between the two groups. It is reported that laparoscopic management decreases the severity of complications as compared with that in open surgery ,, and mild complications were more observed in laparoscopic group as compared to the open surgery group.
There are a few limitations of this study. Although, for laparoscopic surgery patients, there were some inclusion criteria (nonhomogenous groups), cystic features including locations and diameters were not similar between groups. The follow-up to time is not enough long to note any long-term data about recurrences; this topic was not extensively covered in this study discussion.
| Conclusions|| |
We suggest that with conventional laparoscopic instruments, the laparoscopic approach in the management of hepatic hydatid cysts is safe and feasible. It showed shorter operative time and hospital stay, with relatively decreased postoperative complication rate. It is the recommended technique of choice in selected cases.
Financial support and sponsorship
The study was funded by the National Liver Institute, Menoufia University.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]