|Year : 2019 | Volume
| Issue : 2 | Page : 57-62
Current trends in the management of hydatid disease: Surgeons' perspective
M Ezzedien Rabie1, Khaled ElShaar2, Mohammad Al Skaini1, Hussein Ageely3, AbdelNasser Zaid4, Ismail El Hakeem1, Saad Al Qahtani5
1 Department of Surgery, Armed Forces Hospital Southern Region, Khamis Mushayt, Saudi Arabia
2 Department of Surgery, King Fahad Central Hospital, Jazan, Saudi Arabia
3 Department of Medicine, College of Medicine, Jazan, Saudi Arabia
4 Department of Surgery, College of Medicine, Jazan University, Jazan, Saudi Arabia; Department of Surgery, College of Medicine, Assiut University, Assiut, Egypt
5 Department of Interventional Radiology, Armed Forces Hospital Southern Region, Khamis Mushayt, Saudi Arabia
|Date of Web Publication||6-Sep-2019|
Department of Surgery, King Fahad Central Hospital, B.O. 8123, Jazan 45196
Source of Support: None, Conflict of Interest: None
Background: Surgery was the only known curative treatment for hydatid disease. Currently, this is being changed.
Aims: The aim of this study was to explore the evolution of our management policy for hydatid disease.
Patients and Methods: We retrieved records of patients with hydatid disease, treated in our unit in the period from January 1998 to February 2012.
Results: Twenty-seven patients were identified. For comparison and driven by the appearance of nonsurgical means in the series, patients were divided into two groups: the first group included the first 12 patients and the second group included the last 15 patients. In the first group, all patients received surgery and only two (16.7%) received postoperative albendazole therapy. In the second group, only four patients (26.7%) received surgery with perioperative pharmacotherapy, eight patients (53.3%) received pharmacotherapy alone, and three patients (20%) received puncture-aspiration-injection-reaspiration (PAIR) with periprocedural pharmacotherapy. In those who received surgery with adjuvant pharmacotherapy, one patient died and the cyst disappeared in the remaining three. In those who received PAIR, the cyst disappeared in one case and regressed in the other two. In those who received pharmacotherapy alone, two patients showed disappearance of the cyst, one showed partial response, and five are under follow-up.
Conclusions: Surgery is no longer the first-line treatment for hydatid disease. It should be reserved for complicated cases and those presenting as an emergency. When applied, surgery should be backed by pharmacotherapy which has a pivotal role, both as a sole agent and as an adjunctive to therapy.
Keywords: Hydatid cyst, pharmacotherapy, puncture-aspiration-injection-reaspiration, surgery
|How to cite this article:|
Rabie M E, ElShaar K, Al Skaini M, Ageely H, Zaid A, El Hakeem I, Al Qahtani S. Current trends in the management of hydatid disease: Surgeons' perspective. Saudi Surg J 2019;7:57-62
|How to cite this URL:|
Rabie M E, ElShaar K, Al Skaini M, Ageely H, Zaid A, El Hakeem I, Al Qahtani S. Current trends in the management of hydatid disease: Surgeons' perspective. Saudi Surg J [serial online] 2019 [cited 2019 Nov 13];7:57-62. Available from: http://www.saudisurgj.org/text.asp?2019/7/2/57/266214
| Introduction|| |
Hydatid disease is endemic in many cattle- and sheep-rearing countries including Saudi Arabia., The disease is caused by the tapeworm Echinococcus granulosus, and canines are its definitive hosts. Livestock and, accidentally, humans are the intermediate hosts by consuming food or water contaminated by the eggs of the parasite. Eggs hatch in the small intestine, where the released larvae penetrate its wall and, circulating with the blood, can settle in any organ of the body, primarily the liver.
Currently, there are several treatment options. Pharmacotherapy, puncture-aspiration-injection-reaspiration (PAIR), and surgery, in its open and laparoscopic forms, are all available, and the choice between them has not been standardized yet.
In the recent past, interest in the nonsurgical means gained popularity, and high success rates have been claimed.
We performed this study to explore how our management of hydatid disease evolved with time.
| Patients and Methods|| |
Our records were reviewed to identify patients with hydatid disease, who were treated in the surgical unit, in the period from January 1998 to October 2011. The medical records of the patients were retrieved and relevant details were extracted. These included patients' demographics, modes of presentation, location, number and size of the cysts, treatment given, and its results and complications.
When surgery was performed, the following steps were followed:
- Localization and isolation of the cyst from the general peritoneal cavity using laparotomy pads soaked with hypertonic saline (10%–20%) as a scolicidal agent
- Aspiration of one 30%–50% of the cyst contents using a 50-ml syringe
- Injection of hypertonic solution (10%–20%) equivalent to the volume aspirated
- After the lapse of 10–15 min, to allow the scolicidal agent to work, the contents are aspirated again
- Deroofing of the cyst is done, and the remaining cyst contents are meticulously suctioned under direct vision while irrigating the field with hypertonic saline solution and avoiding spillage of the potentially infective cyst contents
- A thorough search is made in the interior of the cyst for any source of bile leak, which should be suture ligated to avoid biliary fistula
- The interior of the cyst cavity is collapsed by the application of a series of absorbable sutures starting in the bottom and working toward the surface (capitonnage), or more favorably, a vascularized pedicle of omentum is tucked inside the cyst (omentopexy)
- Finally, a drain is inserted in the vicinity of the cyst, and the abdomen is closed.
When PAIR was done, steps 2, 3, and 4 were followed but performed percutaneously. This was done under computed tomography (CT) guidance for a hepatic cyst in one case and by direct puncture of a huge thigh cyst without radiology guidance in another.
Pharmacotherapy entails the administration of albendazole (GlaxoSmithKline, Australia) with or without praziquantel (Egyptian International Pharmaceutical Industries Company, Egypt). Our preferred chemotherapeutic regimen is composed of three cycles of Albendazole, 10 mg/kg/day orally in 2 divided doses for 1 month, along with Praziquantel, 50 mg/kg/day orally in 2 divided doses for 2 weeks. The cycles were separated by 2-week intervals, with serial Ultrasound follow up. Lately, these cycles are not adhered to, and prolonged treatment periods are prescribed.
| Results|| |
We were able to identify 27 patients, 6 males and 21 females, with a mean age of 44.6 years (range: 17–90). The mean largest diameter of the cyst on US/CT was 10.2 cm (range: 4.5–19), and the presenting complaints are shown in [Table 1].
The anatomic location of the cysts is shown in [Table 2], and as expected, the liver was the site of predilection.
There were a single cyst in 14 cases (51.9%) and multiple cysts in 13 cases (48.1%), and the cyst was primary in 21 cases (77.8%) and recurrent in 6 cases (22.2%).
Type of primary intervention
For the ease of comparison and trend reporting, the cases were divided into the first 12 cases ( first group) and the last 15 cases (second group). The divisive point was the appearance of other nonsurgical means for management in this series. The primary intervention and its results are shown in [Table 3] and [Table 4].
In the first group, all cases (100%) received surgery and only two of them (16.7%) received postoperative albendazole therapy. In the second group, on the other hand, only four patients (26.7%) received surgery, because of their clinical presentions, as two cases presented with acute cholangitis (one of them died postoperatively due to severe sepsis, (the only mortality in the series). The third case presented with abdominal wall abscess caused by a recurrent infected hydatid cyst and the fourth case had a large (16 cm) cyst.. All the four cases received pre- and postoperative pharmacotherapy. In the remaining 11 cases, three patients (20%) received PAIR [Figure 3] and [Figure 4] and 8 (53.3%) received pharmacotherapy.
|Figure 1: (a) Hydatid cysts of the liver before medical treatment. (b) Hydatid cysts of the liver with complete response after medical treatment|
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|Figure 2: (a) Hydatid cysts of the liver, left hypochondrium, and lower pole of the spleen before medical (yellow arrows). (b) Hydatid cysts of the liver (yellow arrows), left hypochondrium, and lower pole of the spleen after medical treatment. Hepatic cyst showed changed morphology with disappearance of the daughter cysts. Splenic and other intraperitoneal cysts also disappeared|
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|Figure 3: large cystic swelling of the left thigh obstructing the venous return in the great saphenous vein (yellow arrows), exceptionally suitable for puncture-aspiration-injection-reaspiration|
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|Figure 4: Hepatic hydatid cyst after puncture-aspiration-injection-reaspiration. Pigtail catheter inside the collapsed cyst after aspiration of its contents|
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Complications of intervention
Collectively, postsurgery cyst recurrence occurred in three cases, biliary fistula and wound infection occurred in one case each, and death occurred in another case. On the other hand, no major adverse event was attributed to medical treatment or PAIR in this series.
Endoscopic retrograde cholangiopancreatography (ERCP) was used in two cases: one case presented with cholangitis and ERCP was followed by surgical intervention and another case presented with deranged liver enzymes and ERCP was followed by PAIR and periprocedural medical treatment.
| Discussion|| |
Hydatidosis is the most common human larval cestodiasis. The disease is endemic in many areas of the world. Initially, open surgery was the only accepted treatment for this disease, but currently, the possibilities for the treatment of hepatic echinococcosis have increased considerably in recent years (including medical treatment, PAIR, or a combination of these two). Surgery remains the mainstay for healing of hydatid disease.
Our own management of hydatid disease has changed over the time, from heavily counting on surgery as a sole agent to recruiting other nonsurgical options, namely pharmacotherapy and PAIR.
As seen in [Table 3] and [Table 4], surgery was applied to 100% of patients in the first group, whereas it was applied to 28.6% only in the second. The choice of surgery in the second group was mainly reserved for those patients presenting acutely and demanding immediate relief. In addition, the surgery was always backed by pharmacotherapy in the perioperative period in the second group. This practice is well documented in the literature which was not the case previously.
This decline in the role of surgery has been accompanied by a parallel expansion of the role played by medical treatment as a sole agent, where it increased from nil in the first group to 53.3% of cases in the second.
This reflects a general trend in the literature, as medical treatment is believed now to be safe, effective, and well tolerated in the majority of cases., It consists of the administration of albendazole alone or in combination with praziquantel. Albendazole, a benzimidazole derivative, is highly active against echinococcal protoscolices. Its effectiveness is dependent entirely on its ability to achieve high intracystic concentrations. Both cause degeneration in echinococcal mitochondria and endoplasmic reticulum. In recent studies, albendazole has been reported to be preferred more as it has higher gastrointestinal absorption and bioavailability. The most common side effects are nausea, hepatotoxicity, neutropenia, and alopecia. Medical treatment is not recommended in pregnant women and in liver and bone marrow insufficiency.
An estimated 50% of cysts disappear under albendazole,, with a cure rate of more than 88% in simple hepatic cysts. Furthermore, cysts which recur after cessation of treatment have a 90% response rate for further albendazole therapy,, and this assumption provided the basis for our extended follow-up and intermittent pharmacotherapy policy, where five patients are currently under it.
The addition of praziquantel to albendazole increases the plasma concentration of the active metabolite albendazole sulfoxide., Obviously, this favorable therapeutic effect occurs at the expense of a probable increase in the complication rate,,, even though a combined drug regimen has been our preferred method with no observed major side effects.
The response to medical treatment could be assessed radiologically. Reduction in cyst size or deformation of its shape is indicative of a favorable response, but obviously, the most convincing evidence is the disappearance of the cyst. In this series, the complete resolution of the cyst occurred with medical treatment in two cases, and a favorable response was observed in a third huge cyst.
PAIR has established its role as an effective modality in the management of hepatic hydatid cyst. Prudently, it is usually performed under cover of albendazole therapy, to guard against recurrence in the event of spillage of the cyst contents.
Gharbi et al. Type I, II, and probably III cysts are suitable for PAIR under radiology guidance, with low incidence of morbidity and recurrence. Once the cyst recurs, it can be subjected to another session of PAIR, a situation much easier than in open surgery, where subsequent surgeries become progressively more difficult.
When considering PAIR, the internal configuration of the cyst is of paramount importance. Cysts with internal septa caused by daughter cysts and brood capsules are more difficult to aspirate than simple cysts. In such cases, the membranous contents may clog the aspiration catheter. In this series, PAIR was utilized in three cases with a favorable outcome. In one case, with a huge thigh cyst with retroperitoneal extension, the procedure was exceptionally easy. In the other two which were hepatic cysts, the aspirating catheter had to be flushed repeatedly to clear its holes from the clogging membranes.
The different treatment modalities for hydatid disease should be considered complementary rather than exclusive, starting with the least invasive and progressing in an escalating fashion. Based on our experience and backed by the literature, we suggest an algorithm for management of hepatic hydatid cyst [Figure 5].
Obviously, we were delayed in accepting the medical treatment both as a primary and as an adjunctive therapy. Moreover, the study has the inherent defects of all retrospective studies. However, randomized controlled trials are lacking in this area,, and as medical treatment proved effective in this as well as other studies, with no serious side effects, it could always be started with first, either as a definitive treatment or in preparation for another form of therapy, according to our suggested algorithm.
| Conclusions|| |
Surgery is no longer the first-line treatment for hydatid disease, and its role is likely to dwindle in favor of pharmacotherapy and PAIR. It should be reserved for complicated cases and those presenting in an emergency situation, demanding immediate relief. When applied, surgery should be backed by pharmacotherapy which has a pivotal role both as a sole agent and as an adjunct to other forms of therapy.
Financial support and sponsorship
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], [Table 3], [Table 4]