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ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 57-62

Current trends in the management of hydatid disease: Surgeons' perspective


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 Publication6-Sep-2019

Correspondence Address:
Khaled ElShaar
Department of Surgery, King Fahad Central Hospital, B.O. 8123, Jazan 45196
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_50_18

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  Abstract 


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 Top


Hydatid disease is endemic in many cattle- and sheep-rearing countries including Saudi Arabia.[1],[2] 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.[2]

Currently, there are several treatment options. Pharmacotherapy, puncture-aspiration-injection-reaspiration (PAIR), and surgery, in its open and laparoscopic forms,[3] 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.[4]

We performed this study to explore how our management of hydatid disease evolved with time.


  Patients and Methods Top


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.

Surgery

When surgery was performed, the following steps were followed:

  1. Localization and isolation of the cyst from the general peritoneal cavity using laparotomy pads soaked with hypertonic saline (10%–20%) as a scolicidal agent
  2. Aspiration of one 30%–50% of the cyst contents using a 50-ml syringe
  3. Injection of hypertonic solution (10%–20%) equivalent to the volume aspirated
  4. After the lapse of 10–15 min, to allow the scolicidal agent to work, the contents are aspirated again
  5. 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
  6. 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
  7. 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)
  8. Finally, a drain is inserted in the vicinity of the cyst, and the abdomen is closed.


Puncture-aspiration-injection-reaspiration

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

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 Top


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].
Table 1: Modes of presenting complaints

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The anatomic location of the cysts is shown in [Table 2], and as expected, the liver was the site of predilection.
Table 2: Anatomic locations of the cysts

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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].
Table 3: Primary intervention and its result in the first group

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Table 4: Primary intervention and its results in the second group

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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.

Additional measures

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 Top


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.[5]

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[6] which was not the case previously.[7]

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.[8],[9] 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.[10] 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.[11]

An estimated 50% of cysts disappear under albendazole,[8],[12] with a cure rate of more than 88% in simple hepatic cysts.[9] Furthermore, cysts which recur after cessation of treatment have a 90% response rate for further albendazole therapy,[8],[13] 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.[13],[14] Obviously, this favorable therapeutic effect occurs at the expense of a probable increase in the complication rate,[13],[15],[16] 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.[17] 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.[18] Prudently, it is usually performed under cover of albendazole therapy, to guard against recurrence in the event of spillage of the cyst contents.[19]

Gharbi et al.[20] 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,[21] 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].
Figure 5: Algorithm for the management of hepatic hydatid cysts

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Limitations

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,[22],[23] 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ibrahim MM. Study of cystic echinococcosis in slaughtered animals in Al Baha Region, Saudi Arabia: Interaction between some biotic and abiotic factors. Acta Trop 2010;113:26-33.  Back to cited text no. 1
    
2.
Bauman RW. Parasites, protozoa, Helminths and anthropods vectors. In: Microbiology. Ch. 23. San Francisco USA: Pearson Benjamin Cummings; 2004. p. 649-78.  Back to cited text no. 2
    
3.
Gupta N, Javed A, Puri S, Jain S, Singh S, Agarwal AK, et al. Hepatic hydatid: PAIR, drain or resect? J Gastrointest Surg 2011;15:1829-36.  Back to cited text no. 3
    
4.
El Sheikh A, Al Malki A, El Shiekh MA, Al Robayan A. Non-surgical management in 336 patients of hydatid disease: 23 years experience at Riyadh military hospital. Hepatogastroenterology 2011;58:336-46.  Back to cited text no. 4
    
5.
Nabti S, Makhloufi HA, Achouri D, Soualili Z. Therapeutic actualities of liver hydatid cysts in children. EC Paediatrics 2018;7:158-9.  Back to cited text no. 5
    
6.
Manouras A, Genetzakis M, Lagoudianakis EE, Papadima A, Triantafillou C, Kekis PV, et al. Intact germinal layer of liver hydatid cysts removed after administration of albendazole. Neth J Med 2007;65:112-6.  Back to cited text no. 6
    
7.
Topçu S, Kurul IC, Taştepe I, Bozkurt D, Gülhan E, Cetin G, et al. Surgical treatment of pulmonary hydatid cysts in children. J Thorac Cardiovasc Surg 2000;120:1097-101.  Back to cited text no. 7
    
8.
Teggi A, Lastilla MG, De Rosa F. Therapy of human hydatid disease with mebendazole and albendazole. Antimicrob Agents Chemother 1993;37:1679-84.  Back to cited text no. 8
    
9.
Liu Y, Wang X, Wu J. Continuous long-term albendazole therapy in intraabdominal cystic echinococcosis. Chin Med J (Engl) 2000;113:827-32.  Back to cited text no. 9
    
10.
Capan M, Keltner S, Thalhammer F, Winkler S, Jäger W, Zeitlinger M, et al. Intra-cystic drug concentration of albendazole sulphoxide in patients with Echinococcus granulosus cysts. Am J Trop Med Hyg 2009;81:712-3.  Back to cited text no. 10
    
11.
Kazim Duman, Mustafa Girgin and Salih Hamcan, Uncomplicated Hydatid Cysts of the Liver: Clinical Presentation, Diagnosis and Treatment. J Gastrointest Dig Syst 2016;6:3. DOI: 10.4172/2161-069x.1000430.  Back to cited text no. 11
    
12.
Yasawy MI, Alkarawi MA, Mohammed AR. Prospects in medical management of Echinococcus granulosus. Hepatogastroenterology 2001;48:1467-70.  Back to cited text no. 12
    
13.
Haralabidis S, Diakou A, Frydas S, Papadopoulos E, Mylonas A, Patsias A, et al. Long-term evaluation of patients with hydatidosis treated with albendazole and praziquantel. Int J Immunopathol Pharmacol 2008;21:429-35.  Back to cited text no. 13
    
14.
Cobo F, Yarnoz C, Sesma B, Fraile P, Aizcorbe M, Trujillo R, et al. Albendazole plus praziquantel versus albendazole alone as a pre-operative treatment in intra-abdominal hydatisosis caused by Echinococcus granulosus. Trop Med Int Health 1998;3:462-6.  Back to cited text no. 14
    
15.
Lima RM, Ferreira MA, de Jesus Ponte Carvalho TM, Dumêt Fernandes BJ, Takayanagui OM, Garcia HH, et al. Albendazole-praziquantel interaction in healthy volunteers: Kinetic disposition, metabolism and enantioselectivity. Br J Clin Pharmacol 2011;71:528-35.  Back to cited text no. 15
    
16.
Homeida M, Leahy W, Copeland S, Ali MM, Harron DW. Pharmacokinetic interaction between praziquantel and albendazole in Sudanese men. Ann Trop Med Parasitol 1994;88:551-9.  Back to cited text no. 16
    
17.
Todorov T, Vutova K, Mechkov G, Petkov D, Nedelkov G, Tonchev Z, et al. Evaluation of response to chemotherapy of human cystic echinococcosis. Br J Radiol 1990;63:523-31.  Back to cited text no. 17
    
18.
Kahriman G, Ozcan N, Donmez H. Hydatid cysts of the liver in children: Percutaneous treatment with ultrasound follow-up. Pediatr Radiol 2011;41:890-4.  Back to cited text no. 18
    
19.
Yasawy MI, Mohammed AE, Bassam S, Karawi MA, Shariq S. Percutaneous aspiration and drainage with adjuvant medical therapy for treatment of hepatic hydatid cysts. World J Gastroenterol 2011;17:646-50.  Back to cited text no. 19
    
20.
Gharbi HA, Hassine W, Brauner MW, Dupuch K. Ultrasound examination of the hydatic liver. Radiology 1981;139:459-63.  Back to cited text no. 20
    
21.
Crippa FG, Bruno R, Brunetti E, Filice C. Echinococcal liver cysts: Treatment with echo-guided percutaneous puncture PAIR for echinococcal liver cysts. Ital J Gastroenterol Hepatol 1999;31:884-92.  Back to cited text no. 21
    
22.
Moghaddam NS, Abrishami A, Taefi A, Malekzadeh R. Percutaneous needle aspiration, injection, and re.aspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts. Cochrane Database Syst Rev 2006;19:CD003623.  Back to cited text no. 22
    
23.
Stojkovic M, Zwahlen M, Teggi A, Vutova K, Cretu CM, Virdone R, et al. Treatment response of cystic echinococcosis to benzimidazoles: A systematic review. PLoS Negl Trop Dis 2009;3:e524.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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