treatment of the hepatic hydatid cyst by ultrasound

ORIGINAL ARTICLES
TREATMENT OF THE HEPATIC HYDATID CYST BY
ULTRASOUND-GUIDED TRANSCUTANEOUS PUNCTURE
Abdulah Salim1, Doru Bordos1, Ciprian Duta1, Delia Zahoi2, Ecaterina Daescu2
REZUMAT
Introducere: Chistul hidatic hepatic, afecţiune provocată de Taenia Echinococcus, este în prezent tratat cu succes şi prin puncţie transcutanată ghidată
ecografic, metodă minim invazivă cu rezultate bune şi foarte bune, descrisă în literatura de specialitate începând cu anii ‘90. Obiective: În această
lucrare am avut ca scop evaluarea rezultatelor tratamentului chistului hidatic hepatic prin puncţie percutană, metodă comparabilă şi adesea mai sigură
decât chirurgia şi care se poate realiza cu costuri minime. Material şi metode: În perioada aprilie 1996 – decembrie 2011 au fost incluşi în studiu un
număr de 319 pacienţi dintre care 46 au fost operaţi laparoscopic, 56 au fost operaţi pe cale clasică iar la 217 s-a efectuat puncţia transcutanată ghidată
ecografic. Vârsta pacienţilor a fost cuprinsă între 16 şi 67 ani. Rezultate: Durata de spitalizare medie a fost de 3,5 zile. Scăderea diametrului chistelor
a fost: în prima lună – între 58 şi 100%; la trei luni – între 69 şi 100%; la 6 luni – între 72 şi 100%; după 12 luni – între 75 şi 100%. Un număr de 5
(2,3%) pacienţi au prezentat reacţii alergice uşoare ; 86,56% din chiste au dispărut; 5,97% au necesitat repuncţionare; 7,46% din chiste au recidivat.
Concluzii: Avantajele metodei sunt evidente în ceea ce priveşte traumatismul operator, morbiditatea postoperatorie, durata spitalizării, în localizările greu
accesibile chirurgical, în recidivele postoperatorii.
Cuvinte cheie: chist hidatic hepatic, Taenia Echinococcus, puncţie transcutanată ghidată ecografic
ABSTRACT
Introduction: The hepatic hydatid cyst, a parasitic disease caused by Taenia Echinococcus, can nowadays be successfully treated using ultrasoundguided transcutaneous puncture, a minimally invasive method, described in the literature as early as the ‘90s. Objectives: This study aims to evaluate the
results of the percutaneous puncture treatment of the hepatic hydatid cyst, a method that is more cost effective and often safer than surgery. Material
and methods: The study was conducted on 319 patients (aged between 16 and 67 years), treated between April 1996 and December 2011. Out of
the 319, 46 were operated laparoscopically, 56 by classical surgery and 217 were subjected to ultrasound-guided transcutaneous puncture. Results:
The average duration of hospitalization was 3.5 days. The reduction in cyst diameter was: 58-100% in the first month; 69-100% after three months;
72-100% after 6 months and 75-100% after 12 months. A number of 5 (2.3%) patients had mild allergic reactions, 86.56% of the cysts disappeared,
5.97% needed to undertake the puncture procedure again and 7.46% of the cysts relapsed. Conclusions: The advantages of this method are obvious
in terms of surgery trauma, post-operative morbidity, duration of hospitalization, surgically difficult to reach areas and post-surgery relapses.
Key Words: hepatic hydatid cyst, Taenia Echinococcus, ultrasound-guided transcutaneous puncture.
INTRODUCTION
Echinococcus granulosus, which causes cystic
echinococcosis, is one of the smallest members of the
Taenia family. In the larval stage, it causes zoonosis in
humans.1
The hydatid disease is widespread around the
globe but is unevenly concentrated, being more
common in rural areas, and more prevalent among
shepherds, butchers and cattle breeders. The disease
Department of General Surgery No. 2, Clinical Emergency County
Hospital Timisoara, 2 Department of Anatomy and Embryology, Victor
Babes University of Medicine and Pharmacy, Timisoara
1
Correspondence to:
Abdulah Salim, Emergency County Hospital, 10 I. Bulbuca Blvd, 300736,
Timisoara, Romania. Tel. +40-72-223-9078.
Email: surg20032003@yahoo.com
Received for publication: Nov. 24, 2011. Revised: May 20, 2012.
_____________________________
52
TMJ 2012, Vol. 62, No. 1 - 2 is considered endemic in the following areas: the
Mediterranean, Middle East, Eastern Europe, Africa,
Argentina, Australia, Chile, China and New Zealand.2,3
In Romania, the number of cases is increasing due
to increases in livestock numbers and to current
diagnostic possibilities.4
Diagnosis is usually the result of paraclinical
investigations such as ultrasound, X-ray, CT,
hematologic and immunohistochemical tests. It is
rarely established by clinical examination as the disease
has a slow, insidious evolution and, in the absence of
complications, is accompanied by minimum and nonspecific clinical manifestations.5,6
The treatment of hepatic hydatid cysts includes
drugs such as albendazole or mebendazole, classical or
laparoscopic surgery and the PAIR method (puncture,
aspiration, injection, re-aspiration).7
The treatment is usually mixed, but in the case of
small, young cysts with thin walls, only medical methods
can be used. Some studies have shown that high doses
and long term use of drugs can lead to reversible
neutropenia and, in some cases, to modifications of
to the following criteria:
8-11
the hepatic and renal functions.
- Types I and II according to the Gharbi
Open surgery is especially useful in difficult to
classification;
reach locations, in the cases of giant cysts or in the
- Patients for whom drug treatment had failed;
presence of adhesions, but it has a higher rate of
- Patients for whom surgical treatment was
complications and leads to longer hospitalization.
contraindicated due to the multiple comorbidities;
Laparoscopy, recommended only when the cyst
- Cysts in difficult to reach locations;
is easily accessible, ensures a high visibility, a safe
- Patients who accepted this treatment as an
hemostasis and a shorter hospitalization.10-12
alternative to the surgical treatment;
The ultrasound-guided transcutaneous puncture
This treatment was unsuitable for:
is a method that caught on very quickly due to its
- Patients with hydatid cysts classified from the
relatively easy execution and to its incontestable
ultrasound point of view as Gharbi types III, IV and V;
advantages compared to surgery, in terms of post- Patients whose cysts were infected or broken in
operative mortality and duration of hospitalization.10,11
the bile ducts or in the peritoneum.
However, the method also involves a number of risks,
After the certitude diagnosis of hepatic hydatid
such as bleeding accidents, injuries of other viscera,
cysts, therapeutic protocols must be prepared. At the
secondary seeding caused by leaks of the hydatid fluid
moment, the protocol for the percutaneous puncture is
into the abdominal cavity and infections. Also, allergic
standardized and is unanimously approved and applied
reactions including anaphylactic shock may occur.
by specialists in all the countries that have accepted it.
Chirurgia deschisa este utila mai ales in localizarile greu accesibile ale chistelor hidatice hepatice, in cele gigante, in prezenta
We report here the preliminary results of this
The minimally invasive PAIR
treatment
aderentelor, dar are o rata mai mare a complicatiilor si o spitalizare crescuta, pe cand cura laparoscopica este indicata
doar in
15-17
10,11,12
treatment
used
on
217
patients
presenting
268
hepatic
protocol
of
the
hydatid
cyst
localizarile accesibile ale chistelor, insa asigura o vizibilitate foarte buna, o hemostaza sigura si o spitalizare mai scurta.
Punctia transcutanata
ghidata ecografic e o metoda ce a prins foarte repede, pe de o parte
executiei
relativchosen
facile siunder
pe de ultrasound
hydatid cysts.
The datorita
puncture
site was
alta parte datorita avantajelor incontestabile in raport cu tratamentul chirurgical, inguidance.
ceea ce priveste
morbiditatea
postoperatorie
si
Most often, it was the same intercostal
space
durata spitalizarii.10,11 Metoda are insa si o serie de riscuri, respectiv accidente hemoragice, leziuni ale altor viscere, insamantari
MATERIAL
AND
METHODS
recommended
by
most
of
the
authors
as
having
the
secundare determinate de scurgera lichidului hidatic in cavitatea abdominala, infectii. De asemenea pot apare reactii alergice mergand
18-20
lowest
risk
of
peritoneal
seeding.
pana la soc anafilactic.
In acest articol raportam
preliminare
acestui tratament
a 268steps
de chiste
hepatice,
la 217
Betweenrezultate
April 1996
and ale
December
2011, aplicat
319 in cazulThe
of hidatice
the PAIR
minimally
invasive
pacienti.
The
minimally
invasive
PAIR
treatment protocol of
patients with hepatic hydatid cysts were admitted to
treatment protocol of hydatid cysts were observed.
the Department
MATERIAL
ŞI METODĂ of General Surgery No. 2, of the
În perioada
aprilie 1996
- decembrie
2011, Hospital.
au fost internaţi
şi operaţi
Timisoara
County
Emergency
Out of
these, în Clinica Chirurgie II a Spitalului Clinic Judeţean de
Urgenţă, Timişoara un număr de 319 cazuri cu chist hidatic hepatic, dintre care 46 de bolnavi au fost operati laparoscopic, 56 pe cale
46 were operated laparoscopically, 56 were operated
clasică, iar în 217 cazuri s-a efectuat puncţia transcutanată ghidată ecografic (Grafic 1);
through classical methods and 217 were treated using
ultrasound-guided transcutaneous punctures. (Fig. 1)
250
217
200
150
100
50
56
46
Open surgery
Laparoscopic surgery
0
Transcutaneous puncture
No. of cases
Figure 1. Distribution of cases according
to the type of surgery.
As a detection
method
for de
hydatid
cysts, all patients
Grafic 1: Distribuţia
cazurilor
în funcţie
tipul intervenţiei
chirurgicale
undertook abdominal ultrasounds. The hepatic cysts
Ca şi metodă de detectare a chistului hidatic, toţi pacienţii au efectuat ecografie abdominală si chistele hepatice au fost
were classified according to the criteria developed by
clasificate dupa criteriile enuntate de Gharbi13 si Niron14.
Gharbi and Niron.13,14
The abdominal ultrasound was followed
by
2
computed tomography for a more accurate cyst
evaluation, with superior results regarding size and
location. Casona intradermoreactions were also
performed in 67 cases, with serological diagnosis
based on echinococcosis antibodies.
The 217 patients were selected for treatment by
ultrasound-guided transcutaneous puncture according
_____________________________
The puncture site was chosen under ultrasound guidanc
Abdulah Salim et al intercostal space recommended by most of the authors as havi
53
seeding.18,19,20
Table 3 - Cysts parameters:
RESULTS
Table 3. Cysts parameters.
The age of the 319 patients under study was
between 16 and 67 years, with an increased incidence
30 319
and
31reiese
- 40
years
age
2)incidenţă
Thecrescută în
Din in
intreg21
lotul –
de studiu,
pacienti,
ca vârsta
pacienţilor
a fost groups.
cuprinsă între 16(Fig.
– 67 ani, cu
grupele de vârstă 21 – 30 ani şi 31 - 40 ani (Grafic 2), iar raportul sex feminin/sex masculin=1,4 (187 cazuri întâlnite la sexul feminin
female/male
şi 132 cazuri
întâlnite la sexulRESULTS
masculin) -ratio
Grafic 3. was 1.4/1 (187 cases found in
females and 132 cases found in males). (Fig. 3)
120
The age
of the 319 patients under study was between 16 and 67 years, with an
104
81
increased incidence in 21 –5730 and 31 - 40 years age groups (Fig. 2). The female/male ratio
60
31
21
was 1.4/1
(187 cases found in females and25132 cases found in males) – (Fig. 3).
The cysts’ diameter varied from 2.5 cm up to giant
size of 15.8
The diameter
average diameter
the treated
Thecm.
cysts’
variedoffrom
2.5 cm up to gi
No. of cases
Figure 2. Distribution
of
cases
according
to
age
group.
cysts
was
5.8
cm.
Figure 2: Distribution of cases according to age group
All cysts
successfully
treated
usingcm.
the PAIR
diameter
ofwere
the treated
cysts
was 5.8
187
200
Grafic 2: Distribuţia cazurilor în funcţie de grupele de vârstă
method. The results are presented in Table 4.
0
16-20
21-30
31-40
41-50
>61
132
150
100
51-60
cysts were successfully treated using the PAIR
Table 4All
– Results.
Figure 3: Distribution of cases according to gender
Table 4. Results.
5
in Table 4.
50
0
Female
Male
Table 1 – UltrasoundNo.classification
of hepatic hydatid cysts of the entire group, according to
of cases
Figure 3. Distribution of cases according to gender.
Gharbi criteria:13
Grafic 3: Distribuţia cazurilor în funcţie de sex
Table 1. Ultrasound
of hepatic
hydatid
cysts oflotthe
entire
Tabel 1 - Clasificarea
ecografica classification
a chistelor hidatice
hepatice
la intregul
dupa
criteriile Gharbi13:
group,
Tipul ecografic
13
according to Gharbi
criteria.
Pacienti
(nr.)
I = chist bine delimitat, lichid
limpede în interior;
II = chist bine delimitat, cu
dublu contur al pertilor, cu
lichid limpede
Pacienti (%)
120
37,61
97
30,4
6
Following this procedure, five (2.3%) cases of
allergic reactions
werethis
recorded,
which responded
Following
procedure,
5 (2.3%)very
cases of allerg
well to treatment with hydrocortisone hemisuccinate
and
anti-allergic
medication.
this series with
232 cysts
responded
very
well to Intreatment
hydrocortisone
(86.56%) disappeared, 16 (5.97%) needed to undertake
the
puncture procedure
again, due
the stagnation
of disappeared
medication.
In this series
232tocysts
(86.56%)
diameters for 3 months, and 20 cysts (7.46%) relapsed,
OutOut
of of
thethe319
patients, we shall further refer only to those selected for the PAIR method
319 patients, we shall further refer only
so
interventions
were
subsequently
thesurgical
puncture
procedure
again,
due to required.
the stagnation of dia
to those selected for the PAIR method (217 patients,
(217 patients,
presenting 268 cysts).
presenting
268 cysts).
DISCUSSIONS
(7.46%) relapsed, so surgical interventions were subseque
Table
2 – Clinical parameters of the study group*
Table 2. Clinical parameters of the study group.*
Transcutaneous
ultrasound-guided
puncture
Figure 4 – Hepatic
hydatid cyst
before puncture
entered the therapeutic arsenal for hydatid cysts
starting with the mid 80’s.21
Figure 5 - Hepatic hydatid cyst before puncture
Today, most experts believe that the first choice in
the treatment of the univesicular hydatid cyst is drug
Figure 6 - Hepatic hydatid cyst 5 days after the p
therapy with albendazole in the usual doses. If this
treatment fails, the PAIR method is to be associated, and
Figure 7 - Hepatic hydatid cyst 5 days after the p
if the technique cannot be used, traditional laparoscopic
treatment or conventional surgery shall be applied.22-2410
Figure 8 - Hepatic hydatid cyst 9 months after th
_____________________________
54
TMJ 2012, Vol. 62, No. 1 - 2 8
DISCUSSIONS
Figure 7. Hepatic hydatid cyst 5 days after the puncture (CT).
Fig.4- Chist hidatic hepatic la 5 zile dupa punctie(tomografie)
Figure 4. Hepatic hydatid cyst before puncture (ultrasound).
Fig.1 - Chist hidatic hepatic inainte de punctie(ecografie)
Figure 8. Hepatic hydatid cyst 9 months after the puncture (ultrasound).
Figure 5. Hepatic hydatid cyst before puncture (CT).
Fig.5- Chist hidatic hepatic la 9 luni dupa punctie(ecografie)
As with any puncture, there is a risk of hemorrhagic
injuries 11
of adjacent viscera and, if the
recommended
protocol
is not observed, secondary
Fig.2 - Chist hidatic hepatic inainte de punctie(tomografie)
Punctia transcutanata ghidata ecografic a intrat in arsenalul terapeutic al chistului hidatic
21
seeding
dueanilor
to the
hepatic incepand
cu mijlocul
80.rupture of the pericyst and leakage
In prezent
majoritatea
considera cavity.
ca prima
alegere
in chistul hidatic
of hydatid
fluidspecialistilor
into the abdominal
Also,
rupture
univezicular este
medicamentoasa
dozele uzuale.
In cazul esecului se
of terapia
the hydatid
cysts cu
canalbendazol
lead toinallergic
reactions,
asociaza PAIR, iar daca tehnica este imposibil de aplicat se recurge la tratamentul laparoscopic
22, 23,from
24
ranging
mild symptoms to anaphylactic shock.
sau prin abord clasic.
Beneficiile
sunt legate
faptuloccurrence
că este o manevră
minim invazivă,
cu un risc
ThePAIR
frequency
of detheir
is however
not
scăzut în comparaţie
cu
chirurgia,
cu
o
25spitalizare mult redusă faţă de chirurgia clasică şi cu un
sufficiently studied. Due to the allergic potential of
cost mult mai mic decât intervenţia chirurgicală clasică. De asemenea ea îmbunătăţeşte
8
echinococcosis,
antihistamines
anti- penetrabilităţii
eficacitatea chimioterapiei
pre şiprophylactic
postpunctională,
probabil prinand
creşterea
substanţei medicamentoase
în interiorul
chistice.
inflammatory
steroidscavităţii
were administered
to the patients
Ca in orice punctie exista risc de accidente hemoragice, de leziuni a vicerelor adiacente,
in our study before anesthesia, and only 5 cases (2.3%)
iar daca nu se respecta protocolul recomandat, pot apare insamantari secundare determinate de
of mildsi scurgerea
allergic reactions
were inrecorded.
In similar prin ruptura
ruperea perichistului
lichidului hidatic
cavitatea abdominala.Tot
chistului hidaticstudies,
pot aparea
reactii alergice
usoare mergand
pana
la soc of
anafilactic,
authors
also recorded
small
numbers
mild dar frecventa
declansarii acestora nu este suficient studiata.25 Astfel datorita potentialului alergic al
Figure 6. Hepatic hydatid cyst 5 days after the puncture (ultrasound).
allergic reactions and no cases of anaphylactic shock,
Fig.3- Chist hidatic hepatic la 5 zile dupa punctie(ecografie)
echinococozei, in cazul lotului nostru de pacienti, s-au administrat profilactic preanestezic
20 minutes steroidiene,
before theinregistrandu-se
puncture H1 antihistamines
antihistaminicegiving
si antiinflamatoare
doar 5 cazuri(2,3%) de reactii
26 reactii alergice
alergice
usoare.
In
studii
similare
si
alti
autori
au
inregistrat
un
numar mic de
PAIR benefits are related to the fact that this
and an anti-inflammatory steroid (Prednisone).
is a minimally invasive maneuver, with a low risk
As with conventional 12
surgery, this method brings
compared to surgery, as well as much lower costs
into discussion the possibility of sclerosing cholangitis,
and hospitalization times. Also, it improves the
through the injection of a parasiticide into a cyst with
effectiveness of chemotherapy before and after the
a cystic-biliary communication. Thus, if a cysticpuncture, most likely by increasing
the
penetrability
of
biliary fistula is suspected following the analysis of the
9
the drug substance within the cystic cavity.
aspirated fluid, the procedure is aborted.
Discutiiaccidents,
_____________________________
Abdulah Salim et al 55
In such cases, some authors recommend the
introduction of drainage tubes into the cavity, by means
of dilators on the initial tract of the puncture. Drainage
tubes are maintained until the externalized secretion
diminishes and disappears.26 Their results were mostly
good, but in some cases surgery was still necessary in
order to perform an external biliary drainage before
closing the biliary fistulas of the residual cavity. Today,
this disadvantage can also be eliminated by performing
an endoscopic papilosphincterotomy.26,27
Mueller et al. were the first to report a case of a
patient who, after the PAIR procedure, was left with
a drainage tube for three months. Subsequently, it
turned out that maintaining a catheter for a longer
period of time can lead to superinfection and clogging
of the lumen drainage tube with fragments of the
germinative membrane.21 Also, the routine use of
catheterization for the drainage of the remaining
cavity largely extended the duration of hospitalization,
that reached to an average of 8.73 days with limits
between 2 and 30 days, and, in the case of concurring
infection, to an average of 25 days with limits between
20 and 30 days.26
All cysts punctured by us were of types I and
II according to the Gharbi classification, and their
treatment was performed in a single step, without
subsequent drainage.
The cavity that results from the procedure was
found to gradually reduce in diameter. This is due to
the use of alcohol, which ensures the sclerosis of the
germinative membrane and its fibrous transformation.
Through content aspiration, the intracystic pressure
disappears and the hepatic parenchyma expands,
leading to a gradual collapse of the cavity.
There are cases in which, due to the large size of
the cavity, liquid secretion increases from transudation
through the cyst walls, impeding the cavity’s collapse.
In these cases, a puncture repetition may be required
if the diameter of the cavity appears constant for over
3-6 months.
Other authors used the PAIR method for
some cysts of types III and IV under the Gharbi
classification and experienced complications – both
major (anaphylactic shock in 0.1 to 0.2% of cases)
and minor (rash, jaundice, fever, cyst superinfection or
biliary system rupture in 10-30% of cases).28
Even with cysts of types I and II and no
complications, cysts were found to relapse in up to 4%
of patients.29,30
The results of our study are only preliminary, as the
monitoring period necessary to draw safe conclusions
about the effectiveness of the PAIR treatment has not
ended.
_____________________________
56
TMJ 2012, Vol. 62, No. 1 - 2 We believe that the PAIR method is not sufficient
in the case of multivesicular, infected or calcified cysts,
but it represents an efficient and safe solution for the
treatment of the hydatid cyst in carefully selected
cases. Surgical treatment remains the main alternative.
CONCLUSIONS
The PAIR method is increasing in popularity for
the treatment of hydatid cysts because it is easy to
apply and is linked to low mortality.
The advantages of this method are most obvious
when compared to surgery, in terms of trauma,
post-operatory mortality, hospitalization duration,
use in difficult to reach locations and post-surgery
relapses. The combination of medical treatment using
anthelmintic drugs with percutaneous puncture is
a viable alternative to surgery for removing hepatic
hydatid cysts.31
Still, the PAIR method is limited in its’ applicability
and requires careful patient selection.
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