SURGICAL MANAGEMENT OF LIVER HYDATIDOSIS

SURGICAL MANAGEMENT OF LIVER

HYDATIDOSIS

Miroslav Milicevic, MD, Ph D., FACS

The First Surgical Clinic, University of Belgrade Clinical Center,

Pavia, September, 2011.

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the disease

Echinococcosis is a zoonosis caused by the larval stage of tenia Echinococcus (class Cestoda) where humans are the accidental intermediate host and animals are both intermediate and definitive hosts

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surgeons and hydatid disease today

Ozdemir Aktan, MD

Marmara University Hospital

Dept. of Surgery

Eur J Surg 165, 2003

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The essential problem – evolution of the disease

A viable liver hydatid cyst is a space-occupying lesion with a tendency to grow, and as a consequence of cyst enlargement, it can rupture – surgery frequently unavoidable.

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Most surgeons even in developed countries will encounter

the disease at some point of their career either in it’s

simple or it’s complicated form

Endemic areas of the disease exist.

the problem for surgeons still exists !

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HC - IHBD communications is a serious complication

of liver hydatidosis, sometimes difficult to manage.

The disease, benign in nature, can cause devastating

damage to the liver and death to the patient.

the problem for the patient - complications

IHBD

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who informal working group on echinococcosis treatment modalities:

SURGERY

PAIR

CHEMOTHERAPY

“WAIT AND OBSERVE

APPROACH “

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indications for surgery in CE

large cysts with multiple daughter cysts

single liver cysts situated superficially that may rupture

infected cysts

cysts communicating with biliary tree

cysts exerting pressure on adjacent organs vital organs

cysts in the lung, brain, bones, kidneys and other organs

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contraindications for surgery in CE

contraindications for surgery in general patients refusing surgery extreme age pregnant women concomitant severe diseases

multiple cysts

cysts difficult to access

dead cysts

cysts partially or totally calcified

very small cysts

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What to expect from chemotherapy in CE

10 – 30% show cyst disappearance (cure)

50 – 70% degeneration or significant size decrease 20 – 30% no morphological changes

relapses sensitive to retreatment in up to 90%

rate of relapse after chemotherapy is high (14 - 25%)

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management algorithms based on natural history of E. granulosus

potential

pathology

management

complete diagnostics

wait and observe

c h e m o t h e r a p y

surgery

PAIR

chemotherapy complete diagnostics

surgery

PAIR

chemotherapy wait and observe

status of parasite

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• No controlled trials comparing radical and conservative surgery ! • Most data anecdotal, not evidence based. • Most operations done in underdeveloped countries, no standardization, no

quality control, missing data and inadequate follow up. • Reporting and terminology not standardized. • Different procedures on single patient with multiple cysts - concept of

“dominant cyst procedure”. • Different protoscolicidal agents. • Frequently unnecessary improvisation and innovation – confusion. • Frequently conflicting opinions! • Majority of publications are not done by surgeons with the largest

experience.

The evaluation of conservative surgery ?

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The rationale for conservative surgery ?

• Majority of operations done by general surgeons in underprivileged areas.

• Conservative surgery is tissue sparing and that is better for a benign disease. H/A complex frequent.

• Recurrence and reinfestation is possible – reoperation feasible. • Other liver disease is possible – frequently young patients. • The majority of cysts, regardless of site and size, can be managed this

way. • Safe surgery - acceptable perioperative mortality and morbidity. • Acceptable recurrence and complication rate. • Extensive worldwide experience.

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Patients 219 /797 HC - BD comm.

Mean age 42,15 yr.

Experience derived from our series – 1016 operated patients

21.5%

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I II III IV V VI VII VIII

6,75%

30,92%

7,23%

27,01%

17,42%

7,23%

4,03%

0,12%

0%

5%

10%

15%

20%

25%

30%

35%

invo

lved

%

Segment involvement

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Largest cyst more than 20 cm

Average number of cysts per pt. with

multiple cysts is 2,9.

Average size of cyst 9,36 cm

Cyst characteristics

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Lobe involvement

71,86%68,94%

14,07%

19,70%

14,07% 11,36%0,00%

10,00%

20,00%

30,00%

40,00%

50,00%

60,00%

70,00%

80,00%

Right lobe Left lobe Both lobes

NO COMMUNICATION

WITH COMMUNICATION

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Infected cysts and sepsis

Massive destruction of liver parenchyma

Cirrhotic livers

Posterior calcified cysts

Multiple organ hydatidosis

Multiple operations for recurrent disease

Central, hilar cysts

Cyst - bile duct communications

The real problems ...

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• Adequate exposure and mobilization

• Safe decompression and evacuation of cyst contents

• Effective cyst sterilization

• Management of bile duct communications

• Management of the residual cavity

• Drainage

The basic surgical procedures in endocystectomy

(conservative surgery)

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Adequate exposure and mobilization

Standard J incision Retractors Extension

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Adequate exposure and mobilization

Topics for discussion:

Midline for left side Degree of mobilization Liberation of diaphragm Same incision for recurrence One cavity at a time Thoraco-phreno incision

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Safe decompression and evacuation of cyst contents

1 2 3

4 5 6

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Safe decompression and evacuation of cyst contents

1 2 3

? ? ?

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The barrier effect of gauze pads soaked with protoscolicidal agents

Two effects of gauze barrier analysed:

Mechanical effect:

filter effect is 99,73% i

PSE effect on protoscolicides that

passed the gauze filter after 15

minutes of exposition

Complete for all tested solutions

except 3 i 5% NaCl.

Gaza - 15 min.

Ž/M

1. 3% NaCl 14/53 19700 ptsc/ml 2. 5% NaCl 7/26 19700 ptsc/ml 3. 20% NaCl 0/28 11200 ptsc/ml 4. 30% NaCl 0/40 19700 ptsc/ml 5. 3% - H2O2, 0/33 11200 ptsc/ml 6. 5% Povidona 0/23 11200 ptsc/ml 7. 10% Povidona 0/25 11200 ptsc/ml 8. Chloramin 0/7 11200 ptsc/ml 9. 70% etanola, 0/23 11200 ptsc/ml 10. 96% etanola 0/17 11200 ptsc/ml 11. 10% Formalin 0/40 11200 ptsc/ml 12. 5% Formalin 0/19 11200 ptsc/ml 13. 0.01% Rivanol 0/18 11200 ptsc/ml 14. 0.005% Rivanol 0/19 11200 ptsc/ml 15. 0.0025% Rivanol 0/33 19700 ptsc/ml

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Safe decompression and evacuation of cyst contents

Topics for discussion:

How to isolate – “ wall of ” High intracystic pressure Double suction devices Lap. troacars Special devices - cones Evacuation of contents

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Effective cyst sterilization - protoscolicides

Univesicular, small volume Multivesicular, large volume

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Effective cyst sterilization – protoscolicidal agents

Topics for discussion:

Injection of protoscolicidal agents Efficacy of protoscolicidal agents Mechanical cleansing Use of two protoscolicidal agents Use of physical methods Adverse effects of cyst sterilization

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Baccelli - mercury compounds - by the end of XIX century

Franke - formalin - 1900..

Deve - routine procedure during hyd. surgery - 1901.

Hicken - 96% etanol - 1966.

Harris - 3% HSS - 1968.

Saidi - diluted silver nitrate - 1977.

Ahrari and Eslami - cetrimide1978.

The history

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The most effective PA

Scolecidal agents Concentration Estimatedefficacy Reported negative effects

Sodium chloride solution 3-20% + Caustic sclerosing cholangitisConcentrated ethanol 75-95% +++ Caustic sclerosing cholangitis

Cetrimide solution 0.1-0.5% + Caustic sclerosing cholangitis,Metabolic acidosis

Povidone 1% +Colors cystic cavity – difficult toidentify bile ductcommunications

Formalin 4-10% +++Caustic sclerosing cholangitis,anaphylactic shock, formalintoxicity

Hydrogen peroxide 1.5-3% ++Bursting, spillage, tearsAir embolismAnaphylactic shock (10%)

Chlorhexidine (Savalon) 10% +++ Metabolic acidosisSilver nitrate 0.5% ++ Caustic sclerosing cholangitisSol. Rivanoli 0.001% ? No data

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Protoscolicidal agents

100% PSE - NaCL

– 10 min. - 15, 20 and 30%

– 30 min. - 10%

– 180 min. - 5% NaCl

– 220 min. - 3% NaCl

PSE 30% NaCl– a) 200x, eozin; b) 400x, eozin

100% PSE - Ethanol

– 10 min. - 96, 70, 48, and 35%.

– 45 min. - 24 and 17,5%

PSE 96% Ethanol– 400x, eozin

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100% PSE Povidone - iodine

– 5 min. - 10% – 0,156125%

Povidon-iodid solution

PSE 10% Povidon– 400x, eozin

100% PSE Formalin

– 5 min. - 10% formalin,

– 10 min. - 5 and 2,5%,

– 15 min, - 1,25% formalin. PSE 10% Formalin – after 15min. of eosin exposure

- “marginal staining” effect, a)200x, eozin; b) 400x, eozin

Protoscolicidal agents

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100% PSE sol. Rivanoli

– 30 min. - 1‰ - 0,125‰ Rivanoli

PSE 1‰ Rivanoli – 200x, eozin

PSE 3% H2O2– 400x, eozin

100% PSE Hydrogen peroxide

– 15 min. - 3% hydrogen peroxide

– 15 min. - 1,5% hydrogen peroxide

Protoscolicidal agents

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100% PSE

Chlorhexidine gluconate 5% - 1:2000 H2O sol.

– 10 min. 2,5‰

PSE Zeneca –200x i 400x, eozin

Cetrimonium bromid (cetyltrimethylammonium bromid)

Cetavlon - (Cetrimide 20% w/v -)

– 5 min. 0,1% - 0,0125% cetrimid

– 15 min. 0,00625% cetrimid

Savlex®

(Cetrimid 1,5% + Chlorhexidine Gluconat 0,15%)

– 5 min 10% - 0,625%

100% PSE AgNO3

– 5 min - 0,5%; - 0,015625%

Protoscolicidal agents

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PA with 100% PSE in 5 min.

0,00%

10,00%

20,00%

30,00%

40,00%

50,00%

60,00%

70,00%

80,00%

90,00%

100,00%

13. 1% Povidon

14. 0,5% Povidon

15. 0,25% Povidon

16. 0,125% Povidon

17. 0,0625% Povidon

18. 0,03125% Povidon

19. 0,0156125% Povidon

24. 10% Formalin

33. Cetrimide 0,1%

34. Cetrimide 0,05%

35. Cetrimide 0,025%

36. Cetrimide 0,0125%

38. Savlex39. Savlex

40. Savlex

41. Savlex

42. Savlex

43. Savlex

44. Savlex

47. AgNO3 0,5%

48. AgNO3 0,25%

49. AgNO3 0,125%

50. AgNO3 0,0625%

51. AgNO3 0,03125%

52. AgNO3 0,015625% 100% PSE u 5 min.

1% Povidon

0,5% Povidon

0,25% Povidon

0,125% Povidon

0,0625% Povidon

0,03125% Povidon

0,0156125% Povidon

10% Formalin

Cetrimide 0,1%

Cetrimide 0,05%

Cetrimide 0,025%

Cetrimide 0,0125%

Savlex 10%

Savlex 5%

Savlex 2,5%

Savlex 1,25%

Savlex 0,625%

Savlex 0,3125%

Savlex 0,15625%

AgNO3 0,5%

AgNO3 0,25%

AgNO3 0,125%

AgNO3 0,0625%

AgNO3 0,03125%

AgNO3 0,015625%

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0,00%

10,00%

20,00%

30,00%

40,00%

50,00%

60,00%

70,00%

80,00%

90,00%

100,00%

4. 15% NaCl

5. 20% NaCl

6. 30% NaCl

7. 96% etanola

8. 70% etanola

9. 48% etanol

10. 35% etanol

25. 5% Formalin

26. 2,5% Formalin

32. Chlorhexidine

100% PSE u 10 min.

15% NaCl

20% NaCl

30% NaCl

96% etanola

70% etanola

48% etanol

35% etanol

5% Formalin

2,5% Formalin

Chlorhexidine

PA with 100% PSE in 100% PSE in 10 min.

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0,00%

10,00%

20,00%

30,00%

40,00%

50,00%

60,00%

70,00%

80,00%

90,00%

100,00%

27. 1,25% Formalin

37. Cetrimide 0,00625%45. Gigasept

1.25% Formalin

Cetrimide 0,00625%

Gigasept

PA with 100% PSE in 100% PSE in 15 min.

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Management of bile duct communications Peroperative cholagiography performed from “above” through the

site of CBC-2

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visualization and verification of the

communication

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Management of bile duct communications Cholangiography through the cystic duct, the site of CBC and

transintestinal catheter

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RHD COMM.

CBD

CBD

CBD

LHD COMM.

LHD COMM.

GB

GB

Management of bile duct communications I.O. Cholangiography

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Suture of the communication

Simple suture

Suture and T-drainage

Interlamelar pericystectomy and capitonage

Internal drainage procedures

Internal transfistulary drainage with/without transduodenal sphincteroplasty

Bilio-digestive derivation

Transduodenal papilotomy

External drainage procedures

Bipolar drainage procedure

Cysto-biliary deconnection procedure

Biliary reconstruction procedures

Intracavitary bilio-digestive reconstruction - Roux-en-Y

Pericysto-jejunostomy - Roux-en-Y

Intracavitary bile dust reconstruction - T-drainage

Management of bile duct communications The procedures

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Management of bile duct communications Bipolar drainage of cysto-biliary communication

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Management of bile duct communications Cysto-biliary deconnection procedure in treatment of CBC-1

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Management of bile duct communications Cysto-biliary deconnection procedure in treatment of CBC-2

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cath. in right h. duct

CBD

sling in l. hepatic duct

Management of bile duct communications Destruction of left hepatic duct

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GB

Central

cyst

CBD

L. hep.

comm

CBD

Central

cyst Orifice of

l. hep. d.

Roux en-Y

Management of bile duct communications Central communicating cyst

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D-OTHER

PROCEDURES

2%

C - 'T' TUBE

5%

2-SUTURE+'T'

TUBE

10%

1-SUTURE

83%

Management of bile duct communications Type of procedure on bile ducts

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with IHBD - HC comm.

55,46% 28,57% 11,77% 3,36% 0,84%

no IHBD - HC comm.

48,91% 34,35 % 7,83% 8,26% 0,65%

Partial pericystectomy

with omentoplasty

Partial pericystectomy

with capitonage

Combine

procedures

I.C.

M

Management of bile duct communications Type of operative procedures performed on the dominant hydatid

cyst-conservative surgery

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Factor incidence ratio stat. signif.

age > 65 1,2 : 1 ns multiple / solitary cysts 1 : 1,2 ns IHBD - HC / no 1,5 : 1 s

Management of bile duct communications Factors affecting incidence of po. complications

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• Small amounts first few days no concern

• Biliary fistula

• Early discharge of large quantity

• Cause:

• overlooked communication

• injury to bile ducts

• inadequate assessment

• inadequate procedure

• obstructed CBD (eg. debris)

• Liver abscess

Management of bile duct communications Postoperative biliary drainage

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external

fistula

Management of bile duct communications Failure of conservative surgery

(calcified cyst) - persistant po. bile fistula

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fully calcified hydatid cyst – status: inactive

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Long-term complications H-A complex, cholangitis

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Management of bile duct communications

Topics for discussion:

Cholecystectomy and io. cholangiography IOUS Injection of dye Role of “T” tube Bilio-digestive anastomosis Management of fistulas

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Management of the residual cavity

Routine procedures

External tube drainage Omentoplasty Capitonnage

Cavity flattened

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Management of the residual cavity

Other procedures

Internal collapse

Introflexion

Introflexion plus omentoplasty

Myeloplasty

Cystojejunostomy

Marsupialization

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Postoperative morbidity

Nonspecific 48 pts. 4.72%

Procedure related 113 pts. 11.12%

Pleural effusion 60 pts. (5.91%)

Liver abscess 31 pts. (3.05%)

Biliary fistula 19 pts. (1.87%)

Bleeding 3 pts. (0.29%)

___________________________________________

T o t a l 161 pts. 15.84%

Re-operation 37 pts. 3.64%

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Recurrence

Second operation for liver hydatid

165 pts. 16,24%

First operation at the Institute

2.86%

frank recurrence 0.68 %

missed cyst 1.18%

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exogenous vesiculation

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extremly thick wall – exogenous vesiculation and engagement of adjacent organs – surgery !

stomach

cyst

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.

Overall

Mortality rate

20 pts. 1.96%

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conclusion: who needs treatment

wise men say – rule of thumb:

1. all symptomatic cysts

2. asymptomatic cysts > 5 cm, especially peripherally located

3. complications of hepatic hydatid disease

4. 95% of all patients are treated when diagnosed

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Conservative, tissue sparing, hydatid cyst surgery, when performed properly, is adequate for the majority of patients.

The detection of a HC-IHBD communication seldom requires more radical surgery.

Conclusion

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