Thoracic surgery
Surgical treatment of 599 patients with hydatid cysts in the liver and lungs

Introduction

Hydatid cyst disease is characterized by the occurrence of cysts as a result of the transmission of Tenia echinococcus larvae to humans. There are four different forms of echinococcosis. The most frequent ones are Echinococcus granulosus, causing cystic echinococcosis, and E. multilocularis, causing alveolar echinococcosis [1]. The disease has been known since the time of Galen and Hippocrates. It was first described by Thebesius in the 17th century, while the term ‘hydatid cyst’ was used for the first time by Rudolphi in 1808 [1-3]. It is asserted that the disease was carried to Europe by the dogs of Icelandic whale hunters. Human infestation is common in those geographical regions in which people are in constant contact with domestic flesh-eating animals or livestock, such as sheep [4]. The disease is endemic to Southern Europe, North Africa, Asia, South America, Australia, and New Zealand. It occurs sporadically in regions of North America other than Alaska and North Western Canada. Dogs, foxes, wolves, jackals, deer, and sheep are included in the natural cycle of the parasite. The prevalence of hydatid cyst disease in Turkey is estimated at 50 out of 100 000 and the incidence is nearly 2-6 out of 100 000 [5]. The parasite egg hatches in the small intestine, releasing the embryo. The latter reaches the liver through the wall of the intestine, and from there it travels to the hepatic portal vein using its hooks. This is why the liver is the most frequent location for the cysts (60-70%). The embryos which cannot hold on to the liver pass to the lungs (20-25%); they can be found in all tissues and organs in the systemic circulation (10%), including bone joints. They create hydatid cysts in the organs that they attach to [6, 7]. In the presence of contraindications, or if the patient refuses to undergo surgical treatment, medical therapy is used, even though surgery is the first-choice option in the case of this disease. The optimal anti-parasite effect is achieved by administrating albendazole in 3 cycles per day. In our multi-center study, we aimed to present different types of surgical treatment, its results, and the associated complications on the basis of a wide series of cases.

Material and methods

599 patients who received surgical treatment were included in our study. The patients’ data were examined retrospectively using archive records. Patients without liver or lung involvement were excluded from the study. In addition, patients who were treated medically instead of surgically were excluded as well. Tomography was performed on all the patients. Abdominal ultrasonography or tomography was performed as follow-up, depending on the place of involvement. During the preoperative period, the Casoni intradermal test and the Weinberg complement fixation test were not performed because of their low diagnostic value [8]. Bronchoscopy was only conducted in 7 patients, hospitalized due to other thoracic diseases, as part of the differential diagnosis. Bronchoscopy was not utilized in any other patients.

Results

381 of the patients were men and 218 were women. It was established that the disease was more frequent among women than among men, which was in accordance with the literature [9]. The ratio of women to men was 1.747. The average age was 35.6; the youngest patient was 3 and the oldest was 83. The most frequent symptoms were stomach ache, cough, chest pain, shortness of breath, fever, and expectoration of hydatid cyst fluid. With regard to organ involvement, 425 patients had liver cysts and 236 patients had lung cysts. In 62 patients, both liver and lung involvement was revealed. Among the 425 patients with liver cysts, the number of patients with liver involvement only was 338, 62 patients had cysts in both the liver and lungs, while 25 had cysts in both the liver and other organs, excluding the lungs (Fig. 1).

Among the patients with lung cysts, isolated lung involvement occurred in 166 patients. 62 had both lung and liver cysts, while 8 patients had cysts in both the lungs and other organs. 510 cysts in total were found in 425 patients with liver involvement; 341 of them were in the right lobe, 164 in the left lobe, while 5 were in the caudate lobe. 298 cysts were found in 236 patients with lung involvement; 190 of them were located in the right lung, while 108 were located in the left lung (Table I).

The cysts were more frequently observed in the right lung and on the right side of the liver. In children, lung involvement was more common than liver involvement. With regard to lung involvement, the cysts appeared in the lower lobes more frequently than in the upper lobes. Three patients died. Recurrence was observed in 13 patients. Moderate complications occurred in 43 patients in total (Table II).

Endoscopic retrograde cholangiopancreatography (ERCP) was applied in 20 cases with liver cysts, 19 patients underwent cholecystectomy, T-tube drainage was applied in 18 cases, omentoplasty was used in 15 cases, splenectomy was employed in 3 cases, and 2 patients received percutaneous drainage. With regard to the performed surgical interventions, thoracotomy was conducted in 163 patients, thoraco-phreno-laparotomy in 39 patients, thoracotomy plus laparotomy in 23 patients, bilateral thoracotomy in 11 patients, laparotomy in 356 patients, and laparoscopy in 7 patients (Table III).

Cystotomy-capitonnage was applied to 256 out of 298 lung cysts, wedge resection to 36 cysts, segmentectomy to 5, while lobectomy was used in one case only. Partial cystectomy was applied to 283 out of 510 cysts, cystectomy to 50, cystotomy and drainage to 177 (Table IV) (Figs. 2-4).

Discussion

Hydatid cyst disease is as old as the history of medicine, dating back to the times of Hippocrates. In general, hydatid cysts can be observed in every part of the body, but occur mainly in the liver and lungs. Approximately, every two cysts out of three are located in the liver and one out of five in the lungs. The remaining cysts can be found in any part of the body [10]. This is why abdominal and thoracic scans must be performed when searching for hydatid cysts. Especially in the regions that the disease is endemic to, this still poses a serious problem. The primary treatment for the disease is surgery. In the presence of contraindications for surgical intervention, or if the patient refuses to undergo surgery, medical treatment is used. Medical treatment is also employed in order to prevent recurrence. Because of the capsule structure of the cysts, symptoms occur only when pressure is exerted on healthy tissue or when the cyst is ruptured. Rupture risk increases in direct proportion to the size of the cyst. Rupture after trauma is more frequent in the case of liver cysts. Different broad case studies reported that free cyst rupture occurred in the intraperitoneal space in 1.7% or 8.6% of all liver hydatid cyst cases [11, 12]. Its most serious complication is anaphylactic shock. However, depending on the organ the cyst is located in, as well as the cyst’s size and exact place on the organ, the following complications may develop as well: stomach ache, fever, cough, shortness of breath, nausea, vomiting, hepatitis, allergic reactions, and anaphylaxis [13, 14]. The mortality and morbidity caused by hydatid cysts is dependent on the organ in which they are located. Thus, the main goal of surgical treatment is to remove the cysts with minimum damage to the involved organs. Methods sparing the parenchyma should be preferred. Parenchymal sparing surgery was prioritized in our study. In the past years, parenchymal resections were avoided as much as possible; not a single hepatic parenchymal resection was performed. For hydatid cysts located in the lungs, only one patient underwent lobectomy, while segmentectomy was performed in 3 cases. Lung parenchyma was protected as much as possible with the use of wedge resections. Peripherally located small hydatid cysts were removed using a stapler. During the operation, the area containing the cyst was left uncovered, while the surrounding area was covered with gauze bandage saturated with povidone-iodine (polyiodine). Afterwards, a 20 gauge injector with a 50 ml bulb was inserted into the cyst, and 50 ml of hydatid fluid was aspirated. 10% povidone-iodine was then injected into the cyst in the amount equal to the amount of the aspirated fluid. The cyst was opened with cystotomy, and the germinative membrane was excised. In this way, surrounding tissue contamination and cyst recurrence were prevented. Recurrence took place in 7 patients (1.16%). Three patients (0.5%) died: one of them had the hydatid cyst located in the lung, while the remaining two had both liver and lung cysts. In the literature, the mortality rates are 0.6-4.1% and recurrence rates are 0.6-1.7% [1, 4]. Bile leakage occurred in 18 out of 425 patients with liver cysts, who received T-tube drainage. Different rates were reported for bile leakage and bile fistula, ranging from 2.6% to 9.3% [15-17]. Laparoscopic surgery was performed in 7 patients with liver cysts. This relatively new method helps improve morbidity rates. None of the eleven patients with bilateral lung involvement underwent median sternotomy or concurrent bilateral thoracotomy. Two separate thoracotomies were performed with an interval of 6 weeks. In 39 out of 62 patients with liver and lung involvement, both liver and lung cysts were removed during a single thoraco-phreno-laparotomy, because the lung cysts were located in the right lung. The tissue surrounding liver cysts is more solid than that of lung cysts, and there are no structures through which the hydatid fluid could spread, such as the bronchi in the lungs. Therefore, the risk of cyst rupture, resulting from the thinning of the external layer of the cyst by medical treatment, is lower. In lung cysts, the wall of a cyst which was thinned by drug treatment is likely to burst and spread larvae to other parts of the lungs. Hence, medical treatment provides better results in the case of liver cysts than in the case of lung cysts.

Conclusions

As a result, if there are no serious contraindications, surgical treatment should be chosen over medical treatment for lung cysts. Even if the liver or lungs appear to be the only organs involved, the abdomen and thorax must also be scanned. The main aim of surgical treatment for both lung and liver cysts must be to protect the organ parenchyma as much as possible, as well as to make the cyst inactive without harming the function of the organ involved.

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