(a)had (a)had - ResearchGate

Mohammad
Sultan
Khuroo,
MD,
Echinococcu.s
Management
hepatic
Echinococcus
cysts
(maximal
diameter,
± 4.0) in 12 patients
were
aspi-
7.5 cm
rated and
(20%)
irrigated
saline
with
under
the
cysts,
which
hypertonic
sonographic
ance. All patients
had
symptoms
of a hepatic
by
guid-
signs
mass
had
and
caused
a prominent
of scoleces
were
observed
Mean
hospital
stay was
± 3.4. Serial
sonographic
days
nations
revealed
high-level
the cyst cavity
(heterogeneous
pattern),
uniformly
which
ultimately
in all
4.0
exami-
echoes
in
echo
became
echogenic
(pseudotumor).
After follow-up
of 14.0 months
± 5.5,
maximal
cyst diameter
decreased
to
4.1 cm ± 3.1 (P < .001). One patient
died of unrelated
causes;
the remaining 11 patients
experienced
relief of
symptoms
and a decrease
in liver
span.
Index
terms:
Cyst, percutaneous
drainage,
761.3121
#{149}
Echinococcosis,
761.2083
#{149}
Liver,
cysts,
761.3121
#{149}
Liver, echinococcosis,
761.2083
#{149}
Liver, interventional
procedure,
761.12986
#{149}
Liver,USstudies,761.12986
#{149}
Parasites, 76.2083
Radiology
1991;
Ali Zargar,
H
YDATID
man
and
larval
180:141-145
(2).
to the
of the
cases
0 RSNA,
1991
Received
in
primary
cysts,
of disseminated
or
disease
is a much
(3). Medical
therapy
has
especially
advantages,
October
15, 1990;
re11.
in patients
with recurrent
disease
or in patients
for whom
surgery
is otherwise
madvisable
(1,3-5).
There
are some questions about
its efficacy
and safety
(57). Percutaneous
puncture
or aspiration of hydatid
cysts has been contraindicated
(8). However,
there are
reports
of hydatid
cysts
being
punc-
tured
and neither
anaphylaxis
nor
peritoneal
soilage
resulting
(2,9,10).
In this study,
we report
the results
of ultrasound
(US)-guided
percutaneous
transhepatic
patic
hydatid
drainage
cysts
MATERIALS
of 21 he-
in 12 patients.
AND
METHODS
From June 1988 onward,
all patients
with hydatid
disease
of the liver being
treated
at our institution
were considered
for treatment
with percutaneous
drainage
(a)
November
15; revision
26, 1991; accepted
March
requests
to M.S.K.
re-
successful
but management
recurrent
hydatid
greater
problem
symptoms
caused
by
cyst
with
that
appeared
wall
in Table
fluid
anechoic
a
or hypoechoic,
primary
echoes,
form
excluded
solid
of treat-
if the
pattern
(b) was
cyst
with-
infected,
The
cysts,
clinical
formed
parameters
the
study
of the
intradermal
1gM antibodies
(measured
test
of immunogbobulin
to
G
Echinococcus
by means
of the en-
zyme-linked
immunosorbent
assay
[ELISA]) were performed
and the results
evaluated,
as reported
earlier (12).
The patient fasted overnight.
The procedure
group.
group
2. The Casoni
measurement
was
performed
the
next
morning,
or
had ruptured
into the biliary tree or
pleural or peritoneal
cavity.
Twelve patients,
harboring
21 hepatic
hydatid
and
(IgG)
and
granulosus
component
enhancement
of back wall
(c) gave informed
consent
to
Patients
were
had a hyperechoic
out back
shown
in Table 1. The types and descriptions of the hydatid
cysts (11) are shown
if the patient
and
signs
of a hepatic
a hydatid
cyst;
(b) had
a prominent
(a)
(c)
ment.
India.
MD
the
surgical
cysts-is
echoes;
and
use of PD as the
requested
February
reprint
Mahajan,
In the Liver:
Drainage’
bordering
of uncomplicated
with marked
(Kashmir),
areas
Treatment-usually
moval
had
revision
ceived
Address
#{149}
Rakesh
Cysts
(PD). PD was performed
the Department
of Gastroenterology,
of Medical
Sciences,
Srinagar
190 011
DM
Mediterranean
and Baltic seas, South
America,
Australia,
the Middle
East,
and New Zealand.
Immigration
has
bed to an increased
prevalence
of the
disease
in Europe
and North
America
mass
From
Institute
MD,
disease
is the commonest
one of the most severe
hucestodiases
(1). The disease
is endemic
fluid component
that appeared
anechoic
or hypoechoic,
with marked
enhancement
of back wall echoes.
The amounts
of cyst fluid aspirated
and of hypertonic
saline
used were
190 mL ± 240 and 120 mL ± 90, respectively.
Separation
of the endocyst
from the pericyst
and nonviability
cysts.
#{149}
Showkat
granulosus
with
Percutaneous
Twenty-one
granulosus
DM
are
Abbreviations:
ELISA = enzyme-linked
munosorbent
assay,
Ig = immunoglobulin,
PD = percutaneous
drainage.
im-
141
Table
2
Table
Distribution
of 21 Cysts into Five
According
et al (11)
Types
Gharbi
3
of Cyst Fluid Aspirated
Giaracterisfics
to Classification
of
before
and after Infusion
of Saline
into Cyst
Cavity
No. of Cysts
with
Characteristic
No. of
Description
Type
Before
Cysts
of
Characteristic
I
Pure fluid collection;
ifi
Iv
V
After Infusion
of
Saline
14
Appearance
rounded
with welldefined
borders
Fluid collection
with
split wall (localized)
Fluid collection
with
multiple septa; honeycomb appearance
Hypoechoic
with high
internal
echoes
Cyst with reflecting
H
Infusion
Saline
and watery
Clear
0
20
Opalescent
1
0
1
Turbid
21
0
Culture
3
Negative
19
Positive
Cytologic
2
thick walls
*
t
Escherichia
13 (12)
4
21 (1)*
7
3
1
coil (one
patient)
Staphylococcusepidermidis
S Numbers
1
findings
Scoleces
Hookiets
Membrane
1
20
2*
and
(skin
in parentheses
Salmonella
typhimurium
(one
patient).
contaminant).
are number
of cysts
with
scoleces.
viable
with close monitoring.
Facilities were
available
to treat any potential
complication. The location of the cyst was defined
in three
planes
with
sonography
by using
a real-time
linear scanner
(SSD 256; Aloka,
Tokyo) with a 3.5-MHz
probe. The relation
of the cyst to the normal liver was delineated, and a site for puncture
was marked
such that the cyst could be approached
through
thick normal
liver tissue.
If possi-
visit,
patients
underwent
clinical
examina-
patients
masses,
tion and had a blood sample drawn for
serum chemistry
and serologic
testing.
Sonography
was
performed
to PD, were
examination.
to evaluate
the diameter
and appearance
of the cyst.
All values were expressed
as means ± one
ble, the right intercostal
route was preferred to minimize
the chances of peritoneal soilage. Under aseptic conditions,
USguided cyst puncture
was performed
through
the biopsy port of the puncture
probe (3.5 MHz). A transhepatic
catheter
needle (5-F, 40-cm-long
radiopaque
polyethylene
catheter;
Cook Europe, Bjaerver-
standard
skov,
All of the 21 cysts in the 12 patients
were successfully
treated
with PD.
The transhepatic
catheter
needle
was
used to drain
13 cysts, while
the cholangiographic
needle
was used to
drain
eight cysts. The amounts
of cyst
fluid aspirated
and of saline
infused
into the cyst cavity
were 190 mL ±
240 (range,
2.5-600
mL) and 120 mL ±
90 (range,
2-450 mL), respectively.
The characteristics
of the cyst fluid
obtained
before
and after infusion
of
saline
into the cyst cavity
are shown
in Table 3. In one patient,
scoleces
were viable
in the cyst fluid aspirated
after infusion
of saline.
PD was repeated,
and the scoleces
became
nonviable.
The mean
hospital
stay was 4.0
Denmark)
was
tion of unilocular
cysts
containing
giography
employed
for aspira-
large-volume
daughter
needle
(22
cysts.
cysts,
gauge,
In
a cholan-
20 cm
bong
Cook Europe)
was used to puncture
each
daughter
cyst; individual
daughter
cysts
were then aspirated
and irrigated
with
hypertonic
saline. In small-volume
cysts,
the cholangiography
needle was the preferred
choice.
puncture,
Immediately
after
cyst
cyst fluid was aspirated.
was
sterile
ration
hypertonic
(20%) saline. Cyst aspiand reffiling was monitored
contin-
uously
ifiled
by means
with
an equal
The
cavity
volume
of sonography.
of
The
hy-
pertonic
saline was left in the cyst for 20
minutes,
after which the fluid was aspirated. At this time, separation
of the endocyst
from
reduce
exudation
cavity
the pericyst
was
Cyst
with
filled with
fluid
observed.
To
from the cyst wall, the
washed
left partly
was
was
normal
saline
and
to cytologic
and microbiologic
examination.
For cytologic examination,
the fluid was centrifuged and the sediment
examined
for
fragments
hooklets,
of the laminated
and
scoleces.
The
scoleces
was
motility
at immediate
microscopy
staining
with
eosin
tient
assessed
membrane,
viability
neutral
was observed
charged
from
by observing
for 48 hours
the hospital
#{149}
Radiology
their
and
(13). The
pa-
and dis-
if the procedure
had been uneventful.
Thereafter,
were followed
up every month.
142
of
patients
At each
The
in statistical
paired
not
palpable
Cystic
prior
at follow-up
Student
analysis
of the
Cyst
Size
and
Appearance
results.
Repeated
tions
RESULTS
PD
days
Outcome
±
3.4 (range,
patients
left the
hours
after PD.
solution.
subjected
deviation.
test was used
with
hepatomegaly.
palpable
in six patients
4-12
hospital
days).
within
Nine
5.5 (range,
and
pearance
diameter
4.1
cm
size
patients
cysts)
were
(P
<
After
from
± 3.2
.001).
PD,
the
3-18
months).
One
patient
died of unrelated
causes.
Eleven
patients remained
alive. All were relieved
of clinical
symptoms.
They noticed relief of pain in the abdomen,
and the liver span decreased
in all 10
decreased
± 3.1 (P
ruptured.
of three
from
for
diam-
±
4.0 to
echo
cysts
revealed
floating
high-level
within
the
the
hydatid
During
7.2
.001).
(with a to-
separated
Sonography
cavity.
3
in
<
in all 21 cysts;
echogenic
cyst
than
up
patients
endocyst
less
cyst
7.9 cm
the
PD.
diameter
from
cysts
erogeneous
±
for
cyst
in these
pericyst
daughter
aminations,
appeared
followed
up every
of 14.0 months
The
10 patients
decreased
3.4 cm
ap-
of seven
up
PD.
remaining
the
were
a period
followed
after
after
a total
tab of 14 cysts)
were
followed
9-18 months
after
PD, and
eter
in
in cyst
soon
(with
these
two patients
cm ± 4.0 to 4.8 cm
The
decrease
alteration
occurred
Two
months
an
follow-up
(Figs 1-3). The initial cyst
of 7.5 cm ± 4.0 decreased
to
3.1 (P < .001). The decrease
±
in cyst
linear
Follow-up
All patients
month
over
a progressive
cyst
size
examina-
during
revealed
also
48
sonographic
performed
structures
in
follow-up
ex-
internal
cyst cavity
pattern).
echoes
(het-
These
be-
came
more
abundant
and denser
until
the cyst cavity
was uniformly
echogenic
(representing
a pseudotu-
mor).
On
cysts
lost
their
further
and were
sonography.
not
examination,
rounded
visible
five
appearance
at repeated
July 1991
b.
Figure
1.
dimensions
separated
C.
Serial
US scans
of a patient
with
type
1 hydatid
cyst.
of cyst (C) are 6.5 x 5.7 cm. Note
separated
endocyst.
endocyst
and high-level
internal
echoes.
a.
(a) Before
(c) Five
PD, dimensions
months
after
of cyst are
PD, dimensions
14.5 x 11.2 cm. (b) One month
of cyst are 4.5 x 3.5 cm. Cyst
after PD,
is filled by
b.
Figure
daughter
echoes.
2.
Serial
US scans
of a patient
with
cysts.
(b) Three
months
after PD,
(c) Six months
after PD, dimensions
Serologic
type III hydatid
cyst. (a) Before
PD, dimensions
of cyst are 8.2 x 6.2 cm.
dimensions
of cyst (C) are 5.5 x 5.0 cm. Note
linear
echogenic
structures
of cyst are 3.5 x 3.5 cm. Cyst is replaced
by echogenic
mass
(pseudotumor).
Testing
Of the eight patients
with a positive
ELISA for IgG antibodies
(titer>
1:160), seven
had a fourfold
drop in
absorbance
and a negative
serologic
titer at follow-up.
One
patient
with
persistently
positive
titer was fob-
ter PD. To evaluate
this
cyst contents,
US-guided
aspect
of the
aspiration
performed
six cysts were
cysts. Another
at autopsy.
was
The
a
lowed
up for 3 months
after PD. All
three
patients
with a positive
ELISA
for 1gM antibodies
(titer > 1:160) had
a fourfold
drop in absorbance
and a
negative
serologic
titer.
None
of the
patients
had a rise in the hydatid
antibody
titer,
either
of the IgG or the
1gM type.
cyst
in eight
examined
contents
were
studied
± 1.5 (range,
1-12 weeks)
10.3
after
weeks
PD. The fluid was turbid
in all 14
cysts,
and bile stained
in three cysts.
Cultures
for both aerobic
and anaerobic
microorganisms
and
microscopy
were
bris,
and
ples.
hydatid
membranes,
hooklets,
dead
scobeces
in all the fluid
revealed
negative,
cellular
desam-
Complications
Cyst
Reaspiration
We were
term
Volume
viability
180
During
concerned
about
of the
cyst
Number
1
#{149}
long-
contents
af-
PD
and
the
low-up
period,
none
developed
anaphylaxis,
immediate
fol-
of the patients
asthma,
or
Note
and
laryngeal
edema.
type I) developed
after the procedure.
lasted
for
48 hours,
multiple
high-level
septa
and
internal
One patient
(cyst
urticaria
6 hours
The urticaria
and
the
patient
responded
to antihistaminic
therapy.
Two patients
(cyst types I and V)
developed
fever within
48 hours
after
PD. Cyst fluid from both patients
showed
growth
of microorganisms
(E
coli in one and S typhimurium
in the
other).
Specific
antibiotic
therapy
was
instituted,
resulting
in clinical
recovery.
One patient
(cyst type II) developed biliary
rupture
of a hydatid
cyst
4 weeks
after PD. At endoscopic
retrograde
cholangiopancreatography,
a
wide endoscopic
sphincterotomy
was
performed
and laminated
membranes
were basketed
out of the bile duct. At
Radiology
143
#{149}
serial
sonographic
cyst
cavity
examinations,
was
replaced
by
the
an
echogenic
mass that eventually
lost its
rounded
shape
and was not visible
at
repeated
sonography.
One patient
with six liver cysts died
of massive
hemoptysis
3 months
after
PD. Autopsy
revealed
a mediastinal
tubercular
gland
eroding
into the pubmonary
vein and bronchial
tree.
and
cyst
bly
risks
puncture
has been
due to the potential
of anaphylactic
shock,
peritoneal
seeding
and dissemination,
and
growth
of secondary
peritoneab
cysts.
Although
anaphylactic
shock
from
rupture
of an echinococcal
cyst has
been documented,
its exact frequency
and mechanism
have not been well
studied
(9). Lewall
and McCorkell
studied
20 patients
with rupture
of
echinococcal
cysts in the liver; none
developed
anaphylaxis
(14). Schiller
studied
complications
of echinococcal
cyst
rupture
in 30 patients.
tients
had tachypnea,
and hypotension
and
hours
of cyst rupture;
patients
had generalized
autopsy
(15).
These
Two
pa-
tachycardia,
died within
48
both of these
peritonitis
at
authors
con-
cluded
that an anaphylactic
reaction
occurs
infrequently
following
cyst
rupture
and spillage.
Percutaneous
catheter
drainage
is
the treatment
of choice
for the majority
of intraabdominal
regardless
no evidence
ity
contents
ous
occurs
aspiration
abscesses
fluid
of etiology
that any
not
during
of fluid
(16,18).
The
There
is
of cay-
percutane-
collections
use
of fine
and
nee-
dles and catheters;
advances
in radiographic,
sonographic,
and CT techniques;
an approach
through
thick
liver tissue;
a preference
for the right
intercostal
approach;
and sudden
complete
decompression
immediately
after puncture
make the chance
of
spillage
extremely
low and perhaps
less
than
what
might
occur
with
sur-
gical manipulation.
PD was performed
with close monitoring
and with facilities
available
for
treating
any potential
complication,
especially
anaphylaxis.
Hydatid
cyst
aspiration
and/or
drainage
has been
performed
and reported
in the literature (2,9,10,19).
Of the 15 patients
whom
we are aware
of in whom
hydatid
cysts were aspirated,
none deveboped
anaphylaxis.
In the present
study,
21 cysts were aspirated
in 12
patients,
none of whom
developed
asthma,
laxis.
144
laryngeal
Two
patients
#{149}
Radiology
related
edema,
developed
or anaphy-
fever,
to PD.
This
findings
contained
infu-
patient
had
eventually
are caused
by
rupture
(14).
can
lead
rupture
due to high
sure.
Two earlier
reports
therapeutic
drainage
cysts
in the
reported
pigtail
cavity
of a patient
with
six hepatic
hydatid
cysts.
Scan was obtained
15 days after four cysts
were
drained
in a single
session.
Note
separated
endocyst
in four cysts and intact
endocyst
in two cysts.
Arrows
indicate
sites of
cysts.
to biliary
intracystic
pres-
have described
of echinococcal
(2,9).
Mueller
patient
who
et ab (9)
underwent
PD of a recurrent
hydatid
liver.
In their
case,
a 8.3-F
catheter
was
for 3 months.
tinuous
ity
liver
one
successful
cyst of the
catheter
left in place
This allowed
drainage
for a prolonged
(2) treated
three
cysts
of the liver
in the
con-
of the
cay-
Bret
et al
period.
stage.
We
datid
cysts
tinuous
endocyst
all of the
in a single
With
catheter
drainage,
membrane
would
quently
blocked
the
and helped
introduce
residual
cavity.
catheter
lumen
infection
into
Also,
have
been
impractical
ters
in small
cyst
cavities.
However,
the
cyst
ducts and/or
endoscopic
cyst
from
contents
the
common
common
bile
duct
may
function:
agent
it
and
the endocyst
also
from
pattern;
months
± 5.5
the
follow-up
(range,
3-18
of 14.0
months)
in
insufficient
to
clinical
out-
To conclusively
we
are
follow-up
answer
this
performing
of the
long-
patients
in this
study.
However,
the
earliest
response
to cyst
regrowth
or dissemination
is
tive in all three patients
at the last follow-up.
None
of the 12 patients
had a
rise
in 1gM antibody
titer at serial follow-up.
We believe
that the period
of
follow-up
was sufficient
for 1gM antibody
levels
to rise if peritoneal
dissemination
and cyst growth
had occurred.
Serial
sonographic
examination
of
of
bile
at endoscopic
retrograde
cholangiopancreatography
in one patient.
Such patients
to
the appearance
of an 1gM-type
antibody
response
to E granulosus
(12). All
three
of our patients
with
a positive
1gM ELISA
titer showed
a fall in the
antibody
titers,
and the test was nega-
duct has been performed
(20). In the
present
study,
we were successful
in
removing
laminated
membrane
from
the
growth
term
contents
gablbladremoval
separate
question,
meticulous
evacuation
of cyst contents and surgery.
Cysts that communicate
with the biliary
tree require
to evacuate
(20%)
the pericyst.
This agent
is effective
and safe, has no systemic
toxic
effects,
and does
not cause
secondary
sclerosing chobangitis
when
bile duct
communication
is present
(21).
E granulosus
cysts
have
a slow
tion?
successful
in cysts
with
a hyperechoic
solid
pattern
without
back
wall shadows.
Infected
hydatid
cysts
require
from the bile
der. However,
and
come
of PD. Can cyst growth
occur
locally
or in the peritoneal
cavity
due
to cyst fluid
soilage
and dissemina-
cathe-
patients
with suspected
bibiary communication
might
benefit
from prolonged
cyst drainage,
as did the patient reported
by Mueller
et al. Such
cavities
continue
to drain
for a long
time; in many
there is frank biliary
rupture
of cyst material,
as occurred
in one of our patients.
We performed
PD in hydatid
cysts
with a prominent
fluid component.
The procedure
would
not have been
surgery
a dual
the present
study
was
evaluate
the long-term
it would
to place
saline
as a scolexcidal
helped
con-
hypertonic
performed
acted
the thick
have
fre-
of PD
the cysts.
The saline,
which
left in the cyst cavity
for 20 mm-
utes,
21 hy-
stage.
We used
was
patients
with
hydatid
with
PD. After
aspi-
drained
benefit
from
a combination
endoscopic
basketing.
irrigate
ration,
scolexcidab
irrigation,
and reaspiration
of the cyst cavity,
the catheter was immediately
removed
and
the cyst was thus treated
in a single
the
collections,
(16,17).
spillage
before
a cyst with a split wall at US before
the procedure
was performed.
Such
This
cyst
aspirated
showed
growth
of miThis led us to believe
that the cysts were already
harboring
bacteria,
which
were reactivated
by
aspiration.
Similarly,
biliary
rupture
of
a type II cyst in one patient
was possi-
sonographic
cysts
with
DISCUSSION
Hydatid
contraindicated
fluid
sion of saline
croorganisms.
all of the
treated
changes.
high-level
The cavities
were
echoes
consisting
bar debris,
dead
and membranes.
slowly
solidified
further
fluid
docyst,
and
cysts
revealed
scoleces,
These
hooklets,
contents
owing
secretion
the
cyst
similar
filled
with
of cellu-
to the
by the
gave
the
lack
of
enappearJuly
1991
ance of a pseudotumor.
Similar
sonographic
appearances
have been
reported
by other
researchers
after
PD
(2,8)
long-term
Until
treatment
cysts
and
in patients
receiving
albendazole
therapy
(4).
now, surgery
has been the
of choice
for E granulosus
(21).
Surgery
of uncomplicated
sterile,
unilocular
cysts is effective,
with a
morbidity
of approximately
8% and a
mean
hospital
stay of 11.8 days. The
surgical
morbidity
increases-as
does
the hospital
stay-in
cases in which
cyst drainage
is performed;
in patients
with
diseases;
cardiac
and
cessible
and
in cases
sites,
multiple
pulmonary
of cysts
may
and
have
fatal
at mac-
disseminated
those
recurring
after
surgical
procedures.
Peritoneal
age is known
to occur at surgery
cysts,
consequences;
prior
spilland
50%
of
surviving
patients
continue
to harbor
the disease
(21). PD-as
assessed
in 12
patients
in the present
study-was
effective
and safe and resulted
in a
much
shorter
hospital
stay (4.0
days ± 3.4). PD has a particular
advantage
over surgery,
as it can be performed
in patients
whose
cysts are
inaccessible
to surgery
or who are
high surgical
risks due to systemic
illnesses.
PD is particularly
safe in patients with recurrence
of cysts after
surgery,
as the
aspirating
needle
can
be directed
through
the scar tissue
to
reduce
the chances
of cyst leakage
and peritoneal
soilage.
Albendazole,
a benzimidazole,
has
been shown
to be effective
in human
hydatid
disease
(1,3-5).
The drug produces
high concentrations
of albendazobe sulfoxide
in the blood,
cyst fluid,
and cyst wall (1). It causes
death
of
scoleces,
and cysts show objective
evidence
of reduction
in size and may
even disappear
(5). However,
pro-
Volume
180
#{149}
Number
1
longed
therapy
is needed,
the drug is
teratogenic
and hepatotoxic,
and
some patients
fail to respond
(4-7).
PD can be supplemented
with albendazole
therapy
in a number
of ways
to achieve
better
results:
abbendazole
can be used before
PD to make cysts
albendazobe
sulfoxide
can
ud-Din,
The
PA, for secretarial
authors
thank
9.
10.
be
introduced
into the cyst cavity
as a
scobexcidab
agent,
and PD can be foblowed
by albendazole
therapy
to kill
any live scoleces
in the cyst or in the
peritoneum.
We believe
that, in the future,
management
of most hydatid
cysts of the
liver will be possible
with a combination of drug therapy
and PD. Surgery
will be needed
for those cysts that
defy
this combination
treatment.
U
Acknowledgment
8.
11.
12.
13.
14.
Mehraj-
assistance.
15.
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