Liver dome hydatid cyst surgery: Laparotomy or thoracotomy?

ABSTRACT

Background:

The liver is the most common organ of the body that is at risk of getting affected by hydatid cyst (75%). All lobes of the liver can be involved with the formation of hydatid cyst, but the right lobe is more involved than the left lobe. The rate of involvement of liver dome and segments 7 and 8 of the right lobe has not been reported so far, but the best treatment for liver hydatid cyst has been found to be surgery.

Materials and Methods:

In this study, 240 patients with liver hydatid cyst underwent surgery from 2005 to 2017. In this retrospective study, the variables of gender, age, number of liver cysts, involvement of lobe and segments, simultaneous involvement of liver and lung, laparotomy, thoracotomy, the number of patients referred due to the lack of finding cysts in laparotomy, and surgical complications were analyzed.

Results:

The results showed that the majority of patients were males with age ranging from 8 to 68 years. Right lobe involvement was observed in most of the patients. About 62 patients showed involvement of liver dome and segments 7 and 8. Therefore, 62 patients underwent thoracotomy according to the criteria introduced and the rest of the patients (n = 178) underwent laparotomy. The results showed that there was a potential for capitonnage in 46 patients in thoracotomy. The pain score was 4–5 according to the VAS criterion. The rate of using analgesic drug did not show significant difference between the two methods.

Conclusion:

During the manipulation, cysts might be ruptured and give rise to complications such as spread of the disease, shock, and anaphylaxis, which may be followed by legal complaints. Therefore, in order to perform the surgery successfully, a new method along with computed tomography (CT) scan has been introduced in this study, which can be very helpful.

Introduction

Hydatid cyst is a common disease affecting humans and animals and has a high prevalence in the areas of the world where sheep and livestock are bred.[1,2] The disease is also prevalent in countries such as Iran, Turkey, Greece, New Zealand, and Australia. These countries are considered as endemic areas of the disease. In areas where dogs are used as a herd keeper, there is a high risk of hydatid disease.[1,2,3] This disease has a global spread. Liver, mainly the right lobe, is the most common organ involved in this disease, followed by the lung. None of the body organs is immune to hydatid cyst.[4] There are different surgical procedures for liver hydatid cysts. The main methods proposed in this regard are laparotomy, complete exploration, liver mobilization, cyst specification, enclosing the cyst with gas immersed in hypertonic saline, discharge of cyst contents, removing the remaining cavity, sewing the bile leakage site, external drainage with Foley catheter, omentoplasty,[1,2,3,5] and sometimes advanced laparoscopy is used. However, the procedure might be followed by serious complications such as cyst rupture and cyst spread.[3,6,7,8]

However, for large cysts and liver dome cysts or for those in the upper posterior segments (segments 7 and 8), a thoracoabdominal method is usually needed.[3,6] This method is associated with severe pain and pulmonary complications.[3] It is a simpler method with fewer complications; it includes thoracotomy and opening the right diaphragm at the exact site of the cyst and performing all the surgical procedures.[2] Another method that has been performed in only one patient so far includes laparoscopy along with thoracoscopy in one step.[3] However, surgery of liver cysts was performed by the traditional method up to 2006.[9] However, selecting the most appropriate surgical approach depends to a large extent on having a clear idea of the limitations and long-term complications of techniques. Thoracotomy is proposed for all liver hydatid cysts located in the posterior and upper segments of the liver (liver dome and segments 8 and 7), or if the cyst is close to the ribs and the spinal cord and to the posterior side of the diaphragm. The main objective of this study was to determine the gender, age, number of liver cysts, involvement of liver lobes and segments, simultaneous involvement of liver and lung, laparotomy, thoracotomy, number of patients referred due to inability to find cysts in laparotomy, and surgical complications of patients with liver cysts who have undergone surgery in the last 12 years.

Materials and Methods

During the years 2005–2017, about 240 patients with liver hydatid cysts underwent surgery in the hospitals of Rasht. In this method, the trunk of the celiac artery was found through computed tomography (CT) scan images of the abdomen with intravenous contrast and a transverse line was drawn over it in the abdomen. Then, a vertical line was drawn from the xiphoid to the spinal cord, and the liver was divided into three parts, that is, 1, 2, and 3. In fact, all the liver cysts, should undergo thoracotomy and with the minimum surgical complications. Other criteria including proximity of the cyst to the spinal cord and the ribs and the cyst bulging into the pleural space and adhering to the diaphragm were also considered [Figure 1]. Then, this retrospective study was conducted to investigate the following variables: gender, age, number of liver cysts, involvement of lobe and segments, simultaneous involvement of liver and lung, laparotomy, thoracotomy, the number of patients referred due to not finding cysts in laparotomy, and surgical complications and death of patients with liver cyst who underwent surgery.

Figure 1.

Liver hydatid cyst

Results

In this study, the study population consisted of 62 females and 178 males. The age of the female patients was between 6 and 58 years, and the age of the male patients was between 8 and 68 years [Table 1]. Twelve patients were referred to a laparotomy due to failure in finding the liver cysts, and about 18 patients had liver and lung hydatid cysts simultaneously. The study findings showed that 166 patients had one cyst, 54 patients had two cysts, and 20 patients had three cysts. Right liver lobe was involved in 200 patients and the left lobe in 40 patients. Sixty-two patients showed involvement of liver dome and the seventh and eighth segments. Sixty-two patients (including 12 patients who had failure of primary surgery) were operated with thoracotomy approach according to our criteria [Figure 1] and the remaining 178 patients with laparotomy approach. A total of 62 patients with only liver hydatid cysts were treated with thoracotomy surgery. In laparotomy, the complication of bile secretion from the drain was diagnosed in 7 days in 126 cases, 14 days in 62 cases, 21 days in 48 cases, and 35 days in 30 cases. Six patients underwent laparotomy again due to bile leakage, abdominal pain, and biliary peritonitis. In laparotomy, bile secretion took 20 days on average. In thoracotomy, discharge from the drain was seen for 7 days in 38 cases, 14 days in 14 cases, and 21 days in 10 cases. In thoracotomy, bile secretion took 14 days on average. In laparotomy, there was a possibility of complete capitonnage in 86 patients, but it was not possible in the rest of the patients. The results showed that in thoracotomy, 46 patients had the potential for capitonnage. The duration of hospitalization was 4 days in laparotomy and 5 days in thoracotomy. The pain score was 4–5 with visual analogue scale (VAS) criterion. There was no difference between the two groups in the rate of using analgesic drug. Air leakage occurred due to pleural space adhesion in six patients with thoracotomy, which improved with physiotherapy. Atelectasis was seen in eight patients, which improved with physiotherapy. There was no death in any group.

Table 1.

Distribution of demographic and clinical characteristics of patients

	Number (%)/mean±SD (confidence level of 95%)
Variable
Age, years
Gender
Male	178 (74.17)
Female	62 (25.83)
Number of cysts=240
1	166 (69.17)
2	54 (22.50)
3	20 (8.33)
Involved side (n=240)
Right	200 (83.33))
Left	40 (16.67)
Duration of bile secretion from the drain in laparotomy (n=266)
One week	126
Two weeks	62
Three weeks	48
Five weeks	30
Duration of daily secretion from the drain in thoracotomy (n=62)
One week	38 (61.29)
Two weeks	14 (22.58)
Three weeks	10 (16.13)
Complete capitonnage in laparotomy
Yes	86 (48.32)
No	92 (51.68)
Complete capitonnage in thoracotomy
Yes	46 (74.19)
No	16 (25.81)

SD=Standard deviation

Discussion

Hydatid disease is a parasitic infection that is transmitted from animals to humans, and it has a global spread. The disease is prevalent in areas where traditional livestock farming is practiced and cattle, sheep, and goats are in close contact with other animals such as dogs.[1,2] In the endemic regions of the world, the human liver is the most common organ that is at risk of the echinococcosis disease.[1] Also, 65%–75% of all hydatid cysts are found in the liver. When the hydatid cysts are localized in the liver, their size increases over the course of time.[1,2,5] However, any liver cyst can have several types of complications. Those cysts that are located on the upper surfaces of the liver grow upward to the pleural cavity and are pressed against the diaphragm and the lung, and this might cause them to rupture and enter into the pleural space or the lung parenchyma.[10] The cysts located in the lower regions grow either forward or downward to the abdominal cavity and may be ruptured into the peritoneal cavity, which may cause shock, anaphylaxis, and biliary peritonitis.[1,5,10] Thus, the important point in the surgeon’s view is to find where the outermost part of a particular cyst is.[1,2,5] Every cyst normally has only one surface display point for the surgeon to access. CT has provided a new dimension in the diagnosis of liver hydatid disease because it can accurately show the location of the cyst in the liver.[1,2,5,11] One of the current treatments for hydatid cyst in the liver includes aspiration and drug surgery includes aspiration and pericystectomy and anti-helminithic therapy.[3] Laparoscopy and thoracoscopy have been used commonly in recent years, but there is a risk of cyst rupture and anaphylaxis shock in this method.[3,8,10,12] The main goal of hy datid cyst surgery is generally complete removal of all parasitic elements, avoiding leakage of the contents of the cyst, preventing the formation of a new cyst and incidence of anaphylaxis, and finding a solution for residual pericyst cavity.[1,3,5,13] In order to select a special surgical technique in a specific liver cyst, the surgeon must make decision based on the size and location of the cyst and the complications that have been created before or the possible complications during surgery. The surgeon who wants to operate a liver cyst should have adequate information and appropriate knowledge of the liver CT scan and liver anatomy, and he/she should select a method to meet the main goal of the surgery, so that no problem is created for the surgeon mean and the patient.

There are several alternative methods, but selecting the most appropriate approach depends to a large extent on having a clear idea of the limitations and long-term consequences of the techniques. Thoracotomy surgery should be used for all liver hydatid cysts located in the posterior and upper segments of the liver (liver dome and segments 7 and 8), or if they are close to the ribs and the spinal cord and close to the posterior side of the diaphragm, or if the cyst is bulging into the pleural space.[1,2,3,5,10] Dr. Farrokh Saeedi believed that to perform laparotomy or thoracotomy, it would be better if a hypothetical horizontal plate is passed through the xiphoid process to reach the spinal cord and if the liver is at the top of this page, thoracotomy would be used, and if it is below this page, laparotomy would be used.[9] However, another report recommended the use of thoracotomy for large cysts of the upper posterior segment of the liver.[3] However, for those who have both liver and right lung hydatid, it is recommended that the lung cyst should be operated by thoracotomy in the first stage and then the liver cyst should be operated by opening the diaphragm, and there is no need for thoracoabdominal incision or separate laparotomy.[2]

However, based on the method presented in this study, which has not been recorded in the medical documents, before surgery, the CT scan images should be examined accurately and the trunk of the celiac artery should be found through the CT scan images of the abdomen. A transverse line should be drawn over it in the abdomen and a vertical line should be drawn from the xiphoid, and the liver should be divided into three parts. In fact, all liver cysts should be operated with thoracotomy. After opening the chest, the cyst site is found through touching it and the area is covered by gas immersed in hypertonic saline. Then, aspiration is performed beyond the diaphragm, and after the aspiration on the diaphragm, a 6-cm incision is made on the diaphragm. First, cyst fluid and then, all cyst elements are removed carefully, and the remaining cavity is washed with normal saline for several times. Then, the cavity is sewn from its floor to its surface as much as possible (capitonnage). A drain is put in the cavity or side of the cavity under the diaphragm and it is removed from the abdomen. Then, a chest tube is placed and its wall is sutured and cl osed. We used the above-mentioned method for surgery in patients with hydatid cyst. We did not have a serious problem in finding the cyst and in extraction of the cyst, and no serious complication was found.

Conclusion

During surgery of hydatid cysts that are in the liver dome or in segments 7 and 8, access to them through laparotomy is associated with problems. It has been frequently observed that in patients who are referred from other centers, the cysts were not found during laparotomy and the cysts were not extracted completely or had been ruptured, which led to legal complaints. All these patients have been treated well with thoracotomy. Therefore, we recommend that patients with liver hydatid cysts in segments 7 and 8 and liver dome should be treated with thoracotomy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.