Managing multiple hepatic hydatid cysts and a single cardiac hydatid cyst simultaneously through a single surgical entry via the abdomen: A case report

Abstract

Introduction and importance

Hydatid Disease, primarily caused by the larval stage of the parasite Echinococcus granulosus, represents significant health challenges, particularly in endemic regions. Hepatic cysts are more common, while cardiac involvement is rare.

Case presentation

This report presents the case of a 35-year-old woman with atypical abdominal pain persisting for several months. CT scan of the thorax and abdomen revealed multiple hydatid cysts in the liver and a single cyst in the apex of the heart. The intramyocardial cyst was asymptomatic. Albendazole was administered pre- and postoperatively. The surgical approach commenced with the hepatic cysts, accessing the area via a bilateral Kocher subcostal incision in the epigastric region. The second step involved an incision of the central diaphragm, providing clear visualization of the cardiac apex. The operation was successful and the patient was discharged without any complications.

Clinical discussion

There are many surgical techniques described in the literature. Recently, single-stage operations have been recommended to manage multiorgan hydatid cysts; however, having two surgical incisions in one operation can still be dangerous to the patient's health.

Conclusion

To our knowledge, this is the first case that describes a surgical technique that begins in the abdominal cavity and then progresses to the thoracic cavity through the diaphragm to manage both hepatic and cardiac hydatid cysts.

Highlights

• •Hydatid disease (HD) can affect any organ of the human body such as the liver, lungs, brain and the heart.
• •Multiorgan involvement can be challenging to manage.
• •Single stage operations are recommended to manage multiorgan hydatid cysts.
• •We describe a surgical technique starting in the abdomen, extending through the diaphragm to treat hepatic and cardiac HD.

1. Introduction

Hydatid Disease (HD), primarily caused by the larval stage of the parasite Echinococcus granulosus, represents significant health challenges, particularly in endemic regions. Hepatic cysts are more common, while cardiac involvement is rare, occurring in only 0.5–2 % of cases [1,2]. A comparative study of single-stage versus two-stage surgeries found that the single-stage approach resulted in significantly shorter operative times, reduced hospital stays, and fewer complications, making it a safer and more efficient option for managing dual-site HD [3]. We present a unique case demonstrating the successful management of hepatic and cardiac HD using a single-stage approach via a single subcostal incision, highlighting the favorable outcomes achieved with this approach. This case represents the first report describing this novel surgical technique. This case is described in accordance with the criteria of SCARE [4].

2. Case presentation

A 35-year-old female patient from a rural area with no prior medical or surgical history presented with atypical abdominal pain persisting for several months. Initial investigations, including physical examination and laboratory tests, yielded unremarkable results.

Ultrasonography revealed nine hepatic cystic lesions, ranging in size from 20 mm to 40 mm, located in both the right and left lobes of the liver, strongly suggestive of hydatid liver cysts. Chest X-ray findings demonstrated cardiomegaly and left ventricle hypertrophy. Subsequent computed tomography (CT) scan of the abdomen and magnetic resonance imaging (MRI) confirmed the diagnosis, revealing dual visceral localization of hydatid cysts in both the liver and the heart (Fig. 1). The intramyocardial cyst, located in the heart apex within the left ventricular wall and measuring 40 × 38 mm, was asymptomatic and did not cause cardiac hemodynamic compromise or valvular dysfunction.

Fig. 1.

CT scan shows multiple hydatid cysts in the liver and a single cyst in the apex of the heart.

A surgical intervention was deemed necessary, and the patient received pre-operative albendazole therapy at a dosage of 400 mg twice a day for two weeks prior to surgery. The surgeon elected for a single-stage procedure to address both the hepatic and cardiac cysts simultaneously. The surgical approach commenced with the hepatic cysts, accessing the area via a bilateral Kocher subcostal incision in the epigastric region. Cyst fluid was aspirated using large needles attached to aspirators, and the cyst walls were opened to further aspirate the cavity. The cyst membranes were then removed, and the cavities were meticulously cleaned with povidone‑iodine-soaked gauze. Saline was introduced into the cavities, followed by the placement of a clear sponge for five minutes to assess for biliary communication. Active drainage of the remaining cavity was achieved.

The second step involved an incision of the central diaphragm, providing clear visualization of the cardiac apex. The cardiac cyst was removed with high precision and completely by withdrawing the fluid from inside it via a 28-French drain and isolating it well during that to prevent possible contamination from the cyst fluid. After that, the disseminated membrane was completely removed, and thus the cyst was completely removed from the left ventricle of the heart with the least possible contamination to reduce the occurrence of a possible allergic reaction and then the diaphragm was firmly closed (Fig. 2, Fig. 3).

Fig. 2.

The subcoastal entry incision along the three drainage tubes which were inserted post-surgery: one in the mediastinum, removed after 3 days; one at the cystic cavity in the liver, removed after 2 weeks; and one between the liver and diaphragm, removed after one week.

Fig. 3.

A view of the heart through the diaphragm incision.

The surgery lasted approximately two hours, and the patient was discharged five days postoperatively. Albendazole therapy was prescribed for four months at a dosage of 400 mg twice a day for 21 days followed by a 7-day break. Post-operative follow-up with echocardiography and CT scan confirmed an excellent post-surgical outcome, with no complications or recurrence of the disease.

3. Discussion

HD can affect any organ of the human body, the most common involvement of HD is in the liver and the lungs, followed by other organs such as the spleen, brain, heart, and kidneys [1,2,5,6]. Cardiac involvement is uncommon, and is typically secondary to more commonly involved organs like the liver and lung [1,2]. HD can affect any part of the heart, most commonly the left ventricle because of the dominance of the left coronary artery [1,2].

Clinical manifestations of HD depend on the cyst's location in the body and may be asymptomatic [5]. Hepatic HD may manifest jaundice, fever, atypical abdominal discomfort, hepatomegaly with an abdominal mass, and stomach pain [1], while cardiac HD can be asymptomatic until the development of complications such as dyspnea, chest pain, palpitation, arrhythmias, and AV nodal block. These complications may vary depending on location, size, compression, or involvement of abutting structures [1,2,7].

Imaging is the first investigation that used to diagnose HD such as ultrasonography, CT-scan and MRI [5]. Diagnosis of cardiac HD is challenging due to the long period between the infection and the onset of symptoms [2]. ECG may reveal non-specific signs [1]. Chest X-ray can also show a nonspecific cardiomegaly [7]. There are many highly sensitive and specific serological methods such as latex agglutination, immunoblots, ELISA, indirect hemagglutination, or immunoblots; however, these methods are not usually used to diagnose cardiac HD [1,5]. Histopathology is a confirmation method for the diagnosis; however, a CT scan can confirm cardiac HD [2,7].

The treatment options vary based on the size and complexity of the cysts with albendazole medications being the preferred option for smaller cysts, while surgical intervention is for larger cysts, cysts at risk of rupture, or complex cysts [5]. Single-stage approach has a better outcome for the patients than a two-stage approach, with lower rates of complication and mortality, regardless of the specific surgical strategy employed [3]. Albendazole can decrease the viability of the cysts when used preoperatively, and it can also help prevent recurrence when used postoperatively [8].

In this case, the surgeon decided to perform a one-stage surgical approach to manage both the hepatic and cardiac cysts through a single subcostal incision. The procedure began by addressing the hepatic cysts first, followed by making an incision in the central part of the diaphragm to access the apex of the heart and remove the singular cardiac cyst. The trans-diaphragmatic intervention had been described before to manage certain cases of liver and lung HDs, and it has been regarded as a preferable option [9]. However, only one case in the literature described such an intervention to deal with liver and cardiac HDs. One challenge encountered was the difficulty in observing the hepatic cyst after addressing the cardiac one [10]. In our case, we avoided this issue by first addressing the liver cysts, allowing for a clear view of the cardiac apex through the diaphragm.

4. Conclusion

The treatment approach for multiorgan hydatid cysts should be based on each specific case. When suitable, the technique we used can be considered as it reduces the surgery time and saves the patient from the various complications of undergoing two surgical incisions simultaneously.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-inChief of this journal on request.

Ethical approval

This paper was exempt from ethical approval because it does not include any personal information inside it.

The institution is Hama University.

Funding

No funding applicable.

Author contribution

Ahmed Aldolly: Conceptualization, Data curation, Writing – original draft, Writing - review & editing.

Yousef Alsaffaf: Writing – original draft, Writing - review & editing.

Saja Karaja: Writing – original draft.

Hazem Arab: Writing – original draft.

Naser Alshaikh: Performed the surgical procedure, Patient care, Supervision, Writing - review & editing.

Guarantor

Ahmed Aldolly & Naser Alshaikh.

Research registration number

Not required.

Conflict of interest statement

The authors have no conflicts of interest.