A safe and inexpensive method for laparoscopic hydatid cyst evacuation

Sir,

Laparoscopic approach was recently introduced to treat hydatid liver disease but main concerns still remain in regard to possible spillage of hydatid material during cyst manipulation with the consequent risk of recurrence and dangerous anaphylactic reactions. Several devices were developed to evacuate laparoscopically hydatid cysts. Insertion of a needle into the cyst for aspiration of its content and to replace the same volume with a scolicidal agent is the most widely known method but its main drawback is the occlusion of the needle. Alper et al. developed an aspirator–grinder apparatus driven by an electrical spiral motor with good results, but the device is not available in every operating room due to the rarity of hydatid disease. Other methods were described by authors working in endemic areas but all suffers of a complexity that precludes their diffusion ¹. Here we describe a simple and inexpensive method to drain laparoscopically hydatid liver cyst and to carry out safely the liver resection. A 43-year-old man was admitted at our Department for abdominal pain and jaundice. Ultrasonograpy revealed a 12 cm cystic mass of liver segments II and III with inner daughter cysts and dilatation of the main bile duct (14 mm). CT scan and serology were consistent with hydatid disease. Endoscopic Retrograde Cholangiopancreatogram (ERCP) was performed in order to identify the biliary fistula – developed at the level of the biliary branch for segment II – and to drain the biliary three by means of sfincterotomy and drainage. Patient was then scheduled for a laparoscopic robot-assisted liver resection due to the favorable location of the lesion. Pneumoperitoneum was induced at 12 mmHg with the Verres needle. Camera port was placed at the umbilicus and three operative trocars were inserted in the right and left upper quadrants and in the left flank, respectively. The left liver surface was covered with gauzes soaked in hypertonic saline solution introduced through a 10-mm trocar. A stitch was passed on the cyst surface for liver retraction in order to avoid spillage during its incision. A small incision was then produced and a 6.5 gauge endotracheal tube (ET) armed with a 5-mm suction device was inserted through the 10-mm left-quadrant trocar and cuffed once introduced into the cystic cavity. Continuing suction avoided spillage during tube introduction and complete evacuation of the hydatid content was reached by external drainage through the ET facilitated by the cystic pressure. The suction device passed through the ET tube instead achieved aspiration of the daughter cysts. Finally, the cavity was washed with 3% saline solution for five minutes through the ET to inactivate the remaining scolices. The ET was then removed and the cystic wall incision closed with a running suture. Pericystectomy was completed with the three-arm da Vinci® surgical system docked over the patient's left shoulder. The cyst was removed through the umbilical port-site. Gross pathological examination revealed complete removal of all daughter cysts. Patient had an uneventful postoeperative period, was discharged on day six and is actually disease-free at six-month follow-up. We believe that the use of a ET is a safe, inexpensive and reproducible method to evacuate hydatid liver cyst. During its use we did not observe spillage of the cyst content. Evacuation and instillation of the scolicidal fluid were easily carried out allowing a safe resection. This method could enlarge indications for laparoscopic treatment of hydatid liver disease also in Western hospital where devices for its treatment are not easily available.

Alberto Patriti, Graziano Ceccarelli,

Luigi Maria Lapalorcia, Luciano Casciola

Department of General, Vascular

Minimally Invasive and Robotic Surgery

San Matteo degli Infermi Hospital

Spoleto (Perugia)

Italy

Squamous Cell Carcinoma of the Ampulla of Vater – A Rare Case Successfully Managed By Pancreaticodudenectomy

To the editors

A 30-year-old female patient presented with jaundice, pain in abdomen and loss of appetite. A CT scan showed a circumferential thickening in the periampullary region mildly indenting the second and third part of duodenum. Endoscopic biopsies from the ulcer were suggestive of a squamous cell carcinoma (SCC). A radical pancreaticodudenectomy (Whipple's procedure) was performed. The surgical specimen consisted of part of stomach, duodenum, common bile duct and pancreas. At the ampulla there was a 1 cm diameter chalky white ulcero-infiltrative growth, sections from which showed infiltration of ampullary region by sheets and islands of malignant squamous epithelial cells. Intercellular bridges, cellular keratinization and keratin pearl formation were seen. No evidence of glandular or adenocarcinomatous component was found on whole processing the tumor. Physical examination and a whole body CT scan did not show any other site in the body which might have given rise to a metastatic SCC of the ampulla. Final diagnosis was well-differentiated SCC of the ampulla infiltrating the duodenum.

Majority of the ampullary tumors are adenocarcinomas ¹. Rare cases of adenosquamous carcinoma, carcinoid tumor, primary malignant lymphoma, liomyosarcoma, gastrointestinal stromal tumors, rhabdomyosarcoma, sarcomatoid carcinoma and metastatic SCC of the ampulla have been described ¹. Only three cases of primary SCC of the ampulla have been reported in literature. First was reported in 1952, second in 1960 and third case was reported in 1996. The third case was reported in a 72-year-old Chinese female in whom the diagnosis was made by histologic examination after duodenoscopy. The patient developed biliary tract infection after undergoing ERCP and expired due to persistent bleeding ². The patient in our case was successfully managed by pancreaticoduodenectomy.

The histogenesis of ampullary SCC is not known. It has been hypothesized that tumors such as SCC of the extrahepatic bile ducts either arise from squamous metaplasia of columnar lining epithelium secondary to chronic inflammatory process or from squamous metaplasia of the tumor itself. A similar mechanism may also explain the occurrence of SCC at the ampulla. Ampullary carcinomas may extend into duodenum, pancreas and common bile duct and may show perineural and vascular invasion, nodal metastasis or distant metastasis to liver, lung and pleura. Carcinomas of the ampulla need to be differentiated from the carcinomas of distal third of the bile duct. The bile duct carcinomas produce longitudinal thickening of the bile duct and a granular appearance of the mucosa. Majority of these tumors are well differentiated and produce severe desmoplastic reaction, while ampullary carcinomas tend to be poorly differentiated without desmoplasia.. Surgical resection in the form of Whipple's pancreaticodudenectomy remains the treatment of choice in ampullary carcinomas.

To conclude, SCC of the ampulla is a very rare neoplasm and must be kept in the differential diagnosis of ampullary tumors. These tumors can be successfully managed by pancreaticodudenectomy. If a SCC is seen at the ampulla, patient must be investigated to rule out SCC of other sites in the body which may give rise to a metastasis at the ampulla.

Deepak Kumar Singh, Archana Rastogi,

Ravi Shankar, Ranjana Gondal

Department of Pathology

Govind Ballabh Pant Hospital

New Delhi, India

Pramod K. Mishra

Department of Gastrointestinal Surgery

Govind Ballabh Pant Hospital

New Delhi, India