Asian Cardiovasc Thorac Ann 2005;13:20-23
© 2005 Asia Publishing EXchange Ltd
Non-Capitonnage Method for Surgical Treatment of Lung Hydatid Cysts
M Nesimi Eren, MD,
Akin E Balci, MD,
evval Eren, MD
Department of Thoracic and Cardiovascular Surgery, Dicle and Firat University School of Medicine, Elazi
, Turkey
For reprint information contact: Akin E Balci, MD Tel: 90 424 238 8080 Fax: 90 424 233 5038 Email: abalci{at}firat.edu.tr, Department of Thoracic Surgery, Dicle and Firat University School of Medicine, Elazi 23100, Turkey.
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ABSTRACT
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Capitonnage is usually advocated for obliteration of the residual cavity after removal of a hydatid cyst. To assess a non-capitonnage method, results in 33 patients were compared with those of 80 patients who had capitonnage. The non-capitonnage patients had a shorter mean hospital stay and earlier radiologic improvement but higher morbidity than the capitonnage patients. Extended air leak caused significant morbidity in each group. Bronchoscopic intervention was needed for atelectasis in 1 patient. There was no mortality in either group. In the follow-up period, no late complication or recurrence was observed in non-capitonnage patients. Among the capitonnage patients, 2 had bronchiectasis, and suture material expectoration occurred in one. The non-capitonnage method may be a good alternative to the capitonnage procedure for lung hydatid cyst. Better management of bronchial openings should improve the results of the non-capitonnage method.
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INTRODUCTION
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Spontaneous improvement of hydatid cyst of the lung is very rare, and medical treatment may be useful only for small cysts.1 The combination of albendazole and praziquantel seems to be the most effective medical treatment, but it is not an alternative to surgery.2 The goal of surgical therapy is to remove the cyst while preserving as much lung tissue as possible.3 Although small cysts can be removed by enucleation, the usual method is cystotomy. The optimal treatment following cystotomy is controversial. Capitonnage for obliteration of the residual cavity is usually advocated.4,5 On the other hand, capitonnage has the disadvantage of causing distortion of the pulmonary parenchyma, especially after removal of multiple cysts, and it has been recommended that only partial capitonnage be performed for large cysts.6,7 However, there is no clear consensus on the use of capitonnage in surgical series that included giant cysts.3,8 This study was carried out to compare the capitonnage and non-capitonnage methods of treating lung hydatid cysts.
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PATIENTS AND METHODS
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The hospital records of all 113 patients who underwent surgery for lung hydatid cysts in our department between 1993 and 2001 were reviewed retrospectively. Of these patients, 33 (29%) were operated on by a non-capitonnage method and 80 underwent capitonnage. The choice of method was made preoperatively. No selection criteria were used to obtain similar specifications for each group. The 2 groups were compared with respect to postoperative complications, mortality, duration of hospitalization, postoperative drainage, time of radiologic improvement, and recurrence rate. The criteria for radiologic improvement were loss of the shadow of the operated cyst and resorption of the postoperative pericystic inflammation and pleural reaction. Radiologic evaluation was performed in collaboration with the radiology department. Complicated cysts were those that were perforated or infected. Air leaks persisting for more than 10 days were defined as extended air leaks. Each group underwent the same standard preoperative preparation and postoperative management. The preoperative diagnosis was based primarily on chest radiographs. Abdominal ultrasound was used to assess liver involvement. However, a definite diagnosis was established by postoperative pathological assessment. Due to their lack of specificity, Casoni’s intradermal test and the Weinberg complement-fixation test were not used.
The same surgical team operated on all patients. A posterolateral thoracotomy through the 5th or 6th intercostal space was accomplished with the patient in the lateral decubitus position in all except 11 patients who had a median sternotomy for bilateral hydatid cysts. Another 7 patients with bilateral involvement underwent a staged thoracotomy. When the hydatid cyst was identified, the surgical wound and adjacent lung tissue were covered with gauze steeped in 10% povidone-iodine poly-iodine complex, so that only the area of the lung containing the cyst was exposed. A 20-gauge lumbar puncture needle connected to a 50 mL glass syringe was inserted into the cyst and the hydatid fluid was aspirated. The same volume of 10% povidone-iodine poly-iodine complex was injected into the cyst. This solution was aspirated with the same syringe, and cystotomy and removal of the laminated membrane were performed. In patients treated without capitonnage, only the bronchial openings were closed after cystotomy and removal of the laminated membrane; residual cavity obliteration was not performed. In the capitonnage group, large bronchial openings were closed with 3/0 silk suture, and the residual cavity was obliterated with imbricating sutures from within. Simultaneous operations were performed with thoracophrenotomy in cases of concomitant liver echinococcosis. No patient in either group underwent lung resection. Non-narcotic nonsteroidal analgesics were administered and pain decreased to a minimum on the first postoperative day. The non-capitonnage and capitonnage groups were compared using the unpaired t test for two independent groups. Values of p < 0.05 were accepted as significant.
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RESULTS
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The mean age and mean cyst diameter were not significantly different between the 2 groups, and the other parameters were also similar (Table 1
). There was a total of 40 cysts in the 33 non-capitonnage patients, and 84 cysts in the 80 capitonnage patients. In both groups, lower lobe involvement by the cyst was more frequent than upper lobe involvement. Nineteen (57.5%) patients were symptomatic in the non-capitonnage group, and 49 (61.2%) of the capitonnage patients were symptomatic (p > 0.05). The most prominent symptoms in both groups were cough and thoracic pain (Figure 1).
Mean hospital stay and the interval before radiologic improvement (Figure 2) were shorter in the non-capitonnage patients ( p < 0.05). Non-capitonnage morbidity was 15.1% vs. 5% for the capitonnage group ( p < 0.05). No differences were detected in the duration or total amount of drainage (Table 2). Extended air leak was an important factor for morbidity in both groups. No negative suction was undertaken but coughing was encouraged and the patients were carefully observed. In one patient with extended air leak, empyema thoracis developed. Four weeks after the initial operation, decortication was performed in this patient and in another empyema case. Atelectasis was managed by nasotracheal aspiration and intensive respiratory exercises as well as negative suction. For one patient in the capitonnage group, bronchoscopy was needed on the 6th postoperative day. Atelectasis resolved in all cases. Minor causes of morbidity were serous fluid collection and minor wound dehiscence. No mortality was observed in the intraoperative or postoperative periods.
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Figure 2. (A) Preoperative chest radiograph of a patient with hydatid cyst. (B) Postoperative chest radiograph after non-capitonnage surgery.
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The mean follow-up in the capitonnage group was 51.9 months (range, 11–88 months). The non-capitonnage patients were followed up for 43.2 months (range, 13–91 months). In the follow-up period, there were no late complications or recurrences, but there were 2 cases of bronchiectasis and 1 of suture material expectoration with hemoptysis in patients operated on by the capitonnage method. Diagnosis of bronchiectasis was made by computed tomography. These two patients had also undergone computed tomography at the time of the hydatid cyst operation; however, no bronchiectasis was observed. The patients with late complications did not have giant or complicated cysts at surgery. The interval between the hydatid cyst operation and the diagnosis of bronchiectasis was 77 months in one case and 87 months in the other. There was no recurrence of hydatid cyst in any of the patients in this series.
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DISCUSSION
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Cystectomy and pulmonary resection have been advocated as the best ways of decreasing the most frequent postoperative complications: bronchopleural fistula and post-cystectomy residual cavity.4,5,9,10 In this series, no residual cavity was encountered in the non-capitonnage cases. Pulmonary resection should not be routinely performed for hydatid cyst of the lung as the condition primarily affects children and relatively young adults who may acquire the parasite anew. Only destroyed parenchymal tissue should be removed. No lung resection was performed in our patients. In cystotomy with capitonnage, there is no loss of lung tissue; the non-capitonnage method also avoids parenchymal loss.4,11
In cases of large peripheral cysts in children, capitonnage could restrict expansion of the lung.10,12 With positive pressure during anesthesia, capitonnage sutures could lead to laceration of the pulmonary tissue, especially in complicated cysts. The imbricating sutures of capitonnage could damage vessels and bronchia, resulting in bleeding and atelectasis. Capitonnage has been reported to have no advantage in the long term, and it could lead to distortion of the residual lobe or lung.12,13 Thus, it has been performed in small cysts only.7,12 Because of these reports, we only sutured bronchial openings if they were within the residual cavity after cystotomy. Although we encountered higher morbidity in non-capitonnage patients, re-operation due to complications was needed only among capitonnage cases. Higher morbidity may be due to discharge or relaxation of sutures that settle on bronchial openings in patients with infected or perforated cysts. Greater effort has been applied to closure of the bronchial openings in recent cases, and no similar complications have occurred. This complication did not contribute to longer hospital stay or chest drainage. Other complications were resolved by general management methods with little impact on hospital stay.
Without capitonnage, the cystic cavity completely disappeared on radiography within approximately two weeks after the operation, due to the ability of the lung to expand. It was concluded from these results that capitonnage is not essential in the surgical treatment of lung hydatid cysts. Careful closure of the bronchial openings should reduce morbidity.
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ABSTRACT
INTRODUCTION
