Asian Cardiovasc Thorac Ann 2008;16:392-395
© 2008 Asia Publishing EXchange Ltd
One-Stage Procedure for Lung and Liver Hydatid Cysts
Manucher Aghajanzadeh, MD,
Fizolah Safarpoor, MD,
Hussein Amani, MD1,
Ali Alavi, MD1
Department of Thoracic and General Surgery
1 Department of Pulmonology, Guilan University of Medical Sciences, Razi Hospital, Rasht, Iran
For reprint information contact: Manucher Aghajanzadeh, MD, Tel: 981 13155 50028, Fax: 981 13155 59787, Email: maghajanzadeh2003{at}yahoo.com, PO Box 41448, Respiratory Diseases & TB Research Center, Razi Hospital, Rasht, Iran.
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ABSTRACT
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Concomitant pulmonary and liver hydatid cysts occur in 4% 25% of patients with echinococcosis. To evaluate the safety of a single-stage operation, experience with this procedure between 1992 and 2005 was reviewed. Of 152 patients who underwent surgery for pulmonary hydatid cyst, 30 had an additional hepatic cyst that was located on the upper dome of the liver in all cases. Pulmonary cysts were excised first via a posterolateral thoracotomy. After phrenotomy, the hepatic hydatid cyst was evacuated without capitonnage, and a Folly catheter was left in the cavity. Postoperative complications in the 30 patients with cysts in both locations included empyema in 2, bronchopleural fistula in 1, excessive biliary discharge in 3 and hemorrhage in 1. Hepatic hydatid cysts recurred in 2 patients. There was no hospital death. A single-stage posterolateral thoracotomy for extraction of pulmonary and liver hydatid cyst is an effective and safe surgical technique with few complications.
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INTRODUCTION
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Hydatid disease is a serious health problem in some countries such as Iran where it is endemic.1 Although it may involve any organ, it most often affects the liver and lung.2 Concomitant pulmonary and liver hydatid disease may occur in 4% 25% of patients.3,4 Medical management with oral mebendazole and albendazole has been used, and it is the preferred treatment in children.5 However, it may be associated with serious complications such as hepatitis, hence surgery is preferred in adults.6 In some reports, a single-stage operation for pulmonary and liver hydatid cysts was found to be a safe procedure with low morbidity and mortality.7 The aim of this retrospective study was to evaluate the results of a single-stage posterolateral thoracotomy for right pulmonary and liver hydatid cysts.
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PATIENTS AND METHODS
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Between 1992 and 2005, 152 patients were operated on for pulmonary hydatid cysts. Of these, 30 (20%) had concomitant hepatic and right lung cysts (Table 1
). Diagnosis was achieved by various combinations of chest radiography (Figure 1), computed tomography (CT) of the chest and abdomen (Figures 2 and 3), and abdominal ultrasonography. Rigid fiberoptic bronchoscopy was carried out when a mass lesion was present. Serologic tests were not routinely used. Eight patients had a complicated cyst pulmonary, defined as rupturing into the bronchus and pleural cavity with or without infection. During the first 5 years of our study, all patients underwent prophylaxis with antihelminthic therapy (mebendazole for 10–15 days before surgery). In the next 8 years, prophylaxis (albendazole) was given for 10–15 days before the operation and maintained postoperatively with mebendazole (40 mg·kg–1 daily) and albendazole (10 mg·kg–1 daily) for 2 months.
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Figure 1. Chest radiograph of a patient with complicated hydatid cyst of lung, with a water lily sign.
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Figure 2. Computed tomography of a patient with a liver hydatid cyst and intrapleural rupture of a lung cyst.
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A posterolateral thoracotomy is our preferred approach to a pulmonary cyst. In cases of bilateral pulmonary cysts, a second posterolateral thoracotomy is carried out 1 month later. We do not use a median sternotomy for bilateral cysts. The side with the largest cyst or greatest number of cysts was treated first. In patients who had an intact cyst on one side and a ruptured cyst on the other, the intact cyst was operated on first, unless a serious symptom such as hemoptysis or intrapleural rupture occurred. Pneumolysis and decortication were performed in patients with intrapleural ruptured cysts. The hepatic cyst was removed after excising the cyst in the right lung. Double-lumen endotracheal tubes were used during general anesthesia in all patients. After thoracotomy and exploration, the cyst was identified, both the cyst and the pleural space were surrounded by gauze impregnated with saline (3%). If intact, the cyst was carefully aspirated, and its cavity was opened at the fibrotic portion. In both intact and complicated cysts, after removal of remnants of laminated membranes, the residual cavity was irrigated with saline, and all bronchial openings were carefully located during hyperinflation and closed with Vicryl. All surrounding fibrotic tissues of the residual cavity were resected. Capitonnage was not performed in any patient. patients who had an After surgery on the pulmonary hydatid cyst, a right-sided radial phrenotomy was carried out, the hepatic hydatid cyst was removed by cystotomy without capitonnage, and the fibrotic tissue of the pericyst was resected. A Folly catheter was left in the residual cavity below the diaphragm, and the phrenotomy site was closed with nonabsorbable suture. At the end of the operation, 2 chest tubes (32F and 28F) were placed posteriorly and anteriorly. All patients were followed up for at least 1 year. Follow-up studies included ultrasonography and CT in selected patients.
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RESULTS
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The operations performed in the 30 patients with pulmonary and hepatic hydatid cysts are listed in Table 1
. Eight (27%) patients had undergone previous surgery for hydatid disease (2 liver, 4 right lung, and 2 left lung). The most frequent symptoms were abdominal pain, cough, dyspnea and chest pain. Four patients were asymptomatic and the diagnosis was made incidentally on chest radiography or abdominal ultrasonography for other reasons, the diagnosis was made intraoperatively in 6 (20%), and by ultrasonography or abdominal CT in the other 20. The locations of the cysts are given in Table 2. One patient had intrabiliary rupture of a cyst, with common bile duct obstruction due to laminated membranes and daughter cysts; one had intrapleural rupture with effusion and empyema; and another had intraabdominal rupture with a severe allergic reaction. These patients were followed up for 12 to 36 months. Postoperative complications are shown in Table 3. During follow-up, there were 2 cases of recurrence of hepatic hydatid cyst, which were treated with albendazole. Comparable rates of postoperative complications were noted in the other 122 patients who underwent surgery for pulmonary hydatid cysts without hepatic involvement.
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DISCUSSION
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Hydatid disease is a parasitic infection that has been known since the time of Hippocrates.8 It remains a significant health problem endemic in areas where sheep and cattle are raised, including the Middle East, Central Asia, South America, New Zealand and East Africa.9 The liver is the most common site of infection in adults (50% 70%). The lungs are the second most commonly affected site, accounting for 20% 30% of all cysts. Less frequently, the spleen, kidneys, heart and central nervous system may be involved, and it can affect every part of the body and multiple organs.10 Hydatid cyst of the breast, spleen, quadriceps muscle and thyroid have been operated on in our department.
As the incidence of concomitant pulmonary and hepatic hydatid cysts is high, it is necessary to investigate the possibility of additional cysts in patients diagnosed with either a pulmonary or hepatic cyst.7 When hydatid cysts are present in both the liver and lung, it is desirable to achieve combined resection via a right posterolateral thoracotomy. Hepatic cysts may remain asymptomatic for a long time. On enlargement, they can cause abdominal pain, a palpable mass, and complications such as obstructive jaundice, liver abscess and intraabdominal rupture.10 Intact hydatid cysts of the lung produce no characteristic symptoms; some patients complain of dry cough or chest pain.9 Rupture of cysts into an adjacent bronchus may be manifested by vigorous coughing and expectoration of salty sputum (consisting of mucous, hydatid fluid and occasionally fragments of the laminated membrane), bronchospasm and severe dyspnea, which may lead to suffocation and death due to obstruction.9 Intrapleural rupture occurs in 5% of cases and may produce an acute clinical picture: intense chest pain, persistent cough, severe dyspnea and cyanosis, shock, or suffocation.9,11,12 Symptoms such as generalized urticaria, intense purities, severe anaphylactic shock and death occur frequently.9
Diagnosis of hepatic and pulmonary hydatid cysts is very important for the approach to surgery.9 Diagnosis of an intact pulmonary cyst is usually based on suspicion resulting from an unexpected finding on routine chest radiography (homogeneous spherical opacity with definite edges). An intact cyst can cause distal bronchial obstruction, manifested as atelectasis and pneumonitis.9 Diagnosis of complicated (ruptured) cysts is made by history, physical examination and imaging (pulmonary meniscus sign, double-dome arch sign, water lily sign).1,9 In our study, the most important diagnostic tools for pulmonary hydatid cysts were chest radiography and CT, while for hepatic hydatid cysts, abdominal ultrasonography and CT were essential.7,9 Computed tomography is also successful for detecting complicated hydatid cysts, and it can differentiate the cystic nature of a lung mass and permit accurate localization for planning the surgical approach.9 Liver cysts can also be detected by abdominal ultrasonography and CT.7 We did not routinely conduct serologic tests for hydatid disease because of the high number of false positive and false negative results.7–10
Treatment of pulmonary hydatid cyst is essentially surgical; however, benzimidazole agents (mebendazole and albendazole) are more accessible to pulmonary cysts than to those in other organs.5,6,9 We used albendazole or mebendazole only for intact cysts and as prophylaxis before surgery on complicated cysts. The basis of current surgical treatment of pulmonary hydatid cyst is to eradicate the parasite, prevent intraoperative rupture and subsequent dissemination, and manage the residual cavity with maximum preservation of lung tissue.7,9 Because of great variability in pathology of pulmonary hydatid cysts, surgical treatment must be tailored to each case.9 For removal of multiple cysts, nucleation of the cyst, pericystectomy by closing the bronchial opening with or without capitonnage, segmentectomy or wedge resection, and lobectomy (for a cyst involving >50% of the lobe), pneumonectomy and video-assisted thoracic surgery may be used.7,9 Pneumonectomy and video-assisted thoracic surgery were not performed in our patients. Resection rates have been reported as 5% 7% for intact cysts and 19% 32% for complicated cases.12,13 Surgical approaches include a posterolateral thoracotomy and a median sternotomy for bilateral cysts.14 In our patients, bilateral cysts were resected in 2 stages. Bilateral pulmonary cysts with concomitant hepatic cysts are uncommon.15–17 Aribas and colleagues16 also removed hepatic cysts transdiaphragmatically in 49 of 141 patients with a pulmonary hydatid cyst. Our complication rates were comparable to those in previous reports.7,10,12,13 We concluded that concomitant pulmonary and subdiaphragmatic hepatic hydatid cysts can be treated effectively and safely in a single-stage operation via a right posterolateral thoracotomy and phrenotomy.
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ACKNOWLEDGMENTS
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We thank Dr Hakime Sarshad, Gilda Aghajanzadeh and Golnar Mortaz Hejri for revision and final editing of this manuscript.
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REFERENCES
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ABSTRACT
INTRODUCTION
