Management of Hepatic Hydatid Cysts ( Echinococcus granulosis )

1. Management of Hepatic Hydatid Cysts (Echinococcusgranulosis) KhalilGeorges MD, PhD Medical Microbiology Department Faculty of Medecine and Faculty of Science Saint Joseph University 8ème Congrès de Médecine Interne- Le Royal Debayeh Saturday April 6 2013

2. References • Uptade management of hepatic E.granulosis. M.C. HADDAD et al. Lebanese Medical Journal 2011. Volume 59 (3) p 154-159 • Medscape • Parasitoseset Mycoses,ANOFEL.Editions 2007 Masson. Echinococcoseshumaines p 181-187 • Atlas of Medical Helmenthology & Protozoology, Churchill Livingstone, Chiodini, Moody, Manser, 4th edition 2001

3. The presentation is about the management of Liver Hydatid Cyst caused by E granulosis

4. Many species for the genus Echinococcus (tapeworm) • E granulosis is the most common • E multilocularis • E vogeli

5. Life cycle • Definitive host: dog • Intermediate host: sheep -The adult tapeworm is in the intestine of the dog - eggs in the environment - Metacestodes in the intermediated host

6. CYCLE

7. Adult Worm

8. Anthropozoonosis Patients are contaminated via contact with the dogs or ingestion of the eggs in the foods or water contaminated by the feces of the infested dog

9. The liver is the most common organ involved, followed by the lungs

11. Natural evolution of CE • CL : Cystic lesion(Unilocular cyst). ≠∆: biliarycyst After 12 to 18 months • Active /Fertile cyst : -CE1: Hydatid sand -CE2: daughter cysts • Transitional/degenerating: - CE3 containing floating membranes (detachment of the endocyst) • Inactive/Degenerated cysts : - CE4 : heterogeneous cyst with solid content - CE5: thick calcified wall /no fluid content

12. The protoscoleces appear only late and the cyst becomes fertile after a long evolution in the intermediate host (12 to 18 months)

13. HYDATID L'hydatide se forme à partir d'un embryon :

14. At the end of its development, the hydatid may contain hundreds of thousands of infective elements, the protoscoleces. Membrane proligère Vésiculeproligère Protoscolex

15. DaughterCysts: CE2

16. Radiology ( Example of CE1) • Ultrasound, • CT scanner, • RMI

17. Laboratory studies • Initial screening test of choice: the indirect hemagglutination test and ELISA ( overall sensitivity 80% ) • Immunodiffusion & immunoelectrophoresis: antibodies to antigen5 . Specific ELISA : useful in follow-up to detect reccurence

18. Chemotherapy • inoperable liver or lung cysts • Cysts in > 2 organs • Peritoneal cyts

19. Albendazole: 10-15mg/kg/d • 1 month separated by 2 weeks interval • Continuous treatment • Optimal period of treatment : 3-6 months ( or more if necessary)

20. Contrindications • Early pregnancy(teratogenic/embryotoxic) • Bone marrow suppression • Chronic hepatic failure • Large cysts with the risk of rupture • Inactive or calcified cysts

21. Outcome for medical treatment • Cure : 30% ( less in liver localization) • Size decrease : 30-50% • No change: 20-40%

22. Monitor patients for adverse effect / 2 weeks for the 3 months and then every 4 weeks: CBC count and liver enzyme

23. PAIR(Puncture Aspiration Injection Reaspiration) • Albendazole ( 15-20mg/Kg/day) is given one week prior to the procedure and is maintained for 1 to 3 month thereafter • The Solicidal agents are : -hypertonic saline 20% -95% sterile alcohol

24. PAIR • Use US or CT guidance • Aspiration of the cystic content via a special cannula • Injection of a solicidal agent for ≥ 15 mn • Reaspiration of the content • Repeat until the return is clear • The cyst is then filled with NaCl 9%

25. PAIR • Liver, bone & kidney • CI: lung & brain

26. PAIR indications • Inoperable patients • Multiple cysts in segment I,II & III • Relapse after surgery or chemotherapy • Patients refusing surgery

27. Pair CI • Early pregnancy • Lung and brain cysts • Inaccessible cysts • Superficially located cysts ( risk of spillage) • Cysts communicating with the biliary tree : risk of sclerosingcholangitis from the scolecoidal agent • Type II honeycomb cyst and type IV

28. PEVAC ( Percutaneous Aspiration) Intracystic insertion of a large bore catheter(14 F) with large side holes for evacuation of the membranes fragments after use of solicidal agents

29. Indication Surgery • Large liver cysts ( + daughter cysts) • Superficially located single liver cysts( risk of rupture) • Biliary tree communication • Pressure effects on vital organs or structures • Infected cysts • Cyst localisation: lung, brain, kidneys, eyes, bones,…

30. CI to surgery • General CI to surgery • Multiple cysts in multiple organs • Difficult to access • Dead cysts • Calcified cysts • Very small cysts

31. Surgical technique • Radical surgery ( total pericystectomy or partial affected organ resection) • Conservative surgery ( open cystectomy) • Simple tube drainage for infected or communication cysts

32. Surgical technique: mechanical and chemical evacuation &destruction of all cyst content Solicidal agents • 0.5 % Cetrimid • 70-95% ethanol • 15-20% NaCl • Formalin • H2O2 • Chlorhexidine

33. Natural Evolution • Liver CE may undergo spontaneous degeneration • Inactive degenerated cysts do not rquire treatment

34. 32 years old female: eight hydatidcyts. Medical treatment effective only on the lung disease

35. PAIR : injection. The hypertonic is white

36. Hydatid Cyst. General CI to anesthesia

37. PAIR technique

38. VIDEO CHIRURGIE MERCI