Pedunculated giant hepatic hydatid cyst: Largest ever reported.

Hepatic hydatidosis is common in many parts of our country. Largest cyst reported measured 37 × 14.88 × 15.4 cm. We encountered a case of giant hepatic hydatid cyst arising from the left lobe of liver, measuring 45 × 35 × 25 cm. It was completely occupying the peritoneal cavity and had a narrow pedunculated attachment to the liver. This hydatid cyst is larger than the largest reported cyst. Also, a pedunculated hydatid cyst has never been reported. Hence, the report.

INTRODUCTION

Hydatid cysts are usually asymptomatic masses, resulting in delayed presentation and large size at presentation. Largest hydatid cyst of liver reported so far is of 37 × 14.88 × 15 cm.[1] A case of larger than the largest reported cyst is being reported.

CASE REPORT

A 60-year-old male patient presented with chronic distention of abdomen, loss of appetite, loss of weight, and disturbed bowel habits. Patient had moderate pallor and pedal edema. There was uniform distention of the abdomen from xiphisternum to symphysis pubis and hydatid thrill could be elicited [Figures 1 and 2]. Computed tomography scan revealed a pedunculated hydatid cyst arising from the left lobe of liver. The dimensions of the cyst were 45 × 35 × 20 cm. It occupied the whole peritoneal cavity, displacing the bowel loops posteriorly [Figures 3 and 4]. Review of English literature indicated that the largest hydatid cyst recorded earlier was of dimensions 37 × 14.88 × 15 cm.[1] Case under review had a cyst larger than the largest reported.

Figure 1

Hydatid cyst leading to uniform, huge, abdominal distention

Figure 2

Giant hepatic hydatid cyst

Figure 3

CT scan showing giant cyst occupying whole peritoneal cavity (Size – 45 × 35 × 25 cm)

Figure 4

CT scan showing giant cyst extending into pelvis

Partial cystectomy was performed. Precautions were taken to avoid peritoneal spillage. Sites of biliary communication were closed. Postoperatively, patient recovered well.

DISCUSSION

Echinococcus granulosus is a small, 5-mm-long tapeworm being responsible for unilocular hydatid cyst disease. Human infection by E. granulosus occurs most commonly in sheep- and cattle-raising areas, where dogs assist in herding; the infection is more frequent in Eastern Europe, the Mediterranean, Australia, New Zealand, Chile, Argentina, and Africa. Human beings are usually infected as intermediate hosts when they ingest egg-contaminated food or water. More than 50% of all human E. granulosus infections involve the liver.[2] Additional common sites for hydatid cysts are the lungs, spleen, kidneys, heart, bones, and brain.[3]

The word “Giant” has different connotations for different places and organs of the body. 2 cm cysts are described as giant hydatid cyst in the heart (interventricular septum).[45] As small as 1 cm cyst may be a giant cyst in the orbit. This denotes that the term giant cyst is probably relative to the site and size of the cyst, in relation to the hosting organ.

Battyany et al. encountered giant hepatic hydatid cyst in a postoperative case of bowel obstruction. On the second postoperative day, patient started to complain about dull right upper quadrant abdominal pain and bloating. Abdominal computed tomography scan revealed very large cystic lesion occupying the whole right lobe of the liver, dislocating the left lobe of the liver toward the left hypochondrium. It was compressing the surrounding organs. The patient had the largest hepatic hydatid cyst reported till then.[1] Later, we treated the hydatid cyst larger than that.

In theory, there are three treatment options for hepatic cystic echinococcosis: chemotherapy, surgery, and percutaneous drainage or a combination of these therapies.[67] However, the use of chemotherapeutic agents alone, such as mebendazole or albendazole, is controversial because of their limited efficacy. These antiparasitic drugs are often administered as adjuvant therapy during surgery or percutaneous treatment. In selected cases, they can be the primary approach when surgery is not feasible or is unsafe.[7-9]

With the advent of PAIR (Puncture, Aspiration, Injection, Reaspiration) technique, treatment of hydatid cyst is simplified to a large extent.[10] Although certain types of hydatid cysts are successfully treated by PAIR, surgery remains the treatment of choice.[111]

Battyany et al. performed PAIR to manage their case. They punctured the cyst on its free surface with an 18 G needle. Because of the huge size of the cyst, an 8F pigtail catheter (polyurethane drainage catheter) with 32 side holes was introduced into the cyst. The cycle of hypertonic 15% saline injection and 20 minutes later, reaspiration was repeated daily with 40 ml 15% sterile saline. During the last 5 days, 30 ml absolute alcohol was injected and removed after 20 minutes. After 6 weeks of percutaneous drainage, they removed the catheter. Abdominal computed tomography scan exhibited total disappearance of the cyst. Thus, total time of percutaneous drainage took 43 days.[1]

We did not try PAIR in our case because of the following reasons:

Very large sized cyst,

Fear of communication with biliary tree, where PAIR is contraindicated,

Possibility of requirement of prolonged aspiration,

Because of small size of the pedicle of the cyst attached to the left lobe of liver [Figure 5], we were prompted to explore the possibility of segmentectomy of liver along with the cyst.

Figure 5

Pedicle (arrow) of giant hepatic hydatid cyst

But as the cyst was lying in the superficial plains of left lobe, segmentectomy was not performed. Partial cystectomy was performed. Postoperative course was uneventful. Follow-up of the patient for about 2 years showed successful recovery with no clinical signs and symptoms of the disease.

CONCLUSION

The term giant cyst is probably relative to the site and size of the cyst, in relation to the hosting organ. The case under discussion was larger than the largest reported cyst.

Various modalities of treatment of giant hepatic hydatid cyst like chemotherapy, PAIR, and surgical treatment are available, of which we have to choose the appropriate treatment best suiting our patient.