Percutaneous ultrasonography-guided nephroscopic evacuation of hydatid cyst in posterior segment of liver.

Hydatid disease commonly affects liver and treatment of choice is surgery. Ultrasound examination is helpful to diagnose, classify and plan management of the cyst. Surgical treatment is done using a conventional open technique or minimal access technique. We report our experience of using ultrasound-guided percutaneous nephroscopic approach to treat liver hydatid cyst.

INTRODUCTION

Echinococcus Granulosus a parasite, commonly affects the liver (52%–77%) in human and is known as hydatid disease.[1] The treatment of hydatid cyst of liver depends on topographic location of cyst, extent of the liver involvement, presence of complications, type of biliary fistulae and expertise of operating team.[2] Surgical techniques advocated range from aspiration, laparoscopic to open radical resection.[3] In the recent years, Percutaneous, Aspiration, Injection and Reaspiration (PAIR) and Laparoscopic surgery have gained ground in the treatment of hydatid disease of liver. Single-incision laparoscopic surgery has been described for single giant renal hydatid.[4] However, PAIR and Laparoscopic approach is not feasible in complex cyst and cyst in posterior segment of liver, respectively[25] We describe a technique of percutaneous ultrasonography-guided nephroscopic treatment for hepatic hydatid cysts located in segment VII and VIII with the WHO classification 3B–4.

CASE REPORT

A 60-year-old female patient presented with complaints of pain in right upper abdomen and right lower chest during inspiration for 4 months. No history of fever and jaundice or any associated co-morbidities. Ultrasonography showed a 10 cm × 7 cm × 7 cm thick walled cyst in segment VIII of liver with multiple loculations, septations suggestive of daughter cysts and partially calcified cyst wall [Figure 1].

Figure 1

Ultrasonography

Contrast enhanced computed tomography (CT) shows a multiloculated cyst in the segment VIII of liver with calcification at multiple sites in the wall and humping of the diaphragm [Figure 2]. The diagnosis being hydatid cyst WHO classification type 3 B.

Figure 2

Contrast computed tomography scan

As the hydatid cyst was WHO type 3B with solid matrix and few areas of calcification in the wall, PAIR was not possible. The location of the cyst was such that laparoscopic treatment was not feasible. The patient was already treated with albendazole tablet for 3 weeks.

We thought of an innovative technique, using a nephroscope for percutaneous evacuation of the cyst.

Technique

The procedure was done under general anaesthesia. Patient positioned with 45° with right side up, to gain an easy access to the cyst percutaneously. Ultrasonography [Figure 3] was to identify the cyst and a 18 Fr spinal needle was used to puncture the hydatid wall through the midaxillary line. The cyst was punctured where it was closest to the parietal wall. After puncture intracystic position of the needle was confirmed by aspiration and a guide wire was introduced using Seldinger's technique.

Figure 3

USG-guided puncture of cyst with a spinal needle

Metal Dilators of increasing size from 9 to 27 were introduced over the guide wire. After sufficient dilation of tract, an Amplatz sheath was slided over the dilators and the metal dilators were then removed. As the dilators were removed there was a gush of clear fluid with white membranous material.

Through the Amplatz sheath suction was then introduced in the cavity and fluid with pieces of hydatid membrane were sucked out. 3% normal saline (NS) was introduced into the cyst cavity and kept in for 20 min, then sucked out. A nephroscope was introduced into the cyst and the hydatid material was evacuated under vision [Figures 4 and 5].

Figure 4

External Nephroscopic view of hydatid cyst membrane and daughter cysts

Figure 5

Nephroscopic view of the hydatid cyst with membrane

The cavity was repeatedly irrigated with 3% NS. Suction irrigation of cavity was done under nephroscopic control until all daughter cysts and membranes were evacuated. Nephroscopic examination confirmed complete evacuation of cyst contents and inner wall and no bile noted into the cavity.

Completion ultrasonography confirmed an empty cavity. 28 no abdominal drain placed through the Amplatz sheath indwelling the cavity. Post-operative course of the patient was uneventfull. The drain on post-operative day 1 was 50 ml and 25 ml on day 2. Cavity was washed with 3% hypertonic NS twice in the post-operative period.

On post-operative day 2, a plain CT scan was done to confirm the absence of hydatid contents in the cavity. The patient was discharged on day 5 with drain in situ as it was draining 15–20 ml/day. On follow-up after 4 days, the drain collection was almost nil and hence the drain was removed.

On follow-up after 2 months, the patient was asymptomatic and a ultrasonography showed a completely collapsed cavity with no residual fluid or daughter cysts.

Soni et al. have described a technique of single incision laparoscopic hydatid cystectomy as a curative approach for sement VII liver hydatid.[6]

DISCUSSION

Hydatid disease is caused by Echinococcus granulosus. Commonly, it manifests as liver hydatid cyst accounting to 55%–77%.[1] Hydatid cyst gradually increases in size and remains asymptomatic for years. Patients have symptoms such as abdominal pain, fullness, obstructive jaundice or complications such as infection and peritoneal, pleural or rarely intrabiliary rupture of cyst.[1]

The diagnostic investigation is ultrasonography with sensitivity being 100%.[1] The ultrasonographical WHO classification - informal working group of Echinococcus [Table 1], describes the cyst and the treatment modalities feasible according to the cyst stage.[1] CT is also highly sensitive and specific investigation and scores over USG in determining complications and operative accessibility.[1]

Table 1

WHO classification

Albendazole is the primary chemotherapeutic agent for medical management of hydatid cyst, given in dosage of 10–15 mg/kg/day in divided doses for minimum 3 months, in cyclic pattern with 10–14 days interval.[4] Chemotherapy alone is not ideal in treating hydatid of liver, considering the high rate of failure and recurrence[1] and not suitable for complex partially calcified cyst as in the present case.

The cornerstone treatment of hydatid cyst is surgical approach: Resection or evacuation and scolicidal treatment. Open surgical treatment includes radical (pericystectomy or hepatic resection) or conservative surgery (deroofing of the cyst and managing residual cavity).[1]

In 1980s PAIR was introduced as a treatment option for hydatid disease of liver where ultrasonographically the cyst is punctured, aspirated, then injected with scolicidal agent and re aspirated. PAIR can be used for cysts type I to III according to the WHO Classification and are not amenable for type IV and V.[5] PAIR was not suited approach in the present case, considering partially calcified thick cyst wall.

In 1992, the first laparoscopic approach for hydatid cyst was described and there has been a steady growth over the years in the use of laparoscopic treatment over open surgery.[3] However, laparoscopic accessibility is difficult in cysts in certain location such as posterior segment of liver[27] and hence in the present case, laparoscopic approach was not feasible as cyst was in segment VIII.

Open surgery still remains choice of treating liver hydatid with biliary communication, peritoneal hydatidosis and multiple cysts in a liver segment requiring segmentectomy.[1]

The use of nephroscope has been described as a PCNL approach for renal hydatid cyst.[89]

In our patient, ultrasonography was used to puncture the cyst and the tract was dilated and thus entered the cavity with a nephroscope and cleared it after treating with scolicidal agent – 3% NaCl. The technique can be useful when the hydatid cyst is close to the anterior abdominal wall.

Limitation of the technique is, it is only applicable for cyst in contact with parietal wall so that there is no intraperitoneal spillage of contents while puncturing the cyst.

The advantage of the treatment is the complete evacuation of cyst membrane and daughter cyst can be achieved. The cavity can be inspected for remnants of daughter cyst, and bile leak. It is one stage procedure being minimally invasive.

CONCLUSION

This innovative technique can benefit patients in whom the hydatid liver cyst cannot be approached laparoscopically or treated with PAIR.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.