Comparison of laparoscopic and open surgery in hepatic hydatid disease in children: Feasibility, efficacy and safety.

Background: : Surgery continues to be the mainstay of treatment of hydatid cysts of the liver. Laparoscopy provides a lesser invasive tool for achieving results same as with the established open surgical techniques. The purpose of the study was to evaluate the feasibility and safety of laparoscopic management of hepatic hydatid disease in children. Patients and
Methods: It was a prospective randomised study conducted over a period of 7 years. Children with Gharbi Type I, II, III cysts, ≤3 cysts and superficial accessible cysts were treated laparoscopically and their outcomes were compared with matched controls treated by open approach.
Results: Sixty patients were included in the study with thirty patients in each matched group. Thirty paediatric patients (male 12:female 18) with 35 liver hydatid cysts underwent laparoscopic surgery. The mean cyst size was 8.8 ± 2.39 cm. Two patients needed conversion to open. No significant spillage of cyst contents was observed in any of the patients. Duration of hospital stay, time to removal of drains, duration of parenteral analgesia, severity of pain in postoperative period, time to ambulation and time to return to full orals were significantly lower in laparoscopic group compared to open group. Complication rates in both the groups were similar.
Conclusion: With proper patient selection, laparoscopic management of hydatid cysts of the liver in children is feasible and safe option with low morbidity, low rates of conversion and minimal complications.

INTRODUCTION

Echinococcosis in which the humans act as accidental intermediate hosts is caused by the larval stage of Echinococcus granulosus. It can affect any age group and may present with large hepatic cysts.[1234] In endemic countries, up to 25% of hydatid disease is reported in children.[56] The symptoms of hydatid disease are protean and depend on which organs are affected. The most commonly affected organ is the liver in adults, though lung and liver are nearly equally involved in children.[78]

The treatment modalities of hepatic hydatidosis in children are mainly a combination of surgery and medical therapy. Although open surgery is the present standard of care, in recent years, laparoscopic approach to treat hydatid disease of the liver has gradually been introduced. The reported advantages are minimal invasiveness, reduced wound complications, less postoperative pain, shorter hospital stay, quick social and professional rehabilitation and cost-effectiveness. Disadvantages include the limited manipulation area that increases the operative risk and the potential spillage due to the difficulty in drainage of the cyst by laparoscopy. The data on feasibility and safety of laparoscopic management of hepatic hydatidosis in children are very scarce; hence, our endeavour in the present study was to evaluate the role of laparoscopy in hydatid cyst liver in children.

PATIENTS AND METHODS

This was a prospective randomised study conducted in the Department of Paediatric surgery at Sheri-I-Kashmir Institute of Medical Sciences, Srinagar, India. Ethical approval was obtained from Institutional Ethical Committee Sheri-I-Kashmir Institute of Medical Sciences, Srinagar with No. SIMS 1131/IEC-SKIMS/2016. The study was conducted for 7 years from January 2013 to 2020. New cases were recruited up to January 2018. Only hepatic hydatid cyst cases were taken. Children with Gharbi Type I, II, III cysts, ≤3 cysts, superficial laparoscopically accessible cysts were included in the study. Type IV and V cysts, more than 3 cysts, inaccessible cysts were excluded from the study. Diagnosis was established by ultrasound abdomen, CECT abdomen pelvis and IgG antibody.

Sample size

Based on a pilot study, the mean value of operative time in lap was 101 ± 29.02 minutes and in open was 124 ± 28.81 minutes. Taking these values as reference, the minimum required sample size with 80% power of study and 5% level of significance is 25 patients in each study group. To reduce margin of error, total sample size taken is 60 (30 patients per group).

Formula used is:

For comparing mean of two groups

Where Zα is value of Z at two-sided alpha error of 5% and Zβ is value of Z at power of 80% and mean difference is difference in mean values of two groups.

Where S1 is standard deviation of 1 group.

and S2 is standard deviation of another group.

Calculations:

After obtaining proper consent, parents/patients willing to be the part of the study were randomised by simple randomization with a sealed envelope 1:1 technique into Group A and Group B. Group A underwent laparoscopic surgery (LS) and Group B open surgery. Intra- and post-operative parameters of interest were assessed and analysed in the two groups [Figure 1].

Figure 1

CONSORT diagram

All patients were treated with albendazole 15 mg/kg/d for at least 4 weeks preoperatively and continued postoperatively for minimum 3 cycles with each cycle extending up to 3 weeks with 1-week gap in between which was in accordance with the study by Morris et al.[910]

Follow-up was conducted for a minimum of 2 years and ultrasound abdomen was performed at 6 monthly intervals to look for any recurrence and to assess any residual cyst cavity.

Statistical analysis

The data analysis was done using Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, ver 21.0. Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean ± standard deviation or median (interquartile range). Normality of data was tested by Kolmogorov–Smirnov test. If the normality was rejected then a nonparametric test was used. Quantitative variables were assessed by Independent t-test/Mann-Whitney Test (when the data sets were not normally distributed) between the two groups and qualitative variables by Chi-Square test /Fisher's exact test.

Primary outcomes were Operative time and recurrance at 2 years, and secondary outcomes were hospital stay, duration of analgesia, post-surgery pain on VAS, time to ambulate, time to tolerate orals, bowl movements, and time to remove drains.

Surgical method

Laparoscopic technique

All procedures were performed in the supine position. Antibiotics were administrated 30 min before the incision. Position of the patient, surgeon, assistant, scrub was standard as for any laparoscopic hepatic surgery. With the patient under general anaesthesia, pneumoperitoneum was created by open technique. An intra-abdominal pressure of 12 mm Hg was achieved. A 30-degree scope is introduced through a 5-mm umbilical port and a 10-mm suction cannula through a subxiphoid port. Two other 5-mm trocars were placed at the standard sites as per the location of cyst in the liver after performing diagnostic laparoscopy through 5 mm umbilical port. After initial laparoscopic evaluation, the suitability of the cyst for laparoscopic management was confirmed. Essentially the following steps were adopted; pericystic packing with cetrimide soaked or betadine soaked gauze to take care of spillage [Figure 2a], decompression of the cyst by aspiration using a wide bore needle introduced at an antigravity position through one of the 5-mm ports with placement of two 5-mm suction cannulas next to the aspirating needle to control the spillage [Figure 2b], naked eye examination of the fluid for the presence of bile or pus suggestive of cysto-biliary communications (CBC), injection of 3% hypertonic saline or cetrimide for 10 min to ensure complete killing of the organism, followed by aspiration. Cystotomy was made in the pericyst in nondependent area with scissors or with the hook electrode [Figure 2c], followed by removing the germinative membrane in a plastic bag or by using locally improvised specimen bags to prevent contamination followed by extraction through the epigastric port. Cyst cavity was telescoped for any remaining membranes or CBC. The management of the residual cavity was achieved by placement of omentum into the residual cavity if the location or the configuration of the cyst warranted [Figure 2d] or by simple tube drainage, unroofing, partial pericystectomy. CBC if any were managed by primary suturing and omentopexy. During the procedure, spillage of cyst contents was anticipated and its severity rated by an independent observer.

Figure 2

(a) Pericystic packing with gauze, (b) Decompression of the cyst, (c) Cystotomy in the pericyst, (d) Residual cavity

Open technique

A right subcostal approach was used in most patients. The operative field was carefully protected from hydatid fluid spillage using packs soaked in cetrimide or betadine. The cyst was decompressed by inserting a large-bore angiocath needle and hydatid fluid was aspirated with a syringe after which cetrimide solution was injected into the cavity and left there for 10 min. The pericyst was opened and the cyst contents were evacuated including, the laminated membrane and hydatid fluid. The cavity was cleaned with gauze soaked in a cetrimide solution. At the end of the procedure, the cavity was examined for any bile duct leakage which, if found, was closed with vicryl suture. The residual cavity was finally managed by mainly either of the two techniques

External tube drainage

Omentopexy.

The duration of surgery from skin incision to closure was noted. The amount of blood loss was recorded in each patient. Postoperatively, all the patients were put on intravenous fluids and parenteral antibiotics. Oral nutrition was allowed once the bowel sounds reappeared. The amount and nature of postoperative drainage and the time of removal of drain were noted. Postoperatively, all the patients were monitored for complications such as prolonged ileus, bleeding, biliary leaks, pleural effusion, wound infection, suppuration, intra-abdominal collection, deep vein thrombosis and thromboembolism. The duration of hospital stay was recorded in each patient.

RESULTS

Sixty patients (30 Laparoscopic and 30 Open) were included in the study. The two groups were comparable in terms of age, gender, size of the cyst, type of cyst, location of the cyst, nature and number of the cyst [Table 1]. In our study, the mean age in the laparoscopic group was 10.82 years, and in the open group, 10.9 years, ranging from 6–14 years in both groups. Thirty patients underwent LS for hydatid disease of the liver (male: female = 12:18) with a total of 35 cysts. The size of the cysts varied from 4 cm to 13 cm (mean 8.8 ± 2.39 cm), of these 20 cases had cysts located in the right lobe, 7 in the left lobe and 1 in caudate lobe of liver. In the open group, 30 patients (male: female = 21:9) with a total of 36 cysts were operated. The size of cysts varied from 5 to 20 cm (mean was 8.97 ± 3.32 cm), 23 had cysts in right lobe, 5 in left lobe, 2 in both lobes. Residual cavity in 71 cysts (35 cysts in laparoscopic group and 36 cysts in open group) were dealt by omentopexy, tube drainage, capitonnage and deroofing [Table 2]. CBC was found in 2 patients in laparoscopic group and 1 patient in open group. One was managed laparoscopically by suturing with vicryl 2-0. The patient had cyst diameter of 12 cm. Another was converted to open.

Table 1

Distribution of cases in the two groups

Parameter	Laparoscopic group (n=30)	Open group (n=30)	P
Age (years)
≤10	14	17	0.606
>10	16	13
Gender
Males	12	21	0.037
Females	18	9
Size of cyst (cm)
≤10	14	17	0.606
>10	16	13
Cyst type
Gharbi type I	25	25	0.97
Gharbi type II	7	8
Gharbi type III	3	3
Mean haemoglobin (g/dl)	12.93±0.827	13.16±0.87	0.29
Mean size of cysts (cm)	8.800±2.39	8.967±3.32	0.82
Location of cyst
Right lobe	20	23	0.67
Left Lobe	7	5
Bilateral	2	2
caudate lobe	1	0
Nature of cyst
Unilocular	32	33	1.00
Multilocular	3	3
Number of cysts
Single	25	24	1.00
Double	5	6
CBC
Absent	28	29	1.00
Present	2	1

CBC: Cysto-biliary communications

Table 2

Handling of the cavity between the two groups

Method	Laparoscopic group (n=30), n (%)	Open group (n=30), n (%)
Tube drainage	14 (46.7)	16 (53.3)
Omentopexy	16 (53.3)	11 (36.7)
Capitonnage	0	2 (6.7)
De roofing	0	1 (3.3)

The various intraoperative and post-operative parameters in both the two groups are shown in Table 3 and Figure 3. No major complication was encountered in either group [Figure 4].

Table 3

Intraoperative and postoperative parameters in the two groups

Parameter	Lap group	Open group	P
Operative time (min)	104±23.1	115.5±25.8	0.07
Hospital stay (days)	4.567±1.33	7.067±1.89	≤0.0001
Duration of analgesia (days)	2.50±0.86	3.567±0.85	≤0.0001
Postsurgery pain on VAS
Day 1	6.36±0.66	7.16±0.53	≤0.0001
Day 2	4.933±1.08	5.46±0.62	0.02
Day 3	1.367±2.14	4.26±1.74	≤0.0001
Ambulation	2.167±1.08	3.333±0.54	≤0.0001
Tolerate orals	2.800±0.846	3.20±0.61	≤0.040
Bowl movement	2.26±0.69	2.83±0.69	0.003
Removal of subhepatic drain	2.76±0.72	3.67±1.04	≤0.0001

VAS: Visual Analogue Scale

Figure 3

Bar diagram showing comparison of perioperative factors of interest

Figure 4

Pie diagram showing distribution of complications in laparoscopic group (left) and open group (right)

DISCUSSION

Echinococcosis is a parasitic infection in humans and most commonly by E. granulosus. Although the common mode of infection is the unhygienic practice of consuming unwashed or improperly washed infected raw fruits and vegetables, direct contact with infected dogs is also another means of contracting the disease, especially in children.[11] In non-endemic areas, all the age groups are usually equally affected with the average age of presentation being older.[1112] The disease usually presents with pain abdomen, discomfort, abdominal swelling due to slow growth of cysts.[111314]

The management of hydatid disease liver is mainly surgical, and a number of surgical procedures to deal with the cyst have been reported.[1516171819] LS has been introduced in the management of liver hydatid cyst in children with results comparable to open surgery. Initial reservations regarding spillage and the ability to manage the cyst wall have been allayed by reports showing satisfying results with minimal complications using laparoscopic techniques.[161920]

PERIOPERATIVE PARAMETERS

Operative time has not been assessed in head to head in paediatric hepatic hydatid cyst in open and LS. Minaev et al.[21] noted an operative time of 90.1 ± 7.8 min and Maazoun et al.[22] noted an average time of 90 min with laparoscopy. In our study, the mean operative time in laparoscopic group was less compared to open group but was not significant. Minimal intra-abdominal dissection and manipulation, virgin anatomy, no open closure of laparotomy, less complex cases and omentopexy for residual cavity are the possible reasons for less operative time in case of laparoscopic group. Pain is less in the post-operative period with minimal access surgery compared to open surgery. The same was evident in our study. This is due to less tissue handling, less amount of suturing and minimally invasive nature of laparoscopy. At present, there has been no study to corroborate the above findings in paediatric population. The convalescence period is short with minimal access surgery as they inflict minimal stress on the body. This translates into early ambulation, early return to orals, early bowl motion and early discharge from the hospital. Baskaran et al.[23] reported similar results in his study of laparoscopic treatment of hydatid cyst liver. Early ambulation (2 days), early return to full orals (2.8 days) was noted in the laparoscopic group in our study.

Hospital stay is less with LS due to early ambulation, earlier drain removal, earlier stool passage, minimal pain in the post-operative period and very minimal abdominal wound. Maazoun et al.[22] who evaluated the safety and efficiency of laparoscopy in the treatment of liver cysts in children, reported average length of hospital stay 5 days in his study. Drain removal is early in the minimal access surgery compared to open surgery which due to minimal tissue dissection and less trauma to tissues. The mean duration of removal of drains was 2.7 days in the laparoscopic group, compared to 3.7 days in open surgical group. These findings were compared with the study conducted by Maazoun et al.[22]

Intraoperative spillage is important concern while handling the hydatid cyst laparoscopically. Preoperative chemotherapy to sterilize the cysts, use of high-pressure suction to aspirate daughter cysts and the laminated membrane, initial decompression with a needle and replacement with an equal volume of scolicidal agents, use of gauze pieces soaked with scolicides, around the perihepatic area are additional precautions to prevent the intraoperative spillage.[1619] In our study, pericystic packing, initial puncture at a non-dependent antigravity position and use of two suction cannulae adjacent to puncture site were used to control spillage. Spillage was monitored by an independent observer while performing surgery in both the groups. In both the groups, intraoperative spillage was minimal. The various precautions, which were adopted during open surgery for hydatid disease of liver to prevent spillage and subsequent scolex reimplantation, can be diligently adhered to during LS.[161920]

CBC is reportedly common in hydatid disease with variable frequencies between 3.5%[24] and 19%.[25] Careful evaluation of blood biochemistry (cholestasis), radiological findings (bile duct dilatation) and the presence of jaundice or cholangitis in the clinical history of the patients are valuable clue. In our patients, CBC was found in two patients in laparoscopic group (6%), which were managed laparoscopically by suturing. The size of cyst is an independent risk factor for CBC. Kilic et al. in their study found that the mean cyst size in patients with biliary leakage was 10.2 cm, compared to 6.2 cm in patients without biliary leakage.[26]

Although there is no randomised clinical trial that has compared laparoscopic and open hydatid surgery, the advantages of laparoscopic liver hydatid surgery as highlighted in many reports include: less pain, better cosmetic results, shorter hospital stay, early return to full orals, early ambulation, and less postoperative adhesion. No surgery-related death was reported for laparoscopic hydatid surgery or open surgical methods.

Complications

Complications in the laparoscopic group vary from 8% to 25%. Maazoun et al.[22] reported a complication rate of 8%–25% whereas Minaev et al.[21] noted a complication rate of 14.3%. In our series, complications in laparoscopic group (6.6%) were noted in two patients. One patient developed cavity abscess and another developed atelectasis. The patient with cavity abscess presented with complaints of fever 2 weeks after the removal of cavity drain. It was managed by Pigtail drainage and antibiotics. The child with atelectasis was managed conservatively. In open group, two children had biliary leak through cavity drain. The cavity drain was kept for 3 weeks during which time, the drain output gradually decreased and was finally removed after 3 weeks.

Recurrence of the cyst with the persistence of parasitic infection is important concern of surgical therapy of hydatid disease of liver. While near-zero recurrence has been obtained with radical operations,[27] high recurrence rates have been associated with conservative surgical procedures.[28] With non-radical and radical laparoscopic treatment of hydatid disease of liver, a number of authors have shown recurrence rates of laparoscopic treatment (1.1%) comparable to those of open operations (0% to 4.5%), thereby establishing the safety of laparoscopy.[16192930] In our study, none of the patients had a recurrence in either of the two methods at 2 years.

CONCLUSION

With appropriate case selection, laparoscopy is a feasible and safe option in the management of hydatid disease of in children with excellent cosmesis, low rates of conversion and operative complications

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.