Pp. 203–209 Hepatic hydatid cyst – diagnose and treatment algorithm

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207
or PEVAC) were used. MoCat type intervention was 
predominantly used, due to the fact that this technique 
extended its indications to cysts with biliary fistula and it 
allows the removal of solid hydatid material. In 3 cases, the 
completion of the MoCat procedure was impossible and 
one of the following three steps was taken: conversion to 
open surgery, timing of the final alcohol time due to a biliary 
fistula or simple inactivation with 30% NaCl.
In one patient with multiple cysts in the CE3 stage and 
biliary fistula, two minimally invasive interventions, PAIR 
and MoCat, were required.
Results
Regarding complications, there were two complicated 
cases after the minimally invasive treatment and 12 after 
open surgery. Among the most common complications were 
prolonged biliary drainage from the remaining cyst cavity, 
due to the existence of a fistula between the cavity and 
the biliary tract, and infection. The difficulties that occurred 
during the procedure weren’t considered, which led to the 
impossibility of practicing minimally invasive treatment and 
forced the conversion to open surgery.
The larger number of patients with prolonged biliary 
drainage after open surgery can be explained by the fact that 
classical techniques mainly deal with complicated cysts with 
fistula, that would not allow minimally invasive treatment. 
Also, large incisions and the presence of drainage tubes 
over extended periods of time predispose to infection.
An average of the number of days of hospitalization 
based on the surgical treatment received was calculated. 
The cases treated with Albendazole as single therapy 
were not taken into consideration. An average longer 
hospitalization period was obtained after open surgery 
treatment (33.6 days). It is expected that minimally invasive 
interventions will require fewer days of hospitalization as 
they are less traumatic (incisions limited to the abdominal 
wall and the use of local anesthesia). A value of 11.76 
days of hospitalization was obtained for minimally invasive 
techniques.
In this study group, the most common post-procedural 
complication was the prolonged biliary drainage, 
determined by the persistence of a residual cavity-bile tree 
communication. There were 3 cases of cholangitis (grade IIIa 
according to the Clavier-Dindo classification) that required 
antibiotic treatment and decompression of the biliary tract 
by ERCP with endoscopic sphincterotomy and, in one case, 
with the extraction of hydatid material. Also, post-surgical 
infection was encountered in 3 cases (grade II according 
to Clavier-Dindo classification). Infections are promoted by 
long immobilization in bed, the incision of the protective 
tegument and the presence of the drainage tubes over long 
periods of time. There have also been two cases of post-
detubation anaphylactic shock (grade IVa according to the 
Clavier-Dindo classification) and a case of papillary stenosis 
(grade IIIa according to Clavier-Dindo classification).
Of the total number of patients, 71 showed 
favorable post-surgical development. Three of them were 
categorized as having a steady evolution because they 
only received medical treatment. In the category of slow 
favorable evolution, we included patients (8 cases) with a 
longer period of hospitalization (28-56 days), in which the 
closing of the remaining cavity was problematic due to the 
presence of biliary fistula and prolonged biliary drainage. 
This category also involved the case of a patient in which 
the MoCAT procedure could not be performed in a single 
operating sequence and it was necessary to complete it 
later, after the biliary drainage stopped. There were 6 cases 
of unfavorable evolution for which additional intervention 
was performed by ERCP with sphincterotomy with or 
without extraction of hydatid material or antibiotic treatment 
(grade IIIa according to Clavier-Dindo classification).
One of the patients that were treated using minimally 
invasive techniques (PAIR or MoCat) needed two 
interventions of this kind for two CE3 cysts located in the 
left lobe. In three patients, surgery was not performed 
because the anesthetist’s evaluation contraindicated it or 
because of the patient’s refusal, so single therapy with 
Albendazole was continued.
Following the above, we can state that the study group 
presented heterogeneity in terms of age and gender. 
Women were more numerous than men (50 vs. 38), and 
nearly half of the patients were in the 30-49 age group.
From the point of view of the symptomatology, the 
majority were those who did not show clinical manifestations. 
Paraclinically, 39% of patients experienced eosinophilia, a 
much more specific change for parasitic infection than hepatic 
syndromes or inflammatory syndrome that were previously 
considered. The imaging investigation represented by an 
abdominal ultrasound was the one that ultimately linked the 
serological modifications and symptoms to the diagnosis of 
hepatic hydatid cyst. Also, according to the imaging, it was 
possible to choose the optimal therapy (depending on the 
stage and the cysts’ dimensions).
The treatment options were mostly surgical (classic 
and minimally invasive) in accordance with the stage (very 
common CE3 and CE1) and the size (mostly over 5 cm) of 
the cyst. Only in 10% of the cases the interventions were 
performed for inactive cysts (CE4 and CE5), in which the 
“watch-and-wait” attitude can be adopted.
If the patient’s condition did not allow general 
anesthesia, surgery was postponed or replaced with drug 
therapy.

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208
The post-treatment evolution was favorable in 81% of 
the cases, a fact that is entirely expected when considering 
a benign condition with multiple therapeutic options and an 
ongoing development.
Comparing the results obtained with those in literature, 
both similarities and consistent differences were found. If 
women were more numerous than men in the study group, the 
general data denies the existence of a significant difference in 
the incidence in the two sexes. Also, the age most commonly 
diagnosed with hepatic hydatid cyst is 45-64 years, but in this 
case, the age group with the most patients was 30-49 years. 
From the paraclinical point of view, there are differences in 
the frequency with which eosinophilia is encountered (25% in 
the literature versus 39% in the present group) and the type 
of hepatic syndrome more common (cholestasis syndrome 
in the literature versus the cytolysis syndrome). The most 
frequent location was in the right hepatic lobe, same as in 
specialist literature. However, the frequency of complicated 
cysts was much lower in the study group (up to 50% in other 
studies vs. 11%). In terms of treatment, it is advisable to 
choose between medication, minimally invasive techniques 
and open surgery, all used depending on the stage and 
size of the cyst. Among the most commonly used open 
surgery procedures is the Lagrot cystectomy with partial 
pericystectomy, both in specialty literature and in our study 
group (88% of open surgery interventions).