Changing Concepts in the Management of Liver

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Review Article

Changing Concepts in the Management of LiverHydatid Disease

Christos Dervenis, M.D., F.R.C.S., Spiros Delis, M.D., Costas Avgerinos, M.D.,Juan Madariaga, M.D., Miroslav Milicevic, M.D.

Hydatid disease is a rare entity primarily affecting the population of developing countries. The parasiteshuttles between the liver and lungs. but almost any organ can be invaded, forming cysts. Septation andcalcification of the cysts with a high antibody titre in the patients serum confirm the diagnosis, although

more sophisticated tests have been applied recently. Surgery constitutes the primary treatment, with avariety of techniques based on the principles of eradication and elimination of recurrence by means ofspillage avoidance. Minimally invasive techniques and percutaneous drainage of the cysts are now feasiblebecause of progress in the field.

The aim of this review is to collect the experience from three different institutions and to providepractical guidelines for diagnostic and therapeutic strategies. (J GASTROINTEST SURG 2005;9:869877)

2005 The Society for Surgery of the Alimentary Tract

KEY WORDS: Echinococcus, hydatid liver disease, laparoscopic treatment, percutaneous drainage,albendazole

INTRODUCTION

Echinococcosis in humans is a parasitic tapeworminfection, caused by a larval stage (the metacestode)of Echinococcus species. The infection can be asymp-tomatic or severe, causing extensive organ damageand even death of the patient. The metacestodes ofall four recognized Echinococcus species can infecthumans. There are three known forms of echino-coccosis in humans: 1) cystic echinococcosis (CE Hydatid disease) caused by Echinococcus granulosus,2) alveolar echinococcosis (AE) caused byEchinococcusmultilocularis, and 3) polycystic echinococcosis (PE)caused byEchinococcus vogelior Echinococcus oligarthus.

The most common sites for cystic echinococcosisinfection are the liver and lungs (60% and 30%, re-spectively), although hydatid cysts may develop,rarely, at other sites, including kidney, bones, brain,and pericardium. In theory, hydatid cysts may developat any site within the human body. The prevalence

From the Unit of Liver Surgery, 1st Surgical Clinic, Agia Olga Hospital (C.D., S.D., C.A.), Athens, Greece; Liver Surgical Unit, Divisionof Transplantation, University of Miami School of Medicine (J.M.), Miami, Florida; and The First Surgical Clinic, Institute for DigestiveDiseases, University Clinical Center Belgrade (M.M.), Serbia and Montenegro.Reprint requests: Christos Dervenis, M.D., Head, 1st Dept. of Surgery, Agia Olga Hospital, 3-5 Agias Olgas str., Athens, Greece. e-mail:[email protected]

2005 The Society for Surgery of the Alimentary Tract 1091-255X/05/$see front matterPublished by Elsevier Inc. doi:10.1016/j.gassur.2004.10.016 869

of echinococcosis varies considerably but is endemic

in the Middle East and Africa.18In this review the current concepts in the manage-

ment of cystic liver echinococcosis (liver hydatid dis-ease) from the perspective of the hepatobiliarysurgeon are presented.

MORPHOLOGIC CLASSIFICATION OFHYDATID LIVER CYSTS

Several ultrasound classifications of liver hydatidcysts based on the morphologic characteristics of the

cyst have been proposed in the past. The ultra-sound classification described by Gharbi et al. seemsto be most widely accepted. The pathognomoniccharacteristics and signs of hydatid liver disease suchas the presence of a detached laminated membranefrom the pericyst, the presence of daughter cysts, and
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Journal ofGastrointestinal Surgery870 Dervenis et al.

Table 1. Classification for hydatid cysts*

Type Description

I Pure(clear) fluid collection (the cyst is similar tothe simple liver cysts)

II Fluid collection with a detached membrane

III Fluid collection with multiple septa and/ordaughter cysts

IV Hyperechoic cyst contents with high internal echoesV Cyst with reflecting calcified thick wall

*Adapted from el-On J, Khaleel E, Malsha Y. Echinococcus granulosus:A seroepidemiological survey in northern Israel using an enzyme-linkedimmunosorbent assay. Trans R Soc Trop Med Hyg 1997;91:529-536.

calcifications of the cyst wall have all been included inGharbis criteria (Table 1).9

The need to evaluate the functional state of theparasite, especially in field studies, has resulted in anew, modified ultrasound classification of liver hy-datid cysts. Based on cyst characteristics described inthe Gharbi classification, the World Health Organi-zation (WHO) Informal Working Group on Echino-coccosis10 proposed a new classification reflecting thefunctional state of the parasite thatfacilitates selectionof treatment modalities (Table 2).

DIAGNOSIS

In the majority of cases definitive diagnosis of thedisease can be established by a combination of im-

aging techniques (Figs. 1,2, and 3) and either serolog-ical or immunoassay techniques. At least two testsare required to confirm the diagnosis. Immunofluo-rescence assay, indirect hemagglutination, immu-noelectrophoresis, or coelectrosyneresis with antigen5 identification confirm the diagnosis in 80% to 96%of patients with liver hydatidosis. The tests are lesssensitive when the cysts are not in the liver. Specialtechniques such as ELISA have a high specificity andaccuracy independent of disease stage and site ofthe cyst.11,12

Table 2. WHO classification

Type of cyst Status Ultrasound features Remarks

CL Active Signs not pathognomonic, unilocular, no cyst wall Usually early stage, not fertile;differential diagnosis necessary

CE 1 Active Cyst wall, hydatid sand Usually fertileCE 2 Active Multivesicular, cyst wall, rosette-like Usually fertileCE 3 Transitional Detachment of laminated membrane, water-lily sign, Starting to degenerate, may produce

less rounddecreased intracystic pressure daughter cystsCE 4 Inactive Heterogenous hypo- or hyper-echogenic degenerative Usually no living protoscoleces;

contents; no daughter cysts differential diagnosis necessary CE 5 Inactive Thick calcified wall, calcification partial to complete; Usually no living protoscoleces

not pathognomonic but highly suggestive of diagnosis

MEDICAL TREATMENT

Thirty years after the first attempts to establisheffective medical treatment, surgery is still the goldstandard for achieving complete cure of liver hyda-tid disease.

Chemotherapy with benzimidazole compounds(albendazole and mebendazole) is currently indicatedfor: (1) inoperable primary liver hydatidosis, (2) mul-tiple cysts in two or more organs, (3) multiplesmall liver cysts, (4) cysts deep in liver parenchyma,(5) prevention and management of secondary hy-datidosis, (6) management of recurrent hydatidosis,(7) unilocular cysts in unfit elderly patients, (8) usein combination with surgery and interventionalprocedures, (9) pulmonary echinococcosis, and (10)long-term administration for cystic echinococcosis atspecific sites (bone, brain, eye, etc.).

The effectiveness of preoperative chemotherapy in

preventing secondary echinococcosis and recurrenceneeds further investigation. Chemotherapy is rou-tinely administered prior to interventional proce-dures, and in some centers it is used preoperatively. Itis still unclear whether preoperative chemotherapy isbeneficial and many centers do not administer it.

Chemotherapy is contraindicated in the following:(1) large cysts, (2) cysts with multiple septa divisions(honeycomb-like cysts), (3) cysts than are prone torupture (superficial), (4) infected cysts, (5) inactivecysts, (6) calcified cysts, (7) severe chronic hepaticdisease, (8) bone marrow depression, and (9) early

pregnancy.13,14

Mebendazole (MBZ) is a broad-spectrum antihel-mintic drug with poor intestinal absorption that isactive against intestinal nematodes. Albendazole(ABZ) has better intestinal absorption, better tissuedistribution, and achieves considerably higher cystfluid concentrations. It undergoes a rapid first-passmetabolism in the liver to albendazole sulfoxide, theantiscolecoidal agent flubendazole. The MBZ fluo-rinated analog does not penetrate the cyst, and there-fore the drug is not an alternative for treatment.1517
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Fig. 1. CT image of hydatid cyst with air-fluid level suggestinginfection with abscess formation.

The benzimidazole carbamates have a direct effecton the cumulus oophorus and on the wall of thecyst. Younger cysts and cysts with thin walls show abetter response. Chemotherapy with ABZ or MBZmay lead to liver enzyme elevation (10%20% ofpatients), bone marrow suppression, pancytopenia,agranulocytosis, and alopecia. These adverse effectsare reversible once the treatment is stopped.1820

The indicated dosage of ABZ is 10 to 15 mg/kg/day postprandially in two divided doses. The manu-facturer suggests a therapeutic cycle of 4 weeks oftreatment followed by a 2-week pause. The usualdosage scheme is 3 to 6 or more cycles for liverhydatid disease. For cystic echinococcosis of other

Fig. 2. Multiple daughter cysts invading both right and leftliver lobes.

Fig. 3. Multiple daughter cysts in the right liver lobe withextension to the abdominal wall.

organs, duration of therapy is much longer. Recentdata have shown equal or improved efficacy of contin-uous treatment for 3 to 6 months or longer withoutan increase in adverse effects.21 Cyclic ABZ treat-ment seems to be no longer advisable. The equivalentdosage for MBZ chemotherapy is 40 to 50 mg/kg/dayin 3 divided doses, for 3 to 6 months. Serum druglevels may vary widely in individual patients, andtherefore correlation with oral doses and drug efficacyis inconsistent.

ABZ, the most efficient agent used so far, mayinduce apparent cure, as indicated by cystshrinkageordisappearance in 20% to 30% of patients.22 Someauthors have reported degeneration of cysts in up to50.6% of patients treated with MBZ and 80% ofpatients treated with ABZ. The interpretation ofthese studies is difficult because of lack of standardiza-tion and interference with the natural history ofthe disease.23

A prospective, controlled, randomized trial hasdemonstrated the efficiency of preoperative ABZ ad-ministration. Following 1 and 3 months preoperativeadministration, 72% and 92% of cysts were found atsurgery to be nonviable, versus 50% of cysts in the

control group, which were treated by surgery alone.24According to the WHO guidelines, preoperative

administration should begin between 1 month and 4days before surgery for ABZ and 3 months beforesurgery for MBZ.25

The expected results of adequate chemotherapyare:(1)10%to30%cystdisappearance(cure),(2)50%to 70% degeneration or significant size decrease, and(3) 20% to 30% with no morphologic changes (treat-ment failure). The rate of relapse after chemotherapyis high (3%30%), but fortunately relapses are sensi-tive to retreatment in up to 90% of patients.26


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Praziquantel, a synthetic isoquinoline-pyrazine de-rivative, has been used in combination with ABZ.Combined chemotherapy seems to be more effectivethan ABZ alone.2729

Coordinated, prospective trials are necessary toestablish the value of chemotherapy in hydatid dis-

ease. All the available data suggest that conservativemanagement of hydatid disease yields poor results,and in the majority of patients the therapy fails orthe disease recurs.30

SURGICAL TREATMENT

There are many surgical procedures for the man-agement of liver hydatid cysts. Much controversyexists regarding the most appropriate surgical tech-nique, which should effectively eliminate the parasiteas well have a low morbidity and mortality rate and

a negligible recurrence rate.Indications for surgery in patients with liver hyda-

tidoses are: (1) large cysts with multiple daughtercysts, (2) single liver cysts situated superficially thatmay rupture, (3) infected cysts, (4) cysts communi-cating with the biliary tree, (5) cysts exerting pressureon adjacent vital organs, and (6) cysts in the lung,brain, bones, kidneys, and other organs.

In addition to overall high-risk factors for surgerysuch as extreme age, pregnancy, and concomitantsevere disease, specific contraindications for surgeryin liver hydatidoses are: (1) multiple cysts, (2) cysts

difficult to access, (3) dead cysts, (4) cysts partially ortotally calcified, and (5) very small cysts.

Surgical procedures can be divided into threegroups: classic open surgical procedures, laparoscopicprocedures, and interventional (minimally invasive)procedures.31

Open Surgical Procedures

The classic open surgical procedures can be subdi-vided into two groups: (1) conservative, tissue-sparingtechniques, limited to removing the parasite, withpart or most of the pericyst left in situ, and (2) radical

procedures that remove the entire pericyst, with orwithout entering the cyst itself. The choice of surgicaltechnique depends on the size, site, and type of thecyst(s), the existence of complications, and the sur-geons expertise.32

The most common conservative, tissue-sparing,techniques are: simple drainage, marsupialization (ex-ternal drainagean historical procedure), partial cys-topericystectomy (partial resection of the pericyst),and near-total pericystectomy. All of these proce-dures have some common goals: (1) safe and com-plete exposure of the cyst, (2) safe decompression of

the cyst, (3) safe evacuation of the cyst contents, (4)sterilization of the cyst, (5) management of cyst-bileduct communications, if present, and (6) managementof the remaining cyst cavity.33

The traditional surgical simple drainage of thecysts is still in use by many surgeons. In this pro-

cedure, the abdomen is carefully packed with padsaround the cysts to reduce the risk of peritonealsoilage and contamination, the cysts are aspirated bya closed system, and antiscolecoidal agents (e.g. alco-hol, chlorhexidine, hypertonic saline, etc.) are infusedin the emptied cavity. After repetitive infusions thecyst is unroofed and drained. The recurrence rate fol-lowing this procedure ranges from 10% to 30%.34,35

Evaluation of the cyst contents is important. Bilestaining implies a communication with the biliarytree and should warn against the injection of antisco-lecoidal agents because of the definite risk of scleros-

ing cholangitis.Marsupialization was commonly used several de-cades ago, especially for infected cysts, and it is practi-cally not used anymore due to the high complicationrate. In this procedure, following evacuation and ster-ilization of the cyst, the cavity is drained externally bysuturing the opening on the pericyst to the abdominalwall.36 The management of such patients is pro-longed, with suppuration and frequent bleeding fromthe cyst. The procedure is ideal for infected cystsbut convalescence is slow and drainage may persistfor months.

Although these techniques are simple, easy, andquick, they are operator dependent and are oftenaccompanied by a high rate of postoperative compli-cations, such as persistence of residual cavity, diseasesoilage in biliary tract or intraperitoneal, bile leak-age, vessel injuries and hemorrhage, sepsis, cholan-gitis and anaphylactic shock. For that reason severaltechnical improvements have been proposed, such asinterrupting all external communications from thecyst and obliterating the remaining cavity with omen-tum (omentoplasty) or muscle flaps. The omentumis sutured into place and a drain is also placed fixedto the rim of the opening. Other surgeons suggest

capitonnage of the remaining cysts wall to reducebile leakage.37,38 This technique involves infoldingthe redundant cyst wall into the depths of the cystwith successive layers of sutures. Capitonnage is con-traindicated when the wall of the cyst is rigid andcalcified. Special attention is also required to avoiddeep suture placementwith subsequent bleeding fromhepatic vein injury.33

In partial cystopericystectomy, the parasitic fociis eliminated and the surrounding pericyst is re-moved. Dr. Milicevic, the corresponding author ofthis study, suggests entailed excision of the exuberant


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part of the cyst that protrudes from the liver, espe-cially in small and young hydatid cysts with elasticand thin pericysts.39

Subtotal pericystectomy (fere totalis) is an alterna-tive to partial cystopericystectomy. In partial cysto-pericystectomy, small pericystic areas close to vascular

and biliary vessels are not resected because of a highrisk of severe complications.40The modification pro-posed by Burgeon et al. includes inner membraneexcision with preservation of the outer layer to protectliver parenchyma, biliary ducts, and blood vessels,minimizing postoperative complications such as bili-ary leaking and hemorrhage.41

In radical operations the parasitic content and theentire pericystic membrane is removed. In this sub-category, the main procedures are total pericystec-tomy and liver resection.

Total pericystectomy, first described in the 1930s,

can be performed either with the open or theclosed-cyst method. In the open technique, the cystis opened, the contained material is removed, antisco-lecoidal substances are infused, and then the pericystis removed. In the closed-cyst method, en block peri-cystectomy is performed with no other manipula-tions. During the pericysts removal, afferent bloodand biliary vessels are ligated in order to preventhemorrhage or postoperative bile leakage. This pro-cedure, although technically more demanding, causescavity disappearance and prevents relapse of thedisease and secondary inflammatory complica-

tions.42,43

There is no doubt that a radical operationin the hands of experts in dedicated centers givessuperior results. The operation has the advantage ofidentifying exogenous daughter cysts adjacent to themain cyst but is to be avoided for cysts impinging onthe major hepatic veins, the inferior vena cava, andclose to the liver hilum. Closed cystopericystectomycreates no residual adventitia, eliminates the need forantiscolecoidal agents, and avoids biliary fistula, butbleeding can be profuse due to the adjacent vesselsin the liver parenchyma.33,38 Open cystopericystec-tomy is preferred when the cyst wall is thin and im-

pending rupture is expected and when major vascularstructures have been encountered during the closedprocedure.44

Many authors suggest liver resection for echino-coccosis. Although this method seems to be the mostcomplete treatment for hydatid disease, the highpostoperative morbidity and mortality rate, and theunknown ability of the remaining liver to regener-ate suggest a more skeptical use of this technique.For that reason, liver resection is indicated whenother more conservative surgical therapies have failedto eliminate the disease, cysts have destroyed an entire

lobe or segment, thus compressing the healthy paren-chyma interrupting the bile ducts, or when externalcyst-biliary fistula draining zones need to be format-ted. In such cases typical left or right hepatectomyor segmentectomy can be performed.45,46

In the modern era of radiofrequency (RF) thermalablation, Brunetti et al. suggest a novel technique forliver hydatid cyst treatment. The RF electrodes wereinserted through liver parenchyma into the echino-coccal cysts. The cysts were destroyed with a patternsimilar to those of hepatic metastases. Histologicexamination in the material that was removed withsuction showed no live parasites or eggs, and in theirsmall series no recurrence was observed, while nocomplications have been reported perioperatively.This modification may present a new alternative inliver hydatid cyst treatment, especially in deep cysts,in multiple cysts, or in complicated cases that requiresevere and multiple operations.47 RF total cysto-pericystectomy and RF liver resection are the mostrecently applied modification. Tissue-desiccatingnecrosis is limited only to the narrow resection sur-face layer of the liver parenchyma, providing excellenthemo-, bile and lymphostasis as well as a safe margin,considering exogenous vesiculation as a potentialcause of local recidivism.

Management of Bile Duct Communication

Preoperative detection and assessment of cyst-bileduct communication is essential. Large cysts occu-pying several liver segments and episodes of chol-angitis are highly suggestive of cyst-bile ductcommunications, and a search for the fistula shouldbe meticulous. The direction of the bile duct can bedetermined by gentle exploration with a thin curvedprobe. Terminal biliary branches can be sutured withor without T-tube drainage. In some patients withbile-stained hydatid debris, no communication is de-tected and no additional procedure is done. Bile ductexploration, choledochoscopy, and T-tube drainageis usually done in order to secure and decompress atenuous closure of a large bile duct in a rigid pericyst.A Roux-en-Y intracystic hepaticojejunostomy maybe necessary for large cysts in which major ductsare disrupted, the jejunum being sutured to the ductwithin the cyst cavity. Choledochoduodenostomy orRoux-en-Y hepaticojejunostomy are performed formassive penetration of hydatid debris and daughtercysts into the common bile duct.48 Indications forsphincteroplasty are very infrequent and include ob-struction of the papilla by calcified hydatid debrisor sclerosis.49


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Laparoscopic Treatment

Laparoscopic treatment of liver echinococcosis hasbeen increasingly popular during the last few de-cades because of the significant progress in laparos-copic surgery, although no randomized clinical

trials comparing laparoscopic with conventional opensurgical treatment of hydatid disease have been re-ported. Laparoscopic treatment includes partial ortotal pericystectomy and cyst drainage with omen-toplasty. A major disadvantage of laparoscopy is thelack of precautionary measures to prevent spillageunder the high intraabdominal pressures caused bypneumoperitoneum. Some authors suggest thatpneumoperitoneum is beneficial in preventing spill-age,50 while others suggest a decrease in intraabdo-minal pressure.51 The most difficult part of thelaparoscopic procedure is the initial cyst puncture andaspiration of the cyst fluid.52 Pre- and intraoperativeuse of antiscolecoidal factors seems to be of greatimportance because it ensures the inactivation andclearance of the parasites, while some authors avoidthem because of the potential risk of sclerosing cho-langiitis.53,54 Seven et al. suggest that intraoperativespillage can be avoided by fixing the cyst in the ab-dominal wall with a special umbrella trocar and suc-tion with a specific suction device.55 Bickel et al.suggest a combination of filling the right subdi-aphragmatic suprahepatic space with antiscolecoidalfluid (cetrimide) and Trendelenburg position for de-creasing the risk of spillage, although this approach

cannot prevent a sudden jet of fluids escaping thecyst.50 In their study, they propose a new techniquewith a transparent cannula and vacuum for com-plete fluid evacuation. The tip of the device is adheredfirmly to the cyst wall to prevent spillage in the perito-neal cavity.

The indications for laparoscopic excision of liverechinococcosis has changed through the years. In thepast, patients with cysts with a diameter greater than15 cm and those with recurrent disease were excludedfrom laparoscopic treatment. Nowadays, the only ex-cluding criteria for laparoscopic intervention are deep

intraparenchymal cysts or posterior cysts situatedclose to the vena cava, more than 3 cysts, and cystswith thick and calcified walls.56,57

Conversion to open laparotomy may occur becauseof unsafe exposure, unsatisfactory access, intraopera-tive bleeding, or intrabiliary rupture of the cyst. Cho-ledochotomy, irrigation, and T-tube drainage isindicated in these patients, although open laparotomyprolongs significantly hospitalization. A more conser-vative approach is laparoscopic removal of the cystsand endoscopic sphincterotomy for intrabiliary rup-ture or external biliary fistulas.58,59

Postoperative morbidity in laparoscopic studiesranges from 8% to 25%,50,60 while in open seriesvaries from 12% to 63%.43,46 The treatment-relateddeath after laparoscopy is almost zero, while in openseries it ranges from 0% to 3%.39,43,46Major compli-cations (in the form of allergic reactions) seem to be

more common in laparoscopic interventions due toperitoneal spillage during debridement and removalof cysts content.50The rate of short-term recurrencevaries from 0% to 9% after laparoscopy,50,55while inopen series it is even higher (0% to 30%).39,43,46

These favorable results of laparoscopic treatment ofliver hydatid disease may be related to not only theadvantages of minimally invasive surgery but alsothe selection criteria for the patients.61,62

The well-known advantages and the superiority oflaparoscopy are strengthened in the light of the needfor a much larger upper abdominal incision for open

hydatid surgery and the prolonged hospitalization.Mean hospitalization time ranges between laparos-copic (312 days) and open series (920 days), and asignificant statistical difference seems to exist.50,56,62

Criticisms that may be made of the existing stud-ies are that the patients were not randomized intolaparoscopic and open intervention, the total numberof patients is relatively small, and patients with con-traindications for laparoscopic treatment were hand-led with open surgery.

Percutaneous Drainage

Until recently percutaneous treatment of hydatidliver cyst was contraindicated because of the fear ofdissemination, peritoneal spillage, and anaphylacticshock. Since 1989, only a few sporadic, mainly un-intentional, percutaneous aspirations followed bydrainage of hydatid cysts have been reported.63

Nowadays both of these complications are ex-tremely rare and should not be considered as absolutecontraindications.64The development of fine needlesandcatheters, theadvances in imagingtechniques, andthe introduction of the intercostal intrahepatic ap-

proach minimizes the risk of anaphylactic shock orspillage.65

Percutaneous aspiration can be performed eitherby ultrasound- or CT-guided control. The initialpuncture can be established either by a freehand tech-nique with ultrasound guidance or by a needle-guid-ing device mounted on a probe. After insertion thecysts content is aspirated, a sample is derived, con-trast is injected in order to opacify the cyst, andan antiscolecoidal drug is infused followed by a Be-tadine infusion. The catheter remains clamped for 30minutes, and after a second Betadine infusion the


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catheter remains for drainage. In addition to Betad-ine, other antiscolecoidal agents have been usedsuccessfully.66,67

Percutaneous treatment is indicated for type I andII cysts, some groups of type III that do not involvenondrainable solid material, subtypes of type IV, sus-

pected fluid collections, and infected hydatid cysts. Inaddition, percutaneous treatment should be consid-ered in patients at high surgical risk, pregnant pa-tients, and patients with multiple or disseminatedcysts.

Percutaneous procedures are contraindicated insome subgroups of type III and IV (hydatid cysts withheterogeneous echo pattern) and in liver cysts thathave ruptured into the biliary system or peritoneum.25

It is generally accepted that hydatid cysts of type Vdo not need any intervention but can be managedwith regular follow-up instead.68

Treatment failure is defined as recurrence in thesame location or complications related with the inter-vention. For uncomplicated hydatid cysts of type Iand II, percutaneous treatment seems to be the opti-mal treatment. Recurrence ranges between 0% and4% among several series with a low morbidityrate.69,70The overall complication rates in percutane-ous drainage varies from 15% to 40%. Major compli-cations such as anaphylactic shock range from 0.1%to 0.2%, and minor complications (urticaria, itching,hypotension, fever, infection, fistula, rupture in bili-ary system) varied from 10% to 30%.71

The overall mortality is 0.9% to 2.5% among sev-

eral studies and associated with perioperative compli-cations, patients age, and infection of the remainingcyst cavity.72

Percutaneous drainage is gaining wide acceptancebecause of its low morbidity and easy applicability, butselection of the patients is of paramount importance.73

A meta-analysis of percutaneous drainage of liverhydatid cyst showed no significant complications andimmediate relief of the symptoms, and no recurrencewas observed during 33 months of follow-up.74

We suggest that percutaneous treatment has animportant role in the treatment of hydatid liver cystswith results proved by several series with long-termfollow-up. Therefore, we believe that in indicatedcases percutaneous drainage is a very effective and re-liable interventional minimally invasive procedure as-sociated with low mortality and morbidity.75

Surgeons should play a key role in the managementof patients with hydatid disease and cooperate withthe radiologists using these novel techniques.

CONCLUSION

What are the perspectives in the beginning of thethird millennium? The answer can be obtained with

the determination of the disease-associated problems.Although several therapeutic procedures have beenproposed, no randomized clinical trials for their com-parison have been organized. Randomized clinicaltrials may define the therapeutic strategy to combineboth low morbidity and radical elimination of recur-

rences. Encouraging results have been achieved re-cently by minimally invasive approaches. Currentdata suggests that laparoscopic and percutaneousdrainage are feasible and in certain cases render opentechniques unnecessary or obsolete. More sensitivediagnostic methods should be developed. The radicalelimination of the disease can be achieved with im-provements in agriculture, educational, social, andeconomic factors of the endemic regions and vac-cine development.

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