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

Figure 3: Brunetti E. Echinococcosis Hydatid Cyst 2015. Available from: http://emedicine.medscape.com/article/216432-overview.

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Journal of Medicine and Life Vol. 11, Issue 3, July-September 2018
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were between 30 and 49 years of age. Male patients were 
distributed relatively evenly between 18 and 69 years of age.
More than half of the patients lived in rural areas. 
A higher incidence of hepatic hydatid cyst in rural 
patients may be explained by more frequent contact with 
herbivorous animals (sheep, goats, and others) that allow 
the E. granulosus life cycle to end with the perpetuation of 
the infection to dogs (the definitive host) and thus reach 
humans. However, the increased number of dogs in the 
urban environment (with or without an owner) makes the 
difference between the two environments not to exceed 6%.
The majority of the cases of hepatic hydatid cyst in this 
study were admitted in 2015, mentioning the fact that only 
the cases treated at the first visit were taken into account.
Regarding the symptomatology, the most commonly 
reported symptom was spontaneous or palpatory pain in 
the right hypochondrium. Other frequent manifestations 
were: asthenia and jaundice/slight jaundice.
Before surgery, liver function was investigated in all 
patients. Using the values of the two enzymes, the Ritis 
coefficient (AST/ALT, with normal values between 0.7 - 1.6) 
can be calculated.
Hepatic cytolysis syndrome, investigated through serum 
transaminases (AST and ALT), was most often identified. 
Excretory biliary syndrome or cholestatic syndrome was 
evaluated by measuring the serum alkaline phosphatase 
and serum bilirubin values. It was the least detected. 
Coagulation tests were used to investigate the hepatic 
insufficiency syndrome and were modified in 31 patients.
Over half of the patients presented inflammatory 
syndrome with plasma fibrinogen values above normal 
(200-400mg/dl).
Most of the patients were hospitalized, the symptoms 
investigated and treated at first in the Clinic of Parasitology. 
Having already had the results of previous paraclinical 
investigations, it was considered necessary to carry out 
immunological investigations in only 15% of patients. 
The serum IgG anti-Echinococcus granulosus antibody 
value was detected (it is considered positive when above 
1,1 MU). Only one patient showed negative values in the 
immunological tests.
All patients received an abdominal ultrasound scan. 
Only 23.86% of patients required additional CT imaging. 
Many patients also required other imaging investigations, 
such as a chest X-ray, needed for the anesthesiologist’s 
evaluation. Also, in the imaging investigations we can 
include 3 cases of cholangiography (percutaneous 
transhepatic cholangiography in two cases and one case of 
cholangiography through a Kehr tube), and multiple cases 
of ERCP for diagnostic and/or therapeutic purposes, pre- 
or postoperative. Following the ultrasound examination of 
the entire group of patients, it was possible to collate a 
general distribution of cystic stages according to the WHO 
classification. More than half of the patients were treated 
for cysts in the CE3 stage. Nearly one-quarter of the study 
group presented cysts in the CE1 stage. Multiple liver cysts 
were met to the same extent as CE4 and CE2. The CE5 
stage was the rarest.
A large percentage of CE1 and CE3 cysts with surgical 
treatment indication have been identified, although, at 
less than 5 cm diameter, the drug treatment as the only 
therapy is the primary intention. 10% were inactive cysts, 
but they needed to be treated, although the treatment 
recommendation in this case is a “watch-and-wait” 
approach. However, the patients included in the study 
group had characteristic symptoms (right upper quadrant 
pain on palpation and spontaneous fever and so forth) 
even under treatment with Albendazole.
In over half of the cases, the hydatid cyst was located 
at the level of the right lobe. Multiple cysts located in both 
hepatic lobes were met in 9% of cases.
Regarding the hepatic segments, the VII-th, the 
VIII-th and the VI-th were most often involved, followed by 
left segments III and IV, with 12% each. The most rarely 
involved was segment I. In most cases, two segments of 
the liver were involved.
For multiple cysts, the treatment was individualized 
(according to stage and size) for each cyst. Of the entire 
study group, 82% had cysts over 5 cm diameter, which 
excludes the possibility of single drug treatment (except 
for inactive and asymptomatic cysts). Only 18% of patients 
had cysts smaller than 5 cm, but in most of these cases, 
the invasive and minimally invasive treatment decision was 
justified by being in a CE2 or CE3 stage.
In the investigated group of patients, a majority of 
89% presented uncomplicated cysts. In the other 11% 
of cases, the hepatic hydatid cysts were complicated by 
biliary fistula or superinfection. Five patients developed 
the fistula with the biliary tree as the only complication. 
There were 2 patients who, associated with the biliary tree 
communication, presented the following: angiocholitis, 
superinfection or both superinfection and pneumobilia.
Open surgical interventions prevailed (48 cases), 
followed closely by the minimally invasive ones (36 cases). 
There is no evidence of laparoscopic interventions. 
The most commonly used open-surgery procedure was 
cystectomy with partial pericystectomy (Lagrot operation), 
which was performed in 88% of patients. In 10% of patients, 
cystectomy was performed with the pericyst being left in 
place and the drainage of the remaining cavity. The healing 
of this cavity is dependent on the quality of drainage and 
the existence of biliary fistulae.
Of the minimally invasive treatment techniques, 
the PAIR technique and the modified version (MoCat 

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