Hydatid cyst of the liver is very rare problem in the urban population of INDIA. However, we must know the disease its presentation, the review of literature for the same and its management with current updates.

1. Dr. Keyur Bhatt
MS, MRCS (UK), FACS (USA)

2. HYDATID CYSTSHydatid Disease

3. Overview
• Organism
• History
• Epidemiology
• Transmission
• Disease in Humans
• Disease in Animals
• Prevention and Control
Center for Food Security and Public Health, Iowa State
University, 2012

4. The Organism
• Cestode parasites
• Family Taeniidae
• Currently recognized species
• Echinococcus granulosus
• Echinococcus multiocularis
• Echinococcus vogeli
• Echinococcus oligarthrus
• Echinococcus shiguicus
Center for Food Security and Public Health, Iowa State
University, 2012

7. Diagnosis :
• Best done with
• USG
• For best characterization of typings
• In complex cases
• CECT
• For extent / possible biliary radical anatomy

8. Classifications based on USG findings

9. Serology
• CE serology is usually based on the detection of antibodies against
hydatid fluid (HF), but the use of this heterogeneous antigenic
mixture shows several drawbacks, including false positive and
negative results, unsatisfied predictive values, and long persistence
of detectable antibody levels in cured patients
Neglected Tropical Diseases | https://doi.org/10.1371/journal.pntd.0006741

10. Evaluation of the recombinant antigens B2t and 2B2t
• Two recombinant antigens derived from one of the immunodominant HF
antigens (antigen B2) have been tested in enzyme-linked immunosorbent assay
(ELISA) and in immunochromatographic strips (IC) against 721 serum samples.
Although more specific than the HF, the recombinant antigens in ELISA showed
low sensitivity for patients with inactive (CE4 and CE5) cysts
and for patients not subjected to drug treatment.
• This limited their use for follow-up, although promising, to those patients with
positive serology at the beginning of the follow-up period. These results will aid in
the future development of a serological test with enhanced performance in the
diagnosis and follow-up of patients with CE.
Neglected Tropical Diseases | https://doi.org/10.1371/journal.pntd.0006741

14. Immunodiagnosis
• Cystic echinococcosis (CE) immunodiagnosis is still imperfect. We recently set-up a
whole-blood test based on the interleukin (IL)-4 response to the native Antigen B (AgB)
of Echinococcus granulosus. However, AgB is encoded by a multigene family coding for
five putative subunits. Therefore, the aims of this study were to analyse the IL-4 response to
peptides spanning the immunodominant regions of the five AgB subunits
and to evaluate the accuracy of this assay for CE diagnosis. Peptides corresponding to
each subunit were combined into five pools. A pool containing all peptides was also
used (total pool). IL-4 evaluated by enzyme-linked immunosorbent assay
was significantly higher in patients with CE compared to those
without (NO-CE subjects) when whole-blood was stimulated with AgB1 and with the
total pool.
• Moreover, IL-4 levels in response to the total pool were significantly increased in patients with
active cysts.Receiver Operator Curve analysis identified a cut-off point of 0.59 pg/mL predicting
active cysts diagnosis with 71% sensitivity and 82% specificity in serology-positive CE patients.
• These data, if confirmed in a larger cohort, offer the opportunity to develop
new diagnostic tools for CE based on a standardized source of AgB as the peptides.
Parasite Immunology. 2017;39:e12499.

15. Treatment
• Wait-and-see
• Small, inactive cysts
• Anti-parasitics
• Surgical removal of cysts – Conservative Vs Radical
• May not be possible to remove entire cyst depending on size and location
• Liver transplant

16. Is medical Rx sufficient?
• The use of benzimidazole compound derivatives, albendazole (ALB) and
mebendazole (MBZ), has been studied in 7 RCTs
• Compared with a shorter treatment course, three months of oral treatment
appears to have better outcomes in terms of cyst degeneration (based on
imaging) and cure rates.
• However, in 5 of the 7 clinical trials published, the cure rate for HC treated with
ALB alone was below 60%.
• Only trials that included 3 months of ALB treatment and surgery had cure rates
> 90%.
• Based on the results of published RCTs, benzimidazole derivatives alone cannot
fully eliminate cysts.
Review WJS: 1007-9327/full/v21/i1/124

17. Medical therapy
• Indications: Chemotherapy is indicated in patients with primary liver
or lung cysts that are inoperable (because of location or medical
condition), patients with cysts in 2 or more organs, and peritoneal
cysts.
• Chemotherapeutic agents: Two benzimidazoles are used, albendazole
and mebendazole. Albendazole is administered in several 1-month
oral doses (10-15 mg/kg/d) separated by 14-day intervals. The
optimal period of treatment ranges from 3-6 months, with no further
increase in the incidence of adverse effects if this period is prolonged.
Mebendazole is also administered for 3-6 months orally in dosages of
40-50 mg/kg/d.

18. Contraindications
• Early pregnancy, bone marrow suppression, chronic hepatic
disease, large cysts with the risk of rupture and inactive or
calcified cysts are contraindications.
• A relative contraindication is bone cysts because of the
significantly decreased response.

19. Outcome
• Response rates in 1000 treated patients were that 30% had cyst
disappearance (cure), 30-50% had a decrease in the size of the cyst
(improvement), and 20-40% had no changes.
• Also, younger adults responded better than older adults.
• But there are many factors behind this as well as the typing of the
cysts are also important

20. Albendazole therapy in human lung and
liver hydatid cysts: A 13-year experience.
• Among 164 patients with echinococcosis who were referred to the surgery clinic, Ghaem hospital,
Mashhad University of Medical Sciences between 2001 and 2013, two were diagnosed with
alveolar echinococcosis (AE) and 162 with CE; 43 of whom underwent surgery. The rest 119
patients received medical therapy by Albendazole 15 mg/kg/day for three phases. Each phase
included 6 weeks of Albendazoletherapy followed by 2 weeks of no medication. The patients were
classified according to radiologic evaluations into four groups: (1) cured, (2) improved, (3)
unchanged, and (4) worsened or relapsed.
• RESULTS:
• Patients who completed more phases had significantly greater chances of better response. Of the
56 patients who completed all three phases, 37 (66.1%) were cured, 15 (26.8%) improved, 4
(7.1%) remained unchanged, and none worsened or relapsed. [Odds ratio (OR):4.78, 95%
confidence interval (CI): 2.95-7.74, P < .0001].
• CONCLUSION:
• Albendazole can be beneficial for inoperable, multiple cysts, and
multiple organs CE patients.
Clin Respir J. 2018 Mar;12(3):1076-1083. doi: 10.1111/crj.12630. Epub 2017 Apr 20.

21. Albendazole and Treatment of Hydatid Cyst:
Review of the Literature
Abstract
Human hydatid cyst or cystic echinococcosis is a life-threatening zoonotic disease that occurs in most countries worldwide and is
recognized as a major public health problem. Following ingestion of Echinococcus granulosus eggs, hydatid cysts which are the larval
stage of the worm are formed mostly in liver and lungs, and occasionally in other organs of human. The usual treatment for hydatid cyst is
open surgery. One of the problems following surgery is the recurrence. In the last decades, albendazole has been used for the treatment
of hydatid cyst. This drug can be used alone or jointly with surgical procedures. However, its efficacy has not been well documented.
Thus, in this work, the treatment of hydatid cyst with albendazole in different investigations including case studies, clinical trials in human
and experimental works in animals has been reviewed. According to the findings of this
review, it can be concluded that treatment of hydatid cyst with
albendazole may be associated with the prevention of
recurrence and reduction of the size and death of the hydatid
cysts.
Infect Disord Drug Targets. 2019;19(2):101-104. doi: 10.2174/1871526518666180629134511.

22. Percutaneous drainage, Is it useful?
• Two non-comparative prospective studies of 34 and 87 patients treated with
percutaneous drainage concluded that it is a safe and effective treatment that
can be used in patients with contraindications to surgery and for types Ⅰ-Ⅲ
disease, according to Gharbi et al. (1981)
• A randomized study involving 33 patients supported the effectiveness of
treatment with oral ALB alone, percutaneous drainage/ALB/puncture, aspiration,
injection, re-aspiration (PAIR), or combining PAIR. Oral ALB showed the best
results in terms of cyst size reduction (P < 0.05) when ALB and PAIR were
combined.
• The results of these studies suggest that percutaneous drainage combined with
ALB is a safe and effective treatment for liver HC
Gharbi HA,Ultrasound examination of the hydatic liver.Radiology. 1981;139:459-463.
Khuroo MS, Percutaneous drainage versus albendazole therapy in hepatic hydatidosis: a prospective, randomized study.Gastroenterology. 1993;104:1452-1459.

23. PAIR
• This technique, performed using either ultrasound or CT
guidance, involves aspiration of the contents via a special
cannula, followed by injection of a scolicidal agent for at
least 15 minutes, and then reaspiration of the cystic
contents. The cyst is then filled with isotonic sodium chloride
solution. Perioperative treatment with a benzimidazole is
mandatory (4 d prior to the procedure and 1-3 mo after).
• The cysts should be larger than 5 cm in diameter and type I
or II according to the Gharbi ultrasound classification of
liver cysts

24. Preferable Indications of PAIR
Inoperable patients; patients refusing surgery; multiple
cysts in segment I, II, and III of the liver; and relapse
after surgery or chemotherapy are indications for the
PAIR technique

25. Contraindications of PAIR
Early pregnancy, lung cysts, inaccessible cysts,
superficially located cysts (risk of spillage), type II
honeycomb cysts, type IV cysts, and cysts
communicating with the biliary tree (risk of
sclerosing cholangitis from the scolecidal agent)

26. Surgery or PAIR?
• In a meta-analysis of 21 studies, Smego et al compared 769 patients who
received ALB/MBZ treatment and PAIR to 952 patients treated with surgery
alone. They concluded that PAIR in conjunction with ALB/MBZ is more
effective than surgery and is associated with lower rates of morbidity and
mortality, decreased recurrence risk and a shorter hospital stay. However,
these results were obtained considering surgical interventions,
conservative or radical approaches in the same group.
Clin Infect Dis. 2003;37:1073-1083.
• PAIR may be a promising treatment for liver HC, but there is not sufficient
evidence to support its use as a standard procedure for patients with
uncomplicated cysts. There is a need for well-designed clinical trials to
confirm these results.
J Gastrointest Surg. 2011;15:1829-1836.

27. Can PAIR be considered as a first line Rx!?

28. Outcome
The reduced cost and shorter hospital stay associated
with PAIR compared to surgery make it desirable. The
risk of spillage and anaphylaxis is considerable,
especially in superficially located cysts, and
transhepatic puncture is recommended. Sclerosing
cholangitis (chemical) and biliary fistulas are other
risks. Experience is still limited.

29. PAIR – present status
• Presently, there is no evidence to support PAIR as a
standard treatment and further well-designed studies are
necessary prior to recommending it.
• J Gastrointest Surg 2011; 15: 1829-1836 [PMID: 21826545 DOI: 10.1007/s11605-011-
1649-9

30. Surgical Management
• Indications:
1-Large liver cysts with multiple daughter cysts; superficially
located single liver cysts that may rupture (traumatically or
spontaneously).
2-Liver cysts with biliary tree communication or pressure
effects on vital organs or structures.
3-Infected cysts .
4-Cysts in lungs, brain, kidneys, eyes, bones .

31. Surgical Treatment
• Radical surgery for liver HC refers to pericystectomy and liver
resection
• Whereas conservative surgery involves the removal of the cyst
content and sterilization of the residual cavity, together with partial
cyst resection.

32. Conservative surgery!
• A comparative retrospective study by Aydin et al of 242 patients described
significantly higher morbidity and recurrence rates in patients who
underwent conservative surgery (11% vs 3%; 24% vs 3%).
The optimal treatment of hydatid cyst of the liver: radical surgery with a significant reduced
risk of recurrence. Turk J Gastroenterol. 2008;19:33-39.
• In another comparative retrospective study by Tagliacozzo et al that
included 454 patients, 214 underwent conservative surgery (external
drainage, marsupialization or omentoplasty), while the remaining 240 were
treated with radical surgery. Morbidity and recurrence rates were
significantly higher in the group that underwent conservative surgery.
Surgical treatment of hydatid disease of the liver: 25 years of experience. Am J
Surg. 2011;201:797-804.

33. How can complications be prevented ?
• A variety of techniques have been described (omentoplasty,
introflexion, capitonage, external drainage or synthetic fibrin) to
prevent postoperative complications caused by the presence of the
residual cavity following conservative surgery.
• A comparative retrospective study of 304 patients by Balik et al
concluded that external drainage had a significantly higher rate of
complications (e.g., infection of the residual cavity and biliary
fistulization) than omentoplasty or capitonage.

34. Something different!
• The use of fibrin glue has been assessed in non-
randomized studies both for radical (Cois et al) and
conservative surgery (Hofstetter et al), and has been
shown not to play a significant role.
• World J Surg 2004; 28: 173-178 [PMID: 14708059 DOI: 10.1007/s00268-003-6932-9]
• Ann Ital Chir 1997; 68: 701-706; discussion 706-709 [PMID: 9577048]

35. Drug Rx along with the surgery – What is the evidence
• A non-randomized prospective study of 70 patients by Aktan et al, which compared preoperative
administration of ALB for three weeks vs no ALB treatment, found a significantly higher number of non-
viable liver cysts in patients treated with ALB.
• Türkçapar et al published a non-comparative prospective study in which ALB was administered one month
before surgery and then again 2 mo after surgery to 25 patients. In two cases, drug treatment had to be
suspended due to abnormal liver enzymes. In the remaining 23 patients, no recurrences were observed,
with an average follow-up period of 29 mo.
• In a RCT of 72 patients by Shams-Ul-Bari et al, patients were randomized to two groups: group A received
ALB for 12 mo before and after surgery, whereas group B went straight to surgery. The recurrence rate in
the surgery-alone group was 16%, whereas in the group treated with ALB, no recurrences were detected (P
< 0.01) at an average follow-up of 5 years.
• Another randomized study by the same group (Arif et al) divided 64 patients into 4 groups: surgery alone,
treatment with ALB and then surgery, ALB followed by surgery and postoperative ALB, or surgery followed
by ALB. Lower recurrence rates were observed in patients treated with ALB (4.16% vs 18.75%).
• Combined treatment with ALB + surgery leads to a lower risk of recurrence than
surgery alone.
Preoperative albendazole treatment for liver hydatid disease decreases the viability of the cyst. Eur J Gastroenterol Hepatol 1996; 8: 877-879 [PMID: 8889454]
Surgical treatment of hepatic hydatidosis combined with perioperative treatment with albendazole. Eur J Surg 1997; 163: 923-928 [PMID: 9449445]
Role of albendazole in the management of hydatid cyst liver. Saudi J Gastroenterol 2011; 17: 343-347 [PMID: 21912062 DOI: 10.4103/1319-3767.84493]
Albendazole as an adjuvant to the standard surgical management of hydatid cyst liver. Int J Surg 2008; 6: 448-451 [PMID: 18819855 DOI: 10.1016/j.ijsu.2008.08.003]

36. A systematic review and meta-analysis on the
treatment of liver hydatid cyst: Comparing
laparoscopic and open surgeries.
• Between January 2000 and December 2016 to evaluate the outcomes of liver hydatid cyst in terms of mortality, post-
operative complications, cure rate and recurrences. The data related to the four outcomes of liver hydatid cyst were
extracted, assessed and then used as their corresponding effect sizes in the meta-analysis process.
• RESULTS:
• Six studies totally consisting of 1028 patients [open surgery group=816 (+7 converted to lap) and laparoscopic
group=212] were analysed. In this meta-analysis study, random effects models of outcomes (i.e. post-operative
complications, mortalities, recurrences and cure rate) of the two procedures were OR=0.852, LL=0.469, UL=1.546, Z=-
0.526, p=0.599 (for post-operative complications); OR=0.849, LL=0.141, UL=5.105, Z=-0.179, p=0.858 (for mortality);
OR=0.903, LL=0.166, UL=4.906, Z=-0.119, p=0.906 (for recurrence); and OR=0.459, LL=0.129, UL=1.637, Z=-1.201, p=0.230
(for cure rate). Meta-analysis and illustrated forest plots showed that there are no superiorities between the two
approaches. The results of heterogeneity tests of the above mentioned outcomes were Q=8.083, df=5, p=0.152,
I2=38.142% for post-operative complications; Q=0.127, df=2, p=0.938, I2=0% for mortality; Q=4.984, df=2, p=0.083,
I2=59.874% for recurrence; and Q=10.639, df=5, p=0.059, I2=53.001% for cure rate. The results of regression tests based
on Egger's, smoothed variance based on Egger (SVE) and smoothed variance based on Thomson (SVT) showed that the p
values are not significant, and there are neither significant statistical differences nor publication bias between the
outcomes of the two treatment procedures.
• CONCLUSION:
• The results show no promising trends towards advantages of open versus
laparoscopic surgeries in the treatment of liver hydatid cyst.

37. Long-term results of hepatic hydatid disease
managed using palanivelu hydatid system: Indian
experience in tertiary center.
• BACKGROUND:
• Incidence of hepatic hydatid disease is increasing due to globalization. Surgery is the gold standard
treatment. Laparoscopy has gained enough evidence regarding its safety and efficacy. Complete evacuation
of hydatid contents without spillage remains a challenge. We aimed to determine long-term results of
hepatic hydatid disease managed laparoscopically using palanivelu hydatid system (PHS) at our institution.
• METHODS:
• One hundred and five patients underwent laparoscopic surgical management using the PHS at our institute
from May 1997 to May 2013. Clinical presentations, surgical strategy, postoperative morbidity, and long-term
recurrence rate were evaluated.
• RESULTS:
• Of the 105 patients, 76 were male and 29 female with a mean age of 32 years (range 14-71 years). The most
common presentation was abdominal pain in 61 patients (58%). Sixteen patients had multiple cysts of which
nine had involvement of both lobes. Seventy-seven (73.3%) cysts were uncomplicated. Nineteen (18.09%)
had a cyst-biliary communication, two were ruptured cysts, and seven were recurrent cysts. All patients
underwent successful laparoscopic management where conservative surgery was performed in 94 patients
and radical surgery in 11 patients. Post-operative morbidity was seen in 18 (17.14 %) patients, which
included deep cavity infection in two cases, post-operative bile leak in 13 cases, and duodenal injury in one
case without any mortality. Mean long-term follow-up was 36 months (range 6 months-5 years) with
recurrence in two cases.
Surg Endosc. 2014 Oct;28(10):2832-9. doi: 10.1007/s00464-014-3570-2. Epub 2014 Jun 6.

38. Radical versus conservative surgical treatment of
liver hydatid cysts.
• BACKGROUND:
• The management of liver hydatid cysts is controversial. Surgery remains the basic treatment, and can be
divided into radicaland conservative approaches. The purpose of this study was to compare the results
of radical and conservative surgery in the treatment of liver hydatid cysts.
• METHODS:
• Data from all patients with liver hydatid cyst treated in a hepatobiliary surgical unit, between January 1990
and December 2010, were retrieved from a retrospective database. To minimize selection bias, propensity
score matching was performed, based on 17 variables representing patient characteristics and operative risk
factors. The primary outcome measure was hydatid cyst recurrence.
• RESULTS:
• One hundred and seventy patients were matched successfully, representing 85 pairs who had either
a radical or a conservative approach to surgery. At a median follow-up of 106 (59–135) and 87 (45–126)
months in the radical and conservative groups respectively, the recurrence rate was 4 per cent in both
groups (odds ratio (OR) 1.00, 95 per cent confidence interval 0.19 to 5.10). There were no statistically
significant differences between conservative and radical surgery in terms of operative mortality (1 versus 0
per cent; P=0.497), deep abdominal complications (12 versus 16 per cent; OR 1.46, 0.46 to 3.49), overall
postoperative complications (15 versus 19 per cent; OR 1.28, 0.57 to 2.86), reinterventions (0 versus 4 per
cent; P=0.246) and median hospital stay (7 (i.q.r. 5–12) days in both groups; P=0.220).
• CONCLUSION:
• This study could not demonstrate that radical surgery reduces recurrence and no trend towards such a
reduction was observed.
Br J Surg. 2014 May;101(6):669-75.

39. A bit of Surprise!!
• Background: large retrospective clinical study describing the long-term experience of a single center in
the surgical management of liver echinococcosis in an endemic area.
• Methods: 232 patients were operated for liver hydatid disease between 1978 and 2012. Seventy-three
patients (Group A) underwent a radical procedure (total pericystectomy or hepatectomy), while 145
(Group B) were treated with a more conservative method (partial cystectomy, with external drainage,
omentoplasty or capitonnage) and 14 (Group C) received a combination of total and partial
cystectomies. Morbidity, mortality, post-operative complications and recurrence rates in the long-term
setting were retrospectively evaluated.
• Results: Group A patients were treated with zero mortality and a morbidity rate of 10.95%. No
recurrence was documented. In Group B, mortality reached 2.76%, (p ¼ 0.153 compared to Group A)
morbidity 24.13% (p ¼ 0.021) and there were 10 cases of relapse (6.9%) at three-year complete follow-
up (p ¼ 0.989). Extrahepatic sites of disease were not uncommon.
• Discussion: radical surgical procedures were better tolerated by patients and yielded better results in
terms of recurrence rates.
International Journal of Surgery 20 (2015) 118e122

40. The optimal treatment !!
• Although conservative surgical procedures are considered simpler and
safer to perform, the rate of postoperative complications such as
biliary fistula, residual cavity and recurrence, and cavity suppuration
has been reported to be about 35%. On the other hand, radical
surgery can be performed with low risk of recurrence (3.2%).
• We believe radical surgical procedures present a lower rate of
recurrence and less morbidity, and thus should be the surgical
treatment of choice for hepatic hydatid disease
Turk J Gastroenterol 2008; 19 (1): 33-39

41. Expected one!
• Data was retrospectively collected for patients who underwent operative
management for HHC between the years 1994 -2014.
• Results: Sixty-nine underwent surgical treatment for HHC. Group A included 34
treated with an unroofing procedure, group B included 24 patients who
underwent hepatectomy and group C included 11 patients who underwent peri-
cystectomy.
• Postoperative complications occurred in 16, 11 and 5 patients in group A, B and C,
respectively, as assessed by clavien-dindo classification (CDC). The average CDC
was significantly higher in the hepatectomy group as compared to the unroofing
group (2.3 vs.1.5, P Z 0.04).
• Recurrence was significantly higher after the unroofing procedure as compared to
the hepatectomy group (P Z 0.05).
Asian Journal of Surgery (2019) 42, 702e707

42. Review of laparoscopic treatment of liver CE—914
patients
• Objective: The aim of this study was to provide a review of the world literature on the laparoscopic
treatment of liver hydatid cyst.
• Methods: We conducted a literature search using PubMed, screening all English language publications
on the laparoscopic treatment of liver hydatid cysts. Operative characteristics, perioperative morbidity,
and clinical outcomes were tabulated.
• Results: A total of 57 published articles including 914 patients with 1116 hydatid cysts were identified.
Of the resections done in the 914 patients, 89.17% were performed totally laparoscopically and 5.58%
were gasless. The most common procedure was cystectomy (60.39%), followed by partial
pericystectomy(14.77%) and pericystectomy (8.21%); the rest were segmentectomies. Conversion to
open laparotomy occurred in 4.92% of reported cases (45/914). The common cause of conversion was
anatomical limitations/inaccessible locations (16/45). The overall mortality was 0.22% (2/914 patients)
and morbidity was 15.07%, with no intraoperative deaths reported. The most common complication
was bile leakage (57/914). The postoperative recurrence was 1.09% (10/914 patients).
• Conclusions: The laparoscopic approach is safe with acceptable mortality and
morbidity for both conservative and radical resections in selected patients.
Clinical outcomes are comparable to open surgery, albeit in a selected group of patients
International Journal of Infectious Diseases 24 (2014) 43–50

43. • Concomitant treatment with benzimidazoles (albendazole or
mebendazole) has been reported to reduce the risk of secondary
echinococcosis. Treatment is started 4 days preoperatively and lasts
for 1 month.

44. Contraindications
• General contraindications to surgical procedures (eg,
extremes of age, pregnancy, severe preexisting medical
conditions);
• Multiple cysts in multiple organs; cysts that are difficult to
access; dead cysts; calcified cysts; and very small cysts

45. Complications:
1-All the usual complications related to the surgical procedure and anesthesia
2-Related to the parasite Recurrence
• Infection
• Spillage and seeding (secondary echinococcosis) - Allergic reaction or anaphylactic shock
3-Related to the medical treatment Hepatotoxicity
• Anemia
• Thrombocytopenia
• Alopecia
• Embryotoxicity
• Teratogenicity.

46. Complications
4-Related to PAIR
• Hemorrhage
• Mechanical damage to other tissue
• Infections
• Allergic reaction or anaphylactic shock
• Persistence of daughter cysts
• Sudden intracystic decompression leading to biliary fistulas
5-Related to scolicidal agents - Chemical sclerosing cholangitis

47. HC Ruptured in Biliary tree
• Intrabiliary rupture is the most common complication of hepatic HC;
however, it is unusual, occurring in only 3%-17% of cases
• ERCP defines the cystobiliary relationship to guide management
decisions during the pre- and postoperative periods.
• Preoperative endoscopic sphincterotomy may decrease the incidence
of postoperative external fistula from 11.1% to 7.6%.
• Am J Surg 2006; 191: 206-210 [PMID: 16442947 DOI: 10.1016/j.amjsurg.2005.09.014
• During the postoperative period, ERCP may provide an opportunity to
manage postoperative external biliary fistulae.
• J Clin Gastroenterol 2002; 35: 160-174 [PMID: 12172363 DOI: 10.1097/00004836-
200208000-00009

48. Incidence and risk factors of biliary fistulation in
clinically asymptomatic patients
• Biliary fistulation from a hepatic hydatid cyst is its most frequent
complication.
• Out of total 60 patients in study - Demographics and
anatomical characteristics, such as cyst type, location, number,
diameter and laboratory findings were examined.
• A full 50% had biliary fistulation, with increased risk if
the cyst diameter was ≥8.8 cm.
Trop Doct. 2018 Jan;48(1):20-24. doi: 10.1177/0049475517717177. Epub 2017
Jun 29.

49. Extremely difficult hepatectomy for biliary
fistula
• video

50. Complicated Hydatid cysts
• Age (> 40 years)
• Cyst size (> 10 cm)
• The number of cysts (> 3)
• Cholangitis
• Conservative surgery, have been identified as high-risk factors in HC
• Langenbecks Arch Surg 2007; 392: 35-39 [PMID: 17021792 DOI: 10.1007/s00423-006-0064-2]
• J Am Coll Surg 2008; 206: 629-637 [PMID: 18387467 DOI: 10.1016/j.jamcollsurg.2007.11.012]

51. Peritoneal hydatid disease
• Peritoneal hydatidosis can be primary or more frequently secondary
to hydatid cysts in the liver or rarely in the spleen
• Primary peritoneal hydatidosis is rare
• The mechanism of primary peritoneal hydatid INFESTATION IN SUCH
CASES IS NOT CLEAR
• Dissemination via lymphatics or systemic circulation has been
implicated as a possible route
• Secondary peritoneal hydatidosis almost always from liver cysts
rupturing in peritoneal cavity leading to seeding and formation of

52. Primary peritoneal hydatid cyst our case
report

53. Extremes of case!!

57. A rare retroperitoneal With lung hydatid cyst
video

58. Conclusion:
• Many hydatid cysts remain asymptomatic, even into advanced age. Parasite load,
the site, and the size of the cysts determine the degree of symptoms.
• The liver is the most common organ involved, followed by the lungs. These 2
organs account for 90% of cases of echinococcosis.
• Antihelminthic treatment is superior to placebo but is not the ideal treatment for
HC of the liver when used alone.
• The level of evidence for this recommendation is 2a, and the recommendation is
grade B.

59. Cont…
• The majority of published studies conclude that radical surgery is a better option
than conservative treatment, with a level of evidence of 2b and recommendation
grade B.
• Omentoplasty associated with conservative surgical treatment is effective in
preventing postoperative complications, with a level of evidence of 2b and
recommendation grade B.
• Further studies are necessary to evaluate recurrence rates following laparoscopic
surgery for liver HC, with a level of evidence of 4 and recommendation grade C.
• Combined treatment with ALB + surgery leads to a lower risk of recurrence
compared with surgery alone, with a level of evidence of 2 and recommendation
grade C
The Oxford Center for Evidence-based Medicine – Levels of evidence (March 2009).
http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/

60. WHO Classification Suggested practice
CE1 Albendazole alone if < 5 cm
PAIR + Albendazole if > 5cm
CE2 Surgery + Albendzole
Or
Non-PAIR PT + Albendazole
CE3a Albendazole alone if < 5 cm
PAIR + Albendazole if > 5 cm
CE3b Surgery + Albendzole
Non-PAIR PT + Albendazole
CE4 and 5 Wait and watch

61. Our data
• Total patients : 62
• Type 1-2 : 0
• Type 3-4 : 60
• Liver : 60 – with Jaundice – 12, ERCP-12
• Retroperitoneal :1
• Laparoscopy : 60 Open -2 (conservative surgery all)
• Daughter cysts - 100%