HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Maninder S. Kalkat Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dhaliwal, R. S. Articles by Kalkat, M. S. Search for Related Content PubMed PubMed Citation Articles by Dhaliwal, R. S. Articles by Kalkat, M. S.

Ann Thorac Surg 1997;64:338-341
© 1997 The Society of Thoracic Surgeons

---

Original Articles: General Thoracic

One-Stage Surgical Procedure for Bilateral Lung and Liver Hydatid Cysts

Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Accepted for publication January 31, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Echinococcus disease is endemic in areas where livestock are raised in association with dogs. The majority of patients reporting in the Department of Cardiovascular and Thoracic Surgery at Postgraduate Institute of Medical Education and Research have unilateral pulmonary hydatid disease.

Methods. From March 1988 to May 1996 we came across 58 patients with pulmonary hydatidosis, of which 5 patients presented with combined bilateral pulmonary and hepatic hydatid cysts. In these patients, to avoid three-stage operation of two thoracotomies and a laparotomy, we proceeded with simultaneous combined resection of hydatid cysts in one stage through midsternotomy along with laparotomy or transdiaphragmatic removal of liver cysts.

Results. Results indicate that combined resection of pulmonary and hepatic hydatid cysts is feasible with minimum morbidity and no recurrence.

Conclusions. We conclude that a one-stage surgical procedure for bilateral lung and liver hydatid cysts is superior to the classic three-stage approach as it decreases morbidity, hospital stay, and cost.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Hydatid disease is a parasitosis caused by Echinococcus granulosis and is prevalent in sheep- and cattle-raising areas in the Mediterranean region, South America, Australia, and New Zealand. In India it is common in the northern states of Jammu, Kashmir, Himachal Pradesh, and Rajasthan, and the Southern states of Andhra Pradesh and Tamil Nadu. The organisms are inadvertently ingested and the larvae are carried to the liver, from where some can escape and lodge in the lungs. The hydatid cyst consists of a round lesion consisting of two membranes containing fluid in which daughter cysts and scolices are found. The cyst is surrounded by pericystic compressed tissue of the host organ with its associated inflammatory reaction and fibrosis.

Our institute is a tertiary level hospital and referral center, dealing with large number of patients with hydatid disease. In our department we encountered 5 patients between March 1988 and May 1996 who had combined bilateral pulmonary and liver hydatid cysts. This report deals with the results and our strategy of a one-stage surgical procedure in the management of these patients.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Patients
In the period between March 1988 and May 1996, from 58 patients with pulmonary hydatidosis there were 5 patients with bilateral lung hydatid cysts. All had associated liver hydatid cysts as well. They were operated on with a single-stage combined resection of these cysts.

Symptoms, signs, and investigations are summarized in Table 1. Most of the patients had intact cysts, except one who had a ruptured cyst in the bronchus and presented with cough and expectoration of membranes. In addition 1 of the patients had already undergone enucleation for the liver hydatid 2 years ago in another hospital before reporting with recurrence of the liver hydatid cyst and associated bilateral lung hydatid cysts.

A cruciate incision was made over the cyst, which was enucleated under positive-pressure ventilation by the anesthetist using Barrett's technique [1, 2]. The bronchial communications were sutured and the cyst cavity closed with multiple purse-string sutures of Vicryl (Ethicon, Somerville, NJ). In 1 patient with a ruptured cyst, part of the lung was significantly destroyed, requiring segmental resection.

In 3 patients the right hemidiaphragam was incised radially over the liver cysts, which were removed, and the space was closed primarily after diluted povidine-iodine solution was instilled in the space.

In 2 patients, 1 of whom had recurrence of hepatic cysts, the cysts were in an anteroinferior position of the liver, and were approached transabdominally through a vertical midline incision as a continuation of the midsternotomy incision.

All cysts were subjected to histopathologic examination, which confirmed the diagnosis.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Postoperative course in all patients was uneventful, with none having any of the complications, such as bronchopleural fistula, persistent air leak, hemorrhage, or empyema.

In upright abdominal roentgenogram a fluid level, usually seen within the liver shadow, disappeared in due course (Figs 1 and 2).

View larger version (151K): [in this window] [in a new window]   Fig 1. . Chest roentgenogram 2 days after operation showing fluid level in the liver cyst cavity.

View larger version (139K): [in this window] [in a new window]   Fig 2. . Chest roentgenogram 2 months after operation. There is no fluid level in the liver.

View larger version (155K): [in this window] [in a new window]   Fig 3. . Preoperative chest roentgenogram showing bilateral hydatid cysts in right upper and lower lobes and left lower lobe.

View larger version (91K): [in this window] [in a new window]   Fig 4. . Computed tomographic scan of the chest showing hydatid cysts in both lungs.

View larger version (111K): [in this window] [in a new window]   Fig 5. . Computed tomographic scan of the abdomen showing large hydatid cyst in right lobe of liver.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
This article emphasizes two points: first, the need to search for additional hydatids in patients who present with either pulmonary or liver hydatids, and second, the need to undertake combined resection of hydatid cysts at both the sites during the same operation.

The cysts may remain asymptomatic for a long time. As they enlarge, patients complain of cough, expectoration of membranes, hemoptysis, and thoracic pain in cases of pulmonary cysts. Patients with liver hydatids may present with abdominal pain, and a palpable mass in the right hypochondrium and epigastrium. Occasionally patients may have sputum stained with bile in the case of liver cysts rupturing into the lungs, or jaundice hydatidenteria or hydatidemesis if they rupture into the bile ducts. The surgical goals are total eradication of parasite, prevention of cyst rupturing at operative field, and care of the residual cavity.

Most authors advocate conservation of lung parenchyma, reserving resections for ruptured cysts that have caused destruction or infection of the adjacent tissue [3–5]. Various surgical procedures have been described in the literature, namely, excision of entire cyst by enucleation (Barrett's technique), wedge resection, segmentectomy, lobectomy, and needle aspiration of the cyst in situ. Enucleation of lung hydatid cyst was first described by C.V. Armand Ugon in Uruguay in 1947 under the name of "hydatic delivery" [6]. Barrett and Thomas described a similar technique in 1952 [1]. We found Barrett's technique to be quite satisfactory for pulmonary hydatid cysts. Cysts larger than 10 cm in diameter can be better managed by needle aspiration followed by enucleation to prevent tracheobronchial flooding with hydatid fluid.

Many liver cysts can be approached from a thoracic route after incising the diaphragm as in three of our operations. The hydatid cyst in the liver can be excised by using the natural plane of cleavage that exists between the germinating layer and adventia. Primary closure of the residual cavity without drainage was accomplished by us without any complications as described by others [1, 6].

Bilateral lung hydatid cysts along with liver hydatid cysts are an uncommon manifestation of hydatidosis. Many reports do not mention such a coincidence. Tomalino described this manifestation of hydatidosis in 1961 [7]. Crauzaz [8] and Saidi [3] discuss the intrathoracic evolution of liver hydatids and their approach through right thoracotomy but the simultaneous problem of liver hydatid cysts was not dealt with. Peleg and coworkers [9] reported 10% of patients with pulmonary hydatid cysts on the right side had their liver hydatid cysts removed in the same operation. Burgos and associates [10] also removed hepatic cysts transdiaphragmatically in 7 of 331 patients with pulmonary hydatids.

Cetin and colleagues [11] reported removal of bilateral hydatid cysts of the lungs through midsternotomy. However, simultaneous removal of bilateral lung and hepatic hydatid cysts has only been referred as a single case reported by Jacob and coworkers [12].

Chemotherapy alone is not reliable in controlling this disease. Even if the parasite in the lung dies, the membranes retained in the lung are the source of recurrent infections [9, 13]. We routinely prescribe mebendazole starting a week before surgery and continuing postoperatively for about 6 to 8 weeks (20–40 mg/kg each day).

In the follow-up period ranging from 6 months to 7 years we did not find any recurrence of echinococci in lung or liver in these patients.

Combined resection for bilateral pulmonary and hepatic hydatid cysts is superior to classic three-stage approach as it decreases morbidity and mortality as well as stay in the hospital. Our study also emphasizes the need to search meticulously for contralateral pulmonary hydatid and hepatic hydatid involvement in the same patient.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Dhaliwal, Department of Cardiovascular and Thoracic Surgery, H.NO. HSQ-5, PGI Campus, Sector 12, Chandigarh 160012, India.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Barrett NR, Thomas D. Pulmonary hydatid disease. Br J Surg 1952;40:222–44.[Medline]
2. Litcher I. Surgery of pulmonary hydatid cyst, the Barrett technique. Thorax 1972;27:529–34.[Abstract/Free Full Text]
3. Saidi F. Surgery of hydatid disease. London: Saunders, 1976.
4. Papadimitriou J. Surgical treatment of hydatid disease of the lung. Surgery 1969;66:488–91.[Medline]
5. Aytac A, Yurdakul Y, Ikizler C, Olga R, Saylam A. Pulmonary hydatid disease: report of 100 patients. Ann Thorac Surg 1977;23:145–51.[Abstract]
6. Armond Ugon CV. Tecnice de la extirpacion del quiste hidattidico de pulmon. Boletin de la Sociedad de Cirugia del Uruguy 1947;18:167.
7. Tomalino D. Equinococosis pulmonar multiple. El Torax, Montevideo, Uruguay, 1961;10:75–126.
8. Crausaz PH. Surgical treatment of hydatid cysts of the lung and hydatid disease of liver with intrathoracic evolution. J Thorac Cardiovasc Surg 1967;53:116–29.[Medline]
9. Peleg H, Lael-Anson B, Gaitini D. Simultaneous operation for hydatid cyst of right lung and liver. J Thorac Cardiovasc Surg 1985;90:783–7.[Abstract]
10. Burgos L, Baquerizo A, Munoz W, de Aretxabala X, Solar C, Fonseca L. Experience in the surgical treatment of 331 patients with pulmonary hydatidosis. J Thorac Cardiovasc Surg 1991;102:427–30.[Abstract]
11. Cetin G, Dogen R, Yuksel M, et al. Surgical treatment of bilateral hydatid disease of the lung via median sternotomy. Experience in 60 consecutive patients. Thorac Cardiovasc Surg 1988;36:114–7.[Medline]
12. Jakob H, Kohlhaüfl M, Hürter T, Steppling H, Oelert H. Echinococcal disease of both lungs and liver: successful simultaneous resection. J Thorac Cardiovasc Surg 1989;97:640–1.
13. Gil-Grande LA, Boixeda D, Garcic-Hoz F, et al. Treatment of liver hydatid disease with mebendazole: a prospective study of thirteen cases. Am J Gastroentrol 1983;78:584–8.[Medline]

This article has been cited by other articles:

				T. Junghanss, A. M. da Silva, J. Horton, P. L. Chiodini, and E. Brunetti Clinical Management of Cystic Echinococcosis: State of the Art, Problems, and Perspectives Am J Trop Med Hyg, September 1, 2008; 79(3): 301 - 311. [Abstract] [Full Text] [PDF]

				E. Sahin, S. Enon, A. K. Cangir, H. Kutlay, S. Kavukcu, H. Akay, I. Okten, and S. Yavuzer Single-stage transthoracic approach for right lung and liver hydatid disease J. Thorac. Cardiovasc. Surg., September 1, 2003; 126(3): 769 - 773. [Abstract] [Full Text] [PDF]

				R. Morar and C. Feldman Pulmonary echinococcosis Eur. Respir. J., June 1, 2003; 21(6): 1069 - 1077. [Abstract] [Full Text] [PDF]

				S. Topcu, I. C. Kurul, T. Altinok, U. Yazici, and A. Demir Giant hydatid cysts of lung and liver Ann. Thorac. Surg., January 1, 2003; 75(1): 292 - 294. [Abstract] [Full Text] [PDF]

				I. C. Kurul, S. Topcu, T. Altinok, U. Yazici, I. Tastepe, S. Kaya, and G. Cetin One-stage operation for hydatid disease of lung and liver: Principles of treatment J. Thorac. Cardiovasc. Surg., December 1, 2002; 124(6): 1212 - 1215. [Abstract] [Full Text]

				A. E. Balci, N. Eren, S. Eren, and R. Ulku Ruptured hydatid cysts of the lung in children: clinical review and results of surgery Ann. Thorac. Surg., September 1, 2002; 74(3): 889 - 892. [Abstract] [Full Text] [PDF]

				O. K. Aribas, F. Kanat, E. Turk, and M. U. Kalayci Comparison between pulmonary and hepatopulmonary hydatidosis Eur. J. Cardiothorac. Surg., March 1, 2002; 21(3): 489 - 496. [Abstract] [Full Text] [PDF]

				O. K. Aribas, F. Kanat, N. Gormus, and E. Turk Pleural complications of hydatid disease J. Thorac. Cardiovasc. Surg., March 1, 2002; 123(3): 492 - 497. [Abstract] [Full Text] [PDF]

				D. B. Petrov, P. P. Terzinacheva, V. I. Djambazov, M. Ph. Plochev, E. P. Goranov, T. R. Minchev, and P. V. Petrov Surgical treatment of bilateral hydatid disease of the lung Eur. J. Cardiothorac. Surg., June 1, 2001; 19(6): 918 - 923. [Abstract] [Full Text] [PDF]

				S. Topcu, I. C. Kurul, I. Tastepe, D. Bozkurt, E. Gulhan, and G. Cetin Surgical treatment of pulmonary hydatid cysts in children J. Thorac. Cardiovasc. Surg., December 1, 2000; 120(6): 1097 - 1101. [Abstract] [Full Text] [PDF]

				N. Karaoglanoglu, A. Eroglu, and K. Y. Polat Surgical procedure for bilateral lung and liver hydatid cysts Ann. Thorac. Surg., September 1, 1998; 66(3): 988 - 988. [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Maninder S. Kalkat Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dhaliwal, R. S. Articles by Kalkat, M. S. Search for Related Content PubMed PubMed Citation Articles by Dhaliwal, R. S. Articles by Kalkat, M. S.