Ann Thorac Surg 2003;75:292-294
© 2003 The Society of Thoracic Surgeons
Case report
Giant hydatid cysts of lung and liver
Salih Topcu, MDa,
smail Cüneyt Kurul, MDa*,
Tamer Altinok, MDa,
Ülkü Yazici, MDa,
Aydin Demir, MDb
a Department of Thoracic Surgery, Atatürk Center for Chest Disease and Thoracic Surgery, Ankara, Turkey
b Department of General Surgery, Ankara Hospital, Ankara, Turkey
Accepted for publication April 1, 2002.
* Address reprint requests to Dr. Kurul, Oyak Sitesi Blok 1/12, 06610 Çankaya, Ankara, Turkey.
e-mail: ckurul{at}hotmail.com
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Abstract
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A 13-year-old girl was admitted to our clinic with the complaints of dyspnea, abdominal distention, cough, and right-sided chest pain. The diagnosis of disease was made with physical examination and radiologic evaluation. She underwent right thoracotomy and phrenotomy for the management of the hydatid cysts of the lung and the liver. The postoperative course was uneventful and she was discharged on the 10th postoperative day. We believe that the simultaneous management of concomitant pulmonary and hepatic hydatid cysts through a thoracic route is a convenient option.
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Introduction
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Hydatid disease is a parasitosis and is endemic in many sheep-rearing regions in the world especially in the Middle East and the Mediterranean countries [1–3]. The lungs are the most common sites of infection in children and the liver is the most common site affected in adults [2]. In some cases, adults or children can have liver cysts in addition to the pulmonary cysts. For these patients phrenotomy is an easy and convenient treatment [1, 2, 4]. Here we present a case with concomitant lung and liver hydatid cysts of unconventionally large size.
A 13-year-old girl was admitted to our clinic with the complaints of dyspnea, cough, right-sided chest pain, and abdominal distention commencing about a year earlier and progressively increasing in the recent months. On physical examination she was weakly cooperative, heavily cachectic, and pale, and the expansion of the right hemithorax was reduced. Decreased chest sounds were detected on the right side. Laboratory data were within normal limits.
Posterolateral chest radiograph revealed a well-circumscribed mass of 13 x 10 cm with homogenous density located on the right hemithorax. The mass was confined to the right pericardial area and the hilum. An upright abdominal radiograph revealed a widespread homogenicity from the epigastrium to the iliac fossa. On a computerized tomography scan of the thorax there appeared a right-lung lesion of 12 x 14 x 11 cm, 15 mm distal to the take-off of the right main bronchus, causing minimal shift of the mediastinal structures. The compressive nature of the lesion resulting in apparent collapse of the surrounding lung parenchyma was suggestive of hydatid cyst. The lesion filled the entire right hemithorax with minimal accompanying pleural effusion. Abdominal tomography showed a hepatic lesion in fluid density with the dimensions of 27.5 x 23 x 21 cm. Some dissociation on the dependant surface consistent with germinative membrane was suggestive of hydatid cyst. The giant cyst starting from the dome of the liver compressed the surrounding liver parenchyma, of which it caused apparent thinning. The displacement of the intraabdominal organs by the cyst resulted in abdominal distention (Fig 1).
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Fig 1. (a) Preoperative appearance of the patient. (b–d) Preoperative evaluation of the patient: (b) chest radiograph and (c and d) computed tomography scans of the lung and liver.
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The patient was approached surgically through a right thoracotomy at the seventh intercostal space. The 15 x 10 cm cyst in the lower lobe was opened by cystotomy after the needle aspiration of the cystic fluid. The germinative membrane was excised and the cystic cavity was capitonnaged with 2-0 absorbable sutures. The giant hepatic cyst of 25 x 25 x 20 cm was then reached through a subsequent phrenotomy on the anterolateral side of the diaphragm. Approximately 11 L of yellowish-green cystic fluid was aspirated. After removal of the germinative membrane through a cystotomy, leakage of the biliary secretion into the cystic cavity was detected. The ligamentum falciforme hepatis was dissected to mobilize the liver. The pericystic wall entirely composed of the liver parenchyma was removed at its thinned sections. The openings of the biliary duct were closed with absorbable sutures and the remaining pericystic wall was inverted with absorbable 3-0 sutures. After an additional cholecystectomy was deemed necessary, a single latex drain was placed in the subhepatic area from below the diaphragm. The diaphragm was repaired by interrupted silk sutures. After the insertion of two chest tubes the thoracotomy was closed.
The abdominal drain was removed on the sixth postoperative day and the chest tubes were removed on the second and fourth postoperative days. The patient recovered uneventfully and was discharged on the 10th postoperative day (Fig 2).
She remained well at follow-up 1 year later.
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Comment
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The clinical manifestations of hydatid cysts depend on the site and size of the cyst. Larger cysts may manifest with symptoms of compression of adjacent organs. Most hydatid cysts of the liver, like pulmonary cysts, may remain asypmtomatic for a long time until they grow large enough to cause signs and symptoms such as abdominal pain or a palpable mass. Sometimes complications such as rupture, secondary infection, and suppuration may precede the diagnosis [1, 3]. Patients with pulmonary cysts present with symptoms of dyspnea, nonproductive cough, chest pain, and particularly in those with centrally located cysts, blood-streaked sputum. Rupture of the hydatid cyst may be manifested by vigorous coughing and expectoration of membranes [1, 2, 4].
Surgery is the treatment modality of choice for both pulmonary and hepatic cysts. The operative principles for pulmonary hydatid cysts should be evacuation of the cyst with complete removal of the endocyst, avoidance of contamination, and management of the residual cavity [1–4]. Maximum preservation of the pulmonary parenchyma is the golden rule for the surgical treatment of hydatid cyst of the lung. In our clinic we prefer the most conservative surgical techniques and the method we advocate for pulmonary cysts is cystotomy and capitonnage of the residual cavity.
From 1971 to 1999, 2,509 patients underwent 2,604 operations with the diagnosis of hydatid disease at our institution. In all, 485 of the patients had concomitant pulmonary and liver cysts and 405 of those were operated on using combined procedures of right thoracotomy and phrenotomy. For the liver cysts located at the dome of the liver we prefer the transthoracic approach, which includes right thoracotomy and phrenotomy. In our experience phrenotomy is an effective and satisfactory procedure in such cases even for giant cysts as in our patient. The main problem with liver hydatid disease is management of the residual cavity. We generally prefer not to place a drain in the cystic cavity. Any detected opening of the biliary duct is closed with absorbable sutures. Introversion or capitonnage of the residual cavity is followed by the insertion of a latex drain below the diaphragm in the subdiaphragmatic area.
We recommend surgery as the treatment of choice for hydatid disease of the lung. And we conclude that the thoracic approach, which implies right thoracotomy and phrenotomy, has been proven to be very effective in the simultaneous management of concomitant pulmonary cysts and subphrenic liver cysts.
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Acknowledgments
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We thank Dr Ay
in Alper for her skillful preparation of the manuscript and Drs Irfan Tastepe and Güven Cetin for their contribution to the work.
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References
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- Dhaliwal R.S., Kalkat M.S. One-stage surgical procedure for bilateral lung and liver cysts. Ann Thorac Surg 1997;64:338-341.[Abstract/Free Full Text]
- Topçu S., Kurul
.C., Tatepe ., Bozkurt D., G
han E., Çetin G. Surgical treatment of pulmonary hydatid cysts in children. J Thorac Cardiovasc Surg 2000;120:1097-1101.[Abstract/Free Full Text]
- Sayek ., Yalin R., Sanaç Y. Surgical treatment of hydatid disease of the liver. Arch Surg 1980;115:847-850.[Abstract/Free Full Text]
- Do
an R., Yüksel M., Çetin G., et al. Surgical treatment of hydatid cysts of the lung: report on 1055 patients. Thorax 1989;44:192-199.[Abstract/Free Full Text]
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Abstract
Introduction
