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External drainage of the hepatic posthydatid remnant cavity
M. Marincas, E. Brãtucu, A. Badarau, D. Straja, C.E. Boru, I. Stefan, E. Drilea (Chirurgia, 104 (2): 151-157)
Introduction
Hepatic hydatid cyst (HHC) originates from the Taenia echinococcus granulosus larva (Laennec 1812, von Siebold 1853), developed in the duodenum of the intermediate host (sheep or humans) after accidental swollen of the eggs eliminated by the definitive host (dogs, cats). The larvae reach the final localization after crossing the intestinal wall and entering the portal system. Liver is the most frequent localization of the unique or multiple hydatid cysts; spleen, lung and brain are affected as well, with a lower incidence. Therapeutic options of the HHC are: surgical approach in 60–70% of the cases (predominant open surgery, but lately laparoscopic approach as well), PAIR (puncture – aspiration – injection of scolex eliminating substance – reaspiration) and medical therapy. Surgery still remains the most effective treatment, both for complete and durable cure (1,2,3). The main objective is the inactivation and elimination of the parasite, while hepatic remnant cavity represents an important issue.
The surgical treatment of the remnant hepatic posthydatid cavity consists in radical and conservative methods (2,3,4,5). In the radical methods the cyst is evacuated: the pericystectomy realizes the total resection of the cyst together with the hepatic pericyst. Pericysto-resection includes as well the resection of the additional hepatic territory, which means an atypical hepatectomy or a typical one (regulated): the resection includes cyst, pericyst and healthy hepatic paren-chyma. All these methods have specifically surgical risks, especially due to the extension of the hepatectomy (2).
Conservative surgical methods are sparing totally or partially the pericyst, while the cavity is minimized and closed (obliterating methods) or left wide open (non-obliterating): marsupialization of the cyst can eventually be complicated by persistent biliary fistula, bleeding or infection of the remnant cavity; cavity-minimizing with no drainage (partial pericystectomy and closure of the remnant cavity, with consecutive volume reduction). The latter method is indicated in children with young cysts, otherwise it generates hepatic abscesses. Another conservative method is the remnant cavity omentoplasty (fulfilling with great omentum due to its plastic proprieties), limited by the cyst localization and the risk of drainage tubes obstruction, which can generates hepatic abscess (6). A totally contraindicated method in our experience is the Lagrot unroofing pericystectomy (resection of the dome) which leaves the remnant cavity open under the diaphragm (7,8), usually generating closed collections and subphrenic abscesses with severe evolution. Pericysto-digestive anastomoses (pericysto-gastric, pericysto-duodenal, pericysto-jejunal) represent useful conservative methods, when respecting the patient selection and the surgical technique (cysts that are partial exteriorized on the visceral surface of the liver). These methods are compulsory associated with cavity’s drainage (9).
Extraperitoneal transomphalic drainage is a simple method that can be associated with the minimizing of the remnant posthydatid cavity, and determines an efficient drainage followed by total closure of the cavity (10,11). It can be applied in any hepatic localization (inclusive ones on the dome or the central ones). Endoscopic papillo-sphincterectomy (EPS) can be associated in case of bilio-cavitary fistula, with no longer need of classic bipolar drainage of the cavity and of the bile duct. The risk of specific complications, such as cyst bleeding and remnant cavity abscess, is reduced and it avoids useless and dangerous surgical techniques. The method was initially applied by Prof. Dr. Burlui in 1968, when a cysto-biliary communication would have required a bipolar drainage of the cavity and of the choledoc duct (12,13).
The emergent laparoscopic treatment should be mentioned as well, while the importance of proper patient selection for the laparoscopic approach was underlined (10,14-16). The laparoscopic approach of the remnant cavity includes simple drainage, omentoplasty with capitonnage and/or external drainage, abandon of the remnant cavity, pericystosuture. The association with omentoplasty was suggested as beneficial for decreasing recurrences’ incidence (6). Laparoscopic approach can be used as well for the minimally-invasive application of Burlui’s extraperitoneal transhepatoomphalic drainage (10,17).

Materials and methods
Medical records of all patients who were diagnosed with liver hydatid cyst and hospitalised in the Department of Surgery, “Caritas” Clinical Hospital, Bucharest between January 1997 and February 2007 were retrospectively reviewed. A total of 112 patients were operated in our department. The following parameters were recorded:
Hepatic localization of the hydatid cysts (Fig. 1)
Cysts were localized in the anterior segments in 26 patients (23,2%), in the posterior segments in 36 patients (32,1%), while in 50 patients (44,7%) cysts were identified in the central segment. A total of 86 patients (76,8%) were characterized by a difficult surgical approach (central and posterior segments position).
Number of the hepatic cysts (Fig. 2)
Multiple cysts were identified in 49 patients (43,75%).
Figure 1
Figure 2
Figure 3
Figure 4

Cysto-biliary fistula (Fig. 3)
32 patients (29%) with cysto-biliary fistula were identified intra- or postoperative. Ten patients (9%) had high flow fistula. Intraoperative diagnosed cysto-biliary fistula were sutured. The postoperative fistula appeared to be a recurrence of the ones sutured intraoperative or small fistula not identified during surgery due to the difficult visual examination of the remnant cavities localized in the posterior or central segments.
Treatment of the remnant cavity (Fig. 4)
The external transhepato-omphalic drainage was applied in 106 patients (95%); much lower percentages were represented by other techniques (pericysto-digestive diversions, hepatectomies or pericystoresections).

Figure 5A
Figure 5B
Figure 6A
Figure 6B

Postoperative follow-up consisted in weekly clinical and radiological surveillance. Radiological follow-up consisted in: abdominal ultrasound (see Fig. 5a preoperative ultrasound scan of unique hepatic hydatid and Fig. 5b postoperative control that shows partial fibrosis of the remnant posthydatid cavity); contrast study on the drainage tube (see Fig. 6a that shows opaque remnant cavity, with concomitant opaque biliary tree due to cysto-biliary fistula while Fig. 6b shows partial fibrosis of the remnant cavity, with the persistence of the cysto-biliary fistula; CT scan can show partial fibrosis of the remnant multiple cavities (see Fig. 7).
Complementary treatments
A total of 10 EPS were performed in patients with bilio-cavitary fistula (see Fig. 8) with no response to the conservative treatment (oral nitroglycerine 4 times daily, in order to determine the relaxation of the Oddi sphincter). EPS were usually performed after 14 days, with successful response in all cases (flow reduction and healing).

Figure 7
Figure 8

Postoperative evolution
Infection of the remnant cavity was registered in 12 patients (11%). Treatment consisted in oral antibiotics, wash-up on the drainage tube with Betadine solution and metronidazol, with mobilization of the tubes where necessary. Complete healing was achieved after mean 55 days (range 20-80), with no reintervention necessary.

Discussions
Echinococcosis remains a serious health problem even in the 21th century, while Romania represents a highly endemic zone (1). Human hepatic localization is predominant and a variety of treatment solutions have been described. Surgical treatment remains the most effective, but new modalities have been added to the previously described techniques like routine use of antihelminthic treatment before and after surgery, PAIR and laparoscopic approach.
Almost all of the known old and new techniques have been use in our department for the treatment of hepatic hydatidosis, with well-established surgical indication for each case, in order to obtain the lowest possible recurrence, morbidity and mortality rates. From all these, the external drainage seem to be the most effective in our experience. This method consists in the complete evacuation of hydatid cavity, single or multiple drainage and suture of the pericyst, with cavity-minimizing associated when possible. In case of a projecting portion, with no hepatic parenchyma included and local sclerosis of the pericyst, the minimizing consist in the resection of this portion. Inspection of the remnant cavity is highly recommended for complete evacuation and identification of possible cysto-biliary fistulas. In our experience 29% of the cases were registered with cysto-biliary fistulas, while one third were high flow fistulas. In case of large cavity, with small pericysto-hepatic space, with no possible direct vision of the remnant cavity, the use of the laparoscope was essential in the identification of small cysto-biliary fistulas.
Surgical approach represented the suture of any identified cysto-biliary fistulas, unless fistulas not seen or not appropriate to suture due to their position. External drainage of the remnant cavity (monopolar approach) was preferred to the bipolar approach (cavity and bile duct drainage) due to the possibility of EPS. In case of high flow cysto-biliary fistula (more than 200 ml of bile daily exteriorized on the drainage tube), the EPS was successfully performed early postoperative. In case of initial favorable response to oral nitroglycerine, the EPS was postponed (14/30 days postoperative). Due to this approach only 10 patients (30% of the patients with cysto-biliary fistulas) undergone EPS.
Suture of the pericyst was performed after single or multiple drainages (16/18 Ch) were positioned. Exteriorization of the drainage tubes was performed in maximum declivity, through the pericystic suture line or transhepatic (depending on the vascular and biliary ducts anatomic position), while the transomphalic drainage (Burlui) was applied where ever possible. In case of multiple cysts (44% of the cases), each cavity was separately drained. Cholecystectomy was performed only in selected cases (biliary lithiasis, posthydatid jaundice or due to the tactical approach).
As it was underlined before, the external drainage of the hepatic posthydatid remnant cavity was applied on a basic routine, without regard on the number, the localization or the dimension of the cysts; the other mentioned techniques were applied exceptionally, on certain indication. Cystectomy, pericysto-resection and hepatectomy were used in case of almost complete exteriorized cysts, usually when the pericyst was calcified. A low incidence of calcified pericyst was registered in our study (1997-2007), probably due to the routine use of ultrasound and early diagnosis. Cysto-digestive anastomoses were performed in case of exteriorized cysts on the visceral hepatic surface, associated with compulsory drainage of the remnant cavity. The external drainage could have been used even in this situation, a much easier technique and with less intra- and postoperative complications (18).
The remnant cavity undergoes a fibrosis process, with consequent obliteration. After a mean hospital stay of 12 days, follow-up was mandatory, ambulatory controls are performed every 7 days, when drainage tubes are checked. Insufficient clinical and radiological controls (ultrasound, contrast X-ray on the drainage tube, CT scan) may cause remnant cavity infection, which reached 11% in our study. There was no need of reintervention in case of cavity infection: wash-up on the drainage tubes, with mobilization and repositioning, associated with endovenous antibiotics. In case of persistent infection, CT- or ultrasound guided drainage of the posthydatid abscess could be useful. Complete healing was obtained after a mean period of 55 days (range 20-80) of continuous postoperative drainage of the remnant cavity and was influenced by the initial cyst dimensions and the presence of cystobiliary fistulas. Drainage was removed only after fibrosis of the remnant cavity, certified by radiological and ultrasound screening.
Reported mortality is 1,2% for the conservative methods and up to 6,5% for the radical treatment (19-22). In our study mortality was nil, probably due to the better imagistic approach (applied much easier in the last decade) and earlier diagnosis that permitted a better surgical technique with favorable postoperative results.

Conclusions
1. The external drainage of the hepatic posthydatid obliterated remnant cavity is simple, safe and effective, regardless the cyst number and position.
2. The drain is passing through the hepato-omphalic ligament’s leaves, in a strictly extraperitoneal manner. The defect in the wall of the remnant cavity must be obliterated by suture.
3. This method is not indicated in case of calcified walls of the posthydatid remnant cavity, when cystectomy or hepatectomy is mandatory.
4. EPS was effective in the treatment of cystobiliary fistulas and contributed to the extension of the indications of this type of conservative treatment.
5. Intra- and postoperative complications rate was low, while the risk of remnant cavity infection is strongly influenced by the preoperative contaminated cyst.
6. Mean postoperative follow-up till complete recovery was 55 days.
7. The transhepato-omphalic drainage offers a good outcome, avoiding unnecessary removal of an undefined amount of normal hepatic parenchyma.

References
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