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AJR:172, January 1999 91
PercutaneousTreatment of HydatidCysts of the Liver: Long-Term Results
Bahri Ust#{252}ns#{246}z1Okan Akhan2
MehmetAli KamiIo�lu1Ibrahim SomunCu1Mehmet �ahin U�ureI1Saadettin #{231}etiner3
OBJECTIVE. The purpose of the study was to present the long-term results of percutane-
ous treatment of liver hydatid cysts.
SUBJECTS AND METHODS. Seventy-two patients (44 male and 28 female, ranging
in age between 10 and 69 years; mean age, 35 years) with 106 liver hydatid cysts underwent
percutaneous treatment with albendazole prophylaxis. Puncture, aspiration. injection. and
reaspiration (PAIR) were used for hydatid cysts smaller than 6 cm (n = 66). Larger cysts (ii =
40) were treated by catheterization. Hypertonic saline solution and absolute alcohol were
used as the cytotoxic and sclerosing agents. Sonographic guidance with or without fluoros-
copy was used in all patients. Follow-up was mainly by sonography every third month of the
first year, every sixth month of the second year. and once a year thereafter. The mean follow-
up time was 37 months.
RESULTS. The mean reduction in volume at the time ofthe first follow-up was 87.0% and
73.5% in catheterization and PAIR patients. respectively. The immediate sonographic changes
after treatment were detachment of the endocyst and disappearance of the regular endocyst,
with a reduction in the fluid component. The solid appearance of the cyst remnant indicated
complete cure as the cyst wall became irregular and thicker. The average time for develop-
ment ofa solid appearance was 19 months in PAIR patients and 26 months in catheterization
patients. Seventy of 72 patients were cured, whereas two recurrences (2.8C/e) were observed.
No mortality, abdominal dissemination, or tract seeding occurred. Minor complications were
urticaria and fever in eight patients ( 1 1 . I %). Major complications were infection of the cyst
cavity in two patients (2.8%) and development ofbiliary tistula in four patients (5.6%). Mean
hospitalization times were I 7 days for complicated cases and I day for uncomplicated cases.
CONCLUSION. The long-term results of percutaneous liver hydatid cyst treatment ac-
cord with short-term results, indicating that the procedure is efficient and safe and offers com-
plete cure in selected patients with a short hospitalization.
Received February 12, 1998;accepted after revisionJune 29, 1998.
1 Department of Radiology, GUlhane Military Medical
Academy, 06018 Etlik, Ankara 06100, Turkey. Address
correspondence to B. UstUnsdz.
2DepartmentofRadiology, Hacettepe University, Faculty of
Medicine, Sihhiye, Ankara 06100, Turkey.
3Department of Surgery, GUlhane Military Medical
Academy, 06018 Etlik, Ankara 06100, Turkey.
AJR 1999;172:91-96
0361 -803X/99/1721--91
© American Roentgen Ray Society
H ydatid disease caused by Eehino-
(‘Ot’(’ttS granulosus is endemic and
a common health problem in Med-
iterranean countries, the Middle East. South
America. New Zealand, and Australia I I 1. Thedisease may be asymptomatic, or. rarely. pa-
tients may clinically present with life-threaten-
ing anaphylactic shock from cyst rupture 121.Surgical treatment of hydatid disease is tradi-
tional and carries a higher risk of complica-
tions, death. and lengthy hospitalization than
does nonsurgical treatment 13-51. Nonsurgical
treatment such as percutaneous. endoscopic.
and medical procedures and combinations
such as percutaneous plus medical or percuta-
neous plus endoscopic procedures have been
novel for the last two decades [6-9]. Large
studies with long-term results are lacking.
Among nonsurgical treatments. medical ther-
apy with benzimidazole compounds (albenda-
zole or mebendazole) is not usually curative
[8, 10]. Endoscopic treatment has limited mdi-cations, with a role mostly in biliary hydatid
cysts [9. 1 1 1. Percutaneous treatment of hy-
datid cysts has been gaining acceptance be-
cause of its positive short-term results since it
was first introduced in I 985 by Mueller et al.
I I 2]. We present our long-term results from
percutaneous treatment.
Subjects and Methods
From February 1992 to February 1997. 72 pa-tients (44 male and 28 female: age range, 10-69years: mean age. 35 years) with 106 hydatid cysts
underwent percutaneous treatment. All patients
were regularly k)llowed up every 3 months in their
Ustuns#{246}z et al.
92 AJR:172, January 1999
first year, every 6 months in their second year, and
then once a year subsequently until September1997. Sonography was used for follow-up. Fol-low-up criteria were the echo pattern and the size
and wall structure of the cyst. The follow-up pe-nod ranged from 7 to 67 months, with a mean of
37 months (SD, 18.7 months).Inclusion or exclusion criteria were determined
mainly in accordance with the sonographic type of
the cyst or cysts as described in the classificationof Gharbi et al. [ 13]. Patients with type I hydatid
cysts (pure fluid collection), type II hydatid cysts(fluid collection with a split wall), and type III hy-
datid cysts (fluid collection with daughter cyst)
with drainable matrices were included. Patients
with type III cysts containing nondrainable degen-crated matrices due to solid components, type IVcysts (heterogeneous echo pattern), or type V cysts
(reflecting calcified wall) were excluded. Patientswith ruptured (into the biliary tract, peritoneum, or
pleural cavity) or secondarily infected cysts and
patients who had not attended to follow-up sono-
graphic examinations were also excluded.
Fifty-six patients had one cyst (56 total), eight hadtwo cysts (16 total), four had three cysts (12 total),
one had four cysts (four total), two had five cysts (10total), and one had eight liver cysts (eight total) and
one kidney cyst, which was treated percutaneously
as well but excluded from the present liver study.Twenty-two patients had a history of hydatid
cyst or cysts treated surgically. One of these pa-
tients had three operations, 1 1 had two operations,
and one had one operation due to hydatid disease.One patient among these 22 had undergone sur-gery for both lung and liver hydatid cysts. The sur-
gery treated the pulmonary cyst successfully, but
the liver cyst recurred.The most common presenting symptom was
right upper quadrant pain (n = 27) or abdominal dis-comfort and swelling (n = 13). The other patientswere not symptomatic at the time of diagnosis. The
most common physical findings in patients who didnot undergo surgery were hepatomegaly (n = 34)
and liver masses with or without hepatomegaly (n =
12). The patients in whom disease recurred after sur-
gery experienced abdominal discomfort (n = 1 1) andpain (n = 6). The remaining five were asymptomatic.All recurrences were diagnosed with imaging,mainly sonography and Cl’.
After giving written informed consent, every
patient received prophylactic albendazole (Anda-
zol; Biofarma, 1st, Turkey), 15-20 mg/kg twice aday by mouth, starting 1 week before the proce-
dure and continuing for a total of 4 weeks.
An anesthesiology team was available to treatpossible hypersensitivity reactions during the in-
tervention. All interventions were carried out un-
der local anesthesia after peripheral IV accesswas obtained.
The technique of the procedure was chosenmainly according to the size of the cyst. Cystssmaller than 6 cm (n = 66) were treated with punc-ture, aspiration, injection, and reaspiration (PAIR),
a technique developed and described by Ben Amor
Ct al. [14]. Cysts larger than 6 cm (n = 40) were
treated with the catheterization technique de-
scribed by Akhan et al. [6]. A cyst 6 cm in diame-ter contains a volume of approximately I 00 cm3.Hence, catheterization is essential to ensure
quicker and more effective involution of the cay-ity; alcohol may further promote this involutionwith its sclerosing effect. Smaller cyst volumes,however, do not need catheterization or sclerother-
apy with alcohol. Besides, catheterization of such
small cysts requires more manipulation. whichmay mean an increased complication rate.
The PAIR technique may be summarized as
follows: puncture of the cyst with a 19-gaugesheathed needle under sonographic guidance, aspi-
ration of half the volume of the cyst, injection of
hypertonic saline solution (20%) amounting to onethird the initial estimated cyst volume, a 20-mm
wait, and reaspiration of the cyst fluid.
The catheterization technique differs from the
PAIR technique. After injection of the hypertonicsaline solution, a 6- to 9-French pigtail catheter is
placed into the cavity for 24 hr ofgravity drainage.
If cystographic study through the pigtail cathetershows no communication between the cyst cavity
and the biliary tract, a volume of absolute alcoholhalf the initially estimated volume of the cyst is
applied for 20 mm to produce protoscolecidal andsclerosing effects. If, however, cystographic study
through the pigtail catheter shows communication,
alcohol should not be used because secondarysclerosing cholangitis may result.
Because of high pressure inside hydatid cysts,
cyst fluid spreads out and contaminates the interven-
tion area at the time of the initial puncture. To avoid
this contamination, a one-way valve system was
adapted to the top of a 19-gauge sheathed needle,
and this type of needle was used in all patients.
All cyst fluid aspirated, both before and afterinjection of the hypertonic saline, was sent for cy-tologic and microbiologic examination. Staining
with neutral red indicated that the cyst was viable,and staining with methylene blue and eosin mdi-
cated that the cyst was not viable [15].
Results
Before the Procedure
All patients tolerated the oral albendazole
prophylaxis well for the first week, but seven
(9.7%) showed gastric intolerance after the
second week and had to stop taking the medi-
cation. No recurrence was seen in this group,
as opposed to the group treated for 4 weeks. In
three cysts from three patients, the endocyst
separated from the pericyst after 1 week of al-
bendazole therapy. These patients were given
albendazole therapy for an additional 7 weeks.
Because no additional sonographic change
was observed in this period, all three under-
went percutaneous therapy. Cyst contents aspi-
rated just before percutaneous treatment in
these three patients stained with neutral red, in-
dicating that the cysts were viable.
The average volume of cysts before the
procedure was 37 ml in the 66 treated by the
PAIR technique and 285 ml in the 40 treated
by the catheterization technique.
During the Procedure
Clear fluid under high pressure-occasion-
ally called “spring water”-was obtained at the
initial puncture, before the injection of saline
solution. This observation and the sonographi-
cally detected separation of the endocyst from
the pericyst were accepted as pathognomonic
for the viability of the hydatid cysts [6] (Fig. I).
The fluid became yellowish after injection of
the saline solution, and the endocyst separated
from the pericyst during the procedure in all pa-
tients. At the beginning of the reaspiration, no
fluid could be withdrawn in four of the 66 pa-
tients treated by the PAIR technique, mainly
because of needle occlusion by membrane
fragments. After simple maneuvers such as
changing the position of the needle, injecting
small amounts of saline solution, and pushing
back the membrane fragments by floppy J-type
guidewires, we were able to draw back the in-
jected fluid in two of these patients. The other
two patients, however, required catheterization
with a 10-French pigtail catheter.
No deaths or hypersensitivity reactions
occurred during the procedure.
After the Procedure
Eight patients (I I . I %) experienced minor
complications (fever and urticaria). Two pa-
tients (2.8%) presented with mild urticaria
within I .5-4 hr after the procedure and re-
sponded to antihistamines. Four patients
(5.6%) developed a mild fever spike that
subsided spontaneously without treatment.
Two patients (2.8%) presenting with both ur-
ticaria and fever were treated with antihista-
mines only.
Six patients (8.3%) experienced major
complications (cavitary infection and biliary
fistula). The residual cystic cavities became
infected in two patients (2.8%) treated by the
PAIR technique, 9 and I I days after the in-
terventions, and required percutaneous cath-
eter drainage for 5 and 7 days. Of four
patients (5.6%) who presented with biliary
fistulas, two required prolonged catheteriza-
tion, for 24 and 37 days. In one patient, the
fistula was managed by endoscopic papillot-
omy, irrigation, and nasobiliary drainage and
resolved within 39 days. The last patient of
these four also had endoscopic intervention,
but she eventually required surgery because
the fistula was still present (Fig. 2). The first
three fistula patients stayed in the hospital for
Fig. 1-21-year-old man with hepatomegaly.A, Sonogram obtained before intervention shows type I hydatid cyst of liver.B, Sonogram obtained 5 mm after injection of hypertonic saline solution reveals endocyst separated (arrows) from pericyst.Cand 0, Sonograms obtained at sixth (C) and 12th (D) months of follow-up show increasingly settling solid component.
Fig. 2.-53-year-old woman with percutaneously treatedhepatic hydatid cyst. Cystogram shows cystobiliaryfistula.
Percutaneous Treatment of Hydatid Cyst of the Liver
AJR:172, January 1999 93
1 week before being discharged for outpa-
tient follow-up. The last patient was unable
to take care of herself at home. She stayed in
the hospital for 7 1 days.
Patients whose course was uncomplicated
stayed in the hospital only overnight and
were discharged after a routine sonographic
examination on the next day.
Follow-Up ofCyst Changes
The sonographic appearance generally
changed from cystic to solid. At the first fol-
low-up examination, the cysts generally were
more fluid than solid. Gradually. the solid
component of the cysts increased until. on
complete cure, only a solid cyst remnant was
seen (Fig. 3). Rarely, we could not detect
where the cyst had been (F’ = 4). The time re-
quired for a solid appearance to develop varied
according to the size of the original cyst and
the type oftreatment. Small cysts (6-s cm) be-
came solid in the catheterization group earlier
than in the PAIR group (average. 16 months).
The average time for a solid cyst remnant to
appear was 19 months (6 months to 3 years) in
the PAIR group and 26 months ( I I months to
4 years) in the catheterization group.
Cysts were considered to have recurred if
routine follow-up revealed them to be persis-
tently round and anechoic, with a regular and
thin wall and without a ruptured endocyst.
Although the cysts of two PAIR patients mi-tially showed a reduction in volume, 3- and
6-month follow-up examinations showed
that the cysts had recurred. Microscopic cx-
amination of aspirate from the cysts revealed
Ust#{252}ns#{246}zet al.
94 AJR:172, January 1999
Fig. 3.-Temporal evolution of sono-graphic appearance of liver hydatidcyst during percutaneous treatmentA, Sonogram obtained before inter-vention shows type I hydatid cyst atright lobe of liver.B, Needle and hypertonic jet flow(arrow) are evident on sonogram ob-tamed during intervention.Cand 0, Sonograms obtained atfirst(C)and second (D)years offollow-up showsolid appearance of cyst remnant
neutral red staining, or viability. Both pa-
tients underwent a second, successful, PAIR
session and had no further recurrences.
The size and sonographic appearance of all
cysts changed after intervention. Immediately
after the procedure, a volume reduction of
78.0% occurred with the PAIR technique and
94.6% with the catheterization technique. Of
the cysts treated successfully without compli-
cation, the reduction in volume was 73.5%
with the PAIR technique and 87.0% with the
catheterization technique. These results were
obtained at the first follow-up sonographic ex-
amination in the third month.
Discussion
Hydatid disease is a major health problem in
endemic areas [1, 16]. Epidemiologic studies
indicate a pastoral distribution, with a concen-
tration in the sheep-raising and rural areas [16].
However, extensive immigration has spread hy-
datid disease worldwide; it is increasingly prey-
alent in areas, including Europe and North
America, previously known to be free from it [17].
This worldwide distribution requires that all
physicians be aware of hydatid disease.
The actual prevalence of hydatid disease is
unknown, mainly because of lack of reliable
screening methods. Gargouri et al. [18] found
that approximately 2% of the population in Tu-
nisia was infected, and they quoted this rate as
being “100 times higher than World Health Or-
ganization estimates.” Screening and diagnostic
studies ofhydatid disease have been improving,
and satisfactory diagnostic criteria have been
established with the help of new technology
such as sonography, CT, and MR imaging [19].
Among these, sonography is the accepted tech-
nique for general screening and follow-up and
is more reliable than serologic tests [19].
Percutaneous treatment of hydatid cysts has
been considered contraindicated because of
the risk of inducing anaphylactic shock, seed-
ing, and spillage [17]. This assumption is,
however, erroneous, having been brought into
question by many related studies of diagnos-
tic, experimental, and therapeutic percutane-
ous intervention series in which no additional
significant, immediate complications were ob-
served [12, 17, 18, 20-24]. Lewall and Mc-
Corkell [25] published their experiences with
20 cases of rupture of intrahepatic hydatid
cysts. No anaphylactic shock had then been
observed. The exact frequency of anaphylaxis
is not known. Obviously, the risk of anaphy-
laxis in percutaneous treatment is not signifi-
cantly different from that in surgical
intervention. No clear-cut criterion exists for
protection from anaphylaxis before interven-
tions [20]. Hence, anaphylaxis should always
be anticipated, and treatment should be readily
available for patients both in surgical and per-
cutaneous interventions.
Spillage of the cyst contents and dissemi-
nation into the peritoneal cavity has not, to
our knowledge, been reported in any short-
Percutaneous Treatment of Hydatid Cyst of the Liver
AJR:172, January 1999 95
term study of percutaneously treated patients
[12, 17, 18, 20-241. The two long-term stud-
ies of percutaneously treated patients that we
are aware of [26, 271, and the present study,
have agreed with the results of short-term
studies. We believe the main reason for this
safety record was the use of a transhepatic
approach and real-time sonographic guid-
ance during needle insertion. The potential
for leakage of cyst contents into the hepatic
parenchyma before injection of the hyper-
tonic solution is only a theoretic risk, be-
cause it is almost eliminated in clinical
practice by the immature tract around the
needle and immediate cyst decompression.
The protective effect of albendazole reported
in one animal study is another factor against
potential spillage 1281 and the reason we
used prophylactic albendazole.
Because disseminated scoleces from a hy-
datid cyst can recur, regrowing and develop-
ing into mature cystic forms asexually, it is
imperative to follow up patients for a reason-
able period after the intervention. The time
of recurrence varies with the age of the pa-
tient and host factors and ranges from 6 to 36
months in one study 1291. That range is a
main reason that long-term studies are
needed. Unfortunately, detection of early re-
currence after treatment is still a problem be-
cause of the lack of a sensitive serologic test
for follow-up I 19J. The recurrence rate after
surgery varies widely. Postoperative recur-
rence rates less than I 2% were reported for
studies before 1980 129, 301, whereas recur-
rence rates of up to 30% have been reported
for studies after 1980 13, 31 J, in whichsonography and CT were readily used as the
follow-up tools. Befcre 1980, for example, a
surgical study group used laparoscopy for
evaluating recurrence in symptomatic cases
1291. In contrast, the recurrence rate in percu-
taneous series varies in a narrow range from
Fig.4.-43-year-old woman with eightliver cysts and one renal hydatid cystA, CT image obtained before percu-taneous treatment shows two he-patic cysts.B, CT image obtained 3 days aftersonographically guided percutaneoustreatment of same cysts showsmarked volume involution.
0% to 2% fl2, 17, 18, 21, 23, 24, 26, 271.
Sonography was the follow-up tool in these
reports. Persistence of round shape and
anechoic appearance, regularity and thin-
ness of the cyst wall, and absence of a rap-
tured endocyst during the routine follow-up
examinations were accepted as indicators of
recurrence. A change over time in the sono-
graphic appearance of the cavity after percu-
taneous treatment from cystic to solid. with a
final purely solid cyst remnant, is a widely
acknowledged sign of cure.
Two of our PAIR patients with type I hy-
datid cysts had recurrences 3 and 6 months
after the percutaneous treatment. These pen-
ods are too short for a real recurrence. As
mentioned befrre, the expected time for re-
currence varies between 6 and 36 months
[291. Suboptimal therapy may be considered
responsible for our recurrences. The possible
mechanism underlying this failure might be
the irregularities and undulation of the en-
docyst, creating pockets for live cyst con-
tents during the intervention and reducing
the time of contact between parasite and hy-
pertonic solution.
Surgical treatment for liver hydatid cysts
mainly involves evacuation of cyst contents, in-
jection of scolecidal agents into the cavity, re-
moval of the cyst contents, treatment of the
residual cavity with or without omentum, and
sometimes resection of the infested part of the
organ. The overall mortality and complication
rates of surgery depend on many factors includ-
ing the chosen surgical technique. the duration
of follow-up, and the presence of previous cyst-
related complications such as cholangitis or
rupture. The surgical mortality rate ranges be-
tween 0% and 6f�.3% [3-5, 32 I, and the surgi-
cal complication rate ranges between 12.5%
and 80.0% 3. 30. 32, 331. The mean hospital-
ization period after surgery is 14 days for un-
complicated cases and 30 days for complicated
cases [3-5. 281. The percutaneous treatment of
hydatid cysts in selected patients of our study
has better results. with no mortality, a 19.4%
complication rate, and a hospitalization time of
1 day in noncomplicated and I 7 days in com-
plicated cases. We did not include secondanly
infected or raptured cysts in this study.
Because repeated surgeries are technically
difficult because of adhesions and fibrosis,
recurrence of hydatid cysts after initial sun-
gery harbors additional morbidity besides
the well-known risk from general anesthesia.
For that reason. some patients of this study
were referred to our department because of
recurrences after surgery. No additional risk
has been reported for repeated sessions of
percutaneous treatment.
The number of hydatid cysts in a patient
may influence the length of the operation and
anesthesia. From this point of view, additional
hydatid cysts may mean additional complica-
tions. One patient in this study with eight liver
cysts and one renal hydatid cyst was treated
without any of the aforementioned risks (Fig.
4). Local anesthesia used in percutaneous
treatment is another advantage over the gen-
eral anesthesia used in surgical treatment.
The presence of jaundice with dilated bil-
iary ducts and a cystic lesion in the liver should
suggest the possibility of hydatid cyst rapture
into the biliary system [25 l� best revealed by a
sonographic examination. We did not include
these patients for percutaneous treatment be-
cause of the risk of secondary cholangitis
caused by chemical agents such as absolute al-
cohol or hypertonic saline solution 1341. We
had four patients who developed biliary fistu-
las after percutaneous treatment. All were
catheterization patients having hydatid cysts
larger than 10 cm. None of these patients had
obvious sonographic clues of a biliary commu-
nication before the treatment. The develop-
ment of these tistulas may be explained by
Ust#{252}ns#{246}zet al.
96 AJR:172, January 1999
considering the changes in pressure gradients.
High intracystic pressure drops to normal dur-
ing or after the procedure. The previously non-
communicating biliary ducts surrounding the
cyst convert to a low resistance area where the
bile ducts may directly drain. This pressure
gradient affects a larger area, increasing the
chance of biliary communication in larger
cysts. On seeing these communications on
cystograms, we did not use absolute alcohol as
a sclerosing agent because of its potential
chemical effects, especially on the biliary tree.
The rest of the catheterization patients did not
show any bile duct communications in their
cystograms and thus underwent alcohol sclero-
therapy. We did not observe complications
such as sclerosing cholangitis on use of hyper-
tonic saline solution and absolute alcohol dur-
ing follow-up. Reinjection fluid was free of
bile in all PAIR patients, a finding that was ac-
cepted to indicate absence of communication.
Besides, during their follow-ups the PAIR pa-
tients displayed volumetric involution, which
means no extra input of bile into the cyst.
PAIR patients with secondary cavity in-
fection had cultures positive for Staphylo-
coccus aureus that were not related to the
biliary route of infection but instead to a pos-
sible external cutaneous or instrumental
source. These patients were treated with per-cutaneous drainage and antibiotics.
The fever seen just after the intervention
was accepted as a kind of reactive immune
response to the tissue degradation products
induced by the hypertonic saline solution,
ending with the release of pyrogenic media-tors. Generally, the fever disappeared in 12
hr without therapy.
The major complications were cavity infec-
tion, recurrence, and biliary rupture. Although
these were first reflected over the short term,
long-term results did not reveal any additional
complications such as cyst recurrences or scle-
rosing cholangitis and supported the favorable
short-term results of percutaneous treatment.
Although additional long-term and large-
scale studies are needed, this series provides
evidence that percutaneous hydatid cyst ther-
apy is an effective and safe procedure in prop-
erly selected patients. In conclusion, our
results indicate that percutaneous treatment of
hydatid disease is the best alternative among
the available techniques.
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