784
LIVER
Key Words:
Hydatid disease;
Liver surgery;
Laparoscopy;
Complication rate.
Corresponding author: Asc. Prof. Oguzhan Karatepe, Bezmialem Vakif Universty, Department of Hepatobiliary and Pancreatic Surgery, Vatan Street, 34715, Istanbul, Turkey; Tel.: +90 5335408070; E-mail: drkaratepe@yahoo.com
ABSTRACT
INTRODUCTION
Echinococcosis, often referred to as echnococcal
disease or hydatid disease, is caused by the larval
stages of the tapeworm Echnococcus. This parasitic
disease manifests in 3 forms: cystic (the most common),
alveolar or polycystic echinococcosis. Echinococcosis is
a significant public health problem around the world,
including South and Central America, the Middle East,
some sub-Saharan African countries, China and Turkey
(1). It can cause severe infection in humans. Eggs
hatch in the small intestines and release an ocosphere
that penetrates the intestinal wall and moves through
the circulatory system into different organs where
oncospheres develop into cysts. In humans, disease
spreads from primary infection in the liver to other
organs (including the lungs and the brain) either by
direct extension or hematogenous dissemination (2,3).
Surgery, traditionally the treatment of choice for
E. granulosus cysts, is increasingly being reserved for
those in whom percutaneous treatment is not feasable
(4-6). A variety of surgical techniques have been used
for cystic echinococcosis, with the particular procedure
individualized for each cyst according to its features
(7-10). The first treatment of choice for complete
removal of the parasite is open surgery, an option in
patients who can tolerate surgery and who have cysts
in amenable locations (9-11). Because of progress in the
field, minimally invasive techniques and percutaneous
drainage of the cysts are now also feasible (12-14).
Laparoscopic treatment of liver echinococcosis has
become increasingly popular, although no randomized
clinical trials have been performed for comparison with
the conventional open surgical treatment of hydatid
disease (15). The laparoscopic approach is demanding,
but increasingly used, mainly in major centers. Its
feasibility has been proven in various studies (16-21).
Using the available published literature, the aim of
this review was to define important outcomes such as
feasibility, safety, risk of complication, recurrence and
benefit to patients with hydatic liver disease.
Hepato-Gastroenterology 2013; 60:00-00 doi 10.5754/hge12527
H.G.E. Update Medical Publishing S.A., Athens
Hepato-Gastroenterology 60 (2013)
Data extraction and critical appraisal
The level of evidence of each paper was established
following the Oxford Centre for Evidence-Based
Medicine Level of Evidence scale (23). The quality of the
cohort studies was
assessed according to the Newcastle-Ottawa Scale
(NOS) for observational and case-control
studies. NOS scores selection, comparability and
outcome (24).
RESULTS
Twenty-two studies published between 1990
and 2012 were retrieved (Table 1), all consisting of
retrospective single center series. Due to the absence
of any randomized controlled trials and comparative
studies, a formal meta-analysis was not performed.
A total of 666 patients who underwent laparoscopic
surgery for hydatid cysts localized to the liver were
included in this study. Surgery in all cases was
conservative, including unroofing of the cyst by partial
pericystectomy and cavity management. In all cases,
laparoscopic intracystic drainage was set up.
Early complications, in order of descending frequency,
were biliary fistulas (treated conservatively or with
endoscopic sphincterotomy), infections of the residual
cavity, and wound infections. The average postoperative
hospitalization was 4.66 days (range 1-30) for cases
managed by the laparoscopic method (Table 2).
Morbidity was 13.2% (88/666) and in-hospital
mortality was 0.3% (2/666). Patients were operated
laparoscopically, but most were converted to
laparotomy. The main reason for conversion was
unsafe exposure, unsatisfactory access and/or the
impossibility of identifying the hydatid cyst. Early
Reference
Khoury (25)
Berberoglu (26)
Seven (27)
Bickel (28)
Manterola (29)
Altinli (30)
Ertem (31)
Al-Shareef (32)
Giuliante (33)
Chowbey (34)
Zengin (35)
Baskaran (36)
Georgescu (37)
Dervisoglu (38)
Yagci (39)
Popescu (40)
Busic (41)
Palanivelu (42)
Wang Chen (43)
Sharma (44)
Misra (45)
Rooh-ul-Muqim (46)
Total
Origin
1999
1999
2000
2001
2001
2002
2002
2002
Lebanon
Turkey
Turkey
Israel
Chile
Turkey
Turkey
Saudi Arabia
2003
2003
2003
2004
2005
2005
2005
2005
2006
2006
2007
2009
2010
2011
Italy
India
Turkey
India
Romania
Turkey
Turkey
Romania
Croatia
India
PRC
India
India
Pakistan
Study Type
Retrospective
Comperative
Retrospective
Prospective
Prospective
Retrospective
Retrospective
Prospective
Retrospective
Retrospective
Prospective
Retrospective
Retrospective
Review
Prospective
Retrospective
Attempted
laparoscopy
Completed
laparoscopy
83
87
30
31
8
13
48
10
80
87
30
30
8
11
46
10
15
15
8
23
24
12
30
19
6
66
76
10
9
43
666
13
15
8
21
18
12
30
17
6
64
76
10
7
40
639 (96%)
785
786
Hepato-Gastroenterology 60 (2013)
Hospitalization
(day)
Khoury (25)
1999
Seven (27)
2000
78
2001
105
2002
4.2
82
2003
5.6
198
Reference
Berberoglu (26)
Bickel (28)
Manterola (29)
Altinli (30)
Ertem (31)
1999
2001
2002
Al-Shareef (32)
2002
Chowbey (34)
2003
Giuliante (33)
Zengin (35)
Baskaran (36)
2004
Dervisoglu (38)
2005
Georgescu (37)
Yagci (39)
Popescu (40)
2006
2009
Total
2.3
80
55
84
102
5.6
2006
7.6
2010
2011
80
60
Sharma (44)
Misra (45)
2005
2006
Rooh-ul-Muqim (46)
6.05
Palanivelu (42)
2005
2005
Busic (41)
2003
Operation
time (min)
91.44
70
-
144
67.5
52
81
146.5
115
4.66
46
DISCUSSION
Laparoscopic treatment of liver echinococcosis
has become increasingly popular (15), although no
randomized clinical trials comparing laparoscopic with
conventional open surgical treatment of hydatid disease
have been performed. Laparoscopic treatment includes
partial or total pericystectomy and cyst drainage
with omentoplasty (25-29). In appropriately selected
patients, such as those with anteriorly located hepatic
cysts, laparoscopic surgery has high success rates, low
complication rates and low recurrence rates (30,31).
A thorough search of laparoscopy in the literature
showed that most studies were retrospective and open
to selection bias (25,32,33,37). Successful completion of
a minimally invasive approach was possible with 96% of
the patients (Table 1). The main reason for conversion
from laparoscopy to open surgery was unsafe exposure
and unsatisfactory access (38). Besides inaccessibility,
conversion is also required due to calcification or
other complications of the cyst and occasionally due to
technical factors (25,37).
Reference
Khoury (25)
Berberoglu (26)
Seven (27)
Bickel (28)
Hepato-Gastroenterology 60 (2013)
TABLE 3. Cyst size and complication rate.
Year
1999
2000
6.5
1999
Complication
(n)
9
23
5
8.36
2002
7.2
Al-Shareef (32)
2002
10
Chowbey (34)
2003
9.2
Baskaran (36)
2004
7.4
Manterola (29)
Altinli (30)
Ertem (31)
Giuliante (33)
Zengin (35)
Georgescu (37)
Dervisoglu (38)
2001
2002
2003
2003
2005
6.6
14.3
9.6
8.1
8.71
2010
Total
10.5
2011
2006
Rooh-ul-Muqim (46)
2009
2006
Sharma (44)
7.2
Busic (41)
2006
Palanivelu (42)
2005
2005
Yagci (39)
Popescu (40)
Recurrence
(n)
2005
11
False
87/666 (13.1%)
46/666 (6.9%)
0
0
11/666 (1.6%)
ACKNOWLEDGMENTS
We would like to thank Susan Delacroix for English editing.
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