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riginal Paper

784

LIVER

Feasibility and Safety of Laparoscopic


Hydatid Surgery: A Systematic Review
Bulent Citgez1, Muharrem Battal1, Gokhan Cipe2, Oguzhan Karatepe2 and Mahmut Muslumanoglu2
1
Department of Surgery, Sisli Etfal Tranng and Research Hospital, Sisli, Istanbul, Turkey
Department of Hepatobiliary and Pancreatic Surgery, Bezmialem Vakif University, Istanbul, Turkey

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

Background/Aims: Eccinococal disease is an


important problem in regions such as Turkey, where
tapeworms are endemic. Surgery is the main key to
successful treatment. Among the various techniques,
laparoscopy has recently come to be preferred over
the commonly used open technique. The aim of this
review was to evaluate the feasibility, safety and
potential benefits of laparoscopic hydatid surgery.
Methodology: Three independent investigators
conducted comprehensive research using PubMed,
MEDLINE, Embase and the Cochrane library.
Language was restricted to English; reference lists

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

were searched manually. Results: Tweny-two


retrospective studies were selected for review, none
of which were randomized controlled trials. It was
found that the laparocopic approach was attempted
in 666 patients. The overall conversion rate to
laparotomy was 4% (27/666) with a recurrence rate
of hydatid disease of 1.6% (11/666). Average length
of hospital stay was 4.7 (1-30) days. Conclusions:
Based on this meta-analsysis, evidence confirms that
the laparoscopic surgical technique is feasable and
safe. Good randomized controlled trials are lacking.
METHODOLOGY
All aspects of the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA)
statement (22) were followed.

The literature search strategy


MEDLINE, PubMed, Embase and the Cochrane library
were systematically searched for articles relevant to
laparoscopic or open hydatid cyst surgery that were
published between 1990 and 2012 (Before 1990,
the literature offers little to no clinical data on the
laparoscopic technique). The MeSH heading hydatid
cyst surgery was used in PubMed. Other keywords used
were laparoscopic, laparotomy, open, conventional
and minimally invasive. Manual reference checks of
accepted papers in recent reviews and included papers
were performed to supplement electronic searches.

The literature screening (process)


Two independent researchers (BC, MB) evaluated
studies as to their relevance to the subject. A random
check was performed by a supervisor (OK). Study
selection was accomplished through a three-phase
study screening. In phase 1, the following (types of
studies) were excluded: reviews, case-reports, letters,
editorials, case series, those using non-human or infant/
adolescent patients and papers written in a language
other than English. In phase 2, abstracts were reviewed
for relevance, studies with less than 8 subjects were
excluded, and the full-text articles were obtained. In
phase 3, full-text articles were reviewed. Inclusion
required studies describing laparoscopic surgery
and one or more of the following outcome measures:
incidence of complication, recurrence and length of
hospital stay. One study was excluded for describing
patients already described in another paper.
Any discrepancies, doubts or questions about
the appropriateness of inclusion were resolved by
discussion between the reviewers with supervision of a
third. Figure 1 presents the flow diagram of our study.

Review of Laparoscopic Hydatid Surgery

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

FIGURE 1. PRISMA flow diagram of the literature search.

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

TABLE 1. Studies of laparoscopic management of hydatid cyst.


Year

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)

Citgetz B, M Battal, G Cipe et al.

TABLE 2. Hospitalization and mean operative time.


Year

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)

Wang Chen (43)

2005

2005

Busic (41)

2003

Operation
time (min)

91.44

70
-

144

67.5
52

81

146.5
115

4.66

46

hydatid cyst recurrence - defined as recurrence within 1


year of surgery - occurred in 11 of 657 patients (1.6%).
Insufficient data precluded being able to calculate a late
recurrence rate. Table 3 sets forth the complication and
recurrence rates.

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).

A major disadvantage of laparoscopy and the


main reason for the reluctance to adopt it is the
lack of precautionary measures to prevent spillage
induced by high intra-abdominal pressure caused by
the pneumoperitoneum (27-28,34-36). Because of
peritoneal spillage, allergic reactions are more common
in laparoscopic interventions. On the other hand, length
of stay is generally shorter and morbidity rates lower
than for open procedures (31,33,34). The overall
mortality and morbidity of laparoscopy for hydatid
surgery is 0.1% and 13.1%, respectively.
Communication of the cyst and the biliary tree is
the most frequent complication of hepatic hydatid cyst
(39,40), with bile leaks reported to be 5-25% (41-46).
Our review showed a 7% incidence of bile leakage
after laparoscopy. Preoperative assessment to exclude
biliary communication must be performed to avoid
sclerosing cholangitis or pancreatitis (47). In case
of communication between a cyst and the bile ducts,
protoscolicodal agents should be avoided to reduce
risks of chemically-induced sclerosing cholangitis (48).
During laparoscopy, precautions should be no less
stringent than in conventional surgery, with gauzes
soaked with scolecidal agents surrounding the puncture
site and the suction catheter on guard (31). The most
dangerous step is the initial puncture and aspiration
of the cystic fluid. Every effort should be made to avoid
fluid spillage. If feasible, a protoscolicide agent should
be injected into the cyst before opening it. A 20%
hypertonic saline solution is recommended to be in
contact with the germinal layer for at least 15 minutes
(31,32).
The main problem associated with both open
and laparoscopic surgical therapy of hydatid cysts is
recurrence of a cyst and the persistence of parasitic
infection. Because germinative membranes and
daughter cysts are the most common cause of recurrence,
their removal is imperative (45,46). While near zero
recurrence has been obtained with radical operations
such as closed cystopericystectomy and hepatic
resections, recurrence rates in excess of 20% have been
associated with conservative open surgical procedures
like evacuation of cyst contents and pericystectomy (4146). The overall recurrence rate found in our review
was 1.6%.
The laparoscopic technique has two (major)
disadvantages. First, it leaves a large residual cavity and
an attendant risk of residual abscess. Second is the risk
of relapse due to incomplete sterilization in the case of
calcified walls. However, using an ultrasonic dissector,
ligasure or electrocauterization, the risk of relapse
decreases dramatically and the calcified walls can be
destroyed (30,31,43-46). Conversely, compared with
the percutaneous technique, laparoscopy has many
advantages. These include the possibility of controlling
the location of the cyst and of protecting the surgical
area from hydatid leaks (15,31,34). Laparoscopy also
allows for the sterilization of the remaining walls, the
detection of possible biliary fistulas, the treatment
of biliary complications and the treatment of the
cystic cavity using the omentum (44,45). In addition,
enlargement of the laparoscopic image enables a direct
observation of the entire cystic cavity.
In conclusion, because of its acceptably low rates of
complications and morbidity, laparoscopy is a feasible
alternative to laparotomy for removal of hydatid liver
cysts when performed by experienced surgeons. In
the absence of randomized controlled trials, which
are unlikely to be undertaken, standardized reporting
of institutional experience and longer follow-up is
essential to assess the benefit of laparoscopy with
respect to safety for the treatment of the hydatid surgery.

Review of Laparoscopic Hydatid Surgery

Reference
Khoury (25)

Berberoglu (26)
Seven (27)

Bickel (28)

Hepato-Gastroenterology 60 (2013)
TABLE 3. Cyst size and complication rate.

Year

Cyst Size (cm)

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)

Wang Chen (43)


Misra (45)

2009

2006

Sharma (44)

7.2

Busic (41)

2006

Palanivelu (42)

2005

2005

Yagci (39)

Popescu (40)

Recurrence
(n)

2005

Biliary fistula (n)

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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