Modified capitonage in partial cystectomy performed for liver hydatid disease: Report of 2 cases

Hydatid cyst is a parasitic disease caused by the tapeworm Echinococcus granulosus or Ech. alveolaris. The prevalence of the disease varies around the world. Hydatid disease is encountered in specific areas, as Mediterranean countries, Australia and New Zealand, South and Central America, Middle East, India and China [1].

Most common locations of the parasite infection are liver (60%) (Figure 1) and lungs (30%), while rarely cysts can be found in kidney, pericardium, brain and bones [2].

As far as medical therapy of hydatid disease has been disappointing, surgery remains the cornerstone in the treatment of this disease. Numerous surgical techniques have been proposed for liver disease. These include open and laparoscopical surgical techniques, while lately; minimally invasive techniques have also been developed. PAIR (Percutaneous Aspiration Infusion Reaspiration technique), which belongs to the minimally invasive techniques, a real alternative to surgical procedures and chemotherapy, is of great value especially in cases where surgery and prolonged medical treatment with benzimidazoles is difficult or too expensive [3].

Classic open surgical techniques include ablation of the cyst, marsupialization, partial cystopericystectomy, subtotal pericystectomy, total pericystectomy and for large cysts liver resection (hepatectomy or segmentectomy) [4].

One of the major postoperative complications in liver hydatid disease surgery is bile leaking and the formation of a "dead" space in which abscess is easy to develop. Our purpose was to minimize the "dead" space, which usually remains after cystectomy or partial cystectomy [5].

We treated two patients with liver hydatid disease. One of them was male (58 years old, farmer), having a 15 cm diameter right-sided hydatid cyst (Figure 1). The other was a 62 years old female patient, with a 20 cm diameter left sided hydatid cyst. Both presented with mild symptoms (weight feeling, mild pain). The disease was diagnosed with computed tomography scan (CT), which demonstrated the cysts. Both of the patients had free medical history (no previous operations or severe illness requiring medical treatment). Our patients were treated with albendazole. Albendazole was administrated preoperatively (400 mg × 2) for a month and postoperatively (400 mg × 2) for three months. Although our cases were suitable for the PAIR procedure neither of these two patients were treated with PAIR because they refused and asked to be treated surgically. We conducted an open partial cystectomy including the proposed technical modification. In each one of the patients we found a billiary orifice, which was sutured. Neither of them presented postoperative complications including bile leaking. Postoperative examination of the formal cyst cavity with ultrasound failed to reveal fluid collection. The patients mobilized fast and quickly (mobilization started the 1^st postoperative day) and they discharged the fourth and fifth postoperative day subsequently.

The most common techniques for liver hydatid disease treatment are marsupialization, partial cystopericystectomy with resection of the pericyst and subtotal pericystectomy by peeling the pericystium. The traditional surgical ablation of the cysts is still used by many surgeons all over the world, although the recurrence rate of this procedure is high and ranges from 10 to 30% [2, 4–6].

Marsupialization was the most common used procedure because it is quick and safe, although is accompanied by a high rate of postoperative complications like residual cavity, disease soilage in biliary tract or intraperitoneal, bile leaking, vessels injuries and hemorrhage, sepsis, cholangiitis and allergic shock [2, 6]. For those reasons several technical improvements have been proposed, such as closing of all external communications of the cyst, and obliterating the remaining cyst with omentum or muscle flaps [7].

In Partial Cystopericystectomy not only the parasitic foci is eliminated but also the surrounded pericyst is removed. In this technique as in subtotal pericystectomy, small pericystic areas, which are located close to vascular and biliary vessels, are not resected because of the high risk for severe complications [8].

Finally in radical operations the parasitic content and the entire pericystic membrane is removed. In this subcategory the main procedures are total pericystectomy and liver resection. These operations are accompanied by increased morbidity and mortality [9].

All of the techniques applied in liver echinococcosis surgery present minor or major disadvantages and various postoperative complications. The method we propose is easy to perform, quick, safe and avoids most of the major postoperative complications, while eradicating the disease [10–12]. Although several authors suggest capitonage of the remaining cyst cavity, we avoid it because of the high incidence of postoperative necrosis of the omentum and the development of septic complications [1]. Soiling and peritoneal contamination can be avoided with the simple prophylactic measures that every surgeon must apply in hydatid cyst surgery.

Some other authors suggest introflexion of the cyst. Our technique is a modified combination of capitonage and introflexion. It is well known that these techniques can be used without omentum. We propose a new alternative technique with good results, and it is easy to perform it. In cases that are complicated with postoperative bile leakage the "rosette-like" modified capitonage may facilitate the drainage easier than the "snail-like" introflexion. The results of the classic type of introflexion seem to be similar to ours, although the number of our patients is too small to allow comparison [13, 14].

We just describe our technical modification in these two patients. The efficacy of this method should be estimated in a large clinical trial.

In our cases we had no specific difficulties or method related complications. The only possible limitation of this technique may relate with the anatomic location of the hydatid cyst.

Concerning the bile dust and vessel injury, we do not use deep sutures that may cause vessel or bile duct injuries. Our sutures are not deep except from some fixation sutures. We also suggest avoiding deep sutures in locations close to hepatic vessels and inferior vena cava.