Surgery Hydatid cyst disease

Cyst: is a pathological fluid filled sac bound by a wall .

In true cysts the sac bound by cells of epithelial origin. They may be Congenital Or Acquired.

Hydatid Cyst (H.C) Disease : is a parasitic infection of man caused by the adult & larval stages of the Echinococcus cestodes mainly Echonococcus granulosis species. Endemic in sheep rearing districts of many countries like middle east ,Mediterranean ,Australia , newzeland. Very ancient disease known to Hippocrates over 3000 years ago ,and AL-rhazes the Arab physician 900 years AD. But the nature of the Echonococcus worm and the mode of infection was only established by about the middle of nineteenth century.

Life cycle & mode of infection of this parasite :Echonococcus adult worm develops & lives in the intestine of the carnivorous animals such as dogs ,fox ,
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length of the worm is between 2.9 9 mm the eggs 30 38 micro m .the dogs are mediators of the hydatid to man , in endemic areas 20- 100% of the dogs are infected . Adults worms have three segments The immature, mature , gravid segments which produce thousands of ova voided in feces of the dogs contaminating grass, vegetables , water ,man eat contaminated food or have the infection by direct contact with dogs . Dog is the definitive host complete the cycle by eating infected offal's The outer chitonic layers of the ova is dissolved by gastric guise after ingestion of the ovum Releasing embryo which penetrates the intestine and enter the portal circulation to become lodged in the capillaries of the liver,where cystic larval stage develop forming H.C

Embryo could pass into various sites in the body which differs according to the series consulted , but E.G cysts R found most commonly in the liver (52%) followed by the lung (8.4%) Abdominal cavity (8%) kidneys(7%)
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CNS (0.2-2.4%)and Bone (1-2.5%)

Hydatid cyst consist of 3 layers

1-pseudo cyst (adventitia)which results from host reaction to the parasite its outer gray fibrous layer which intimately blended with the liver or host tissue 2-Ectocyst .(laminated membrane )is the middle chitinous whitish elastic layer. And formed by parasite itself it could peels from the outer pseudo cyst unless there is infection. 3.Endocyst is the inner layers of germinal epithelium . which is made of single layer . Its the only living layer of the hydatid cyst. It secret the ectocyst & internally it secrets the hydatid fluid ,broad capsules, within brood capsules R thousands of scoliosis which R the heads of future worms.

Clinical features
Many R asymptomatic & become discovered incidentally at postmortem Or on investigations 4 other purposes .clinical features of symptomatic cysts depend on the
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site of the cyst,pressure symptoms , presence of complications. In hepatic hydatid the most common presentation is painful or painless hepatomegaly or abdominal mass biliary colic ,sometimes associated with transient jaundice & occasionally with cholangitis as signified by rigors sweating &fever , in brain hydatids raised intracranial pressure with focal neurological signs , in bone pathological fractures of along bone , collapsed vertebra ,in pulmonary hydatids the most common symptoms & fever , cough , expectoration , dyspnea , hemoptysis ,in renal hydatids lumber pain & very rarely hydatidiuria occurs.

Complications includes:
Suppuration, due to secondary inf. Causing fever , increased pain & tenderness with all clinical manifestations of the liver or pulmonary abscesses when these organs R involved by hydatid cysts Rupture of hydatid cyst according to site of rupture if it's on peritoneal cavity which may present as emergency with sign of acute abdominal pain & generalized peritonitis . Anaphylactic phenomena ,notably urtecaria R prone to occur . sometimes the rupture of the cyst will lead to anaphylactic shock , urtecaria , bronchospasm , asthma , & even convulsion coma ,& Death
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If the patient survive multiple daughter cysts could occurs with ascitis & subsequent intestinal Obstruction . If the rupture into alimentary tract causing a fistula If it is into biliary channels :into an intra hepatic radicals ,gall bladder , C.B.D With passage of daughter cysts causing intermittent biliary colic , chills &fever , bouts of jaundice & occasionally urinary . If into the pleural cavity ,leading to pleural effusion with fever & S.O.B .

Diagnosis

Imaging techniques including:

Ultrasonography , computed sonography ,plain radiography , radionuclide scanning using agent like technetium

Immunological diagnosis like :Immunoelctrophoresis this investigation depend on its positivity ,upon formation of specific of respiration (called arc5) produced by the interaction of the serum from the patient with the antigen . this useful not only in primary diagnosis but also in post surgical follow up . the test revert to negative 2-3 years after successful

operation & its a good indicator about the recurrences of the disease . This investigation is at present the one of choice in primary diagnosis and follow up among the other tests which includes :A- Indirect haemagglutination test (IHT) B- Latex test(LT) C- Complement fixation test (CFT) D- ELISA

Treatment of H.C

Surgical treatment : surgery offers the only effective

treatment 4 living abdominal H.C , & is recommended 4 both symptomatic & asymptomatic cases . Effective surgical treatment includes : 1- Evacuation of the cyst content :hydatid fluid ,proscolises ,& hydatid sand R evacuated . Even with the ultra most care spillage of the content might occur with the risk of disseminating the disease . there R many chemicals that can destroy the cyst content within 3-5 minutes including 20% hypertonic saline ,0.5% silver nitrate , absolute alcohol . there is no place 4 formaldehyde nowadays . scolicial agents coming into contact with biliary tree may cause
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sclerosing cholangitis . scolicidal agents couldn't kill daughter cysts so they should be regarded as potentially infective & removed meticulously . 2. removal of the ectocyst (laminated membrane )with the end cyst & daughter cysts. 3. treatment of the residual cavity . after inspecting the cavity & cleaned with scolicidal agents the remaining cavity dealt with either by: Primary closure in small cyst , with placement of nearby drains Saucerasation :in bigger cyst especially if infection present. It's done by excision of the extra hepatic adventitia of the cyst & doing meticulous hemostasis Omental patching or grafting in big cavities other surgical procedures may be used in special circumstances i. Excision into including the pseudo cyst in pedunculated cysts. ii. Removal of part or the whole of the organ involved . this is possible in the liver , spleen , kidney . For uncomplicated simpler liver cyst, percutaneous therapy by puncture , aspiration , injection & respiration (PAIR) , combined with Albendazole treatment is used widely now , there is no generally agreed standard
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method 4 laparoscopic treatment of hepatic hydatid cysts . Medical treatment : primary chemotherapy as an alternative to surgery is still controversial as cure rate with Albendazole R not yet available . Indication & contraindications: If hydatid disease is inoperable because of site , multiple cysts disseminated peritoneal disease other disease making operation & anesthesia hazardous Adjuvant therapy in either preoperative or post operative period should be considered to reduce the risk of recurrence from unavoidable spillage of infective material during surgery . the risk of recurrent disease in uncomplicated disease is approximately 10% Pregnancy & lactation R contraindicated to medical treatment also complicated cysts with cystobiliary communications, infection ,rupture will not benefited from the treatment Albendazole is currently the choice 4 medical therapy of cyst not prophylactic ).10mg\kg B.W daily in 2 doses 4 a month Prazequantel is the best prophylactic agent 4 preventing implantation of spilled protoscoleses

& dose of 50mg \kg per day is required 4 pre or post operative prophylaxis 1 month of Albendazole treatment or even 2 weeks of prazequantelis probably length of treatment there is too much debate about the time needed 4 treatment or prophylaxis in H.C medical treatment but follow up the treatment using US or immunological assay used in assessment of the benefits of the treatment .