Surgical treatment for pulmonary hydatidosis (a review of 422 cases)

M. DAKAK, O. GENÇ, S. GÜRKÜK, A. GÖZÜBÜYÜK and K. BALKANLI

Thoracic Surgery Department. GATA Military Medical Academy, Ankara, Turkey

Introduction Clinical material and results

Discussion References

Keywords: Pulmonary, hydatid disease, surgery

Objective: Hydatidosis in man is frequently encountered in sheep and cattle raising regions of the world. We reviewed 422 patients, treated surgically for pulmonary hydatid disease in our clinic between January 1980 and January 1998, assessing the clinical features and results of results of operative treatment management in our centre. Patients and Methods: 52 of the patients were female and 370 were male. The median age of the patients was 33 years (range, 11 to 66 years).The cysts were located in the right lung in 214 (50.7%) patients, the left lung in 156 (37%) and bilaterally in 17 (4%) cases. We found an intrathoracic extrapulmonary cyst in 35 (8.3%) patients. We performed enucleation and capitonnage in 202 cases, wedge resection in 40, cystotomy and capitonnage in 171, and lobectomy in 9 patients. The high-risk patients were treated with Albendazol (10mg/kg/day), for a period of 3 months postoperatively. Results: Preoperative diagnosis was based primarily on chest roentgenograms and led to correct diagnosis in 347 cases (82.2%). An additional computerised tomography (CT) scan in 56 cases and magnetic resonavive imaging (MRI) were required in 15 cases. The diagnosis is established intraoperatively in 4 cases. Most (296) patients presented with a solitary lung cyst. The rest were found to have multiple cysts in one or more lobes. 87 of 422 also had cysts in the liver, 19 in the spleen, and 1 in the pancreas. The follow-up data was completed in 392 of 422 (92.8%) patients. The mean follow-up period was 4.3 years (2 to 19 years). We detected recurrence in 3 patients (0.71%). Conclusion: The effective treatment of hydatid cyst(s) in the lung is complete excision of the cyst(s) with maximum preservation of the lung parenchyma. Additional medical treatment with Albendazole should be carried out for high-risk group patients

J.R.Coll.Edinb., 47, October 2002, 689-692

INTRODUCTION

Hydatidosis has a wide geographic distribution around the world. In man, hydatid disease affects the liver in 50 to 60% and the lung in 18 to 35% of cases.^1,2

The lungs are the second most common sites of lodgment of the parasite. Although the liver and lung are most common sites for the disease, hydatids can occur in other organs of the body. The incidence of concomitant liver and lung hydatidosis varies from 5.8% to 13.3%.^1,2 Extrapulmonary cysts can occur in the chest wall, mediastinum, pericardium, and myocardium, and within the pleura cavity.^1,3 Although hydatid cysts are a rare cause of pulmonary nodules in most of the western countries, they are one of the most frequent causes in the Mediterranean region. The incidence of pulmonary hydatidosis is 20/100000 in Turkey.4,5 We present our experience, documenting the clinical features, the diagnostic methods used and the treatment employed.

CLINICAL MATERIAL AND RESULTS

We reviewed the clinical records of 422 patients who underwent operative treatment for pulmonary hydatid cyst disease between, January 1980 and January 1998, assessing the results of surgical treatment in our centre. We performed 439 operations in 422 patients for hydatid disease of the lung; 52 (12.5%) of the patients were female and 370 (87.6%) were male. The median age of the patients was 33 years (range, 11 to 66 years). Preoperative diagnosis was based primarily on chest roentgenograms and led to a correct dignosis in 347 (82.2%) cases. An additional CT in 56 cases and MRI in 15 (3.5%) was required for diagnosis. The diagnosis was established intraoperatively in 4 (0.94%) cases, but in 85 (20%) the patients were asymptomatic (Table 2). The most common symptoms were cough, chest pain and fever.

All of the patients underwent a posterolateral thoracotomy under general endotracheal anesthesia. The lung was freed from any pleural adhesions. The cyst was covered with sponges moistened with 20% saline solution to prevent implantation of daughter cysts in the event of rupture. The adventitia was incised carefully to avoid perforation of the cyst. The incision was enlarged in 2 directions using blunt scissors and the cyst enucleated. If a cyst was ruptured during dissection, hydatid fluid was aspirated and the cavity irrigated with 20% saline solution. The enucleation of a cyst is not easy when the cysts are large and under tension. In such cases the cystic fluid was aspirated with a large sized needle, then the cyst was opened with a 1cm incision and a suction tip entered into the cystic cavity to evacuate the remaining fluid. Germinal membrane was removed with forceps. After flushing the cystic cavity with 20% saline solution the bronchial openings were sutured and then capitonnage performed with polyglactin sutures. The bronchial openings were sutured when the cysts were presenting on the pleural surface; capitonnage was not used to close the cavity. The edges of the incision were sutured to control any bleeding and air leakage. Cysts placed centrally required segmental resection or even lobectomy.

Table 1: Localisation of hyatid cysts in patients studied

The cysts were located in the right lung in 214 (50.7%) patients, left lung in 156 (37%) and bilaterally in 17 (4%). These and other results are detailed in Table 1. Thirty-five of the 422 (8%) hydatid cysts were in the thorax, without involving the lung. These extrapulmonary intrathoracic cysts were in the chest wall in 13, diaphragm in 10, mediastinum in 8, and pericardium in 4 patients. There were 209 patients in whom hydatid cyst were in the right lung; 58 (14%) were in the upper, 46 (11%) in middle and 105 (25%) in lower lobes. Hydatid cysts were in the left lung in 153 of patients; 66 (16%) were located in the upper and 87 (20%) in the lower lobes. 296 (70.1%) of the 422 patients presented a solitary lung cyst. The other cases had multiple cysts in 1 or 2 lobes. A concomitant hydatid cyst was present in the liver in 87 cases (20.6%), spleen in 19 (4.5%) and the pancreas in 1 (0.25%) patient. The distribution of intrathoracic cysts is shown in Table 1.

We performed enucleation and capitonnage in 202 cases. Wedge resection was performed in 40 cases with small and peripherally located cysts. We were unable to perform an enucleation in 171 cases and the patients underwent a cystotomy capitonnage operation instead. Lobectomy was performed in 9 cases. The operative methods employed are shown in figure 1. The mean hospitalisation was 13.9 days (range, 9 to 28 days). There was no significant preoperative morbidity or mortality and the survival rate was 100%.

Figure 1: Operative methods employed to deal with cysts

The mean follow-up period 4.3 years (2 to 19 years). All patients followed-up by plain chest radiographs at 6 months for the first year and then annually. The follow-up data was complete for 392 of the 422 (92.8%) patients.

Recurrence of hydatid disease from spillage during the operation or further re-infestation of the patient cannot be easily differentiated in follow-up. If a new hydatid cyst was diagnosed 6 months after operation, it was accepted as a re-infestation. Re-infestation is not rare in an endemic country such as Turkey. We detected recurrences in 3 patients (0.71%). Those 3 patients underwent a second successful operation.

DISCUSSION

Hydatid disease of the lung remains a challenging problem for general and thoracic surgeons in endemic countries.^1,2 If the surgeon has some experience with hydatid disease, a simple chest roentgenogram is enough to make a diagnosis in most cases in endemic areas. Round homogenous opacities in the lung parenchyma are characteristic of simple uncomplicated cysts, the water lily or Camelot sign is characteristic of perforated cysts and the crescent sign is characteristic of air in the cystic cavity. Computerized tomography was required in 56 of our cases and MRI in 15 cases for a correct diagnosis. These imaging modalities can be useful, especially for inrathoracic extraparenchymal cysts. The diagnosis was established intraoperatively in 4 cases. We made a diagnosis 347 (82%) of our cases with a simple chest radiograph. The distribution and clinical manifestation of hydatid cysts in our series are similar to other published series.^5,7

Serological tests can be used for diagnosis of pulmonary hydatidosis. These serological tests are, Casoni’s intradermal test, Weinberg complement fixation test and the indirect hemagglutination test. But these tests have limited value for the accurate diagnosis of hydatid disease.^1,5

Table 2: Symptoms of pulmonary hydatidosis in 422 patients

The aim of operative treatment of pulmonary hydatid cysts is to eradicate the parasite, to prevent the intraoperative rupture of a cyst and obliteration of residual cavity.^5-8 Capitonnage is used for obliteration of the cystic cavity.^5-8 Location of the cyst and operative findings determine the proper operative technique for each patient. We used a posterolateral thoracotomy in cases of pulmonary hydatid cysts. When the hydatid cysts were located bilaterally, the operation was done in two stages. Median sternotomy can be used for operating in selected patients using a one stage procedure.

Pulmonary resection for hydatid cyst of the lung was used commonly in the past. If the patient comes into hospital at a late stage of the disease, when the cyst has destroyed the adjacent lung parenchyma, an anatomic resection (lobectomy, pneumenectomy) is required.2 We performed only 9 lobectomies in our series. Enucleation-capitonnage and cystotomy-capitonnage techniques are nearly similar. The only difference is that the cyst is removed without rupture, in the former procedure. 

Some authors have reported that thoracoscopic procedures could be used for the treatment of pulmonary hydatid disease.^9,10 Paterson in 1996 reported thoracoscopic evacuation of dead hydatid cysts.¹⁰ Mawhorter et al (1997) reported percutaneous drainage and Albendazole treatment.¹¹ Percutaneous drainage and treatment with a cystocidal agent have not been widely practised because of the possible dissemination of cysts and potential risk of anaphylaxis from the released cystic fluid.¹¹ We used a 20% saline solution for irrigation of the cystic cavity. Hypertonic saline solution is widely accepted in most centres. Some authors use 0.05% silver nitrate.⁹

The results of medical treatment for hydatid disease of the lung are controversial. Some authors have reported differing results with the use of medical treatment alone.^6,11 Response to medical therapy is related to the thickness of the cyst wall which drug must penetrate to reach the germinal layer. Young patients with small cysts, in whom the cyst walls are usually thin, have a better response to this form of treatment. According to the publish current literature, the failure rate of medical therapy and the recurrence rate after the treatment are high.¹ In our experience there is a limited beneficial effect from medical therapy alone, on a selected patient group.

Multiple hydatid cysts in thoracic cavity, multiple organ hydatid disease, or patients with ruptured hydatid cysts are accepted as high-risk patients. Dissemination of parasites either by cyst rupture or spillage of cyst contents at operation, has led to our use of Albendazole, given as a supplementary treatment after operation, since 1993. Albendazole was given 10mg/kg/day for 21 days postoperatively and the treatment was repeated twice with an interval of one week in high-risk groups.

Albendazole has been used recently for the treatment of pulmonary hydatidosis in high-risk patients and for prevention of recurrence in other series.^2,5,6 In to our experience, medical treatment with Albendazole is useful when operation is contraindicated or if there is a risk of dissemination at operation. Eighty-three of the 422 patients were regarded as high-risk patients in our series were given medical treatment after 1993. We applied the same Albendazole regimen to those patients, when the operation was contraindicated, because of their poor general condition or limited pulmonary reserve.

In conclusion, the most effective treatment for hydatid cysts of the lung is complete excision of the cyst with maximum preservation of the lung parenchyma. Additional medical treatment with Albendazole should be reserved for patients at high-risk of recurrence.

REFERENCES

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8. Balkanli K, ÷ztek I, Okay T. Pulmonary hydatid cyst and results of surgical treatment. Turkish Journal of Pathology 1991; 7(1): 45-49
9. Aarons BJ. Thoracic surgery for hydatid disease.World J Surg 1999; 23(11): 1105-1109
10. Paterson HS, FRACS, Blyth DF, FRCS. Thorascopic evacuation of dead hydatid cysts. J Thorac Cardiovasc Surg 1996; 111: 1280-1281
11. Mawhorter S, Temeck B, Chang R, Pass H, Nash T. Non surgical therapy for pulmonary hydatid cyst disease. Chest 1997; 112: 1432-1436

Copyright: 26 April 2002

Correspondence to: M. Dakak, GATA Gˆg¸s Cerr. AD, 06018 Etlik, Ankara, Turkey