Correspondence
Percutaneous Drainage of Hydatid Cysts
N Engl J Med 1998; 338:391-393February 5, 1998
- Article
To the Editor:
Khuroo et al. (Sept. 25 issue)1 demonstrated that percutaneous drainage, combined with albendazole therapy, is a safe alternative to surgery for the treatment of uncomplicated hepatic hydatid cysts. A remarkable point in this study is that nine patients with multivesicular cysts were treated with percutaneous drainage.
Generally, multivesicular cysts are not considered to be an indication for percutaneous drainage, according to the guidelines of the World Health Organization's Informal Working Group on Echinococcosis.2 All daughter cysts have to be punctured separately during the same procedure, which is technically difficult and time-consuming and may result in additional complications.
Khuroo et al. seem to have solved these problems, since percutaneous drainage of multivesicular cysts, in their hands, apparently did not result in major complications. It would be interesting to know the details of their approach to percutaneous drainage of multivesicular cysts.
We are also interested in knowing the results of follow-up and data on late complications after percutaneous drainage of univesicular and multivesicular hydatid cysts. The results of long-term follow-up (over a period of two to five years) are necessary to evaluate the treatment of hydatidosis. The follow-up results for the 75 patients previously treated with percutaneous drainage by the authors will also provide valuable information.
2 ReferencesHans G. Schipper, M.D., Ph.D.
Piet A. Kager, M.D., Ph.D.
Academic Medical Center, 1105 AZ Amsterdam, the Netherlands1
Khuroo MS ,Wani NA ,Javid G , et al. Percutaneous drainage compared with surgery for hepatic hydatid cysts. N Engl J Med 1997;337:881-887
Full Text | Web of Science | Medline2
WHO Informal Working Group on Echinococcosis
Web of Science | Medline
To the Editor:
In the study reported by Khuroo et al., was there not a bias in the protocol? The authors randomly assigned their patients to treatment with percutaneous drainage plus albendazole or cystectomy. Why was albendazole administered only to the patients who underwent percutaneous drainage? The authors stated that there is not enough scientific support for the use of the drug in patients treated with surgery. Although there are no published data on the effect of albendazole in such patients, two recent recommendations suggest its use.1,2 From a theoretical point of view, the effect of albendazole is not related to any subsequent mechanical intervention in the cysts.
2 ReferencesWalter Vasen, M.D.
Hospital Nacional de Gastroenterología“Dr. Bonorino Udaondo”
1264 Buenos Aires, Argentina1
Liu LX ,Weller PF . Antiparasitic drugs. N Engl J Med 1996;334:1178-1184
Full Text | Web of Science | Medline2
WHO Informal Working Group on Echinococcosis
Web of Science | Medline
To the Editor:
We have several comments about the report by Khuroo et al. The authors excluded from the study children and pregnant women. However, percutaneous drainage (which we call PAIR, for puncture, aspiration, injection, and reaspiration) may be the only way to prevent the otherwise almost certain rupture of a large hepatic cyst during labor. In the Lake Turkana region in Kenya, we used PAIR successfully to treat six pregnant women and five children less than five years old, thus avoiding surgery.1-3
The peak serum level of albendazole is reached four hours after administration. Therefore, for prophylactic purposes, it is sufficient to start treatment four hours before the procedure, but the duration of post-PAIR treatment is debatable in our view. We administer albendazole for a maximum of four weeks after drainage only in cases of large cysts (>7 cm in diameter). With smaller cysts, the duration of prophylaxis is shorter.
Endoscopic retrograde cholangiopancreatography is mandatory before percutaneous drainage to rule out any possible connections with the biliary tree. Injection of contrast medium is the only way to know immediately whether there are any connections with the biliary tree. These may be hidden by the distention of the cyst before aspiration, but are visible before injection of the scolecidal agent.
The absence of nonviable scoleces in the reaspirated fluid may not be sufficient to declare the procedure successful. Among patients with larger cysts, in whom we prefer to use the catheter, we noticed that in some cases viable protoscoleces were present even after the injection of alcohol, which therefore was repeated until three subsequent parasitologic controls had been obtained. An ideal procedure would include microscopical verification of permanent damage of the germinal membrane.
Finally, the puncture of multiloculated cysts is sometimes technically impossible.
3 ReferencesCarlo Filice, M.D.
Enrico Brunetti, M.D.
University of Pavia, 27100 Pavia, Italy1
Filice C ,Brunetti E . Use of PAIR in human cystic echinococcosis. Acta Trop 1997;64:95-107
CrossRef | Web of Science | Medline2
Filice C ,Pirola F ,Brunetti E ,Dughetti S ,Strosselli M ,Foglieni CS . A new therapeutic approach for hydatid liver cysts: aspiration and alcohol injection under sonographic guidance. Gastroenterology 1990;98:1366-1368
Web of Science | Medline3
Filice C, Brunetti E, D'Andrea F, Filice G. Minimal invasive treatment for hydatid abdominal cysts: PAIR (Puncture, Aspiration, Injection, Reaspiration) — state of the art. Geneva: World Health Organization, 1997.
Author/Editor Response
Dr. Khuroo replies:
To the Editor: In our experience, a multivesicular cyst is not a contraindication to percutaneous drainage.1-3 The procedure is performed in one session and with one needle puncture. Once a vesicle has been punctured, aspirated, and instilled with saline, the needle is advanced to penetrate the next vesicle, and the procedure is repeated. After a few vesicles have been instilled with saline, the remaining ones usually rupture from the hypertonic saline. The whole cyst then becomes unilocular, with ruptured vesicle membranes floating in the cyst cavity. The rest of the procedure is then performed as for univesicular cysts.
Before drainage, we use ultrasonography to detect breaks in the cyst wall, cyst–biliary communication, and biliary hydatidosis.4 Endoscopic retrograde cholangiopancreatography is indicated for therapeutic purposes in patients with manifest biliary hydatidosis.1-4
We examine the cyst fluid on immediate microscopy and dye testing to determine the viability of the scoleces. This technique is simple, rapid, and dependable and can be done at the bedside.5 Cyst fluid from nonviable scoleces in our patients failed to grow into hydatid cysts after intraperitoneal inoculation in albino mice (unpublished data). Moreover, none of the cysts with nonviable scoleces showed evidence of regrowth during follow-up.
We used albendazole in the percutaneous-drainage group because of its proven additional benefit,2 possibly from its effect on residual hydatid contents in the leftover cyst. At surgery, the cyst and all its hydatid contents are removed, and the residual cavity is sterilized by swabbing with povidone–iodine. Albendazole is unlikely to have any added benefit after surgery and is indicated only when there is cyst spillage at surgery, partial cyst removal, or biliary rupture. Our study was not biased, since we were comparing a standard interventional technique with an established surgical procedure. Our aim was not to compare the relative efficacy of albendazole therapy in the two groups. A total of 78 patients (mean age, 37.4 years) with 95 cysts (70 univesicular and 25 multivesicular; mean diameter, 8.5 cm) have now been followed for 9 to 69 months (mean, 45). In 58 patients, the cysts disappeared (cures), and in 12, there was a pseudotumor appearance of the cysts on follow-up ultrasonographic examinations. Eight patients (10 percent) required additional endoscopic interventions, surgery, or both. There were complications in 10 patients: anaphylaxis in 1, urticaria in 2, pleural effusion in 2, biliary rupture in 2, and cyst infection in 3. None of the patients had localized or disseminated spread of peritoneal disease, and there were no procedure-related deaths.
5 ReferencesMohammad Sultan Khuroo, M.D.
King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia1
Khuroo MS ,Zargar SA ,Mahajan R . Echinococcus granulosus cysts in the liver: management with percutaneous drainage. Radiology 1991;180:141-145
Web of Science | Medline2
Khuroo MS ,Dar MY ,Yattoo GN , et al. Percutaneous drainage versus albendazole therapy in hepatic hydatidosis: a prospective, randomized study. Gastroenterology 1993;104:1452-1459
Web of Science | Medline3
Khuroo MS ,Wani NA ,Javid G , et al. Percutaneous drainage compared with surgery for hepatic hydatid cysts. N Engl J Med 1997;337:881-887
Full Text | Web of Science | Medline4
Zargar SA ,Khuroo MS ,Khan BA ,Dar MY ,Alai MS ,Koul P . Intrabiliary rupture of hepatic hydatid cyst: sonographic and cholangiographic appearances. Gastrointest Radiol 1992;17:41-45
CrossRef | Medline5
Smyth JD ,Barrett NJ . Procedures for testing the viability of human hydatid cysts following surgical removal, especially after chemotherapy. Trans R Soc Trop Med Hyg 1980;74:649-652
CrossRef | Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
E. Zerem, R. Jusufovic. (2006) Percutaneous treatment of univesicular versus multivesicular hepatic hydatid cysts. Surgical Endoscopy 20:10, 1543-1547
CrossRef2
R. A. Smego, S. Bhatti, A. A. Khaliq, M. A. Beg. (2003) Percutaneous Aspiration-Injection-Reaspiration Drainage Plus Albendazole or Mebendazole for Hepatic Cystic Echinococcosis: A Meta-analysis. Clinical Infectious Diseases 37:8, 1073-1083
CrossRef
