PercutaneousTreatment Cysts of the Liver:

Bahri Ust#{252}ns#{246}z1 Okan Akhan2 MehmetAli KamiIolu1 Ibrahim SomunCu1 Mehmet ahin UureI1 Saadettin #{231}etiner3
OBJECTIVE. ous treatment SUBJECTS
in age between

of Hydatid Long-Term Results

was to present patients
years) with

The purpose of liver AND

10 and

of the study

the long-term (44 male

106

results and hydatid

of percutaneranging underwent
(ii

hydatid cysts. METHODS.

69 years; mean

Seventy-two
age, 35

28 female, cysts

liver

percutaneous reaspiration
40) were

treatment with albendazole (PAIR) were used for hydatid

treated by catheterization.

prophylaxis. cysts smaller

saline

Puncture, aspiration. injection. than 6 cm (n = 66). Larger cysts

solution and absolute alcohol

and =

Hypertonic

were

used copy
first

as the cytotoxic was used

year, every sixth

and
month

sclerosing Follow-up

agents. was

Sonographic mainly year. and once

at the respectively. time

guidance a year
ofthe The

with every

or without third The month mean

was

fluorosof the followand

in all patients.

by sonography

of the second
in volume patients.

thereafter.
first follow-up

up time was 37 months. RESULTS. The mean reduction 73.5%

in catheterization and PAIR

87.0%

immediate

sonographic

changes

after treatment with a reduction complete ment ofa patients.

No urticaria mortality, and

were

detachment
fluid

of the endocyst
component. The solid

and

disappearance
of the

of the regular
cyst remnant

endocyst,
indicated

in the

appearance

cure as the cyst solid appearance Seventy

fever abdominal in eight

wall became irregular and thicker. The average was 19 months in PAIR patients and 26 months were cured, whereas
seeding

time for developin catheterization were observed.

were complications

of 72 patients
patients

two

recurrences
occurred. Minor

(2.8C/e) were

dissemination,

or tract

( 1 1 . I %).
for complicated

Major

complications tistula
and cases I day

infection patients
cyst safe and uncomplicated

of the cyst (5.6%).

treatment offers

cavity in two patients hospitalization times CONCLUSION. cord with short-term plete cure in selected

(2.8%)
were

and development
I 7 days

ofbiliary

in four
for

Mean
cases. accom-

The long-term
results, indicating

results
that

of percutaneous
the procedure

liver
is efficient

hydatid
and

patients

with

a short

hospitalization.

H
iterranean

ydatid
(Ot(ttS

disease
granulosus

caused

by Eehinoand

Among
apy with

nonsurgical benzimidazole

treatments. compounds is not treatment mostly

medical

ther-

is endemic

(albendacurative

a common
countries,

health problem in Medthe Middle East. South and Australia

or.

zole or mebendazole)
[8, 10]. Endoscopic with [9. a role cations, cysts

usually has limited

mdihydatid of hy-

America.
disease

New
may be

Zealand,

I I 1. The
rarely. pa-

in biliary

asymptomatic,

1 1 1. Percutaneous

treatment acceptance
results by Mueller

Received February 12, 1998;accepted after revision

June 29, 1998.
1 Department

tients
ing

may clinically
anaphylactic

present with life-threatenshock from cyst rupture of hydatid a higher

lengthy

datid

cysts

has

been
in

gaining
short-term I 985

besince it

121.

cause

of its positive

of Radiology,

GUlhane Military

Medical

Surgical tional
tions,

treatment and
death.

disease risk

is tradithan

was

first introduced our

et al. from

Academy,

06018 Etlik, Ankara 06100, Turkey. Address to B. UstUnsdz.

carries
and

of complica-

I I 2]. We present
percutaneous

long-term

results

correspondence

hospitalization

treatment.

2DepartmentofRadiology, Hacettepe University, Faculty of Medicine, Sihhiye, Ankara 06100, Turkey. 3Department of Surgery, GUlhane Military Medical
Academy, 06018 Etlik, Ankara 06100, Turkey. AJR 1999;172:91-96 0361 -803X/99/1721--91 American Roentgen Ray Society

does
and such

nonsurgical
such medical

treatment
as percutaneous. procedures plus

13-51. Nonsurgical
endoscopic. combinations or percuta-

treatment

Subjects

and Methods

and medical

as percutaneous

neous novel
studies

plus
with

endoscopic last two

long-term

procedures decades
results are

have
[6-9].

been
Large

From February 1992 to February 1997. 72 patients (44 male and 28 female: age range, 10-69 years: mean age. 35 years) with 106 hydatid cysts
underwent percutaneous treatment. All patients in their

for the

lacking.

were regularly

k)llowed

up every 3 months

AJR:172, January

1999

91

Ustuns#{246}z et al. first year, every 6 months in their second year, and then once a year subsequently until September 1997. Sonography was used for follow-up. Follow-up criteria were the echo pattern and the size and wall structure of the cyst. The follow-up penod ranged from 7 to 67 months, with a mean of 37 months (SD, 18.7 months). Inclusion or exclusion criteria were determined mainly in accordance with the sonographic type of the cyst or cysts as described in the classification of Gharbi et al. [ 13]. Patients with type I hydatid cysts (pure fluid collection), type II hydatid cysts (fluid collection with a split wall), and type III hydatid cysts (fluid collection with daughter cyst) with drainable matrices were included. Patients with type III cysts containing nondrainable degencrated matrices due to solid components, type IV cysts (heterogeneous echo pattern), or type V cysts (reflecting calcified wall) were excluded. Patients
with ruptured (into the biliary tract, peritoneum, or

treated

with

the

catheterization

technique

de-

The

average

volume

of cysts

before

the

scribed by Akhan et al. [6]. A cyst 6 cm in diameter contains a volume of approximately I 00 cm3. Hence, catheterization is essential to ensure quicker and more effective involution of the cayity; alcohol may further promote this involution with its sclerosing effect. Smaller cyst volumes, however, do not need catheterization or sclerotherapy with alcohol. Besides, catheterization of such small cysts requires more manipulation. which may mean an increased complication rate. The PAIR technique may be summarized as follows: puncture of the cyst with a 19-gauge sheathed needle under sonographic guidance, aspiration of half the volume of the cyst, injection of hypertonic saline solution (20%) amounting to one third the initial estimated cyst volume, a 20-mm wait, and reaspiration of the cyst fluid. The catheterization technique differs from the PAIR technique. After injection of the hypertonic
saline solution, a 6- to 9-French pigtail catheter is

procedure was PAIR technique

by the catheterization

37 ml in the 66 treated by the and 285 ml in the 40 treated

technique.

During the Procedure Clear

ally called fluid under high water-was pressure-occasionobtained at the

spring

initial solution. cally

puncture,

before observation
separation

the injection

of saline from I). of

This

and the sonographiof the endocyst as pathognomonic cysts

after

detected

the pericyst for the viability The fluid

were became

accepted yellowish
and the

of the hydatid

[6] (Fig. injection

separated

the saline solution, from the pericyst tients. fluid could of

endocyst

during

the procedure

in all pano
mainly

At the beginning be withdrawn

by the

of the reaspiration,
PAIR technique,

in four of the 66 paby membrane such

injecting pushing J-type and

pleural cavity) or secondarily infected cysts and patients who had not attended to follow-up sonographic examinations were also excluded. Fifty-six patients had one cyst (56 total), eight had two cysts (16 total), four had three cysts (12 total), one had four cysts (four total), two had five cysts (10 total), and one had eight liver cysts (eight total) and one kidney cyst, which was treated percutaneously as well but excluded from the present liver study. Twenty-two patients had a history of hydatid
cyst tients and or cysts had three treated surgically. One of these paoperations, 1 1 had two operations,

tients treated because fragments. changing

small amounts

placed into the cavity for 24 hr ofgravity drainage. If cystographic study through the pigtail catheter
shows and no communication between the cyst cavity

needle After
of

occlusion simple
saline

maneuvers of the needle,

solution,

as

the position

the biliary tract, a volume of absolute alcohol half the initially estimated volume of the cyst is applied for 20 mm to produce protoscolecidal and sclerosing effects. If, however, cystographic study
through the pigtail catheter shows communication,

back the membrane fragments by floppy guidewires, we were able to draw back jected
two

the in-

alcohol should not be used because sclerosing cholangitis may result.

Because cyst fluid of high spreads pressure inside out and contaminates puncture.

secondary
cysts, To avoid

fluid in two of these patients. The other patients, however, required catheterization with a 10-French pigtail catheter. No
occurred

hydatid

deaths
during

or
the

hypersensitivity
procedure.

reactions

one had one operation One patient among these

gery for both lung and liver

due to hydatid disease. 22 had undergone surhydatid cysts. The sur-

the interven-

tion area at the time of the initial this contamination, a one-way

adapted to the top of a 19-gauge and this type

valve

system

was

After the Procedure Eight patients (I I . I %) experienced (fever and urticaria). presented with mild hr after the procedure antihistamines. Four minor Two paurticaria and repatients spike that treatment.
with with both antihistaur-

gery treated the pulmonary cyst successfully, but the liver cyst recurred. The most common presenting symptom was right upper quadrant pain (n = 27) or abdominal discomfort and swelling (n = 13). The other patients were not symptomatic at the time of diagnosis. The most common physical findings in patients who did not undergo surgery were hepatomegaly (n = 34) and liver masses with or without hepatomegaly (n = 12). The patients in whom disease recurred after surgery experienced abdominal discomfort (n = 1 1) and pain (n = 6). The remaining five were asymptomatic. All recurrences were diagnosed with imaging, mainly sonography and Cl. After giving written informed consent, every
patient received prophylactic albendazole (Anda-

sheathed

needle,

of needle was used in all patients. All cyst fluid aspirated, both before and after injection of the hypertonic saline, was sent for cytologic and microbiologic examination. Staining with neutral red indicated that the cyst was viable,
and
staining

complications tients (2.8%) within I .5-4 sponded

(5.6%)

to

with

methylene

blue

and
[15].

eosin

mdi-

cated that the cyst was not viable

developed a mild fever subsided spontaneously without patients

and

Two Results
Before the Procedure ticaria

(2.8%)
fever were

presenting treated

mines only. patients well tolerated the oral albendazole but seven after the the mediIn Six patients complications
fistula). The

All
prophylaxis

(8.3%) (cavitary
residual patients

experienced major infection and biliary

cystic (2.8%) cavities treated became by the

for the first week,

zol; Biofarma, 1st, Turkey), 15-20 mg/kg day by mouth, starting 1 week before the dure and continuing for a total of 4 weeks. An anesthesiology team was available possible hypersensitivity reactions during
tervention. All interventions were carried

twice
proce-

(9.7%) second cation. three

showed gastric intolerance week and had to stop taking No recurrence to the group from from therapy.
three

infected PAIR

in two

was

seen

in this group, for 4 weeks. the endocyst 1 week of alwere given 7 weeks. change

technique, terventions, and eter fistulas,

fistula

9 and required for

5

I I days after percutaneous and 7 days. with presented prolonged In one

endoscopic

the incathOf four biliary the and of

as opposed to treat the inout un-

treated

drainage
(5.6%)

cysts

patients, after patients

patients

who required

separated bendazole

the pericyst These

two
was

catheterizapatient,
papillot-

tion, for 24 and

managed

37 days.
by

der local anesthesia after peripheral IV access was obtained. The technique of the procedure was chosen mainly according to the size of the cyst. Cysts smaller than 6 cm (n = 66) were treated with puncture, aspiration, injection, and reaspiration (PAIR), a technique developed and described by Ben Amor Ct al. [14]. Cysts larger than 6 cm (n = 40) were

albendazole therapy for an additional Because no additional sonographic

omy,

irrigation,

and nasobiliary 39 days. The had endoscopic required

stayed

drainage last patient intervention, 2). The

hospital

was observed in this period, all three underwent percutaneous therapy. Cyst contents aspirated
dicating

resolved within these four also but she eventually the fistula was

just

before

percutaneous
stained with

treatment
neutral red,

in
in-

surgery (Fig.
in the

because first
for

these three patients

still present

that the cysts were viable.

three fistula patients

92

AJR:172, January

1999

Percutaneous

Treatment

of Hydatid

Cyst

of the

Liver

Fig. 1-21-year-old man with hepatomegaly. A, Sonogram obtained before intervention shows type I hydatid cyst of liver. B, Sonogram obtained 5 mm after injection of hypertonic saline solution reveals endocyst separated (arrows)

Cand

0, Sonograms

obtained

at sixth (C) and 12th (D) months

of follow-up

show

increasingly discharged

settling for

from pericyst. solid component. outpa-

1 week before tient follow-up. to take care the hospital Patients stayed
in

being

The

last patient at home. was

only

was unable She stayed in

quired for a solid appearance to develop varied according to the size of the original cyst and the type oftreatment. Small cysts (6-s cm) became solid in the catheterization group earlier than in the PAIR average was
PAIR group

of herself for 7 1 days. whose

the

course
hospital after

uncomplicated
overnight and

group

(average. cyst (6 months

16 months). remnant to 3 years)

( I I months

The appear
the

time
and

for a solid
26 months

to in
to

were discharged examination

a routine

sonographic

19 months

on the next day.

Follow-Up ofCyst Changes The

changed

4 years) Cysts appearance generally

At the routine

in the catheterization were considered follow-up round revealed and anechoic,

group. to have recurred them with to be persisa regular

if and

sonographic
from cystic

to solid.

first folwere solid

on

tently

low-up examination, the cysts generally more fluid than solid. Gradually. the
component of the cysts increased until.

thin wall Although

and without a ruptured endocyst. the cysts of two PAIR patients mi3- and showed

complete Fig. 2.-53-year-old woman with percutaneously treated hepatic hydatid cyst. Cystogram shows cystobiliaryfistula.
seen (Fig.

cure,
3).

only
Rarely, had

a solid
we
(F

cyst
could =
4).

remnant
not

was
detect

tially showed a reduction in volume, 6-month follow-up examinations that the cysts had recurred. amination of aspirate from

where

the cyst

been

The

time

re-

Microscopic cxthe cysts revealed

AJR:172,

January

1999

93

Ust#{252}ns#{246}z et al.

Fig. 3.-Temporal
graphic appearance

evolution of sonoof liver hydatid

cyst during percutaneous treatment A, Sonogram obtained before intervention shows type I hydatid cyst at
right lobe of liver.

B, Needle and hypertonic jet flow (arrow) are evident on sonogram obtamed during intervention.

Cand 0, Sonograms

obtained

atfirst(C)

and second (D)years offollow-up show solid appearance of cyst remnant

neutral red staining, or viability. Both patients underwent a second, successful, PAIR
session

alent

in areas,

including

Europe

and North

however, question
tic,

erroneous, by many

having related
and

been

brought

into

and had
size and

no further sonographic

recurrences. appearance of all

America, previously known to be free from it [17]. This worldwide distribution requires that all physicians be aware of hydatid disease. The actual prevalence of hydatid disease
unknown, mainly because of lack of reliable

studies

of diagnospercutane-

experimental,

therapeutic in which complications

The
cysts

ous intervention is
significant,

series

no additional
were ob-

changed

after

intervention. a volume the PAIR

Immediately reduction technique technique.

without compli-

immediate

after
78.0%

the procedure, occurred with with treated

of and Of

served Corkell
20 cysts.

[12, [25]
of No

17, 18, 20-24].

published their

Lewall experiences
had

and

Mcwith

screening
nisia was

methods.
infected,

Gargouri
and they

et al. [18] found in Turate as quoted this

94.6% the cysts cation, with

the catheterization
successfully

that approximately being 100 times

2% of the population higher than World Screening Health

cases

rupture

of

intrahepatic
shock then

hydatid
been

anaphylactic

the reduction the PAIR technique

technique.

in volume and
These

was results

73.5% with the were ex-

Or-

87.0%

ganization

estimates.

and diagnostic have been

technology

observed. The exact frequency of anaphylaxis is not known. Obviously, the risk of anaphylaxis

catheterization

studies ofhydatid and satisfactory

established with

disease have been improving, diagnostic

the help

obtained at the first follow-up amination in the third month. Discussion Hydatid
endemic

sonographic

criteria
of new

cantly

in percutaneous treatment different from that No clear-cut from

Hence,

is not signifiin surgical exists

always

intervention. protection
tions [20].

criterion before
should

for

such as sonography, Among disease is a major health problem in areas [1, 16]. Epidemiologic studies these, nique for general is more reliable Percutaneous been
ing,

CT, and MR imaging is the accepted and follow-up tests [19]. cysts because shock,
assumption

[19]. techand has of

is,

anaphylaxis
anaphylaxis

interven-

sonography screening

than serologic treatment contraindicated anaphylactic

[17]. This

be anticipated, and treatment should be readily available for patients both in surgical and percutaneous Spillage nation into our interventions. of the cyst
the peritoneal contents cavity and dissemi-

indicate
tration However,
datid

pastoral

distribution,

with

a concen-

of hydatid

in the sheep-raising extensive

disease worldwide;

and rural areas has spread

it is increasingly

[16]. hyprey-

considered
and spillage

immigration

the risk of inducing

seed-

has in any

not, short-

to

knowledge,

been

reported

94

AJR:172, January

1999

Percutaneous term
[12,

Treatment to

of Hydatid

Cyst

of the

Liver
cases

study
17,

of percutaneously treated

treated patients
the present

patients studthat we
study,

0%

2% fl2, 17, 18, 21, 23, 24, 26, 271.

was the follow-up of round regularity
absence routine

[3-5.
cysts better

281. The
results. rate,

percutaneous
patients no mortality, with

treatment
of our study a 19.4% time in com-

of

18, 20-241.

The two long-term

Sonography reports. anechoic

ness of

tool

in these and thina rap-

hydatid
has complication

in selected

ies of percutaneously

are aware of [26, have agreed with studies. safety approach

ance during

271,
the

and

Persistence appearance,
the cyst wall, during

shape and
of

and

a hospitalization and I 7 days

of

results

of short-term

and the

1 day plicated
infected

in noncomplicated cases. We did cysts not

We believe record was and

needle

the main reason for this the use of a transhepatic sonographic

The into the

tured endocyst examinations recurrence.

graphic

follow-up

include in this

secondanly study.

were A change

accepted over
of the

as indicators time
cavity after percu-

of

or raptured

real-time
contents

guidpotential hepatic

in the sonowith a

Because difficult recurrence

gery

repeated of hydatid

surgeries of adhesions cysts from

are technically and after fibrosis, sunbesides

insertion.

appearance

because harbors

for leakage parenchyma

tonic solution

of cyst before
is

taneous final

treatment purely solid

sign

from cyst

cystic remnant,

to solid.

initial anesthesia. of this because sessions

injection
only

of the in
around

hyperrisk, be-

is a widely

additional risk some to our after for surgery.

morbidity general patients

a theoretic

acknowledged

of cure. with type I hy3 and 6 months These

recurrence. time for

the well-known For were has that reason. referred been The
may

cause
practice

it
and

is
by

almost
the immediate

eliminated
tract cyst

clinical
the

immature

Two of our PAIR patients datid cysts had recurrences after

ods

study of risk of

department repeated cysts

of the

needle

decompression.

the percutaneous
are too short befrre, the

treatment. for a real

expected

penAs re-

recurrences percutaneous

No additional

The protective effect of albendazole reported in one animal study is another factor against potential spillage 1281 and the reason we used prophylactic Because datid cyst
ing into imperative can mature recur, cystic up

reported number From

may

mentioned

treatment. of hydatid
the length

currence responsible
mechanism

varies

between therapy
this

6 and may

36 The

months possible
might be

in a patient
operation and

albendazole.
scoleces regrowing forms patients and asexually, for from a hydevelopit is a reason-

[291. Suboptimal

be considered

influence

disseminated

for our recurrences.

underlying

anesthesia.
hydatid cysts

this point
mean

of view,
additional

additional
complica-

failure

the
docyst,

irregularities
creating

and
pockets

undulation
for live

of the
cyst

encon-

tions. One
cysts and any

patient
one renal

in this study
hydatid

with eight
cyst was risks percutaneous

liver
treated (Fig.

to follow

able period of recurrence

tient months and host in reason

after
factors

the

intervention.
with and

The
from

time
6 to 36 is are a

tents
pertonic

during

the

intervention between for

agents

and parasite liver

of cyst into

reducing and hycysts inre-

without
4). Local

of the aforementioned anesthesia used in

varies
one study that

the age
ranges

of the parange
studies

the time Surgical

mainly jection

of contact
solution.

treatment hydatid
contents, the cavity, eral anesthesia evacuation

is another used

advantage
in surgical

over
treatment.

the genbil-

1291. That
long-term

treatment

main needed.

involves

The presence
suggest into the the

of jaundice lesion
[25

with

dilated cyst

Unfortunately,

detection

of early

rebetest after

of scolecidal

iary ducts and a cystic

possibility system biliary

in the liver should

currence after treatment is still a problem cause of the lack of a sensitive serologic for follow-up surgery
varies

moval

of the cyst

contents,
or without

treatment
omentum, part

of the
and

of hydatid

I 19J. The recurrence

widely. Postoperative I 2%

rate

residual cavity with sometimes resection organ. The

rates ing

l best revealed
treatment

rapture by a
be-

of the infested mortality

on many technique.

of the
includ-

sonographic
these patients

examination.
for percutaneous

We did not include secondary

such

recur-

overall

and complication
factors

rence rates less than studies before 1980 rence rates for studies sonography follow-up
surgical study of up

129,

were reported for 301, whereas recurhave been reported

of surgery the chosen

depend surgical

cause cohol
las

of

the

risk

of
agents

cholangitis
as absolute al-

the duration cystor cholangitis

caused by chemical or hypertonic

percutaneous

to 30%

of follow-up, related
a for

and the presence

such as

of previous rate ranges

32

saline

solution
treatment.

1341. We
biliary
All

after 1980 13, 31 J, in and CT were readily used

tools. Befcre group 1980, used for laparoscopy

which
as the

complications

had four patients

after

who developed

fistuwere

example,

rupture. The surgical tween 0% and 6f.3%

cal complication rate

mortality
[3-5,

besurgi12.5%

I, and the
between

ranges

catheterization patients having hydatid cysts larger than 10 cm. None of these patients had obvious sonographic
nication before the clues of a biliary The be commudevelopby treatment. may

evaluating

recurrence

in symptomatic

cases

1291. In contrast, the recurrence rate in percutaneous series varies in a narrow range from

and 80.0% 3. 30. 32, 331. The mean hospitalization period after surgery is 14 days for uncomplicated
cases and 30 days for complicated

ment

of these tistulas

explained

Fig.4.-43-year-old

woman with eight

liver cysts and one renal hydatid cyst A, CT image obtained before percutaneous treatment shows two hepatic cysts.

B, CT image obtained 3 days after sonographically guided percutaneous treatment of same cysts shows
marked volume involution.

AJR:172,

January

1999

95

Ust#{252}ns#{246}z et al.

considering the changes in pressure gradients. High intracystic pressure drops to normal during or after

apy is an effective and safe procedure in properly selected patients. In conclusion, our results hydatid indicate disease that percutaneous
is the best

ease. 17. Khuroo

Infect

Dis

Clip, North

Am

1993:7:605-616 R. Echinococmanagement 1991 ; 180:

MS.

Zargar

SA, Mahajan

the procedure. biliary directly a larger

The previously ducts drain. area, surrounding area where This increasing

nonthe the the larger on

treatment
among

of

communicating bile ducts gradient chance cysts. may affects of biliary On seeing

alternative

cus granulosus with percutaneous 141-145 18. Gargouri taneous

cysts in the liver: drainage. Radiology

cyst convert to a low resistance

the available References

I. Matossion dosis: WHO
C/iron

techniques.

pressure

M. Amor NB, Chehida FB, et al. Percutreatment of hydatid cysts (echinococcus

Cardiorasc Iniervent Radio!

communication in these communications

RM,

Rickard problem

MD,

Smyth

JD. Hydatiimportance.

granulosis). 13: 169-173 19. Suwan ofthe 20. liver:

1990: disease meth-

a global

of increasing

Z. Sonographic comparison

findings

in hydatid imaging

cystograms, a sclerosing chemical

we did not use absolute alcohol as agent because of its potential especially on the biliary tree. did not in their
sclero-

1977;55:499-507

with other

effects,

The rest of the catheterization patients show any bile duct communications cystograms and thus underwent
alcohol

2. Kok AN, Yurtman T, Aydin NE. Sudden death due to ruptured hydatid cyst of the liver. J Forensic Sci 1993;38:978-980 3. Mentes
4.

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