Echinococcus of the Liver Treated with Laparoscopic Hepatectomy

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Erina N Foster, MD; Gabor Hertz, MD

Summer 2010 - Volume 14 Number 2

https://doi.org/10.7812/TPP/09-146

Abstract

Echinococcosis or hydatid disease is endemic to many countries around the world where livestock, mainly sheep and cattle, are raised with dogs who act as the definitive hosts for the adult phase of the echinococcal tapeworm. We report a case of a man, age 22 years, who emigrated from Kyrgyzstan as a teenager, presenting with abdominal fullness and nausea and found to have a 9 cm echinococcal cyst of the liver which was successfully treated with laparoscopic hepatectomy because of a very favorable location.

Case Presentation

We report a case of a man, age 22 years, from Kyrgyzstan who presented with abdominal fullness and nausea. An ultrasound was performed and revealed a complex cystic liver mass. Computed tomography (CT) showed a large, mixed-density mass in the left lobe approximately 9 cm in size, with nondependent hypodense foci (Figure 1). His mother had mentioned another villager was diagnosed with a similar problem and was treated with surgery. Laboratory evaluation revealed no leukocytosis, normal blood count and liver enzymes. Echinococcal antibody was mildly elevated at 1.32 (positive over 1.2) and he was placed on albendazole 400mg bid preoperatively. Because of the advantageous location of the cystic mass, the patient was able to undergo laparoscopic segmental hepatectomy 4 weeks later (Figures 2 and 3). No postoperative complications were noted and the patient continued to do well 2 months after surgery.

Discussion

Echinococcosis or hydatid disease is endemic in the Mediterranean, Africa, Middle East, South America, Australia, Russia, and China where livestock, mainly sheep and cattle, are raised with dogs who act as the definitive hosts for the adult phase of the echinococcal tapeworm. Kyrgyzstan is a small, landlocked central Asian country, bordered by China, Kazakhstan, Uzbekistan, and Tajikistan with an estimated population of 5.4 million people. Kyrgyzstan has a predominantly agricultural economy, producing cotton, tobacco, wool, and meat.1

Livestock become infected when they eat food or water contaminated with dog feces which contain the larval form of the tapeworm. Infection leads to cysts in the liver in 75% of cases followed by lung, but can involve any part of the body.2 Mortality is estimated at 5% and sensitization can occur with systemic leakage of cysts into the bloodstream potentially leading to fatal anaphylaxis if a cyst ruptures.3 Most infections are caused by Echinococcus granulosus followed by Echinococcus multilocularis.3

Laboratory examination can rarely show a peripheral eosinophilia but usually the complete blood count is normal. Serologic testing is 84% sensitive but cannot definitively rule the diagnosis in or out.3 Imaging with ultrasound can show single or multiloculated cysts with a "snowflake or hail-storm" pattern and signs on CT include daughter cysts with a "wheel, rosette, or honeycomb-like" appearance.4 Treatment varies depending on the location, size of the cyst, and overall health of the patient. Surgical resection has been the treatment of choice but newer modalities through percutaneous aspiration called PAIR (puncture, aspiration, injection, and re-aspiration of scolicidal solutions) show promise. Patients treated with PAIR usually receive oral medication (albendazole or mebendazole) for 7 days before and 28 days after aspiration to help decrease the risk of recurrence.5 Surgical options include total pericystectomy, partial hepatectomy, and lobectomy, and can be complicated by bleeding, bile leak from the residual cavity, biliary fistula, or cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) is employed to mainly assist in postoperative management of these complications. Fortunately, the location of the cyst in our patient made it feasible to perform minimally invasive laparoscopic resection of his lesion.

Disclosure Statement

    The author(s) have no conflicts of interest to disclose.

References
    1.    The World Factbook: Central Asia: Kyrgyzstan [monograph on the Internet]. Washington, DC: Central Intelligence Agency; updated biweekly [cited 2010 Feb 1]. Available from: www.cia.gov/library/publications/the-world-factbook/geos/kg.html#.
    2.    Voros D, Katsarelias D, Polymeneas G, et al. Treatment of hydatid liver disease. Surg Infect (Larchmt) 2007 Dec;8(6):621-7.
    3.    Chrieki M. Echinococcosis–an emerging parasite in the immigrant population. Am Fam Physician 2002 Sep 1;66(5):817-20.
    4.    Czermak BV, Akhan O, Hiemetzberger R, et al. Echinococcosis of the liver. Abdom Imaging 2008 Mar-Apr;33(2):133-43.
    5.    Smego RA Jr, Sebanego P. Treatment options for hepatic cystic echinococcosis. Int J Infec Dis 2005 Mar;9(2):69-76.

 

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