management of hepatic cysts. cyst aspiration is associated with high rates of recurrenceof...

Management ofManagement ofManagement of Management of Hepatic CystsHepatic CystsHepatic CystsHepatic Cysts

S bil V l MDS bil V l MDDepartment of SurgeryDepartment of SurgerySybile Val, MDSybile Val, MD

SUNY Downstate Medical CenterSUNY Downstate Medical Center

August 15, 2008August 15, 2008

www.downstatesurgery.org

QuestionsQuestions1. Ultrasonography demonstrates a liver cyst with a thick wall

d i Th i h ld b d i dand septations. The patient should be adviseda. To have repeat sonograms every 6 months for 2 yearsb. Interventional radiologist for aspiration and biopsyc. Surgical referral for laparoscopic fenestration d. Surgical referral for complete resection

2. Cyst wall in cases of cystadenomas should bea. Partially resectedb. Completely resectedc. Suture ligatedd. Fenestrated


QuestionsQuestions3. Sclerotherapy with alcohol leads to

a. Necrosis of cyst wallb. Fixation of the cells lining the cyst cavity thus disabling

their ability to secrete fluidc. Is never performed because it leads to cholangitisd. Has 100% success rate

4. Polycystic liver disease is a contraindication for laparoscopic fenestration

a. Trueb. Falsec. I don’t knowd. All of the above


QuestionsQuestions5. Laparoscopic fenestration

a. Has lower recurrence rates than open unroofingb. Is considered the procedure of choice for congenital cystsc Is less morbid than traditional unroofingc. Is less morbid than traditional unroofingd. A is the only incorrect answer!


Case PresentationCase PresentationHi tHi tHistoryHistory

• HPI: • PSH:– 56 YOF 5 week h/o

RUQ pain

PSH:– TAH/BSO– Cyst aspiration

• PMH:

y p

• Meds:• PMH:– HTN– Endometrial cancer

– Hyzaar

– No allergies


Case PresentationCase PresentationImagingImagingImagingImaging


Case PresentationCase PresentationI iI iImagingImaging


Case PresentationCase PresentationPh i l E & L bPh i l E & L b

• Physical Exam

Physical Exam & LabsPhysical Exam & LabsPhysical Exam– 7/06: RUQ mass, non-tender

Pre Op: Unremarkable– Pre-Op: Unremarkable• Labs:

C C / / /– CBC - 4/11/38/248– Chem – 140/3.4/100/27/17/0.87/88– LFTs - 7.6/4.6/25/22/65/0.2


Case PresentationCase PresentationI iI iImagingImaging


Case PresentationCase PresentationOperation C st FenestrationOperation C st FenestrationOperation: Cyst FenestrationOperation: Cyst Fenestration

• PneumoperitoneumPneumoperitoneum created via open technique

• Followed by placement of ports for puncture, aspiration and deroofing of cyst

Operative Techniques in General Surgery, Vol 4 (March), 2002 76-87


Case PresentationCase PresentationOperation C st FenestrationOperation C st FenestrationOperation: Cyst FenestrationOperation: Cyst Fenestration

• Cyst wall is incised• Cyst wall is incised• Contents are drained• Flaccid cyst wall is• Flaccid cyst wall is

resected



Case PresentationCase PresentationO ti C t F t tiO ti C t F t tiOperation: Cyst FenestrationOperation: Cyst Fenestration

• Residual cyst wall• Residual cyst wall carefully inspected

• Ablation of remnantAblation of remnant cyst lining performed

• (Omentum can be(Omentum can be placed within cyst remmant)



Case PresentationCase PresentationP th lP th lPathologyPathology

• Benign cyst– Fibrous tissue

Si l l f– Single layer of cuboidal epithelium


Case PresentationCase PresentationP t ti lPost operatively

• POD#0 • POD#6POD#0– Tolerated diet

Pain controlled

POD#6– Clinic f/u

No complaints– Pain controlled

– Discharged home

– No complaints


Questions??Questions??


Simple Hepatic Cysts


ClassificationClassificationwww.downstatesurgery.org

Congenital CystsCongenital Cysts• Simple/Solitary Cysts • Polycystic Diseasep y y

– Abnormal development of intrahepatic BDs

– Lined with

y y– Autosomal Dominant– Also affects kidneys– Progressive

cuboidal/columnar epithelium

– No malignant transformation

ghepatomegaly

– Variable and numerous cysts

transformation– 60% solitary– Rarely communicate with

biliary tree

– Liver function preserved– Prognosis directly

related to severity of kidney diseasebiliary tree

– 90-95% asymptomatickidney disease

– Associated with intracranial aneurysms


Acquired CystsAcquired Cysts

• Neoplastic Cysts • Traumatic Cystsp y– Slow growing– SYMPTOMATIC

May have solid

– Pt w h/o trauma– Parenchymal injury with

disruption of vascular or – May have solid component or calc

– CystadenomasLi d ith

pbiliary structures

– Most resolve spontaneously

• Lined with mucus secreting epithelium

– Cystadenocarcinoma

p y

• Result of malignant transformation

– All treated surgically


Acquired CystsAcquired Cysts

• Infectious CystsInfectious Cysts– Echinococcal (hydatid)– Rare in US– Caused by tapeworm larvae


PresentationPresentation

Symptoms usually result from mass effect, caused by enlarging cyst

Blonski, World J Gastroenterology 2006


PresentationPresentation



Differential DiagnosisDifferential Diagnosis



Diagnostic EvaluationDiagnostic Evaluation

• UltrasoundUltrasound– 10 imaging modality– >90% sen/specp– Anechoic – Smooth margins– Diff b/w solid lesions– Unilocular vs. septae



• ComputedComputed Tomography– Defines relationship

of cyst to structures– Non-enhancing

Thi if ll– Thin uniform wall– No intracystic

septationsseptations



• MagneticMagnetic Resonance– More detailed

anatomic picture– T1 – hypointense

T2 h i t– T2 – hyperintense


TreatmentTreatment

Only indicated when symptoms areOnly indicated when symptoms are present and can be attributed to the

cyst

Cowles and Mulholland Journal American College Surgery Vol 191 2000


TreatmentTreatment

Blonski / World J Gastroenterology 2006


Treatment AlgorithmTreatment Algorithm

M.F. Hansman et al / The American Journal of Surgery 181 (2001) 404-410


TreatmentTreatment

Surgical management has replacedSurgical management has replaced non-operative management

Morino / Annals of Surgery 1994


TreatmentTreatment

Laparoscopic fenestration is an ll t t t t f hi hlexcellent treatment for highly

symptomatic non-parasitic solitary hepatic cystshepatic cysts

Morino / Annals of Surgery 1994


Laparoscopic FenestrationLaparoscopic Fenestration• First described by Z’geggen • Goal is to decompress cyst

in 1991• Indicated for:

– Solitary cysts or

and limit recurrence– Careful patient selection– Widest possible excision y y

– PCLD characterized by large superficial cysts

• Reported complications:

pof cystic wall

– Careful hemostasis of cyst edgeReported complications:

– Pleural effusion– Ascities

Bil l k

y g– Electrocautery/argon

beam of cavity– Ligation of obvious– Bile leak

– Bleeding

Ligation of obvious biliary leaks

– Omental packing as necessarynecessary


Optimal Surgical ManagementOptimal Surgical Management

• Retrospective reviewRetrospective review • 38 patients b/w 1988 and 1997

23 i l t– 23 simple cysts– 15 PCLD

• Mean f/u 41 months• Goal:

– Determine morbidity rates– Assess long term recurrenceg

Martin / Annals of Surgery 1998 Vol 228 167-172



• ConclusionsConclusions– Percutaneous aspiration should be reserved

for patients with questionable symptomsfor patients with questionable symptoms– Recurrence may be expected even if

meticulous and radical fenestration of allmeticulous and radical fenestration of all available cyst is performed

– Laparoscopic deroofing in PCLD patients is p p g punlikely to be successful when only the largest cysts are dealt with




• ConclusionsConclusions– Laparoscopic technique was associated with

a reduced morbidity (25%) and shortera reduced morbidity (25%) and shorter hospital stay (3 days) compared with open deroofing (36% and 8 days)g ( y )

– With respect to recurrence, radical deroofing is key



Well, what about the long termWell, what about the long term results?


Long term resultsLong term results

• Retrospective review over 15 yearsRetrospective review over 15 years• Total of 78 patients

57 h d i l t– 57 had simple cysts– 8 hydatid cysts– 8 hepatobiliary cystadenomas– 1 hepatobilary cystadenocarcinoma

Regev et al Large cystic lesions of the liver in adults: A 15 year experience in a tertiary center Journal of American College of Surgery, 2001 Vol 193 36-45



• Retrospective review over 15 yearsRetrospective review over 15 years• 57 had simple cysts

88% f d b/ i– 88% referred b/c pain– 96.5% had normal hepatic biochemical profile

%– 49% underwent perc aspiration– 84% (48) managed surgically

• 30 laparotomy• 18 laparoscopically

Regev et al Large cystic lesions of the liver in adults: A 15 year experience in a tertiary center Journal of American College of Surgery, 2001 Vol 193 36-45



• Results:Results:– Recurrence seen in all pts s/p aspiration

No operative deaths or major complications– No operative deaths or major complications– 2 pts continued to have pain post operatively

12 5% (6/48) demonstrated recurrence– 12.5% (6/48) demonstrated recurrence• 2/18 in laparoscopic group• 4/30 in open group• 4/30 in open group



• Concluded:Concluded:– Cyst aspiration is associated with high rates

of recurrenceof recurrence– Surgical treatment (wide unroofing or

resection) is associated with good outcomesresection) is associated with good outcomes– Laparoscopic unroofing has become the

procedure of choice for large simple cysts and p g p yis associated with low complication and recurrence rates


Location of cyst is a key factorLocation of cyst is a key factor influencing surgical outcome

Bia et al / Hepatobiliary Pancreatic Dis Int 2007


Adjuncts to lap fenestration?Adjuncts to lap fenestration?


The role of laparoscopic ultrasound in the minimally invasive management of a y as e a age e t o

symptomatic hepatic cysts

Schachter et al / Surg Endosc 2001 15; 364-367


The role of laparoscopic ultrasound in the minimally invasive management of a y as e a age e t o

symptomatic hepatic cysts

Ad t f l i lt d• Advantages of laparoscopic ultrasound– Allows the precise definition of the structure of the

cyst wall componentcyst wall component– Identifies presence of cyst wall nodules,

irregularities and solid papillary growths– Allows for US guided biopsies intraoperatively– Allow differentiation between the portal and venous

structures and the cystic lesionsstructures and the cystic lesions

Schachter et al / Surg Endosc 2001 15; 364-367


ConclusionConclusionManagement of liver cysts should be individualized by cyst type, symptoms and associated complications

Percutaneous aspiration/ablation therapy may be a feasible option in i l did tpoor surgical candidates

Laparoscopic approaches have proven efficacious for simple cysts and are the treatment modality of choiceand are the treatment modality of choice

Management of specific diseases such as PCLD is more complicated and dictates treatment in centers with hepatobiliary and p ytransplantation expertise


QuestionsQuestions1. Ultrasonography demonstrates a liver cyst with a thick wall

d i Th i h ld b d i dand septations. The patient should be adviseda. To have repeat sonograms every 6 months for 2 yearsb. Interventional radiologist for aspiration and biopsyc. Surgical referral for laparoscopic fenestration d. Surgical referral for complete resection

2. Cyst wall in cases of cystadenomas should bea. Partially resectedb. Completely resectedc. Suture ligatedd. Fenestrated


QuestionsQuestions3. Sclerotherapy with alcohol leads to

a. Necrosis of cyst wallb. Fixation of the cells lining the cyst cavity thus disabling

their ability to secrete fluidc. Is never performed because it leads to cholangitisd. Has 100% success rate

4. Polycystic liver disease is a contraindication for laparoscopic fenestration

a. Trueb. Falsec. I don’t knowd. All of the above


QuestionsQuestions5. Laparoscopic fenestration

a. Has lower recurrence rates than open unroofingb. Is considered the procedure of choice for congenital cystsc Is less morbid than traditional unroofingc. Is less morbid than traditional unroofingd. A is the only incorrect answer!


The End


ReferencesReferences1. P. Schachter et al “The role of laparoscopic ultrasound in the minimally p p y

invasive management of symptomatic hepatic cysts” Surgical Endoscopy 15; 364-367, 2001

2. A. Regev et al “Large cystic lesions of the liver in adults: A 15 year experience in a tertiary center” J Am Coll Surg 193:36 45 2001experience in a tertiary center J Am Coll Surg 193:36-45, 2001

3. J.F. Gigot wt al “The surgical management of congenital liver cysts” Surgical Endoscopy 15: 357-363, 2001

4 MF H t l “M t d l t f ll f h ti4. MF Hansman et al “Management and long term follow up of hepatic cysts” The American Journal of Surgery 181; 404-410, 2001

5. I. Martin et al “Tailoring the Management of nonparasitic liver cysts” Annals of surgey 228; 167-172 1998Annals of surgey 228; 167 172, 1998

6. M. Morino et al “Laparoscopic management of symptomatic nonparasitic cysts of the liver” Annals of Surgery 219, 157-164, 1994


management of hepatic cysts. cyst aspiration is associated with high rates of recurrenceof...

Documents