surgical treatment of hydatid disease of the liver 25 años experiencia

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The American Journal of Surgery (2011) 201, 797–804

Clinical Science

Surgical treatment of hydatid disease of the liver:25 years of experience

Sandro Tagliacozzo, M.D., Michelangelo Miccini, Ph.D.,Stefano Amore Bonapasta, M.D., Matteo Gregori, M.D., Adriano Tocchi, M.D.*

Division of Gastroenterologic and Hepato-Bilio Pancreatic Surgery, First Department of Surgery, Sapienza University
Medical School, Rome, Italy
AbstractBACKGROUND: The aim of this study was to evaluate the results of conservative and radical

treatment of liver hydatid disease.METHODS: Records of patients who underwent surgery for liver hydatid disease between 1980 and 2005

were reviewed. Outcomes measured were operative morbidity and mortality, hospital stay, and recurrence.RESULTS: Two hundred fourteen patients underwent conservative treatment (external drainage,

marsupialization, omentoplasty), and 240 had radical surgery (hepatic resection, cystopericystectomy).Operative morbidity was 79.9% and 16.2% for conservative and radical procedures, respectively (P �.001). Operative mortality was 6.5% for conservative procedures and 9.2% for radical procedures (P �.3). The recurrence rate was 30.4% in patients having conservative surgery and 1.2% in patientsundergoing radical surgery (P � .001). No recurrences occurred in patients with clear cysts afterconservative surgery.

CONCLUSIONS: Cystopericystectomy was a safe and effective procedure that achieved excellentimmediate and long-term results. Hepatic resection should be considered only in exceptional cases,because it involves the unnecessary sacrifice of healthy hepatic parenchyma. Conservative surgery andalternative procedures should be restricted to the treatment of clear cysts and to patients who cannotundergo radical surgery.© 2011 Elsevier Inc. All rights reserved.

KEYWORDS:Liver hydatid disease;Cystopericystectomy;Hepatic resection

Hydatid disease (HD) is a zoonotic disease caused by thelarval form of Echinococcus. The most common form is Eranulosus, which gives rise to cysts, primarily in the liver.D has a worldwide distribution and is endemic in many

ountries in the Mediterranean region, the Middle East andar East, and South Africa.1 Because of increasing immi-

gration, the disease is becoming more frequent outside en-demic areas. In recent years, knowledge of its etiology and

* Corresponding author. Tel.: 39-6-4462127; fax: 39-6-4959357.E-mail address: [email protected] received December 2, 2009; revised manuscript February

, 2010

002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved.oi:10.1016/j.amjsurg.2010.02.011

pathogenesis has largely contributed to improved preven-tion and reduced the incidence of HD.2,3 Clarifying someaspects of the biology of the parasite and of its interactionwith the human host represents the scientific basis for amore rational approach to surgery of liver HD (LHD).4–6

Pathophysiologic basis of surgical management

The adult tape worm consists of a head (scolex) and 3following segments (proglottides). The scolex has 4 suckersand a prominent rostellum armed with a double row of 30 to36 hooks. Sexual, mature organs and countless eggs are
contained in the more distal of the 3 proglottides. Each egg
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798 The American Journal of Surgery, Vol 201, No 6, June 2011

consists of a shell containing 6 hook-armed embryohexacanth (6 hooks), as shown in Figure 1. The adult tape-worm lives in the small bowel of its most common defini-tive host, the dog, attached to the mucosa by its hooklets.Infected eggs pass out with dog feces and contaminate soil,water, and plants. Humans become infected via accidentalingestion of eggs. Once inside the human intestine, the eggsopen, and the embryo hexacanth attaches to and then crossesthe intestinal mucosa and via the portal system migrates tothe liver, where the parasite develops into the larval stage,which is the hydatid cyst. The growth of the cyst leads to theformation of a connective lamina in the surrounding paren-chyma (ectocyst or pericyst). The parasite-derived endocystmay consist of either 1 or 2 layers. The outer one, thelaminated layer, is a totally acellular membrane permeableto water and electrolytes, which protects the cyst from hostenzymes, bile, and bacteria. The inner layer, the germinallayer, is the living element of the parasite (Fig. 2). Cystswith the sole laminated layer are sterile cysts, also calledunivesicular or clear cysts, whereas cysts provided withboth laminated and germinal layers are fertile or multive-sicular cysts. Invaginations of the germinal layer form broodcapsules, each containing 5 to 10 protoscolices. When broodcapsules open, protoscolices are released into the cysticfluid, giving rise to daughter cysts, a process called endo-genic vesiculation. The process of vesiculation occurs notonly inside but also outside the cyst within the pericyst(exogenous vesiculation).

We have retrospectively reviewed and analyzed thechanges in the approach and results of surgical treatment of

Figure 1 Echinococcus granulosus. Adult form of tapeworm.E � egg; H � hook; P � proglottides; S � head or scolex; SO �
sexual organs.
LHD according to our evolving, personal knowledge of thepathophysiology of the parasite.

Methods

Patients

Patients were identified by a computer-based indexingsystem containing data on all patients admitted for LHD atthe First Department of Surgery of the University of Rome“La Sapienza” Medical School between January 1, 1980,and January 1, 2005. The overall study group was dividedinto 2 subgroups: group A (1980–1992) and group B(1993–2005). Criteria for exclusion from this study wereprevious medical or surgical treatment for HD, concomitantextrahepatic HD, and the presence of a bronchobiliary fis-tula. No laparoscopic procedure was performed in the cur-rent series. Suitable records of all patients were extractedfrom the computer database and retrospectively analyzed.Variables considered for analysis were age, gender, lengthof clinical history, number of hepatic cysts, and site. Ac-cording to their location, cysts were divided into superficialand deep or vasculobiliary cysts. Cysts extrinsic to thehepatic parenchyma, however distant from main intrahe-patic vessels and vena cava, were defined as superficialcysts. Cysts deeply located in the hepatic parenchyma, nearthe pedicles and stems of the main intrahepatic vessels and

Figure 2 Schematic drawing of a liver hydatid cyst. BC � broodapsule; DC � daughter cyst; GL � germinal layer; L � liver;L � laminated layer; P � pericyst; S � protoscolex.

vena cava, were defined as vasculobiliary cysts. Further-

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799S. Tagliacozzo et al. Surgical treatment of hepatic hydatidosis

more, cysts were classified according to their content asclear or sterile cysts and multivesicular or fertile cysts.Comorbidity, surgical procedures used, operative morbidityand mortality, length of postoperative hospital stay, andrecurrence were other variables considered.

Surgery

Surgical access consisted of laparotomy (median or sub-costal incision) and, mostly in the first period, thoracoph-renolaparotomy. Surgical procedures were classified as rad-ical or conservative. Liver resection, cystopericystectomy(CP), and subtotal pericystectomy were grouped as radicalprocedures and partial cystectomy with tube drainage,omentoplasty, or “capitonage” as conservative approaches.All clear cysts were treated with conservative procedures.Radical and conservative procedures were never done to-gether. Intraoperative cholangiography was always associ-ated with both types of procedures. Cholecystectomy andeither surgical papillotomy or T-tube biliary drainage wereassociated when cystobiliary communication or elevatedpressure in the biliary tract were detected by intraoperativecholangiography and in case lesions of the intrahepaticbiliary system were determined during the course of sur-gery. More recently, in case of preoperative diagnosis ofcystobiliary communication, the biliary tract has beencleared preoperatively by endoscopy. All surgical proce-dures were performed by 2 of the authors (S.T., A.T.).

Outcomes

The early outcome was determined from the medical

Table 1 Clinical and demographic data

Variable Value

Age (y) 51 (15–77)Gender

Male 152 (33.5%)Female 302 (66.5%)

Clinical presentationAbdominal pain 328 (72.2%)History of jaundice 315 (69.3%)Abdominal mass 281 (61.8%)History of fever 124 (27.3%)Nausea and vomiting 106 (23.3%)Asymptomatic 43 (9.4%)

Duration of symptoms (mo) 16 (2–72)Comorbidity

Obesity* 32 (7.0%)Cardiovascular disease 28 (6.1%)Lung disease 11 (2.4%)Diabetes mellitus 10 (2.2%)Neurologic disease 7 (1.5%)

Data are expressed as mean (range) or as number (percentage).*Body mass index �30 kg/m2.

records. Postoperative complications were classified as lo-

cal when they occurred at the site of surgery or as generalcomplications otherwise. After discharge, patients were fol-lowed periodically in the 3rd, 5th, and 12th postoperativemonths during the first year and thereafter every year. Thefollow-up procedures included physical examination, sero-logic tests, plain abdominal radiography, and ultrasound andcomputed tomography after these diagnostic procedures be-came available. The median follow-up period was 87months (range, 36–190 months). The last control was per-formed in January 2009. Reappearance of live cysts at thesite of a previously treated cyst was defined as local recur-rence.

Histology

Histology of the cystic wall and pericyst was performedin all specimens from radical procedures.

Statistical analysis

Comparisons of the continuous variable were performedusing Student’s t test, and categorical variables were com-pared using Pearson’s �2 test. Statistical analyses were per-ormed with Statistica 5’97 (StatSoft, Inc, Tulsa, OK).

values �.05 were regarded as statistically significant.

Results

The present study included 454 patients. Table 1 liststheir demographic and clinical characteristics. Results ofserologic tests (hemagglutination, complement fixation)were positive in 69% of 454 patients. A total of 695 hepaticcysts were treated. Table 2 shows the characteristics of thecysts and their distribution. Cysts were solitary in 296 pa-

Table 2 Characteristics of cysts

Variable Value

Total number 695Type

Multivesicular 639 (87.7%)Clear 56 (12.3%)

Size (cm) 19 (3–41)Number of cysts per patient

1 296 (65.1%)2 103 (22.6%)3 34 (7.4%)�3 21 (4.6%)

LocationRight lobe 458 (65.8%)

Deep 314 (68.5%)Left lobe 203 (29.2%)

Deep 72 (35.4%)Bilobar 34 (4.8%)

Deep 31 (91.1%)

Data are expressed as number (percentage) or as mean (range).


tients and multiple in 158 (one lobe in 85, both lobes in 73).A total of 417 cysts were classified as deep: 314 were sitedin the right lobe, 72 in the left lobe, and 31 in both lobes.Fifty-six cysts were clear (sterile cysts), and 639 were mul-tivesicular. Migration of daughter cysts into the commonbile duct was documented in 71 patients. A conservativeapproach was adopted in 214 patients (319 cysts), whereas240 patients (376 cysts) were treated with radical proce-dures (Table 3). No differences were found in age andgender between these groups.

The local complication rates and hospital stays weresignificantly superior in patients who underwent conserva-tive procedures. No main differences in general complica-tions, with the exception of pleural effusion, were observedin patients treated with conservative or radical procedures.Operation time was significantly shorter for conservativetreatment, which, moreover, required fewer blood transfu-

Table 3 Surgical treatments

Treatment Number of Patients

Radical treatment 240Hepatic resection 73

Right extended 3Right 8Left 18Sectoriectomy 44

CP 167Total 138Subtotal 29

Conservative treatment 214Marsupialization 75External drainage 87Omentoplasty 52

Table 4 Outcomes of radical and conservative procedures

Radical ProcedureOutcome (n � 240)

Local operative complications 39 (16.2%)Biliary leaks 11 (4.6%)Residual cavity infection 11 (4.6%)Residual cavity hematoma 17 (7.1%)General complications 18 (7.5%)Pleural effusion 3 (1.2%)Pulmonary embolism 2 (.8%)Cardiac failure 5 (2.1%)Respiratory failure 2 (.8%)Renal Failure 0Hepatic failure 6 (2.5%)Hospital stay (d) 13.8Recurrences 3 (1.2%)Operation time (min) 281 (240–420)Blood transfusion (L) 3.53 (2–6)Operative mortality 22 (9.2%)

Data are expressed as number (percentage) or as mean (range).*Fifty-six of 214 patients treated with conservative procedures had

multivesicular cysts.

sions. Operative mortality was not significantly differentbetween conservative (6.5%) and radical (9.2%) procedures(Table 4). The number and type of surgical associated pro-cedures were similar in the 2 groups (Table 5). The presenceof daughter cysts outside the cystic wall was observed onhistology in 67 of the 376 specimens (17.8%) from radicalprocedures. The incidence of recurrence was 30.4% in pa-tients who underwent conservative surgery and 1.2% inpatients treated with radical procedures (Table 4). No re-currence was observed in patients with clear cysts.

Table 6 shows a comparison between the 2 subgrouptime periods. Local complication and recurrence rates de-creased from 62% to 32% and from 15% to 8%, respec-tively, between the 2 time periods.

Comments

The desired goals for the treatment of LHD includecomplete elimination of the parasite and prevention of re-current disease with minimum mortality.7 However, selec-

Conservative Procedures(n � 214) P

171 (79.9%) �.00165 (30.4%) �.00180 (37.4%) �.00126 (12.1%) .065 (NS)29 (13.6%) .03417 (7.9%) �.0011 (.5%) .630 (NS)4 (1.9%) .870 (NS)6 (2.8%) .111 (NS)1 (.5%) .289 (NS)

0 .01933.7 �.001

48 (30.4%)* �.001200 (110–261) �.001

r1.35 (0–4) �.00114 (6.5%) .301 (NS)

clear cysts. The rate of recurrence was calculated in 158 patients with

Table 5 Associated procedures

Associated ProcedureRadicalTreatment

ConservativeTreatment

Cholecystectomy 45 38Cholecystectomy � papillotomy 17 19Cholecystectomy � T-tube 9 17Papillotomy 3 5Choledochotomy � T-tube 2 4Endoscopic sphincterotomy 3 2

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tion of the most appropriate treatment to achieve these goalsremains the subject of debate, and 3 main approaches areused to date: systemic chemotherapy, percutaneous proce-dures, and surgical treatment. Systemic chemotherapy ispresently based on benzimidazole carbamate compounds.However, the clinical efficacy of these treatments is notclear; complete regression of cysts has never been reported,whereas persistence of living parasite within the cysts hasbeen documented in �50% of the patients being treatedpreoperatively with benzimidazole compounds.8–11 There-fore, the World Health Organization has suggested restrict-ing the use of medical treatment for disseminated systemicdisease, cases that are not amenable to surgery, and in whichknown intra-abdominal spillage of hydatid fluid has oc-curred, and combined with surgery to prevent postoperativerecurrence.9 Percutaneous procedures have been proposedmore recently.12–14 The main shortcomings of these tech-iques are incomplete evacuation of the cyst content, diffi-ulty in achieving adequate scolicidal concentration, doubtbout the right exposure time, and sclerosing cholangitis inase of cystobiliary communication.15–18 The use of percu-aneous treatment seems to represent an alternative treat-ent in patients who cannot undergo or refuse surgery.urgery thus remains the first-line treatment for LHD. How-ver, there is considerable disagreement about the optimalurgical technique.16,19–22 The major issue is whether com-lete removal of the pericyst is necessary for the proper caref the disease. Proposed surgical procedures can be dividednto 2 groups: conservative procedures and radical proce-ures.

Conservative procedures have been defined as those lim-ted to evacuation of cyst content with part or all the pericystemaining in situ. These techniques, as suggested, should bereferred to radical procedures because they are safer andasier to perform.20,23,24 However, nonnegligible drawbacks

have been reported to affect the outcomes of conservativeprocedures. The main immediate postoperative complica-tions are biliary leakage and fistulas, along with septic

Table 6 Comparison of surgical procedures and main outcome

Group A (1980–1Variable (n � 213)

ProcedureConservative procedures 151 (70.9%)

External drainage 71Marsupialization 44Omentoplasty 36

Radical procedures 62 (29.1%)Hepatic resections 37Pericystectomy 25

OutcomesLocal operative complications 132 (61.9%)General complications 24 (11.3%)Recurrences 32 (15%)Operative mortality 17 (8%)

complications of the residual cavity leading to prolonged

hospital stays.10,21,25 Most of these complications may beascribed to the pericyst lining the residual cavity. A pericystleft in situ, especially if thick and calcified, represents anobstacle to liver regeneration filling the residual cavity, thusleading to serum and blood accumulation or liver abscessformation. Furthermore, the persistence of the pericyst hidespossible biliary communication in the residual cavity, con-sidered the main reason for biliary leakage, which occurs inup to 50% of patients after conservative procedures.26 How-ever, it should be stressed that even when biliary commu-nications are identified, their closure within a stiff, calcifiedpericyst wall would not be easy or effective. The incidenceof biliary leaks and residual cavity infection in patients ofour series treated with conservative procedures was 30.4%and 37.4%, respectively. These data, consistent with thoseof other authors, confirm conservative surgery as a signifi-cant determinant of high complication rates and prolongedhospital stays.27–30 Furthermore, infection, biliary fistula,and slow reduction of the cyst cavity may lead to moreserious complications, such as obstruction of main hepaticducts or the portal vein.31,32 In these cases, reoperation isuite complex, with high mortality due to the technicalifficulties related to distorted liver anatomy, deterioratediver function, and poor general conditions.22

Radical procedures include CP and hepatic resection.Hepatic resection has seldom been considered the principaltechnique to adopt when treating LHD. The notable devel-opment of liver resection surgery in more recent years hasnot changed this trend, so the rate of hepatic resectionsrarely exceeds 10% in different series.15,19,22,25 In our se-ries, the rate of hepatic resections was much higher becausemany patients referred from general hospitals to our tertiaryreferral center had extremely large or multiple localizedcysts responsible for diffuse parenchymal damage. Resec-tions were adopted in these cases because entire sectors,lobes, or hemilivers were destroyed by the cysts, and inter-ruption of main bile ducts would have made their repairquestionable because of an extremely high risk for serious

een the 2 subgroups

Group B (1993–2005)(n � 241) P

63 (26.1%) �.001163116

178 (73.9%) �.00136

142

78 (32.4%) �.00123 (9.5%) .547 (NS)19 (7.9%) .01619 (7.9%) .969 (NS)

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cholerrhagia. With the exception of these particular cases,


our policy has been to avoid liver resection to spare as muchhealthy hepatic parenchyma as possible at the first surgery.This trend has led us to use CP more frequently.

The purpose of CP is the complete removal of the cystalong with its pericyst (CP) without opening the cavity; thisavoids contamination of peritoneum and the risk for leavingbehind daughter cysts within the pericyst in the hepaticparenchyma.15,19,22,30,33,34 CP may be performed either as aclosed or open procedure. The closed procedure was usedmainly in patients with superficial cysts or single-lobe deepcysts. Open CP was performed every time there was a riskfor breaking the cyst wall, in case of cysts of the hepaticdome, strictly adherent to the hepatic veins and vena cava,and in case of deep intraparenchymal cysts with an inter-portocaval location. Both in open and closed procedures, thehepatic lobes were fully mobilized to control the confluenceof the hepatic veins and inferior vena cava as well as theretrohepatic segment of the vena cava and vascular andbiliary elements of the hepatic hilum. In the open method,after evacuation of its content, the cavity is stubbed withswabs soaked in sterilizing substances. The cyst wall is thensectioned and dissection is carried out by molding with theleft hand the residual pericyst to enhance the visual controlof its relationship with the surrounding parenchyma andafferent vessels and biliary duct (Fig. 3). For the deep,interportocaval location, the access to the cyst is greatlyfavored by opening the median fissure, which increases theextension of the cystic wall (Fig. 4). Completion of thedetachment of the residual, deep pericyst from the hepaticparenchyma may be further eased by dividing it into seg-ments and performing the separate dissection of each seg-ment after it has been refolded on itself (Fig. 5). In case ofhard, calcified pericysts strongly adherent to main vessels,

Figure 3 Open pericystectomy. The cyst has been opened andits contents evacuated. The visual control of the relationship be-tween the cystic wall and hepatic parenchyma are in this way
enhanced.
especially to the vena cava, it is advisable to stop dissectionjust before the vascular plane and to leave behind a smallpart of the cystic wall (partial CP) (Fig. 6).

Overall postoperative complications and hospital staysassociated with radical procedures in our series were strik-ingly lower compared with those after conservative proce-dures. Complete removal of the pericyst allows the exact

Figure 4 Deep interportocaval cysts. The access to the cyst iseffectively eased by opening the sagittal fissure.

Figure 5 Dissection of the pericyst is eased by dividing thedeepest part of it into segments that are refolded and separately
dissected.

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detection and safe direct suture in healthy hepatic paren-chyma of biliary and vascular breaches and thus minimizesthe risk for biliary leaks and blood collection. Furthermore,the easy approach of the smooth parenchymal limbs pro-motes the spontaneous reduction of the residual cavitybrought about by natural liver regeneration. Local recur-rence represents a major concern in the treatment ofLHD.35–37 The cause of local recurrence is failure to remover kill all viable cysts and protoscolices at the time ofurgery. Better understanding of certain aspects related tohe survival of infectious agents, mainly exogenous vesic-lation, has shed new light on this argument. Exogenousesiculation, detected in 20.2% of specimens of our serieserived from radical surgery, suggests that this would haveeen the rate of recurrence if conservative procedures hadeen performed in these patients. This rate, evocativelyimilar to the 22.4% recurrence rate observed in all theatients of our series treated with conservative surgery,orresponds to the mean rate of recurrences reported initerature.28,36 The cyst content, which may change fromlear, that is, sterile cysts, to multivesicular with daughterysts, makes it necessary to consider these 2 kinds of cystss different pathologic entities. The absence of the germinalayer excludes clear cysts from the risk for vesiculation, thats, recurrences. In our series, the rate of recurrences in 56reated clear cysts by conservative procedures was nil. Con-ervative procedures should then, quite rightly, be consid-red an adequate treatment for clear cysts. Mixing the re-ults of conservative treatment of clear and multivesicularysts inevitably would introduce, and has introduced in theiterature, a bias that decreases the true rate of immediatend long-term failures of conservative treatment of multi-

Figure 6 Partial pericystectomy. Dissection of the cystic wallhas been stopped and a plug of the calcified pericyst left in situadherent to the vena cava.

esicular cysts. The local recurrence rate following conser-

ative treatment, calculated by removing the results of the6 patients with clear cysts, grew in our series from 22.4%o 30.4%.

In conclusion, the use of radical procedures for treatingHD have been confirmed by the results in our series. These

echniques should be considered safe and effective, espe-ially at high-flow hepatic surgery centers, because they aressociated with an excellent morbidity and mortality ratesnd because the recurrence rate is reduced almost to zero.P should be preferred to hepatic resection whenever pos-

ible because it avoids the undue sacrifice of healthy liverarenchyma. Alternative treatments and conservative surgi-al procedures should be restricted to clear cysts, severely illatients, and situations in which the pericyst tissue stronglydheres to main vessels.

References

1. Richards KS. Biology of Echinococcus and diagnosis of hydatid dis-ease. In Morris DL, Richards KS, eds. Hydatid disease: current med-ical and surgical management. Oxford, UK: Butterworth Heinemann;1992:1–24.

2. Gemmel MA. Australasian contributions to an understanding of theepidemiology and control of hydatid disease caused by Echinococcusgranulosus—past, present and future. Int J Parasitol 1990;20:431–56.

3. Eckert J, Gemmel MA, Matyas Z, et al. Guidelines for surveillance,prevention and control of Echinococcosis/hydatidosis. Geneva, Swit-zerland: World Health Organization; 1984:1–5.

4. Richards KS, Morris DL. Evidence for the development of humanhydatid daughter cysts for protoscolices. Parasitol Res 1989;75:333–4.

5. Tagliacozzo S. Chirurgia della idatidosi epatica. EMSI 1997.6. Bourgeon R, Isman H, Brisard M. Le perikyste et la perikystectomie

au cours du kyste hydatique du foie: a propos de 178 observations.J Chir (Paris) 1979;116:693–8.

7. Gokskoy E, Saklal M, Saribeyoglu K, et al. Surgery for Echinococcuscysts of the liver. Chirurg 2008;79:729–37.

8. Schantz PM. Effective medical treatment for hydatid disease? JAMA1985;253:2095–7.

9. Davis A, Pawlowski ZS, Dixon H. Multicentre clinical trials of benz-imidazole carbamates in human echinococcosis. Bull World HealthOrgan 1986;64:383–8.

10. Falagas M, Bliozotis I. Albendazole for the treatment of human echi-nococcosis: a review of comparative clinical trials. Am J Med Sci2007;334:171–9.

11. Monterola M, Monsilla JA, Fonseca F. Preoperative albendazole andscolices viability in patients with hepatic echinococcosis. World J Surg2005;29:750–3.

12. Mueller PR, Dawson SL, Ferrucci JT Jr, et al. Hepatic echinococcalcyst: successful percutaneous drainage. Radiology 1985;155:627–8.

13. Akhan O, Ozmen MN. Percutaneous treatment of liver hydatid cysts.Eur J Radiol 1999;32:76–85.

14. Saremi F, McNamara TO. Hydatid cysts of the liver: long-term resultsof percutaneous treatment using a cutting instrument. AJR Am JRoentgenol 1995;165:1163–7.

15. Sayek I, Onat D. Diagnosis and treatment of uncomplicated hydatidcyst of the liver. World J Surg 2001;25:21–7.

16. Dawson JL, Stamatakis JD, Stringer MD, et al. Surgical treatment ofhepatic disease. Br J Surg 1988;75:946–50.

17. Belghiti J, Benhamau JP, Perniceri T, et al. Sclerosing cholangitis. Acomplication of surgical treatment of hydatid disease of the liver. ArchSurg 1986;121:1162–5.

18. Polo JR, Garcia SL. Sclerosing cholangitis associated with hydatid
liver disease. Arch Surg 1987;124:637.


19. Cirenei A, Bertoldi I. Evolution of surgery for liver hydatidosis from1950 to today: analysis of personal experience. World J Surg 2001;25:87–92.

20. Safioleas MC, Misiakos EP, Kouvaraki M, et al. Hydatid disease of theliver. A continuing surgical problem. Arch Surg 2006;141:1101–8.

21. Chadli D, Haouet K, Fingerhut A. Treatment of hydatid cyst of theliver: where is the evidence? World J Surg 2004;28:731–6.

22. Gonzales ME, Selas PR, Martinez B, et al. Result of surgical treatmentof hepatic hydatidosis: current therapeutic modification. World J Surg1991;15:254–63.

23. Langer JC, Rose DB, Keystone JS, et al. Diagnosis and managementof hydatid disease of the liver. A 15-year North America experience.Ann Surg 1984;199:412–7.

24. Safioleas M, Misiakos EP, Kakisis J, et al. Surgical treatment of humanechinococcosis. Int Surg 2000;85:358–65.

25. Kayaalp C, Sengul N, Akoglu M. Importance of cyst content inhydatid liver surgery. Arch Surg 2002;137:159–63.

26. Association Universitaire de Recherche en Chirurgie, Association deRecherche Chirurgie, Association de Chirurgiens de l’Assistance Pub-lique pour les Evaluations Medicales, Chipponi J, Huguier M. Leskystes hydatiques du foie operes en France: epidemiologie, attitudesdiagnostiques et therapeutique: etude de 306 cas. Gastroenterol ClinBiol 1986;10:419–23.

27. Agaoglu N, Türkyilmaz S, Arslan MK. Surgical treatment of hydatid
cysts of the liver. Br J Surg 2003;90:1536–41.
28. Yorganci K, Sayek I. Surgical treatment of hydatid cysts of the liver inthe era of percutaneous treatment. Am J Surg 2002;184:63–9.

29. Zaouche A, Haouet K, Jouini M, et al. Management of liver hydatidcysts with a large biliocystic fistula: multicenter retrospective study.Tunisian Surgical Association. World J Surg 2001;25:28–39.

30. Magistrelli P, Masetti R, Coppola R, et al. Surgical treatment ofhydatid disease of the liver. A 20-year experience. Arch Surg 1991;126:518–23.

31. Leese T, Bismuth H. Surgical management of space-occupying lesionsin the liver. Clin Gastroenterol 1989;3:253–77.

32. Demirci S, Eraslan S, Anadol E, et al. Comparison of the result ofdifferent surgical techniques in the management of hydatid cysts of theliver. World J Surg 1989;13:88–90.

33. Belli L, Aseni P, Rondinara GF, et al. Improved results with pericys-tectomy in normothermic ischemia for hepatic hydatidosis. Surg Gy-necol Obstet 1986;163:127–32.

34. Siellaff TD, Taylor B, Langer B. Recurrence of hydatid disease. WorldJ Surg 2001;25:83–6.

35. Hildago PM, Barquet N. Hidatidosis hepatica: studio de una serie de7.435 casos. Rev Esp Enferm Apar Dig 1987;71:103–9.

36. Mottaghian H, Saidi F. Post-operative recurrence of hydatid disease.Br J Surg 1978;65:237–42.

37. Yagci G, Ustunsoz B, Kaymakcioglu N, et al. Results of surgical,laparoscopic, and percutaneous treatment for hydatid disease of theliver: 10 years experience with 355 patients. World J Surg 2005;29:
1670–9.

surgical treatment of hydatid disease of the liver 25 años experiencia

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