Hepatic cysts surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

## Overview

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## Surgery

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### Bile Duct Hamartoma

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The management of BDH has two principal considerations. First, if the patient is asymptomatic, it reasonable to observe the patient and not intervene. Second, if there a confident diagnosis that precludes the possibility of a cystadenoma (which some researchers argue can be achieved using MRI) and patient requires an intervention, the consensus is that the operation of choice is a laparoscopic fenestration. This is usually a brief procedure that involves ‘unroofing’ the cyst with minimal – in any – hepatic resection.[1][2][3] These cysts should not be drained percutaneously as they will only reccur and instrumentation can lead to infection.

### Cystadenoma and Cystadenocarcinomas

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The management of choice for cystadenomas is a complete resection, laparoscopic or open. In the event that a cystadenoma is diagnosed on final pathology and the patient only received a laparoscopic fenestration, the options are either re-operation or long-term follow-up abdominal imaging.

### Polycystic Liver Disease

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The management of these cysts is again driven by the patient’s symptoms – namely pain and discomfort – which are attributed to the scale of a patient’s hepatomegaly. When a patient becomes symptomatic, it is generally held that management ought to be aimed at reducing the liver volume. Still, the vast majority of patients, are asymptomatic and need not pursue any intervention. The standard approach ranges from observation to orthotopic liver transplantation.[4] On the horizon, there is encouraging data that the growth of cysts can be slowed and even reversed to a small degree by secretin-antagonizing somatostatin analogues.[5]

The most conservative – or selective – procedures are cyst aspiration with alcohol sclerosis or hepatic artery embolization. These procedures are typically reserved for patients who are not operative candidates. It has long been known that 100% of aspirated PLD cysts will reoccur.[6] Accordingly, many groups have injected various alcohol (and other) preparations to sclerose the cystic epithelium, with better long-term results.[7] Hepatic artery embolization is well-tolerated but less established and only reduces liver volume by 30% on average.[8]

Operative management is the mainstay of symptomatic cyst therapy. The published rates of symptom recurrence following fenestration are variable depending on the series and are as low as 0% or as high as 100%. The same is true for partial hepatectomy, but the proportion of patients with lasting symptom improvement appears to be reliably higher.[9] Furthermore, volume reduction in cyst fenestration is about 9% on average while partial hepatectomy achieves a 57% reduction.[10] Morbidity, however, tends to be greater for PLD patients undergoing hepatectomy than other patients receiving the same operation.[11]

Finally, liver transplantation is the most radical treatment and is typically reserved for the sickest patients. As observed by one group of clinicians, these patients can develop a syndrome of intractable pain, fatigue and cachexia, that has become known as ‘lethal exhaustion.’[12] Although, their liver function is typically preserved, making their Model for End-Stage Liver Disease (MELD) scores largely insufficient to merit allocation of a transplant. Patients must therefore apply for exceptions on a case-by-case basis.

Outcomes after intervention are dependent on the safety of the procedure and the patient's preoperative condition. Five year survival at a large tertiary referral centre after partial hepatectomy with cyst fenestration, cyst fenestration alone, and liver transplantation was 92%, 90%, and 60%, respectively.[13] Other groups have achieved 80% 5-year survivals in patients receiving liver or combined liver-kidney transplantation. [14][15]

### Hydatid Cysts

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The role for an intervention in asymptomatic patients is unclear. The evidence available regarding the natural history of hydatid cysts is sparse, though the little information we have would indicate that more than 75% of asymptomatic patients remain so at 10 years.[16] It is widely agreed that an intervention is indicated for symptomatic hydatid liver cysts and while there are some reports of successful medical treatment with a benzimidazole (albendazole or mebendazole)[17], the gold standard of care is surgery. That said, there has never been a randomized trial of surgical versus medical management.[18]

The interventions at our disposal are percutaneous aspirations (with or without the injection of a sclerosant) – also known as PAIR (puncture, aspiration, injection, and reaspiration) – and operative cyst drainage (laparoscopic or open). Generally, the procedure of choice is guided by the ultrasound-based Gharbi classification of cyst structure[19].

### Percutaneous Procedures

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Percutaneous procedures were once thought to be dangerous with a risk of anaphylaxis, seeding and spillage. Since 1992, however, there has been a growing body of literature attesting to the safety and efficacy of this procedure.[20][21] In a prospective, randomized trial compared to surgical cystectomy, a percutaneous aspiration (with eight weeks of albendazole) was shown to be as safe and efficacious with a shorter hospital stay.[22] Percutaneous procedures are typically limited to cysts of Type 1 through (and rarely) Type 3.

### Operative Management

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Surgery can be accomplished by a laparoscopic or open approach. The laparoscopic approach is typically reserved for cysts that are both accessible given standard port placement and have less complicated structures. Any operation on hydatid cysts have two stages. First, the cyst is evacuated and drained. Second, the cyst cavity is addressed. The options for this stage are partial cystectomy with sclerosis and tube drainage, capitonage (using continuous, opposing sutures to obliterate the cystic cavity), omentoplasty (using vascular omentum to patch the cavity) or cystenterostomy (suturing a roux-en-y bypass to the cavity).

There are two main complications specific to procedures for hydatidosis. First, the cyst can reocurr. The rate of recurrence is 3-16% depending on the procedure, with cystectomy and drainage being the operation with the highest risk for reccurrence. Second, biliary injury can occur, either as a leak or fistula. Fistulae can be managed endoscopically or, if unsuccessful, re-operation.[23][24]

## References

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1. ↑ Katkhouda A et al. Laparoscopic Management of Benign Solid and Cystic Lesions of the Liver. Annals of Surgery 1999; 229(4):460-466.
2. ↑ Gamblin TC, Holloway SE, Heckman JT, Geller DA. Laparoscopic resection of benign hepatic cysts: a new standard. J Am Coll Surg. Nov 2008;207(5):731-736.
3. ↑ apper EB, Adsay NV, Kalb B, Martin D, Kooby D, Sarmiento JM. Symptomatic Bile Duct Hamartomas: Surgical Management in an MRI Driven Practice. J Gastrointest Surg. 2010 May 18. [Epub ahead of print]
4. ↑ Arnold HL et al. New Advances in Evaluation and Management of Patients with Polycystic Liver Disease. Am J Gastroenterol 2005;100:2569–2582
5. ↑ Van Keimpema L et al. Lanreotide Reduces the Volume of Polycystic Liver: A Randomized, Double-Blind, Placebo-Controlled Trial. Gastroenterology 2009;137:1661–1668
6. ↑ Saini S, Mueller P, Ferrucci J, et al. Percutaneous aspiration of hepatic cysts does not provide definitive therapy. Am J Roentgenol 1983;141:559–60.
7. ↑ Tikkakoski T, Makela JT, Leinonen S, et al. Treatment of symptomatic congenital hepatic cysts with single session percutaneous drainage and ethanol sclerosis: Technique and outcome. J Vasc Interv Radiol 1996;7:235–9.
8. ↑ Takei R, Ubara Y, Hoshino J, et al. Percutaneous transcatheter hepatic artery embolization for liver cysts in autosomal dominant polycystic kidney disease.Am J Kidney Dis. 2007;49:744 –752.
9. ↑ Arnold HL et al. New Advances in Evaluation and Management of Patients with Polycystic Liver Disease. Am J Gastroenterol 2005;100:2569–2582
10. ↑ Schnelldofger T et al. Polycystic Liver Disease: A Critical Appraisal of Hepatic Resection, Cyst Fenestration,and Liver Transplantation. Ann Surg 2009;250: 112–118)
11. ↑ Gali B, Findlay JY, Plevak DJ, et al. Right hepatectomy for living liver donation vs right hepatectomy for disease: intraoperative and immediate postoperative comparison. Arch Surg. 2007;142:467– 471
12. ↑ Starzl TE, Reyes J, Tzakis A, et al. Liver transplantation for polycystic liver disease. Arch Surg 1990;125:575–7.
13. ↑ Schnelldofger T et al. Polycystic Liver Disease: A Critical Appraisal of Hepatic Resection, Cyst Fenestration,and Liver Transplantation. Ann Surg 2009;250: 112–118)
14. ↑ Ueno T, Barri YM, Netto GJ, et al. Liver and kidney transplantation for polycystic liver and kidney-renal function and outcome. Transplantation.2006;82:501–507.
15. ↑ Kirchner GI, Rifai K, Cantz T, et al. Outcome and quality of life in patients with polycystic liver disease after liver or combined liver-kidney transplantation.Liver Transplant. 2006;12:1268 –1277.
16. ↑ Frider B et al. Long-term outcome of asymptomatic liver hydatidosis. J Hepatol 1999;30:228-231
17. ↑ Morris DL et al. Albendazole--objective evidence of response in human hydatid disease. JAMA. 1985 Apr 12;253(14):2053-7
18. ↑ Nasseri MS et al. Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003623.
19. ↑ Gharbi HA, Hassine W, Brauner MW, et al. Ultrasound examination of the hydatic liver. Radiology 1981;139:459–463.
20. ↑ Ustunoz A et al. Percutaneous Treatment of Hydatid Cysts of the Liver: Long Term Results. AJR 1999;172:91-96
21. ↑ Nasseri MS et al. Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003623.
22. ↑ Kuroo MS. Percutaneous Drainage Compared with Surgery for Hepatic Hydatid Cysts. N Engl J Med 1997;337:881-7.
23. ↑ Balik AA et al. Surgical Treatment of Hydatid Disease of the Liver: Review of 304 Cases.Arch Surg. 1999;134:166-169
24. ↑ Yagci G et al.Results of Surgical, Laparoscopic, and Percutaneous Treatment for Hydatid Disease of the Liver: 10 Years Experience with 355 Patients. World J Surg (2005) 29: 1670–1679

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