Applying LASSO logistic regression for the prediction of biliary complications after ex vivo liver resection and autotransplantation in patients with end-stage hepatic alveolar echinococcosis.

BACKGROUND: The purpose of this study was to explore the relevant risk factors associated with biliary complications (BCs) in patients with end-stage hepatic alveolar echinococcosis (HAE) following ex vivo liver resection and autotransplantation (ELRA) and to establish and visualize a nomogram model. METHODS: This study retrospectively analysed patients with end-stage HAE who received ELRA treatment at the First Affiliated Hospital of Xinjiang Medical University between August 1, 2010 and May 10, 2023. The least absolute shrinkage and selection operator (LASSO) regression model was applied to optimize the feature variables for predicting the incidence of BCs following ELRA. Multivariate logistic regression analysis was used to develop a prognostic model by incorporating the selected feature variables from the LASSO regression model. The predictive ability, discrimination, consistency with the actual risk, and clinical utility of the candidate prediction model were evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). Internal validation was performed by the bootstrapping method. RESULTS: The candidate prediction nomogram included predictors such as age, hepatic bile duct dilation, portal hypertension, and regular resection based on hepatic segments. The model demonstrated good discrimination ability and a satisfactory calibration curve, with an area under the ROC curve (AUC) of 0.818 (95% CI 0.7417-0.8958). According to DCA, this prediction model can predict the risk of BCs occurrence within a probability threshold range of 9% to 85% to achieve clinical net benefit. CONCLUSIONS: A prognostic nomogram with good discriminative ability and high accuracy was developed and validated to predict BCs after ELRA in patients with end-stage HAE.

Liver resection with two-step vascular exclusion, in situ hypothermic portal perfusion for the treatment of end-stage hepatic alveolar echinococcosis.

PURPOSE: To evaluate the safety and efficacy of two-step vascular exclusion and in situ hypothermic portal perfusion in patients with end-stage hepatic hydatidosis. METHODS: This study involved patients with advanced hepatic hydatid disease undergoing surgical treatment between 2022 and 2023, which included resection and reconstruction of the hepatic veins, inferior vena cava (IVC), and portal vein (PV). We described the technical details of liver resection and vascular reconstruction, as well as the use of two-step vascular exclusion and in situ hypothermic portal perfusion techniques during the vascular reconstruction process. RESULT: We included 7 patients with advanced hepatic hydatid disease who underwent surgical resection using two-step vascular exclusion and in situ hypothermic portal perfusion. The mean duration of surgery was 12.5 h (range, 7.5-15.0 h). The average hepatic ischemia time was 45 min (range, 25-77 min), while the occlusion time of the IVC was 87 min (range, 72-105 min). The total blood loss was 1000 milliliters (range, 500-1250 milliliters). Postoperatively, patients exhibited good recovery of liver and renal function. The mean ICU stay was 2 days (range, 1-3 days), and the mean postoperative hospital stay was 13 days (range, 9-16 days), with no Grade III or above complications observed during a mean follow-up period of 15 months (range, 9-24 months), CONCLUSION: two-step vascular exclusion and in situ hypothermic portal perfusion for surgical resection of end-stage hepatic hydatid disease is safe and effective. This significantly reduces the anhepatic time.

Disasters that develop in the liver due to hydatid cyst: a case report.

Hilar cavernous transformation is the formation of venous structures rich in collateral around the portal vein. Portal vein thrombosis is a rare entity. Although there are many reasons for its etiology, few cases have been reported secondary to hydatid cysts in the liver. Here, we present a 24-year-old patient with complaints of abdominal pain and swelling. Her CT and MRI scans show cholelithiasis with portal vein thrombosis and hilar cavernous transformation due to giant hydatid cyst compression in the lateral liver sector.

La transformación cavernosa hiliar es la formación de estructuras venosas ricas en colaterales alrededor de la vena porta. La trombosis de la vena porta es una afección poco frecuente. Aunque existen muchas razones en su etiología, se han descrito pocos casos secundarios a quiste hidatídico en el hígado. Aquí se presenta el caso de una paciente de 24 años con quejas de dolor abdominal e hinchazón. La tomografía computarizada y la resonancia magnética mostraron colelitiasis con trombosis de la vena porta y transformación cavernosa hiliar por compresión del quiste hidatídico gigante en el sector lateral del hígado.

Treatment Options and the Management of Complications in Hydatid Cysts of the Liver in Endemic Regions.

BACKGROUND: Hydatid cyst of the liver induced by Echinococcus granulosus is a pervasive zoonotic disease in our region. Its incidence varies across age groups, contingent on community lifespans and hygiene standards. Therapeutic modalities include Puncture, Aspiration, Injection, Re-aspiration (PAIR), and surgery. Due the limited feasability of PAIR, we suggest that surgery represents the optimal treatment in all stages, especially in endemic regions, depending on patient-specific variables. METHOD: Patients with hydatid cyst of the liver treated with PAIR and surgery in our center between January 2016 and January 2022 were analyzed retrospectively. PAIR or cystectomy were applied in treatment. These were then compared in terms of efficacy, feasibility, and complications. RESULTS: A single hydatid cyst of the liver was detected in 184 of the 225 cases, two cysts in 33, and three or more cysts in eight. The largest cyst diameter was 233 × 124 mm in the surgery group and 100 × 90 mm in the PAIR group. One hundred thirty-three of the 225 patients underwent open surgery, and no recurrence was encountered in these. However, recurrence was observed 19 patients treated with PAIR. Allergic reaction developed in one case during surgery, postoperative abscess in two cases, biliary fistula in five, and pneumonia in one. CONCLUSION: Surgical treatment should represent the standard procedure since it is safe and effective, ensures complete elimination of the parasite, involves no intraoperative shedding, preserves healthy tissues, and minimizes the risk of long-term recurrence and cavity-related complications.

Treatment of Cavernous Transformation of Portal Vein Caused by Hepatic Cystic Echinococcosis Using Ex Vivo Liver Resection and Autotransplantation.

BACKGROUND Hepatic cystic echinococcosis (HCE) is a frequently overlooked parasitic liver disease, for which the commonly recommended treatment is radical resection. However, this approach is often associated with severe comorbidities such as HBV/HCV, cirrhosis, and hepatic carcinoma, among others. CASE REPORT In this report, we present a case successfully managed by ex vivo liver resection and autologous liver transplantation (ELRA). In the described case, ex vivo resection was not feasible due to recurrent lesions and infections invading the portal vein, which resulted in portal vein cavernous transformation. CONCLUSIONS Through this paper, we aim to detail the treatment process, showcasing the feasibility and advantages of ELRA. Additionally, we propose a novel approach for the treatment of this disease, while emphasizing the importance of radical resection surgery to prevent long-term complications.

Cystic Echinococcosis of the Liver: Correlation Between Intra-Operative Ultrasound and Pre-Operative Imaging.

Background: Imaging plays an essential role in the management of hepatic hydatid cysts (HCE). The objective of our study was to determine the correlation between pre-operative ultrasound, computed tomography (CT), and intra-operative ultrasound (IOUS) in studying the characteristics and complications of HCE. Patients and Methods: This was a prospective, descriptive, and analytical study conducted in the General Surgery Department of Habib Bourguiba Hospital in Sfax. The study included patients with HCE who underwent conservative surgery between April 2017 and June 2022. Results: We enrolled 49 patients with 94 cysts. At the end of our study, IOUS allowed for better detection of HCE (98.8%) regardless of the number of cysts per patient. IOUS and CT were accurate in studying the location of cysts (κ = 1), whereas pre-operative abdominal ultrasound was less efficient (κ = 0.870). IOUS was the best examination for detecting exocysts (κ = 0.961), studying daughter cysts (κ = 0.823), and exploring vascular relations, but it was less effective (κ = 0.523) in detecting calcifications. Regarding classifications, ultrasound and CT had similar results. However, IOUS was most reliable in differentiating between CE3b and CE4 types (κ = 0.653). Ultrasound, CT, and IOUS were not sensitive in detecting latent HCE suppurations and cystobiliary fistulas. Conclusions: Performing IOUS is essential to prevent recurrences and reduce post-operative morbidity.

Predictive factors of occult cystobiliary fistulas during conservative treatment of hepatic hydatid cyst: a prospective study.

BACKGROUND: Occult cystobiliary fistula (CBF) is a common complication of hepatic hydatid cyst (HHC). It is often the cause of high morbidity of conservative treatment of HHC. This study aimed to determine the predictive factors of occult CBF to establish the indications for the investigation and treatment of these CBFs. METHODS: This was a prospective study that included all operated HHCs over a 3-year period. HHCs complicated with large CBFs were not included in the study. Systematic cholecystectomy and methylene blue test for all cysts were performed. RESULTS: A total of 46 patients operated on with 113 cysts were included in this study. The median cyst size was 6.7 cm (IQR, 1-38). A total of 114 CBFs were detected in 51 cysts (45.1%). The postoperative course was simple in 95.0% of cases. The specific morbidity rate was 2.7%. In a bivariate study, absence of mass and abdominal pain on palpation, hemoglobin level >11.55 g/dL, negative hydatid serology, cyst size, absence of calcifications, vascular compression, existence of a single cyst, and localization at segment VIII were predictive factors of occult CBF. At the end of the multivariate study, cyst size was determined to be the only predictive factor for occult CBF. A threshold of 3 cm was used. CONCLUSION: Cyst size is a major predictive factor for occult CBF.

Cholangiohydatidosis. Clinical features, postoperative complications and hospital mortality. A systematic review.

BACKGROUND: Cholangiohydatidosis (CH) is an evolutionary complication of hepatic cystic echinococcosis, associated with increased morbidity and mortality. The aim of this study was to describe the available evidence regarding clinical characteristics of CH, postoperative complications and hospital mortality. METHODOLOGY/PRINCIPAL FINDINGS: Systematic review. Studies related to CH with no language or publication restriction were included. Sensitive searches were performed in Trip Database, SciELO, BIREME-BVS, WoS, PubMed, EMBASE and SCOPUS. MeSH and free terms were used, including articles up to April 2023. The main outcome variables were postoperative complications and hospital mortality; the secondary ones were publication year, origin and design of primary studies, main clinical manifestation, anatomical location and type of cysts, hospital stay, surgical procedure performed, reinterventions; and methodological quality of primary studies, which was assessed using MInCir-T and MInCir-P scales. Descriptive statistics, calculation of weighted averages and their comparison by least squares logistic regression were applied. 446 studies were retrieved from the searches performed, 102 of which met the inclusion and exclusion criteria. The studies analyzed represent 1241 patients. The highest proportion of articles was published in the last decade (39.2%). Reports are mainly from Turkey (28.4%), Greece (9.8%), Morocco and Spain (8.8% each). With a weighted mean of 14.3 days of hospital stance; it was verified that 26.2% of patients developed postoperative complications (74,3% Clavien y Dindo III y IV), 6.7% needed re-interventions, and 3.7% died. When comparing the variables age, postoperative complications, hospital mortality, and reinterventions in two periods of time (1982-2006 vs. 2007-2023), no statistically significant differences were found. When applying the MInCir-T and MInCir-P scales, the methodological quality of the primary studies was 9.6±1.1 and 14.5±4.3 points, respectively. CONCLUSION/SIGNIFICANCE: CH is associated with severe postoperative complications and significant hospital mortality, independent of the development of therapeutic support associated with the passage of time.

A Novel Technique for the Management of Persistent Biliary Fistulas Developing After Liver Hydatid Cyst Surgeries: Drain Clamping Technique.

BACKGROUND: External biliary fistula, where the residual cyst is associated with the biliary tree, is one of the most common complications after liver hydatid cyst surgery. Surgical procedures become a consideration for patients in whom the biliary fistula persists despite all endoscopic procedures. However, reoperation for biliary fistula after hydatid cyst surgery leads to additional complications and increases morbidity and mortality. AIM: This study aims to treat persistent biliary fistulas that develop after liver hydatid cyst surgery using a simple noninvasive technique. MATERIALS AND METHODS: External drainage surgery was performed on 295 patients with liver hydatid cysts. Endoscopic treatment methods were used in patients who developed biliary fistula after surgery. Despite all endoscopic treatment methods, 14 patients developed persistent biliary fistulas. These patients were subsequently treated using the drain clamping technique. FINDINGS: All persistent fistulas occluded in 11.86 days (with a range of 8-20 days). No complications were observed in the one-year follow-up visits. CONCLUSION: Drain clamping, a novel approach to the treatment of persistent biliary fistulas developed despite all available endoscopic methods, can be safely used. This technique resulted in a complete recovery in patients without the need for surgical procedures.

Diagnosis and treatment experience of atypical hepatic cystic echinococcosis type 1 at a tertiary center in China.

BACKGROUND: Some hydatid cysts of cystic echinococcosis type 1 (CE1) lack well-defined cyst walls or distinctive endocysts, making them difficult to differentiate from simple hepatic cysts. AIM: To investigate the diagnostic methods for atypical hepatic CE1 and the clinical efficacy of laparoscopic surgeries. METHODS: The clinical data of 93 patients who had a history of visiting endemic areas of CE and were diagnosed with cystic liver lesions for the first time at the People's Hospital of Xinjiang Uygur Autonomous Region (China) from January 2018 to September 2023 were retrospectively analyzed. Clinical diagnoses were made based on findings from serum immunoglobulin tests for echinococcosis, routine abdominal ultrasound, high-frequency ultrasound, abdominal computed tomography (CT) scan, and laparoscopy. Subsequent to the treatments, these patients underwent reexaminations at the outpatient clinic until October 2023. The evaluations included the diagnostic precision of diverse examinations, the efficacy of surgical approaches, and the incidence of CE recurrence. RESULTS: All 93 patients were diagnosed with simple hepatic cysts by conventional abdominal ultrasound and abdominal CT scan. Among them, 16 patients were preoperatively diagnosed with atypical CE1, and 77 were diagnosed with simple hepatic cysts by high-frequency ultrasound. All the 16 patients preoperatively diagnosed with atypical CE1 underwent laparoscopy, of whom 14 patients were intraoperatively confirmed to have CE1, which was consistent with the postoperative pathological diagnosis, one patient was diagnosed with a mesothelial cyst of the liver, and the other was diagnosed with a hepatic cyst combined with local infection. Among the 77 patients who were preoperatively diagnosed with simple hepatic cysts, 4 received aspiration sclerotherapy of hepatic cysts, and 19 received laparoscopic fenestration. These patients were intraoperatively diagnosed with simple hepatic cysts. During the follow-up period, none of the 14 patients with CE1 experienced recurrence or implantation of hydatid scolices. One of the 77 patients was finally confirmed to have CE complicated with implantation to the right intercostal space. CONCLUSION: Abdominal high-frequency ultrasound can detect CE1 hydatid cysts. The laparoscopic technique serves as a more effective diagnostic and therapeutic tool for CE.

Severe Hypernatremia During Hydatid Cyst Surgery: An Anusual Cause Of Acute Abdomen.

Treatment of liver hydatid cysts is still in most cases surgical. To avoid the recurrence of hydatid cysts injection of scolicidal products inside the cystic cavity is an important step in the surgical procedure. Many scolicidal solutions are used. Hypertonic Saline Solution (HSS) is widely used by surgeons; however, there is a risk of hypertonic saline resorption and acute hypernatremia. Iatrogenic hypernatremia can be life-threatening. We report three cases of hypernatremia secondary to HSS injection for hydatid cyst disease treatment. The objective of this study was to discuss the clinical features, and treatment of this rare complication.

Gossypiboma mimicking hepatic hydatid cyst after 22 years: a case report.

Gossypiboma is a non-absorbable material that is forgotten during surgery. These are medicolegal pathology that leads to diagnostic confusion from abscess to tumor. We present the case of gossypiboma detected in laparotomy in a 57-year-old male patient who had a history of operation due to a hydatid cyst 22 years ago and was referred to our center due to hydatid recurrence. The case should suggest a history of surgical gossypiboma, especially in asymptomatic patients. In this preventable pathology, the strategy during sur-gery and the careful and proper attitude of the surgical team are the main determinants.

The trajectory of anti-recEm18 antibody levels determines follow-up after curative resection of hepatic alveolar echinococcosis.

INTRODUCTION: Recurrence after curative resection of hepatic alveolar echinococcosis remains a clinical challenge. The current study tested if assessment of anti-recEm18 allows for postsurgical patient surveillance. METHODS: A retrospective study with patients undergoing liver resection for alveolar echinococcosis (n = 88) at the University Hospital Bern from 2002 to 2020 and at the University Hospital and Medical Center Ulm from 2011 to 2017 was performed. Analysis was directed to determine a potential association of pre- and postoperative values of anti-recEm18 with clinical outcomes. RESULTS: Anti-recEm18 had a linear correlation to the maximum lesion diameter (R2 = 0.558). Three trajectories of anti-recEm18 were identified based on a threshold of 10 AU/ml: "Em18-low" (n = 31), "responders" (n = 53) and "residual disease" (n = 4). The decline of anti-recEm18 in "responders" reached a plateau after 10.9 months at which levels decreased by 90%. The only patient with recurrence in the entire population was also the only patient with a secondary increase of anti-recEm18. CONCLUSION: In patients with preoperative elevated values, anti-recEm18 confirms curative surgery at 12 months follow-up and allows for long-term surveillance.

Prevalence of cystic echinococcosis in relatives of patients undergoing surgery for hepatic cystic echinococcosis in an endemic region.

BACKGROUND: Cystic echinococcosis (CE) is an endemic disease in southern Chile. The aim of this study was to ascertain the prevalence of CE among relatives of patients who underwent surgical intervention for this disease in Cautín, a province of southern Chile. METHODOLOGY/PRINCIPAL FINDINGS: Cross-sectional study. Relatives of patients who underwent surgery for hepatic echinococcosis (HE), who lived at the same address, during the period 2000-2020 were studied. A total of 288 relatives of 322 patients who underwent surgery for HE participated in a CE screening. All these relatives were interviewed and underwent abdominal ultrasonography, chest X-ray and immunodiagnostic studies (relatives who had been diagnosed with or had undergone surgery for CE were excluded). Descriptive statistics were applied. Prevalence calculation, odds ratio (OR), and their respective 95% confidence intervals (95% CI) were determined. Abdominal or thoracic CE was verified in 42 relatives of subjects operated on for HE (mean age 41±8 years; 73.8% women; 38.1% of cases had two or more cysts), all of them new and asymptomatic cases. CE was detected in the lungs, liver, peritoneum, and spleen in 16.7%; 71.4%; 7.1%; and 4.8%, respectively. The overall prevalence of EQ during the studied time period was 14,6% (17.9% and 12.3% in relatives of first and second degree respectively (OR:1.56; CI 95%: 0.81; 3.01). CONCLUSION/SIGNIFICANCE: There is a high prevalence of CE in relatives of patients undergoing surgery by this disease in the province of Cautín, Chile.

Kidney invasion occurred 2 years following liver transplantation for hepatic alveolar echinococcosis: a case report.

BACKGROUND: The organ most commonly invaded in echinococcosis is the liver; the lungs, brain, kidneys, heart, and spleen are rarely invaded, and multi-organ involvement in echinococcosis is even rarer. No studies have reported renal invasion after liver transplantation for hepatic alveolar echinococcosis. CASE PRESENTATION: We report here a case of renal invasion 2 years after allogeneic liver transplantation in a 53-year-old female patient with hepatic alveolar echinococcosis combined with lung metastases. At the time of the first consultation, the lesion had been found to involve the second hepatic hilum combined with lung metastases, but the patient requested conservative treatment, and the lesion was not controlled by taking albendazole for 3 years. After discussion in the treatment group, it was decided to use allogeneic liver transplantation and lung segmental resection for surgical treatment, after which the patient was put on long-term oral immunosuppression. She was hospitalized 2 years later for low back pain and diagnosed with renal alveolar echinococcosis. Due to significant compression and left-sided renal insufficiency, the final option was to remove the diseased kidney. It is worth mentioning that signs of unexplained urinary tract infection were present throughout the course of treatment. CONCLUSION: This study suggests that extra attention should be paid to the presence of cryptogenic lesions in patients with hepatic alveolar echinococcosis who already have definite metastatic lesions. Immunosuppressive drugs after liver transplantation in patients with hepatic echinococcosis may cause occult lesions to develop into active ones. In clinical practice, particular attention should be paid to patients with hepatic alveolar echinococcosis with long-term concomitant signs of unexplained urinary tract infections, which may be a precursor clinical feature of cryptogenic renal alveolar echinococcosis.