Hydatid Liver Cyst An 11-Year Experience of Treatment With Percutaneous Aspiration and Ethanol

Article
Hydatid Liver Cyst
An 11-Year Experience of
Treatment With Percutaneous
Aspiration and Ethanol
Injection
Antonio Giorgio, MD, Luciano Tarantino, MD,
Giorgio de Stefano, MD, Giampiero Francica, MD,
Nicola Mariniello, MD, Nunzia Farella, MD,
Anna Perrotta, MD, Vincenza Aloisio, MD,
Francesco Esposito, MD
Objective. To report an 11-year experience of treatment of hydatid liver cysts with double percutaneous aspiration and injection of alcohol. Methods. Of the 129 patients with 174 hydatid liver cysts
admitted to our department between January 1988 and January 1999, 79 patients with 119 vital
hydatid liver cysts were selected for double percutaneous aspiration and injection of alcohol. Under
ultrasonographic guidance, cystic cavities were first drained through fine needles, and then 95% sterile ethanol was injected and left in situ. The same procedure was repeated 3 days later without reaspiration of the injected alcohol. General anesthesia without endotracheal intubation was performed
in 21 selected cases. Results. Double percutaneous aspiration and injection of alcohol was completed
in 78 patients with 118 hydatid liver cysts. In 1 case the procedure could not be accomplished because
of an intracystic hemorrhage. A total of 254 punctures were performed, and the ethanol injected per
session ranged between 12 and 250 mL. The mean hospital stay was 2.9 days (range, 2–7 days). The
overall median follow-up was 48 months (range, 6–122 months). At the last ultrasonographic examination, 45.8% of the treated hydatid liver cysts had a solid pattern, 47.4% were no longer appreciable, and 6.8% had a minimal liquid component. Intracystic relapse occurred in 5% of the patients. In
no case were any new cysts observed either in different hepatic segments or in any extrahepatic location. The morbidity rate was 9%, and 1 death occurred (mortality rate, 1.3%). Conclusions. Over a
long period, double percutaneous aspiration and injection of alcohol proved to be a substantially safe,
effective, and low-cost procedure for hydatid liver cyst treatment. Key words: hydatid disease; liver;
ultrasonography; interventional procedure; ethanol injection.
Abbreviations
D-PAI, double percutaneous aspiration and injection;
HLC, hydatid liver cyst; IHA, indirect hemagglutination
assay; WHO, World Health Organization
Received December 27, 2000, from the Servizio di
Ecografia Interventistica, Ospedale “D. Cotugno,”
Naples, Italy. Revision requested January 17, 2001.
Revised manuscript accepted for publication
February 20, 2001.
Address correspondence and reprint requests to
Antonio Giorgio, MD, Viale Colli Aminei 491, 80131
Naples, Italy.
L
iver hydatidosis in humans is a parasitic disease
caused by the larval form of a tapeworm,
Echinococcus granulosus.1 The disease develops
when the parasite’s eggs are ingested and the
embryonic forms are released into the intestinal lumen
and cross the mucosa, reaching the hepatic sinusoids via
the portal circulation. The hydatid liver cyst (HLC) represents the full-blown expression of the vital parasite,1
whereas a number of other morphologic features that are
finely depicted by ultrasonography2,3 represent various
stages in the parasite’s life cycle. The most recent World
Health Organization (WHO) classification of liver hydatidosis considers all morphologic features that contain liquid (unilocular with or without membrane detachment
© 2001 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 20:729–738, 2001 • 0278-4297/01/$3.50
Hydatid Cyst Treatment With Percutaneous Aspiration and Ethanol Injection
and multilocular) as signs of living worms,
whereas solid and calcific forms are indicative of
the parasite’s death.4 According to this classification, only those patients with vital cysts are suitable for therapy.
Although liver hydatidosis is considered a
benign disease, it is generally accepted that the
severity and frequency of complications of vital
HLCs, especially in endemic areas, make therapy
mandatory, with surgery being the standard form
of treatment.5,6 Surgery may be radical (i.e., total
pericystectomy or liver resection in the case of
multiple cysts localized in 1 lobe) or conservative
(fenestration or simple tube drainage).5,6
Recently, laparoscopic surgery has been introduced to remove HLCs in selected cases.7
Over the last decade, high costs, lack of surgical
facilities, or both in those countries where the
disease is most prevalent,5 together with an
increase in the number of human cases of
echinococcosis detected in population-based
studies and resulting from widely available ultrasonographic examinations5 and the development of minimally invasive procedures such as
percutaneous treatment of a variety of inflammatory and neoplastic liver and abdominal diseases,8,9 have prompted the search for alternative
methods of treatment for liver hydatidosis.
Medical therapy with an imidazole derivative is
rarely curative,5,6,10,11 and side effects occur in as
many as 35% of patients,11 with a 30% relapse rate
also being recorded.12 Percutaneous injection of a
scolicidal agent (absolute alcohol and hypertonic
saline) has been widely used in purely cystic
hydatid disease, especially in Mediterranean and
Asian countries, with excellent results in terms of
the disappearance of liver cysts and low morbidity and mortality rates.13–21 Moreover, 2 randomized trials by Khuroo et al22,23 showed that the
percutaneous approach was superior to medical
therapy alone and had a cure rate of liver cysts
equal to that of surgical cyst drainage but at lower
costs and with a reduced complication rate.
Some of the most relevant questions about the
long-term efficacy and safety of percutaneous
treatment have been addressed by recent studies24–26 in which no case of either spillage of the
echinococci into the abdomen or intrahepatic or
extrahepatic diffusion of the hydatid disease was
reported. The involutional changes after percutaneous treatment appeared stable during the
follow-up period, with a mean observation time
of 19 to 37 months (range, 1–72 months).
730
In 1992 we reported our initial experience with
double percutaneous aspiration and injection
(D-PAI) of alcohol,19 and the impressive results
achieved encouraged us to pursue that therapeutic approach over the ensuing years. In this article, we report our 11-year experience with D-PAI
in the treatment of HLCs and the long-term
follow-up data.
Materials and Methods
Study Population
Between January 1988 and January 1999, 129
patients (68 male and 61 female; mean age,
42 years; age range, 13–80 years) with 174 HLCs
were examined at our institution. In 90 cases the
hydatid origin of liver cysts was suggested by
positive serologic text results (immunohemagglutination >1:128); in the remaining patients,
diagnosis was based on clinical (known exposure to dogs or abdominal pain)5 or ultrasonographic findings consistent with hydatidosis, or
both.2,3
In Table 1 the number, size, site, and ultrasonographic patterns according to the WHO classification4 of HLC are shown.
There were 25 symptomatic patients, all with
type I to III HLCs. Thirteen patients had right
upper quadrant pain usually associated with a
palpable mass; 6 had disease recurrence after
surgical fenestration of the cysts; and 6 had jaundice caused by mild dilatation of the bile ducts
near their HLCs. Extrahepatic disease was absent
in all cases.
The D-PAI Technique
As reported elsewhere,19 we used a protocol that
entailed puncturing the cyst with a fine needle
twice every 3 days and injecting sterile absolute
ethanol without reaspiration as follows. Under
aseptic conditions and after administration of
local anesthesia at the point of puncture, a 15- or
20-cm-long fine needle (22, 20, or 18 gauge) was
inserted into the cystic cavity by a transhepatic
route under ultrasonographic guidance, with
every effort being made to avoid direct puncture
of the cyst. After as much as 90% of the fluid content was aspirated, 95% sterile ethanol was
injected into the cyst and left in situ to replace
50% to 60% of the amount drained. Immediately
after aspiration, direct fresh microscopic examination was carried out for detection of fragments
of laminated membranes, hooklets, and scolices,
J Ultrasound Med 20:729–738, 2001
Giorgio et al
Table 1. Characteristics of HLC Series
WHO Class*
Type
Type
Type
Type
Type
Type
I
II
III
IV
V
VI
No. of Patients
No. of HLCs
14†
45†
13
7†
37
13
18
58
26
17
42
13
Site,
Size [Mean
Right Lobe/Left Lobe Diameter (Range)], cm
12/6
40/18
20/6
10/7
30/12
10/3
2.8 (1.5–4)
8.5 (4.3–20)
4.7 (2.5–7)
5.2 (4–7)
3.7 (2–5)
3.3 (2–4.2)
IHA Titer,
Range
1:256–4,000
1:64–1:16,800
1:256–1:2,000
1:64–1:516
1:64–1:1,024
1:64–1:512
*Type I indicates unilocular cyst smaller than 4 cm; type II, unilocular cyst larger than 4 cm; type III, multiloculated; type IV, detached
membrane; type V, solid heterogeneous; and type VI, calcific.
†In 4 patients there were multiple HLCs (3 or 4) with different patterns (I, II, and IV).
and staining with 0.1% neutral red for vital scolices and 0.03% methylene blue for dead scolices
was performed. To exclude the presence of a biliary fistula, the bilirubin level in the aspirated
fluid was determined by a semiquantitative
method (Combur-Test; Roche Diagnostics,
Indianapolis, IN) within a few seconds before
alcohol injection at each PAI. The same procedure was repeated after 3 days without reaspiration of the injected alcohol; scolex survival was
also reassessed.
To reduce the risk of intraperitoneal seeding of
scolices possibly spilled during the interventional procedure, a brief course of mebendazole
(3 g/d in the first 10 cases) or albendazole
(800 mg/d in all remaining cases) 1 week before
and 3 weeks after D-PAI was completed in all
patients but 2 (1 pregnant woman and 1 patient
with chronic liver disease). No other form of
therapy was carried out.
The procedure was always done on an inpatient basis with an anesthesiologist present.
General anesthesia without endotracheal intubation (using atropine, 0.5 mg intravenously;
induction with propofol, 1.0–1.5 mg/kg intravenously; maintenance with propofol, 9.0–
12 mg ⋅ kg–1 ⋅ h–1; and fentanyl citrate, 50 mg
intravenously) was administered in 21 cases
(anxious patients, very large cysts, and difficult
technical approaches).
The procedure was approved by our
Institutional Ethical Committee. Informed written consent was obtained from all patients.
Follow-up
After the interventional procedure, all patients
underwent clinical, laboratory, and ultrasonographic examinations every month for the first 3
months and every 6 months thereafter. Indirect
hemagglutination assay (IHA) titers were deterJ Ultrasound Med 20:729–738, 2001
mined monthly during the first 6 months and
then twice a year. Chest radiography was scheduled every 6 months, and a total body computed
tomographic scan was scheduled every 2 years.
Results
Double percutaneous aspiration and injection
of alcohol was accomplished in 78 of 79 patients
with 118 HLCs (group I); in 1 case aspiration of
fresh blood due to intracystic hemorrhage
forced us to give up the interventional procedure (see “Complications”).
In 37 of 50 patients with ultrasonographic pattern V, ultrasonographically guided aspiration
yielded a creamy orange substance (“orange
juice-like”) without vital scolices when further
examined. All patients with type V HLCs and 13
patients with a calcific pattern (type VI) were not
treated (group II).
In group I, 254 punctures were performed,
and ethanol injected per session ranged
between 12 and 250 mL. Seventy-four patients
had 1 course of D-PAI; 3 patients had 3 procedures; and 1 patient had 4 procedures. These
latter 4 patients had multiloculated cysts,
which represented the only cases of relapsing
disease after the initial percutaneous treatment (see below). The durations of the interventional procedures ranged between 15 and
45 minutes, and the mean hospital stay was 2.9
days (range, 2–7 days).
In all type I cysts, detachment of the inner
membrane was observed just after the first
aspiration and ethanol injection. Type II cysts
had further detachment and folding of inner
membranes. Generally speaking, hydatid cysts
regained their initial volume almost entirely
within 24 hours after the first PAI. In symptomatic patients, loss of cyst tension caused
731
Hydatid Cyst Treatment With Percutaneous Aspiration and Ethanol Injection
immediate disappearance of abdominal tumefaction and abdominal pain.
The overall median follow-up was 48 months
(range, 6–122 months). Twenty-seven patients
(34.6%) had follow-up of 1 to 4 years; 31
patients (38.9%) were followed for 5 to 8 years;
and 20 patients (25.6%) were followed for more
than 9 years. The follow-up durations for individual types of hydatid disease and the ultrasonographic outcomes of the treated cysts at
the last observations are shown in Table 2.
of evolution was never observed in multiloculated cysts, whereas it occurred without any
significant differences among the other cyst
types (55.5% in type I, 63% in type II, and 59%
in type IV).
The time taken to attain the final ultrasonographic pattern varied considerably. Generally
speaking, the smaller, pure cysts (type I) took a
short time for ultrasonographic pattern changes
to become evident (15–70 days), whereas the
largest, complex cysts took longer (up to 2 years).
However, the type of the final ultrasonographic
pattern was not strongly correlated to either initial HLC volume or follow-up length. As far as the
latter point is concerned, in most of the patients
with a healed pattern, an intermediate phase of
solidification was observed but proved to be
independent of the follow-up time. Similarly,
even patients with long follow-up durations
(>2 years) and a solid or liquid pattern had no
changes over time.
In patients with initial high IHA titers (>1:1024),
levels of antibodies decreased over time and in 17
patients returned to normal.
In Figures 1 and 2, two examples of the ultrasonographic aspects of the interventional procedure and the final ultrasonographic appearance
are shown. Group II (untreated) patients did not
have any change in size or ultrasonographic pattern during follow-up.
Four patients (5%) were treated more than once
because of relapse; they had multiloculated
cysts, which after 6, 12, 15, and 24 months had
new, vital daughter cysts inside the posttreatment heterogeneous masses. Three of these
patients underwent another 2 sessions of PAI for
their large cysts (6, 7, and 7.5 cm), and the last
observed ultrasonographic pattern was a solid
mass. The fourth patient had 3 multiloculated
Ultrasonographic Findings
At the last ultrasonographic examination, 3 ultrasonographic patterns were observed:
1. A liquid pattern characterized by detached
and folded membranes floating in hydatid
fluid. The 8 cysts with this pattern (6.8%)
had fine-needle aspiration to verify parasite
survival. In all cases, an orange juice-like
substance was obtained consisting of
leukocytes and necrotic debris without vital
scolices.
2. A solid pattern (hypoechoic or hyperechoic
mass). This pattern was observed in 54
(45.8%) of 118 cysts. It is worth noting that
this was the final ultrasonographic aspect in
all patients with multiloculated cysts, being
significantly different (P < .01) from all other
types of HLC, in which such a pattern
occurred in about 30% of cases.
In these 2 first patterns, a constant decrease in
cyst size of about 50% to 80% of the initial volume was observed in the course of follow-up.
3. A healed pattern. Fifty-six (47.4%) of 118 liver
cysts were undetectable, with complete
reconstitution of liver parenchyma. This kind
Table 2. Ultrasonographic Patterns of HLCs After Percutaneous Treatment
WHO Class
No. of Patients
No. of HLCs
Follow-up
[Median (Range)], mo
Type I
14
18
58
Type II
44
57
60 (12–122)
Type III
Type IV
13
7
26
17
38 (12–84)
44 (6–96)
732
(9–112)
Sonographic Pattern at Last
Examination, No. of Cases
Healed
Liquid
Solid
Healed
Liquid
Solid
Solid
Healed
Liquid
Solid
(10)
(3)
(5)
(36)
(3)
(18)
(26)
(10)
(2)
(5)
J Ultrasound Med 20:729–738, 2001
Giorgio et al
cysts of 5, 4.5, and 2.5 cm, and all were treated
with 3 additional courses of D-PAI. In this case, a
solid pattern was also observed at the last ultrasonographic examination.
In no case were any new cysts observed either
in different hepatic segments or in any extrahepatic location (namely, the thorax and abdomen).
that, in all patients a short course of betamethasone (1.5 mg 3 times per day 2 days before and 1
day after the procedure) was administered, and
the interventional procedure was carried out
under general anesthesia in selected cases (see
“Materials and Methods”).
Discussion
Complications
As stated above, in 1 case D-PAI could not be
accomplished because of an intracystic hemorrhage, which supervened just after insertion of
an 18-gauge needle. Blood transfusions and
emergency surgery were not required. Double
percutaneous aspiration and injection of alcohol was postponed, but 2 weeks later a new
puncture yielded fresh blood again, and the
patient had to undergo surgery. This case represented the only failure of the interventional procedure in our series.
Minor side effects were nausea and vomiting
(1 case) and abdominal pain lasting 15 minutes
(2 cases). Major complications were recorded in
2.5% of the treated patients. Hepatic abscesses
developed inside 2 treated cysts (2 patients) 15
and 60 days after D-PAI; in both cases the abscess
cavities were drained percutaneously, and at the
last ultrasonographic scan, reconstitution of liver
parenchyma was observed without any focal
lesion. A biliary fistula was diagnosed in 1 case
when bile-stained fluid was collected during the
second aspiration; given the patient’s stable clinical condition, no other diagnostic or therapeutic
procedures were carried out. The second ethanol
injection was postponed until 6 months after
spontaneous closure of the fistula.
We had 1 case of procedure-related death (mortality, 1.3%), which occurred in a 54-year old man
with a 9-cm uniloculated liver cyst in the seventh
segment. Rash, dyspnea, and hypotension
occurred just after aspiration of 5 mL of hydatid
liquid through a 20-gauge Chiba needle (Ecojekt,
Hospital Service, Tokyo, Japan). Despite every
attempt to resuscitate him, the patient died 3
hours after the inception of the procedure. We
hypothesized that a large amount of hydatid fluid
had gained access to the general circulation
through the liver parenchyma because of ruptures in the laminated membrane, which were
caused by unintentional movement of the
patient, who had difficulty tolerating the procedure. That occurrence in June 1998 caused us to
change our methodological approach. After
J Ultrasound Med 20:729–738, 2001
Surgery is still regarded as the standard form of
treatment for liver hydatidosis caused by E granulosus.5,6 The 2 surgical approaches (i.e., radical
and conservative) may be chosen on the basis of
local expertise and the characteristics of each
individual case (e.g., number, size, and location
of the cysts).5 Generally speaking, the more radical the intervention, the higher the intraoperative
risk but the fewer late complications; moreover,
radical interventions, albeit the most desirable,
are the least frequently performed, representing only 21% of the 677 patients in a recent surgical series.27 On the other hand, the more
conservative the approach, the lower the interventional risk but the more common the late
complications, which include fistula formation, bacterial infections, sepsis, and local cyst
recurrence. On the whole, hydatid recurrences
may be wide ranging depending on the diagnostic tool used to detect them (serology,
laparoscopy, ultrasonography, or computed
tomography), ranging from 1% to 30%.28–30 The
morbidity rates of surgery may be as high as
19% to 84%,5,28–30 with mortality ranging
between 1% and 60%.5,28–30 More recently the
laparoscopic approach has been introduced to
treat selected cases of HLCs, but the conversion
rate has been reported as high as 23% in a
recent series,7 and to date only short-term follow-up results have been available.
Over the last decade there has been growing
evidence that percutaneous treatment of
uncomplicated hydatid liver disease may be a
valid alternative to surgery, because it offers an
effective and inexpensive therapeutic tool, particularly in those regions where the disease is
endemic and medical resources are limited.13–26
Two recent randomized trials by Khuroo et al22,23
showed that percutaneous treatment of HLCs
proved to be a superior form of medical treatment when used with albendazole and proved
as effective as open surgical drainage but at a
lower cost and with a more reduced complication rate than surgery.
733
Hydatid Cyst Treatment With Percutaneous Aspiration and Ethanol Injection
Figure 1. Double percutaneous aspiration and injection of alcohol in hydatid cyst (type II). A, Purely liquid cyst (c) shown in the
left lobe of the liver. B, The fine needle (arrow) is shown inside
the cyst during aspiration. C, Ultrasonographic aspect at the end
of aspiration. The needle tip (A) is clearly shown in the small
residual cavity before ethanol injection. D, After injection of 125
mL of ethanol, the cyst cavity regained initial volume; it appears
hyperechoic (arrows). E, Three days later another PAI was performed; the needle tip (white arrow) is shown in the cyst. Note
the detached inner membranes after the first PAI. F (opposite
page), One month later. The cyst is decreased in size and shows
a solid pattern. G (opposite page), Two months after D-PAI.
Ultrasonography shows the restitution of the liver parenchyma.
G indicates gallbladder; and L, normal left lobe.
A
734
B
C
D
E
J Ultrasound Med 20:729–738, 2001
Giorgio et al
F
G
Our long-term experience with D-PAI confirms
the good results in terms of the feasibility and
effectiveness of this ultrasonographically guided
interventional procedure, in keeping with the
findings of other authors.15,16,18,20,21,23–26 In only 1
patient were we unable to carry out D-PAI,
because of an intracystic hemorrhage. In the 78
cases in which D-PAI was performed, the 3 patterns we observed on the last ultrasonographic
follow-up examinations (resolved in 47.4%, liquid in 6.8%, and solid in 45.8%) were all expressions of therapeutic success. Even in those cases
with a residual liquid component, the aspirated
fluid yielded an orange juice-like substance
made up of necrotic debris.
The most notable exception was represented
by the multiloculated cysts. Only in patients
bearing that type of HLC was complete healing
of liver parenchyma never observed, and intracystic relapse occurred in 30% of this group (i.e.,
in 5% of the entire series), which required further cycles (up to 4) of D-PAI. This kind of cyst
may necessitate more aggressive treatment; i.e.,
all cystic cavities should be punctured and
injected with ethanol, and stricter follow-up
should be instituted to recognize early relapse.
The results for the multiloculated cysts may be
explained by the reported high resistance of
daughter cysts to scolicidal agents, as shown in
an experimental setting.31
As far as side effects are concerned, it should be
stressed that the complication rate was acceptably low (≈9% when both minor and major complications were considered), nor was it much
different from that reported in other series dealing with a percutaneous treatment, and it
proved to be lower than that reported in surgical
series, ranging between 18% and 84%.6,23,25,30 It
should be noted that the major complications
were managed without resorting to surgery: in
2 cases percutaneous evacuation of superimposed abscesses was required, whereas the
biliary fistula resolved spontaneously. In all
those cases, D-PAI was accomplished, and the
final outcome was uneventful.
We had 1 death (mortality rate, 1.3%), to our
knowledge the second so far reported in series
dealing with percutaneous treatment of HLC,
the other being a case reported by Men et al.25 In
our opinion, the death in our series was
attributable to rupture of a large cyst with massive absorption of hydatid fluid in the systemic
circulation, which was caused by movement of
an anxious patient who did not tolerate the procedure well at the time of needle insertion. After
that incident, we decided in selected cases (very
anxious patients, large cysts, and difficult technical approaches) to administer neuroleptanalgesia with or without tracheal intubation. That a
fatal complication may occur after percutaneous treatment of HLCs emphasizes the point
that such an interventional technique must be
performed in specialized centers with surgical
and anesthesiologic resources at hand.
Our high success rate along with low morbidity and mortality rates may by explained by certain methodological choices we made at the
beginning of our experience. First, we decided to
use alcohol because of its well-proven scolicidal
effect by dehydrating vital organisms13,15;
indeed, 95% ethanol is considered the scolicidal
agent with the strongest inflammatory effects
J Ultrasound Med 20:729–738, 2001
735
Hydatid Cyst Treatment With Percutaneous Aspiration and Ethanol Injection
Figure 2. Double percutaneous aspiration and injection of alcohol in a multilocular hydatid liver cyst. A, Multiseptated cyst
shown in the seventh hepatic segment. B, One of the cavities
has been punctured. A indicates needle tip. C, The cavity is filled
with ethanol. D, The needle (arrow) is inserted in another cavity.
E, Ultrasonographic appearance 3 months after completion of
the procedure. This pattern remained unchanged after 4 years.
A
736
B
C
D
E
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Giorgio et al
and has been shown to be highly effective in
destroying the germinative membrane where
living protoscolices can usually be found.26
Second, we left injected alcohol in situ without
reaspiration in the belief that longer contact
between the parasite and the scolicidal agent
would have a greater likelihood of killing the
scolices. Indeed, early in our experience we
found vital parasites in 2 patients 3 days after
the first aspiration and injection.19 Further support for our approach has recently come from
an experimental study in which scolicidal
agents (alcohol and hypertonic saline) proved
unable to kill daughter cysts when brought into
contact with them for 24 h.31 Moreover, partially refilling the cyst, along with the strong
inflammatory response elicited by alcohol,
appears to hamper leaks into the biliary tree
through small fissures in the pericyst, thereby
explaining the lower rate of biliary fistula formation (1.2%) when compared with that of
about 6% reported by Ustunsoz et al24 and Men
et al.25 It is worthy of note that no case of sclerosing cholangitis, one of the most serious
complications of scolicidal agents,32 was
observed in any of our patients.
Criticisms about the long-term efficacy of PAI
have been expressed,33 the most important
question being the long-term prognosis of
these patients with special regard to relapse of
the disease in other liver segments or elsewhere
in the body, namely the peritoneum and thorax, perhaps as a consequence of spillage of
hydatid fluid. As in other recent series,24–26 in
none of our patients (65% of whom were followed for >4 years) did such an event occur.
Systemic prophylaxis with albendazole might
have played a contributory role, because it has
been shown to reduce relapse of hydatid disease after surgery.6 The point should be
stressed that in our experience and that of others,24–26 not only did the observed posttreatment changes indicate cure of the disease over
a long period, but also the relapse rate was very
low (in our series only for multiloculated cysts),
and extrahepatic diffusion was never observed.
Another favorable characteristic of the percutaneous treatment modality was its costeffectiveness. The hospital stay in our series, as
in other series,23–26 turned out to be far shorter
than that after surgery, especially if more radical procedures were performed.26
J Ultrasound Med 20:729–738, 2001
In conclusion, percutaneous ethanol injection
for HLCs is a cost-effective procedure not only in
the short term (rapid reduction in size, low complication rate, and short hospital stay) but also in
the long term, because intracystic relapse never
occurred, except in a few multiloculated cysts,
nor did intrahepatic or extrahepatic dissemination supervene. However, although very low in
number, life-threatening complications make it
necessary for this kind of therapeutic modality
to be reserved for centers where resuscitation
measures and surgical facilities are at hand.
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