| Abstract|| |
Background: Hydatid cyst disease is still a health problem in many countries. Surgical removal is the treatment of choice for lung hydatid cysts. However, operating on bilateral lung hydatid cysts is still controversial. The aim of this retrospective study was to evaluate the results of surgical treatment in bilateral hydatid disease of the lung. Methods: In this retrospective study, we reviewed our experience in the surgical treatment of 22 patients with bilateral, and at least three, lung and liver hydatid cysts. These 22 patients (14 male, 8 female) with an average age of 22 years (range 5–50 years) underwent one-staged bilateral anterolateral thoracotomy. Results: Out of 316 patients with hydatid lung, 22 (5.55%) were managed surgically. In total, 48 lung cysts were removed from 22 patients who underwent one-staged bilateral anterolateral thoracotomy. The most frequent symptoms were cough, chest pain, and dyspnea. Most of the cysts (38.2%) were located in the right lower lobe. Three patients had cysts associated with hepatic hydatid cyst; they were treated through phlebotomy during thoracotomies. All cysts were evacuated with capitonnage and without lung resection. We observed some complications such as prolonged air leaks (n = 3), atelectasis (n = 2), pneumonia (n = 2), and empyema (n = 1). No further surgery was required for the management of complications. The mean hospital stay was 5 days (range 8–12 days). No deaths occurred in hospital stay. Oral albendazole was started on the 2nd postoperative day thoracotomy in the dose of 10 mg/kg and was continued for 3 months with a gap of 2 weeks after each 28 days. No recurrences occurred during the follow-up period. Conclusions: One-stage surgery is superior to a classic two-stage approach as it decreases the morbidity, hospital stay, and costs. MS is an excellent approach, but in some cases, video-assisted thoracic surgery mini-thoracotomies could be indicated. In our experience, one-staged bilateral anterolateral thoracotomy is an appropriate surgical option for bilateral pulmonary hydatid cysts because morbidity rates are minimal, and the hospital stay is acceptable for the treatment of bilateral pulmonary hydatid cysts in one-staged option.
Keywords: Bilateral hydatid cyst, echinococcosis, liver, lung, thoracotomy
|How to cite this article:|
Aghajanzadeh M, Kiaabadi AR, Mohtasham B, Saravi MK, Mosafai O, Ghotbi F. One-staged anterolateral thoracotomy for bilateral lung hydatid cysts. Ann Trop Med Public Health 2017;10:1601-6
|How to cite this URL:|
Aghajanzadeh M, Kiaabadi AR, Mohtasham B, Saravi MK, Mosafai O, Ghotbi F. One-staged anterolateral thoracotomy for bilateral lung hydatid cysts. Ann Trop Med Public Health [serial online] 2017 [cited 2018 May 22];10:1601-6. Available from: http://www.atmph.org/text.asp?2017/10/6/1601/222680
| Introduction|| |
Hydatid disease is a serious health problem in some Mediterranean, the Middle East, New Zealand, Australia, and South Africa. In some countries like Iran and South Africa, it is endemic. Recently, the prevalence of the disease has increased in Europe and North America due to increased immigration. Although it may involve any organ, it most often affects the liver and the lungs. The lung is the second most commonly affected organ after the liver, with occurrences ranging from 10% to 40%., Bilateral pulmonary hydatidosis accounts for 4%–26.7% of all cases of pulmonary hydatidosis. Concomitant pulmonary and liver hydatid disease may occur in 4%–25% of patients with hydatidosis. Medical management with oral mebendazole and albendazole has been used, and it is the preferred treatment option in children., Surgical removal is currently the generally accepted choice of treatment for lung hydatidosis. In some reports, a single-stage operation for bilateral pulmonary and liver hydatid cysts was found to be a safe procedure with low morbidity and mortality. Operating on bilateral pulmonary hydatidosis is still controversial., The aim of this retrospective study was to evaluate the results of surgical treatment in bilateral pulmonary hydatid disease of the lung with one-staged bilateral anterolateral thoracotomy.
| Methods|| |
In this retrospective study between 2000 and 2015, 246 patients with pulmonary hydatic cyst were operated in Guilan medical University in the Thoracic Surgery Department of Razi hospital Iran. Of the 246 patients, 22 (10.6%) had bilateral lung hydatid cysts. We reviewed the medical records of 16 (3.7%) patients who had bilateral lung cyst. Two of these patients had hepatic hydatid cysts. Clinical examination, chest X-ray, and computed tomography scan of the chest were the mainstays of diagnosis [Figure 1] and [Figure 2] and an abdominal ultrasound was performed in all cases.
|Figure 1: Chest X-ray and computed tomography scan demonstrates bilateral lung and liver cysts|
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|Figure 2: Computed tomographic scan of a 6-year-old girl demonstrates bilateral contact (L) and perforated (R) lung cysts|
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Preoperative evaluation lung function tests and electrocardiogram were also carried out routinely in all cases over 30-year-old. We do not use serologic testes routinely. One-staged bilateral anterolateral thoracotomy was carried out under general anesthesia with double-lumen endotracheal tubes. [Figure 3] The side with the largest cyst or intact cysts was initially treated.
Operative field was isolated with 20% hypertonic saline pads for protection. Ore surgical techniques were evacuation bronchial opening closure with conservative parenchyma preservation. A 16–18-G needle connected to a suction tip was inserted into the cyst. After needle aspiration, the cyst was aspirated and its fluid removed completely and the top of the cyst was opened (cystotomy) and the all cyst membrane was removed with ring forceps. We did not use injection of antiscolicidal agent or hypertonic saline into the cystic cavity before bronchial opening closure because severe bronchial irritation may occur. All adhesions were totally divided after evacuation to facilitate exploration and re-expansion of the lung; this method decreases the risk of rupture of cysts. The cavity was then irrigated with saline solution. The cavity was obliterated with capitonnage. Anatomical resections were carried out in none of the patients. Patients with associated hepatic cysts were approached through the transthoracic transdiaphragmatic route. Oral albendazole (10mg/kg) was given to patients on postop day2 and continued for 3 months with a gap of 2weeks after each 28 days. Liver function tests were monitored during the course of albendazole. The patients were followed with a chest X-ray each and a 6 month regularly.
| Results|| |
Out of 316 patients of hydatid lung, 22 (5.55%) were managed surgically. In total, 48 lung cysts were removed from 22 patients who underwent one-staged bilateral anterolateral thoracotomy. The most frequent symptoms were cough, chest pain, and dyspnea [Table 1]. Most of the cysts were located in the right lower lobe, left lower lobe, and right upper lobe. Cystotomy with capitonnage was the most common approach in all of the patients except in those with peripherally located small cysts. Others surgical procedures such as wedge resection, decortication, and debridement of necrotic tissues were performed in 12 patients. After evacuation completely the contents of cysts, the lung was reinflated, and the remnant cavity was filled with saline normal and checked all occulted bronchial opening. Three patients had cysts associated with hepatic hydatid cyst; they were treated through phlebotomy during thoracotomies [Figure 4] and [Figure 5].
|Figure 4: Computed tomographic scan of a 20 year old girl showing bilateral lung cysts|
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|Figure 5: Computed tomographic scan of the same patient in figure 4 showing two liver cysts|
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Postoperative complications such as prolonged air leaks, atelectasis, and empyema were observed in 9 of 22 patients [Table 2]. 4 patients prolonged air leak. 4 patients developed empyema and in one patient cyst ruptured into the pleural cavity. The patients with prolonged air leak and empyema received conservative management. Atelectasia occurred in 3 patients and in one patient was managed with bronchoscopy. Others were shown in [Table 2]. The mean pain score was 6. The mean hospital stay was 5 days (Range 8–12 days). No deaths occurred in hospital stay. Oral albendazole was started on the 2nd postoperative day thoracotomy in the dose of 10 mg/kg and was continued for 3 months with a gap of 2 weeks after each 28 days. No recurrences occurred during the follow-up period.
| Discussion|| |
The best treatment of hydatid cyst of the lung is surgery. The potential risk of surgery as aspiration rupture may lead some surgeon to prefer medical treatment. Oral albendazole is the drug of choice for hydatid cyst. Treatment with albendazole is recommended for at least 3 months We use albendazole in three period of 28 days with 14-day interval. There are some side effects in treatment using albendazole such as hepatitis. In some cases, report of this treatment is very rare it is known as remnant of germinate membrane in the cavity of lung parenchyma play as a forgiven body can cause lung abscess and recurrent pneumonia. Parenchymal sparing surgery is the generally preferred opinion in surgical treatment of echinococcosis. In the literature, pulmonary function loss has not been shown in cases when a large number of cysts were removed from a lung. No radiological or clinical problems were seen in the postoperative period. However, in our patients, postoperative radiological shows decreased lung volume and small parenchyma abnormality; on the other hand, in some cases, parenchymal compression will disappear after removal of the huge cysts, and thus, providing a higher lung volume after surgical treatment. Postoperative parenchymal space and pulmonary compression effect will disappear, and ventilation/perfusion mismatch will improve. Therefore, removal of cysts provides a higher lung volume. Aggressive surgical treatment for widespread hydatidosis is associated with morbidity. We recommend minimal surgical treatment with preservation of maximal pulmonary parenchyma. However, the effectiveness of medical treatment is very limited, and it has potential side effects. We use medical treatment in patients with cardiovascular problem, multiple organ involvements, and avoidance of patient of surgery. Bilateral two-stage thoracotomy is an appropriate surgical option with acceptable morbidity rates and duration of hospital stay for the treatment of bilateral widespread lung hydatidosis (pap). However, we do not recommend surgery for widespread pulmonary hydatidosis [Figure 6] and [Figure 7].
|Figure 6: Computed tomographic scan of lung cysts showing recurrent pneumonia (mediastinal view)|
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|Figure 7: Computed tomographic scan of lung cysts showing recurrent pneumonia( parenchymal view)|
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We use medical treatment in such patients. In our study, we did not find any lethal complications of medical treatment. Against some study which recommended radical surgical treatment can provide complete eradication of hydatidosis of lungs (pap), our approach for hydatidosis of lungs is medical treatment because radical surgical treatment is associated with high morbidity and mortality. In [Figure 8], the surgical approaches for patients who have bilateral pulmonary hydatid cyst, include bilateral one-stage thoracotomies, bilateral two-staged thoracotomies, median sternotomy, and Clamshell incision.
Many thoracic surgeons have reported one-stage bilateral thoracotomies for bilateral lung echinococcosis. Each approach has advantages and disadvantages, but probably two-stage thoracotomy and median sternotomy are the most common approaches in the surgical treatment of bilateral lung hydatidosis which provides optimal exposure of each hemithorax and avoids the longer operative and anesthetic time associated with one-stage bilateral thoracotomies., A disadvantage of this two-stage thoracotomy is the potential for delay between the first and second thoracotomies due to slow because of postoperative complications. This may allow progression of disease, rupture and infection of cysts, making eventual surgery more difficult. Burgos et al., Dhaliwal and Kalkat, and Petrov et al. prefer median sternotomy because this approach causes less pain and is better tolerated than bilateral thoracotomy.
Therefore, median sternotomy provides high postoperative patient comfort and shorter duration of hospital stay. Bilateral lung cysts should be resected in one or two stages; therefore, some study avoided to apply bilateral thoracotomies as a single stage (pap). In a case of bilateral involvement, one-stage surgery is superior to a classic two-stage operation as it decreases the morbidity, hospital stay, and cost. In a patient with an uncomplicated lung cyst in one and a ruptured cyst in another lung, the intact cyst should be removed first to prevent its rupture. The contralateral lesions then resected 2–4 weeks after the first operation., In our study, we used one-staged anterolateral thoracotomy in all patient below than 50 years older. We did not use median sternotomy, Clamshell incision, and bilateral two-stage thoracotomy. Median sternotomy is a potentially effective approach, but we did not use this approach in our study because it has been reported in the literature that mediastinal infections may have high mortality consequences.
Accesses to all portion lung and pleural space and cysts were possible with anterolateral thoracotomy, and supine position decreased the risk of aspiration during surgery despite single-lung ventilation. Postoperative thoracotomy pain is not more than other approaches. Surgical treatment of pulmonary hydatid cysts may cause potential complications as rupture, aspiration, and anaphylaxia, especially in patients who have multiple bilateral pulmonary cysts. The possibility of occurring life-threatening complications in one-staged bilateral thoracotomy and may increase the mortality rates  In our study, we have not life-threatening complications or mortality as others study. Prolonged air leak, postoperative lung, and pleura infections are more likely to occur in cases of complicated cysts in such condition two-stage thoracotomy is a preferred approach in some study. However, we used one-staged bilateral thoracotomy in complicated and intact cysts without more complication than others study. On the other hand, the possibility of associated abdominal hydatidosis is very high in patients with bilateral diffuse cystic disease. These diseases can be treated by adding phrenotomy to thoracotomy. In our series, we managed to successfully treat three patients who presented with hepatic cysts through phrenotomy. The complication rate of our series was xx% was due to complication of pleural perforation and large size of cysts as others study. Hospital mortality rates have been reported as 1%–2% although we observed no mortality or recurrence in the follow-up period (1–6 years).
| Conclusions|| |
In our experience, bilateral one-stage anterolateral thoracotomy is an appropriate surgical approach with acceptable morbidity rates, postthoracotomy pain and duration of hospital stay for treatment of bilateral pulmonary hydatid cysts. In literature reviews, we found that two-stage thoracotomy after the first thoracotomy increases the total hospital stay and complications can occur in the other lung between intervals period for second thoracotomy, median sternotomy, and Clamshell incision for complicated cases may produce osteomyelitis.
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Professor of Thoracic Surgery, Guilan University of Medical Sciences, Rasht, Guilin
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]