1. António Menezes da Silva
CYSTIC ECHINOCOCCOSIS
HYDATID CYST
- Defintion and nomenclature
HYDATID CYST IN THE LIVER
- Therapeutic strategy
António Menezes da Silva

2. HYDATID CYST definition
Un kyste hidatique se compose de deux parties:
- le PARASITE échinococcique, et
- l’ADVENTICE qui l’encapsule
Félix Dévé (1905)
The hydatid cyst is composed by two parts:
- the echinococcal parasite (or hydatid), and
- the adventitia that involves it

3. Hydatid cyst (schematic)

4. Anatomical nomenclature
gl – germinal layer;
adv - adventitia
bc – brood capsules
scol - scolices

5. X The adventitia is NOT pericyst It IS part of the cyst
Anatomical nomenclature X
The adventitia is NOT pericyst
It IS part of the cyst
“Pericyst” can be ALL normal tissue around the cyst

6. Anatomical nomenclature
Scolice
Brood capsule
Daughter vesicles

7. UNIVESICULAR (simple) cyst (type 1 WHO)
Anatomical nomenclature
UNIVESICULAR (simple) cyst (type 1 WHO)
ONE vesicle only (mother vesicle)

8. MULTIVESICULAR cyst (type 2 WHO)
Anatomical nomenclature
MULTIVESICULAR cyst (type 2 WHO)
MORE than ONE vesicle (daughter vesicles) X
NOT daughter cysts

9. HYDATID CYSTS IN THE LIVER
THERAPEUTIC STRATEGY

10. What cysts to treat? Therapeutic options?
There is no “best” treatment option for
CE and no clinical trial has compared
all the different treatment modalities,
including “Watch and Wait”
One important difference is between
complicated and uncomplicated cysts
(TJ, AMS, JH, PC, EB – AJTMH, 2008)

11. Cysts characteristics
What cysts to treat?
► COMPLICAED CYSTS !
► Uncomplicated cysts
? - Asymptomatic
- Symptomatic
Cysts characteristics
(US Classification)

12. Complicated cysts Therapeutic options SURGERY (Always ?)
Innovative interventions
Double drainage technique (Benazouz)
- internal – endoscopic
- external – percutaneous 12

13. Complicated cysts:

14. Complicated cysts:

15. Uncomplicated cysts Therapeutic options Non-invasive treatment
● Anti-parasitic drugs
Invasive treatment
● Conservative procedures
- Non-surgical approaches
- Surgical approaches
● Radical procedures
► ONLY surgical approaches 15

16. Invasive approaches Conservative procedures Radical procedures
Cyst sterilization
Parasite (hydatid) removal
Partial cyst removal
Radical procedures
Total cyst removal
Organ resection 16

17. Conservative procedures
Cyst sterilization
- Percutaneous (PAIR/Radiofrequency)
- Surgery (Laparotomy/Laparoscopy)
Parasite (hydatid) removal
- Percutaneous (PEvac)
Partial cyst removal 17

18. Cyst sterilization Puncture and scolicidal solution injection
puncture/aspiration
scolicidal agent injection
total aspiration
Parasite death
Thermo-ablation (radiofrequency)

19. Removal of the parasite (hydatid) ONLY
(HYDATIDECTOMY)
Percutaneous
scolicidal agent injection
total aspiration including the parasite
puncture/aspiration
Surgical
puncture/aspiration
Removal of the parasite (hydatid)
Adventitia is not removed

20. Removal of the ENTIRE cyst (parasite + adventitia)
Radical procedures
Removal of the ENTIRE cyst
(parasite + adventitia)
Total cystectomy
- Open method
- Closed method (Napalkoff operation)
Organ resection
- Segmentectomy
- Lobectomy 20

21. entire cyst “wall” (adventitia) removed
TOTAL CYSTECTOMY
Open method
entire cyst “wall” (adventitia) removed
open the cyst
content aspiration
begning cyst removal
complete cyst removal 21

22. Closed method (Napalkoff)
TOTAL CYSTECTOMY
Closed method (Napalkoff)

23. TOTAL CYSTECTOMY
In the past the dissection was made in sane hepatic tissue (Pericystectomy)
(more bloody dissection and risk of lesion of the hepatic structures)
Nowadays the dissection is made in the virtual space between the adventitia and sane hepatic tissue
(less bloody dissection, less risk of lesions)
(Peng Xinyu technique)

24. Closed total cystectomy (Peng Xinyu procedure)

25. Removal of the ENTIRE cyst
Organ resection
Segmentectomy II/III

26. Anti-parasitic drugs (ABZ)
Approach proposal
Type
(WHO)
Anti-parasitic drugs (ABZ)
Percutaneous
treatment
Surgery
Suggestion 1 X -
1st – ABZ
2nd - PAIR 2
X (?)
1st – Pevac (?)
2nd – Surgery
3 a
3 b
2nd – Pevac (?)
3rd – Surgery
4 & 5
Watch & wait

27. In conclusion
The indications for hydatid cysts in the liver treatment are complex and are based on cyst characteristics, available medical/surgical expertise and equipment, and adherence of patients to long-term monitoring.
Because treatment involves a variety of options and requires specific clinical experience, patients should be referred to recognized reference and national/regional CE treatment centres, whenever available.

28. Lisbon – Portugal
Thank you