1. 18th IASGO Congress - Istanbul, October 8-11, 2008 SURGICAL TREATMENT OF LARGE LIVER HYDATIDOSIS – A COMPARISON OF DIFFERENT PROCEDURES Dr. Avdyl Krasniqi – Kosova( Prishtina ) Dr. Viktor QERESHNIKU – Albania ( Tirana ) E bp. A.Krasniqi¹, V. Qereshniku², B. Elezi ², D. Limani ¹, F. Hoxha ¹,, A. Beqiri ², B. Bicaj ¹, A. Gjata ², R. Musa ¹, S. Agolli ², G. Spahija ¹, A. Kerciku ², S. Krasniqi³, L. Gashi-Luci ³ ¹University Clinical Centre of Kosova, Prishtina, Kosovo ² University Hospital Centre “Mother Theresa”, Tirana, Albania ³ University of Prishtina,Faculty of Medicine, Prishtina, Kosovo

2. 18th IASGO Congress - Istanbul, October 8-11, 2008 INTRODUCTION

3. 18th IASGO Congress - Istanbul, October 8-11, 2008 INTRODUCTION Liver hydatidosis has been a common pathology for years in the surgical departments of our hospitals; Surgery combined with scolicidal therapy is the most often used treatment modality; –Mainly treated large liver hydatid cysts of: Different topographic locations (T)¹ Different levels of complication (C1-C6) »¹ Kjosev KT, Losanoff JE: J Gastroenterol Hepatol. 2005;20:352-9

4. 18th IASGO Congress - Istanbul, October 8-11, 2008 INTRODUCTION Although concept of management of liver hydatidosis is changing, surgery is still gold standard for complete cure² There is still contraversy regarding the appropriate surgical technique³ Open surgical procedures: –Tissue sparing techniques; endocystectomies/partial pericystectomy –Radical procedures; complete pericystectomy/resection »² Dervenis et al.:Journal of Gastrointestinal Surgery 2005;9:869-877. »³Skroubis et.: World Journal of Surgery 2002;26:704-708.

5. 18th IASGO Congress - Istanbul, October 8-11, 2008 OBJECTIVE To analyze the outcome of different surgical procedures that were used for treatment of 545 patients with large liver hydatid cysts.

6. 18th IASGO Congress - Istanbul, October 8-11, 2008 MATERIAL AND METHODS A retrospective study Chart review of patients with large liver hydatid cysts treated surgically over 15 years period in two university hospitals with almost similar settings in terms of patients, hospital resources and surgical teams: University Clinical Centre of Kosova (UCKK) in Prishtina University Hospital Centre “Mother Theresa” in Tirana (UHCT), Albania

7. 18th IASGO Congress - Istanbul, October 8-11, 2008 LARGE CYSTS Preoperative US/CT diameter < 12 cm; Different CE stages; WHO/Gharbi Classif. MATERIAL AND METHODS

8. 18th IASGO Congress - Istanbul, October 8-11, 2008 PATIENTS Total 545 –Goup I 293 (UCCK - Prishtina Female 182 (62.08%) Male 111 (37.92%) –F:M = 1.63:1 –Group II 252 (UHC – Tirana) Age –Median 37 years (Range 17-81) 20-40 range most often attacked MATERIAL AND METHODS

9. 18th IASGO Congress - Istanbul, October 8-11, 2008 TREATMENT – FOLLOWED PRINCIPLES Choice of procedure depends from: –Size of the cyst –Localization –Intrabiliary communication –Age –Equipment –Surgical team

10. 18th IASGO Congress - Istanbul, October 8-11, 2008 TREATMENT – FOLLOWED PRINCIPLES Intraoperative intences: - Adhesion dissection/ freed the cyst from other organs; - Prevention of intraperitoneal spillover and intracystic scolicidal therapy;

11. 18th IASGO Congress - Istanbul, October 8-11, 2008 TREATMENT – FOLLOWED PRINCIPLES Intraoperative intences: - Removal/ennucleation of cysts

12. 18th IASGO Congress - Istanbul, October 8-11, 2008 TREATMENT – FOLLOWED PRINCIPLES Intraoperative intences: –Total/partial pericystectomy

13. 18th IASGO Congress - Istanbul, October 8-11, 2008 TREATMENT – FOLLOWED PRINCIPLES Intraoperative intences: - Careful treatment of the cavity- closure of eroded bile channels -Check main bile channel for daughter cysts (selectively) -Pre/post operative ERCP/removal of daughter cysts (rarely)

14. 18th IASGO Congress - Istanbul, October 8-11, 2008 TREATMENT – FOLLOWED PRINCIPLES Intraoperative intences: –Omentoplication, T-tube (selectively) –Drainage; Cavity and sub hepatic

15. 18th IASGO Congress - Istanbul, October 8-11, 2008 RESULTS

16. 18th IASGO Congress - Istanbul, October 8-11, 2008

19. CYST LOCALISATION IN THE LIVER SURGICAL PROCEDURES Mean postoperative hospital days: –25.3 (min. 5, max. 93) Gr. I: 16.6 (min. 5, max. 71) Gr. II: 34 (min. 9, max. 93) Bile duct exploration: –95 pts (17.43%) Gr. I: 43 pts (14.6%) Gr. II: 52 pts (20.6%)

20. 18th IASGO Congress - Istanbul, October 8-11, 2008

21. CONCLUSION This study showed that: –Enucleation of endocysts, clean up of detritus and other materials from cavity, partial pericystectomy, closure of eroded bile channels, introflexion of pericystic edges and omentolplasty, was most often applied. –Marsupialization, endocystectomy with capitonnage as well as external drainage that were used in the past decades, had a higher postoperative complication rate and longer hospital stay compared to the previous procedure.

22. 18th IASGO Congress - Istanbul, October 8-11, 2008 –Radical surgical approach to a benign pathology such as LH is not an appropriate treatment modality for hospitals with limited resources. Therefore: –For large and complicated LH we recommend endocystectomy, partial pericistectomy with omentoplasty.

23. 18th IASGO Congress - Istanbul, October 8-11, 2008 THANK YOU!