Laparoscopic management of Hepatic cystic echinococcosis in Nepal: A single center experience

Introduction: Advances in laparoscopy has replaced many conventional open surgeries; hepatic cystic echinococcosis (CE) surgery is no exception. This study aims to evaluate the feasibility, postoperative outcomes including complications and recurrence rates after employing laparoscopic treatment for hepatic CE. Methods: This is a prospective study involving patients who underwent laparoscopic intervention for Hepatic CE at Nepal Medical College and Teaching Hospital from 1st July 2014 to 30th June 2019. Laparoscopic partial pericystectomy was done through the Palanivelu hydatid system and technique after classify postoperative complications. Results: Twenty-two patients were enrolled in the study with a mean age of 33.95±15.24 (18.0-75.0) years, 15 (68.18%) of them being female. Abdominal pain (77.3%) was the commonest complaint and a single cyst in the right lobe of the liver was the commonest pathology. The mean size of the cyst was 10.2±3.0 (5.0-15.0) cms. 40.9% of the cysts belonged to WHO-IWGE Grade CE3, while grade CE2 and CE1 consisted of 27.3% each. The mean operation time was 80.7 ± 19.7 (60-120) minutes. Out of the 22 patients, six (27.3%) had minor grades while four (18.2%) had major grades of Clavien-Dindo complications. and stenting, recurrence after three months, intraoperative bleeding requiring conversion to open surgery, and acute kidney injury managed with dialysis. There was no anaphylaxis or operative mortality. Conclusion: In selected patients, laparoscopic treatment for hepatic CE is feasible even in a resource-limited country like Nepal. With a low rate of conversion, recurrence and mortality, laparoscopic management can


Introduction
Cystic Echinococcosis (CE) or Hydatid Disease is a zoonosis caused by the larval (metacestode) stage of taenid cestode of the genus Echinococcus. 1 CE is endemic and a major public health problem in several temperate countries of South America, the Mediterranean region, Middle East, Eastern Europe and Australia. 2 Despite being a nonendemic country, the disease is frequently observed in Nepal, probably due to close cultural and socioeconomic association between human and livestock. 3,4 Humans are the accidental intermediate hosts who acquire infection by direct hand-to-mouth fecal transmission of infective larva or through contaminated water or uncooked food. 5,6 Larval stage develops into a single or multiple (20-40%)  organ involved (70%), followed by the lungs (20%) and less commonly the spleen, kidneys, heart, bone and brain. 7,8 Hepatic CE most commonly presents with vague abdominal pain, abdominal lump and obstructive jaundice. 9 Among the existing treatment modalities for Hepatic CE, surgery has been the mainstay of therapy for large cysts, symptomatic 10 The surgical treatment includes open or laparoscopic partial/total pericystectomy. Alternative options include percutaneous drainage consisting of Puncture, Aspiration, Injection and Respiration (PAIR) combined with chemotherapy with benzimidazole compounds (albendazole and mebendazole). 11 Some advocate radical surgery in the form of complete pericystectomy and liver resection where the entire unopened cyst including the host tissue-derived capsule is removed. 12 In our setting widespread acceptance of laparoscopic approach for hepatic CE is still limited due to the long learning curve, training exposure, risk for spillage of cyst contents with anaphylaxis, and under-treatment of cyst contents. Only a few centers in Nepal have published results of their experience with laparoscopic approach for hepatic CE. [13][14][15] The concerns of incomplete and improper evacuation of cysts, possible intraperitoneal dissemination and subsequent fear of anaphylaxis and recurrence further 16 This study aims to evaluate the feasibility, post-operative outcomes and recurrences after employing laparoscopic modality of treatment for the hepatic CE.

Methods
This is a prospective hospital-based study involving 22 consecutive patients who underwent laparoscopic treatment of Hepatic CE by partial pericystectomy during at the Department of Surgery, Nepal Medical College and Teaching Hospital. The inclusion criteria were the patients with documented Hepatic CE by Ultrasonography (USG) or Computed tomography (CT) and Enzyme-Linked Immunosorbent Assay (ELISA)-IgG test. Patients who were younger than 16 years of age, extrahepatic CE, World Health Organization (WHO) Informal Working Group on Echinococcosis (IWGE) type V Cysts, posteriorly located cysts, patients with cystobiliary communication detected general anesthesia were excluded from the study.
Hepatic CE was diagnosed clinically, serologically by ELISA and radiologically by USG and CT. Cyst size, type 17 All patients were treated with albendazole (10 mg/kg) for at least one week before surgery and continued postoperatively for three cycles of four weeks at the interval of two weeks. The procedure was done under general anesthesia. Ten millimeter umbilical and 10mm epigastric ports were created, and 5mm ports and Palanivelu cannula were added at locations where deemed appropriate. Betadine ® (10% Povidone-iodine) soaked gauge pieces were kept around the cyst along with a 5mm suction cannula in the vicinity of the cyst to occurred. The Palanivelu Hydatid System was introduced was then replaced with 10% Betadine ® solution and reaspirated after 10 minutes. Partial pericystectomy was carried with the help of a laparoscopic hook by using monopolar diathermy, which involved resection of the corticalized pericyst (externalized extrahepatic) up to the border with the liver parenchyma while the part of the intrahepatic pericyst (residual cavity) communicating with the remainder of the peritoneal cavity remained in situ. 18,19 After marsupialization of the cavity, omentoplasty was preferred for the obliteration of the residual cavity in the liver. The laminated membrane, resected pericyst along with the cystic contents and gauge pieces were evacuated through plastic endobag. The drain was kept in proximity to the cyst cavity and removed once the content was non-bilious and less than 2ml/kg body weight for three consecutive days. If the drain was bilious and persistent output for more than two weeks, Endoscopic Retrograde Cholangiopancreatography (ERCP) with sphincterotomy and Common Bile Duct (CBD) stenting was done.
Demographic data, clinical, radiological, and intraoperative The primary outcomes evaluated in all patients were successful completion of the procedure by laparoscopy, post-operative complications and recurrences. They were followed up at intervals of three months, six months, and then annually, for detecting recurrence using abdominal of a new active cyst or reappearance of live cyst at the site of previously treated cyst. 20 was used to classify the postoperative complications. 21 Grade III or higher Clavien-Dindo complications were performed with the help of Statistical Package for the Social Sciences (version 25, SPSS Inc., IBM, Chicago, IL, USA). Variables were expressed as mean ± standard deviation or percentage of patients, as appropriate. A p-value of 0.05 or

Results
A total of 22 patients were enrolled in the study. 15 were female (68.18%) and seven were male (sex ratio of 1:2.14) (Figure 1). The mean age of the patients was 33.9 ± 15.2 years (range 18-75 years). The majority of the patients, i.e. 20 (91%) were from the mountainous region (Himalayas and Hills), and most of them i.e. 16 (72.7%) belonged to the Tibeto-Burmese population while six (27.3%) belonged to the Indo-Aryan population of Nepal (Figure 2).

Clinical Presentation
Abdominal pain was the most common presenting complaint (n=17, 77.3%) followed by abdominal lump (40.9%) ( Table 1). Fever was present in one patient. One patient had an incidental diagnosis while undergoing ultrasonography for some other ailments. ELISA was positive in only 10 patients (45.5%).    Table 4).

port site infection (Clavien-Dindo Grade I complication).
There were minor bile leaks (Clavien-Dindo Grade II complication) in three patients (13.63%) which were noted in the pericystic drain. One patient (4.5%) developed persistent biliary drainage (Clavien-Dindo grade IIIa complication) for more than two weeks who required ERCP with sphincterotomy and CBD stenting. A recurrence (Clavien-Dindo grade IIIa complication) was noted in one of the patients (4.5%) at three months during regular follow up. The patient was later managed by PAIR. Major intraoperative bleeding (Clavien-Dindo grade IIIb complication) occurred in one of the patients (4.5%) whose hemostasis was achieved after converting the procedure to postoperative day but recovered after multiple episodes of hemodialysis and other supportive care. There was no operative mortality or incidence of anaphylaxis during or after surgery.

Discussion
Laparoscopic surgeries are popular worldwide as they 22 well-established advantages of laparoscopic surgeries. The advances in technology and improvement in surgeons' skills have enabled to replicate the principles of conventional hydatid cyst surgery using a laparoscopic approach. 23 Spillage of cyst content and thus contamination of the whole abdominal cavity and concomitant anaphylaxis are overstressed fears that pull back the surgeons from adopting minimal invasive techniques. 19 Various articles have for Hepatic CE. 13,14,19 In fact, the actual risk of spillage and anaphylaxis may be much lower in laparoscopic surgery than open surgery. 24 In our study, twenty-one patients underwent partial pericystectomy through laparoscopic technique. One of the cyst was in close proximity to the right hepatic vein.
Conversion to an open procedure was required for control of hemorrhage. The conversion rate (i.e. 4.5%) in our study was comparable to that of Shrestha et.al (i.e. 7.69%), although some other studies have reported a conversion rate of 0% to 12.5%. 14,15,25 However, the conversion of the procedure from laparoscopic to open should not be regarded as a failure. The safety of the patient should be of primary consideration. 25 The mean age of the patients in our study was 33.9 ± 15.2 years which was comparable to the average age of presentation shown by various other studies. 13,19,26 Female predominance with a sex ratio of 1:2.14 was observed in our study (Figure 1) et.al and Maharjan et.al (Nepal) and Islami Parkoohi et.al (Iran). 13,26,27 However, some other articles from Nepal and abroad have shown equal or male predominance. 14,19 Majority of the patients (73.3%) were of Tibeto-Burmese (Mangoloid) origin in our study (Figure 2). Since other studies have not looked into it and our study number was reason may be dietary as the Tibeto-Burmese population is usually non-vegetarian (consumption of pork and goat is common).
Abdominal pain followed by abdominal lump was the major complaint are consistent with other articles (Table 1). 15,19,28 Likewise, our study showed single cyst in the right lobe of the liver as the most common pathology which has been documented in various other studies (Table 2). 19,28 It is well recognized that the larva burrows through the intestine and travels to the liver via the portal venous system and commonly seeds in its right lobe (60-70%) because of preferential portal [29][30][31] The mean operating time (80.7 minutes) in our study was higher than those reported by Shrestha et.al (40.51 minutes) and Palanivelu et.al. (52 minutes). 14,19 The reason for slightly longer operating time in our study may be partly because our operating time was calculated from the induction of anesthesia till extubation and partly due to our learning curve which decreased gradually on subsequent surgeries. Some of the studies of Li et.al had their average operating time of about 174 minutes. 32 The average duration of hospital stay (13.6 days) in our study was also higher in comparison to other studies. 25 The complications in patients days, p=0.007). Since most of our patients belonged to the relatively inaccessible rural mountainous region and lacked facilities to stay in Kathmandu, they would often opt to stay in the hospital till sutures were removed.
Postoperatively, six of the patients had minor complications; Dindo grade I complication) and three had bilious drainage from the pericystic drain (Clavien-Dindo grade II complication) ( Despite the excessive concern, there are very few incidences of frank anaphylaxis, even in case of a ruptured hydatid cyst. 39 Shah et.al had reported anaphylaxis in two (6.5%) of their patients during the immediate post-operative period. 15 However, there was no incidence of anaphylactic reaction in our study. The use of an extra suction cannula, securing the periphery of the cyst with Betadine ® soaked gauge pieces and retrieval of specimens in plastic endobag were used to prevent uncontrolled spillage of cyst content. The operative mortality in our study was none while Tuxun et.al have reported mortality up to 0.22% during the laparoscopic treatment which is lesser compared to the open surgeries for hepatic CE. 25 laparoscopy for the treatment of hepatic CE with low rates more radical surgeries in view of increased operative risk. 40 However, this was a small study and did not have a control open arm to compare to. We also had a longer hospital stay. Therefore, a large scale prospective multicenter randomized trial comparing laparoscopic with the open approach of treatment for hepatic CE may help establish the superiority over conventional open techniques.

Conclusion
In selected patients, laparoscopic treatment for hepatic CE is feasible even in a resource-limited setting. With a low rate of conversion, recurrence and mortality, laparoscopic management along with pre and post-operative and encouraging treatment modality for the patients of hepatic CE. none Financial support: none