Surgical Treatment of Pulmonary Hydatid Cysts in Children

Purpose: Ten years’ experience is analyzed in pediatric pa- tients with pulmonary hydatid cysts.

Methods: Between 1990 and 2000, 33 pediatric patients (2 to

15 years of age) with pulmonary hydatid cysts were operated on in Department of Thoracic Surgery in Ankara University School of Medicine. There were 17 girls and 16 boys.

Results: Twenty-three cases presented as a solitary lung cyst, whereas the remaining 10 were found to have multiple cysts in one or both lungs. Cystotomy and capitonnage were performed in 25 patients, cystotomy was done in 6 patients,

and only 2 patients underwent the wedge resection. The authors used no scoliocidal agent in our approach. There was no operative mortality. Recurrence after operation was seen in one patient.

Conclusion: Pulmonary hydatid cysts in children can be treated successfully by cystotomy and capitonnage or only cystotomy.

INDEX WORDS: Pulmonary hydatidosis.

_HYDATID DISEASE is a parasitosis caused by

Echinococcus granulosis and has been known since Hippocrates mentioned it as “liver full of water” in

400 BC. Echinococcal infestation is common in sheep- raising countries of the world, and hydatid disease is endemic in the Mediterranean region, South America, Australia, New Zealand, and Middle East.^1-3In Turkey, echinococcosis is an endemic disease, and annual inci- dence of hydatid disease is 12 cases per 100,000 inhibi- tans.⁴In the Department of Thoracic Surgery, Ankara University School of Medicine, 55 to 60 patients per year are operated on for pulmonary hydatidosis.

The lung (18% to 35%) is the second most common location for hydatid disease after liver (50% to 70%) in adults.⁵In children, hydatid disease is found in the lungs in 64% and liver in 28%.⁶Hydatid cyst can be seen in almost every part of the body and almost in every decade. Here we present our experience on surgical treatment of pulmonary hydatid disease in the pediatric age group between the years 1990 and 2000.

MATERIALS AND METHODS

Between 1990 and 2000, 33 patients under the age of 15 with pulmonary hydatid cysts were operated on in Department of Thoracic Surgery in Ankara University School of Medicine. All patients were evaluated with a history and physical examination and blood tests including a complete blood count and serum chemistries. Because of their low diagnostic value, we did not use Casoni’s intradermal test, the Weinberg complement fixation test, or eosinophil count routinely. Radiologic examinations were investigated by chest radiography or thorax computed tomography (CT) and ultrasonography or CT scan of the upper abdomen. The patients were evaluated according to sex, age, symptoms, clinical and radiographic findings, the method of treatment, and prognosis.

We routinely used posterolateral thoracotomy. In bilateral hydatid cysts, if it was not possible to reach the cysts via median sternotomy,

Journal of Pediatric Surgery, Vol 36, No 6 (June), 2001: pp 917-920

the side with a larger cyst or with a greater number of cysts was treated first in bilateral uncomplicated hydatid cyst, second thoracotomy was performed 3 to 4 weeks after the first operation. In patients with an intact cyst and a ruptured one together, intact cyst was treated first. We recommend the operation of the ruptured side first if it causes serious symptoms like hemoptysis. In patients with lung and hepatic cysts, hepatic cysts were operated on after lung cyst surgery.

Posterolateral thoracotomy was performed, and saline pads were packed beneath the lung, elevating it to a fixed position, and pleura also was protected with these pads. Hydatid fluid and scolices were aspi- rated with needle aspirator (Fig 1). The 2 edges of the needle were held by 2 Allis clamps to prevent contamination of the pleural space by hydatid fluid during the aspiration. After needle aspiration, pneumot- omy was performed, and membranes of the cysts were removed. The bronchial openings were sutured. In infected cysts, one of the bronchial openings was left unsutured for the drainage of infected fluid. The capitonnage was performed with fine sutures, and opposing surface was approximated face-to-face in multiple sutured rows to eliminate dead space. Cystotomy was performed when cyst cavities were small. Wedge resection was performed for peripheral cyst when the surround- ing pulmonary paranchyma was damaged.

All cysts were subjected to histopathologic examination that con- firmed the diagnosis.

RESULTS

The sex distribution was 17 girls and 16 boys with ages ranging from 2 to 15 years (mean, 10.8 years). Four patients (12.12%) were asymptomatic, and the cyst was discovered incidentally on plain chest x-ray for other causes. The remaining patients presented with 1 or more

From the Emergency and Trauma Hospital and the Department of Thoracic Surgery, Ankara University Medical School, Ankara, Turkey. Address reprint requests to S¸ evket Kavukc¸u, MD, Department of Thoracic Surgery, Ankara University Medical School, I^˙bn-i Sina Has- tanesi, Go¨g˘u¨ s Cerrahisi Anabilim Dalı, Samanpazarı, Ankara, Turkey.

0022-3468/01/3606-0021$35.00/0

doi:10.1053/jpsu.2001.23974

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Fig 1. Needle aspirator for aspirating scolices and hydatid fluid.

symptoms, the most frequent symptoms being cough, thoracic pain, heamoptysis, and fever (Table 1). The diagnosis was reached by plain chest x-ray in 15 patients

(Fig 2), and an additional thorax CT scan was performed in 18 patients who were operated on after 1991 (Fig 3). The cysts were unilateral in 28 and bilateral in 5 patients. Radiographic examination of 32 patients showed 61 cysts (Table 2). One patient had multiple cysts in the right lung. In 9 cases, ultrasonographic or CT scan examination of the upper abdomen showed liver involve- ment (Fig 4).

Twenty-three cases (69.7%) presented as a solitary lung cyst, whereas the remaining 10 (30.3%) were found to have multiple cysts in 1 or both lungs. There were 5 patients with bilateral hydatid cysts. In 32 patients, the cysts were predominantly located in right lung (41 of 61) and in lower lobes (Table 2).

In 25 (75.8%) patients a simple pulmonary cyst was seen. These patients presented simple cyst image as round, homogeneous, well-defined densities. There were signs of cyst rupture in 8 patients (24.2%). They con- sisted of the meniscus sign, an incarcerated membrane, the “water-lily” sign, and air-fluid levels. Although 7 patients had intrabronchial perforation of the cyst, only 1 patient had rupture into the pleural space with occuring pneumothorax and pleural effusion.

In 32 patients, 35 posterolateral thoracotomy opera- tions were performed, whereas 1 patient underwent a median sternotomy. Only 1 patient with bilateral cyst had spontaneous healing with expectoration of cyst fluid and hydatid membrane.

Cystotomy and capitonnage were performed in 25

Table 1. Occurrence of Symptoms in 33 Patients

Symptoms No. of Patients Percentage

Cough (alone) 16 48.5

Pain 11 33.3

Heamoptysis 10 30.3

Cough plus fever 6 18.2

Asymptomatic incidental findings 4 12.1

patients (Fig 5); cystotomy was done in 6 patients, and only 2 patients underwent the wedge resection because of the damaged surrounding pulmonary tissue. We used no scoliocidal agent in our approach. We did not observe calcification in pulmonary hydatid cyst. Chest tubes were used in all cases.

Postoperative course in all patients was uneventful, with none having any of the complications, such as bronchopleural fistula, persistent air leak, hemorrhage, or empyema. Recurrence after operation was seen in one patient with rupture of cyst into the pleural space (3%), and rethoracotomy was performed.

DISCUSSION

Lungs are the second most frequent location in adults for hydatid cysts.⁷However, hydatid cysts occur in the lungs in 64% of cases and in the liver in 28% in children.^6,8So diagnosis and treatment of the pulmonary hydatid disease are very important in pediatric patients. The clinical and radiographic features and distribution of the pulmonary hydatid cysts in our patients are similar to other series.^9-11The preoperative diagnosis based on radiologic findings was correct in all our cases. Cassoni’s skin test and Weinberg’s complement test are no longer performed because of the high percentage of false-posi- tive results. Eosinophilia is a nonspecific finding that can be seen in many parasitic infections. Thus, we do not use these tests, and we do not recommend these tests for

diagnosis of pulmonary hydatid disease.

The current treatment of hydatid cyst is surgical. The objective of surgery is to maintain the maximum amount of viable lung, especially in children, while providing

Fig 3. Preoperative CT scan of the chest showing hydatid cyst.

Table 2. Location of Cysts in 32 Patients

Right Lung (67.1%) Left Lung (32.8%) Upper lobe 11 (26.8%) 9 (45%) Middle lobe 4 (9.8%)

Lower lobe 26 (63.4%) 11 (55%)

complete removal of all viable parasite material. The most common surgical procedure is cystotomy and capi- tonnage in intact cysts.^5,8Cystotomy with pneumotomy line sutured was preferred in infected and small cysts.⁵In infected cysts, there must be only one drainage bronchus for infected fluid because if all the bronchial openings are closed, lung absces is inevitable. Large peripheral cysts should not be closed by capitonnage because this may restrict lung expansion.⁵We agree that the attempt should be made to remove as little lung tissue as possible and that resection of pulmonary parenchyma is only indicated when the adjacent tissue is seriously damaged or when the atelectatic areas are presumably irrecover- able. We believe that resection should be avoided when- ever possible particularly in children. We think that the parasite can be located in the pericyst.

Resection, such as a lobectomy, in most instances has been reported in countries in which hydatidosis is spo- radic. We do not recommend any resection in any age group and particularly in childhood, although giant cysts, multiple cysts, or lung abscess caused by them exist.

Fig 4. (A) Preoperative chest x-ray of a patient with liver cysts. (B) Preoperative thorax CT of same patient. (C) CT scan of the abdomen showing hydatid cysts in liver. (D) Postoperative x-ray of the same patient.

Fig 5. (A) Preoperative chest x-ray of a patient with intact cyst. (B) Lateral roentgenogram of the same patient. (C) Preoperative CT scan of the chest showing hydatid cyst. (D) Postoperative x-ray of the same patient.

We do not introduce any solution into the cavity, but we protect the operating field with saline pads. However, some investigators recommend the use of scoliocidal agent by injecting into the endocystic cavity to kill protoscoleces. We do not agree with them, because, unfortunately, this may cause undesirable complications and even death for the reason of leaking scoliocidal agent into ectocystic cavity where several bronchial openings lay. We used needle aspiration involving the trocar- suction and eliminated the risk of intraoperative contam- ination. In our series, only 1 rethoracotomy was per- formed for recurrent disease after 3 years.

We do not recommend albendazole in the preoperative period because the parasite in the lung dies, the mem- branes are retained, and the patient needs an operation for recurrent infection.¹²For the same reason, percuta- neous aspiration is not suitable for the treatment of pulmonary hydatid cysts. We now routinely prescribe albendazole (10 mg/kg/d) only after all surgically acces- sible intact cysts have been removed.

We recommend that resection of hydatic cysts should be avoided especially in pediatric patients. Small or peripheric cystic cavities can be left open after closure of the bronchial opening. There must be only one drainage bronchus in infected cysts. These methods can be applied in adults as well in children.

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(in Turkish)

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7. Gouliamos AD, Kalovidouris A, Papailiou J, et al: CT appearance of pulmonary hydatid disease. Chest 100:1578-1581, 1991

8. Blanton R: Pulmonary echinococcosis, in Mahmoud AAF (ed): Parasitic Lung Diseases, vol 101. New York, NY, Marcel Decker Inc,

1997, pp 171-189

9. Katz R, Murphy S, Kosloske A: Pulmonary echinococcosis: A

pediatric disease of the southwestern United States. Pediatrics 65:1003-

1006, 1980

10. Elburjo M, Gani EA: Surgical management of pulmonary hy- datid cysts in children. Thorax 50:396-398, 1995

11. O^¨zc¸elik C, I^˙nci I^˙, Toprak M, et al: Surgical treatment of pulmonary hydatidosis in children: Experience in 92 patients. J Pediatr Surg 29:392-395, 1994

12. Peleg H, Best LA, Gaitini D: Simultaneous operation for hydatid cysts of right lung and liver. J Thorac Cardiovasc Surg 90:783-787,

1985