IJHAS_115_19R1

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Comparison of omentoplasty and 4
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tube drainage as treatment option in 6
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hydatid liver disease: A retrospective 8
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hospital‑based observational study 10
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Website:
12 www.ijhas.in Jehangir Allam Bhat, Shahida Akhter1, Sajad Ahmad Sheikh2 12
13 13
14 DOI: 14
10.4103/ijhas.IJHAS_115_19
15 Abstract: 15
16 16
BACKGROUND: Hydatid disease remains an important parasitic infection requiring surgical
17 intervention. The liver is the most common site of infection, and several methods of surgery have
17
18 been described to treat this common disease. Extensive research is going on to find the best operative 18
19 treatment procedure for hydatid liver diseases. 19
20 AIM: The aim of the study was to compare the results of two surgical methods used in the treatment 20
21 of hydatid disease of the liver, namely omentoplasty and tube drainage. 21
22 METHODOLOGY: Fifty‑seven cases of hydatid liver were treated from January 2005 to January 22
23 2011, out of which thirty patients were treated with omentoplasty (Group A) and 27 were treated with 23
24 tube drainage (Group B). The results of the surgery in terms of mortality, complications, hospital stay, 24
25 and recurrences were analyzed by unpaired t‑test or Fisher’s exact test, and P value was calculated. 25
26 RESULTS: Overall postoperative complications were seen in 9.4% in Group A and 22.5% in 26
27 Group B. The average hospital stay and time to resume routine work in Group A was shorter as 27
28 compared to Group B. The percentage of complications such as wound infections and abscesses 28
29 formation were 3.4% each in omentoplasty group and 11.2% and 7.2% in tube drainage group, 29
30 respectively. The comparison of infection frequency among two groups showed strong statistical 30
31 significance with P = 0.002 in wound infection and 0.0014 in abscess formation. The comparison of 31
jaundice development after both procedures was statistically insignificant (P = 0.037). No patient in
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omentoplasty group developed biliary fistula, and the percentage of this complication in tube drainage
33 was 3.7%. The recurrence of hydatid disease in omentoplasty was nil and 7.41% in tube drainage
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34 patients. There were no recurrences in either group for a follow‑up of 4 years. 34
35 35
CONCLUSION: Omentoplasty is better and must be preferred operative procedure than tube drainage
36 in the treatment of hydatid cyst liver disease. 36
37 Departments of 37
Keywords:
38 Paediatrics and 38
2
Neonatology, World Echinococcus, hydatid cyst, omentoplasty, tube drainage
39 39
College of Medical
40 40
Sciences and Research
41 Institute, Jhajjar, Haryana, 41
42 1
Department of Surgery,
Introduction common types of hydatid diseases are
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Government Medical caused by E. granulosus and Echinococcus
43 43
44
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College, Srinagar, Jammu
and Kashmir, India H ydatid cyst of the liver is a zoonotic
disease caused by the larval stage of
Echinococcus granulosus. [1,2] Humans are
multilocularis.[5,6] Worldwide, the disease is
commonly seen in the Mediterranean region,
South America, the Middle East, Australia,
44
45
46 Address for 46
correspondence:
accidental intermediate hosts, whereas and New Zealand. It is the most common
47 47
Dr. Sajad Ahmad Sheikh, animals are both the intermediate and type of hydatid infection in humans. The
48 48
World College of the definitive hosts. [3,4] The two most involvement of almost every organs and
49 Medical Sciences and 49
body tissues by the hydatid infection is
50 Research Institute, 50
Jhajjar, Haryana, India.
known in literature, but the liver remains
51 This is an open access journal, and articles are 51
52 E‑mail: ajaalam333@ distributed under the terms of the Creative Commons 52
gmail.com Attribution‑NonCommercial‑ShareAlike 4.0 License, which How to cite this article: Bhat JA, Akhter S,
53 allows others to remix, tweak, and build upon the work Sheikh SA. Comparison of omentoplasty and tube 53
54 Received: 04‑12‑2019 non‑commercially, as long as appropriate credit is given and drainage as treatment option in hydatid liver disease: 54
Revised: 24-01-2020 A retrospective hospital‑based observational study. Int
55 Accepted: 12‑02‑2020
the new creations are licensed under the identical terms. 55
56 J Health Allied Sci 2020;XX:XX-XX. 56
Published: *** For reprints contact: reprints@medknow.com

© 2020 International Journal of Health & Allied Sciences | Published by Wolters Kluwer ‑ Medknow 1

 Bhat, et al.: Surgical treatment of hydatid cyst liver

1 the most common organ to be involved. About 50%–75% and tube drainage) and determine which one is better 1
2 of the cysts occur in the liver, 25% are located in the for treatment of pediatric hydatid liver disease. 2
3 lungs, 7% in the kidney, and 5%–10% distributed along 3
4 the vascular system.[7‑9] The outer covering of the cyst Methodology 4
5 called the pericysts is an outer fibrous capsule derived 5
6 from the host tissue as a result of inflammatory reaction. This prospective hospital‑based observational study 6
7 The cyst wall is composed of two layers. Ectocyst is an was conducted on 57 cases of hydatid liver who were 7
8 outer gelatinous membrane and an endocyst is an inner treated in the Department of Surgery, Government 8
9 germinal membrane. Brood capsules are intracellular Medical College, Srinagar, Kashmir, from January 2005 9
10 masses in which future worms develop into scolices. to January 2011. Patients were categorized into two 10
11 In a definitive host, the scolices develop into an adult groups. Group A patients treated with omentoplasty 11
12 worm. In the intermediate host, they differentiate into and Group  B treated with tube drainage. A  total of 12
13 a hydatid cyst. Hydatid sand is the free brood capsules, thirty patients were included in Group  A and 27 13
14 and scolices are found in the hydatid fluid. Death of the into Group  B. The diagnosis of hydatid liver was 14
15 hydatid cysts can lead to degeneration of the membrane made by ultrasonography or computed tomography 15
16 and calcification of the cyst wall. scan [Figure  1a and b]. Proper ethical and scientific 16
17 clearance was taken from respective committees 17
18 The life cycle of E. granulosus has two hosts. The definitive before conducting this research. Informed consent 18
19 host is usually a dog or some other carnivore. The adult was obtained from every patient after explaining risk 19
20 worm lives in the proximal small bowel of the definitive and benefits of each procedure and purpose of our 20
21 host attached to gut wall mucosa by hooklets. Eggs are research. 21
22 released and excreted in the feces. Sheep are the most 22
23 common intermediate host. These animals get infected Detailed history and physical examination was done 23
24 while grazing in the fields. The ovum once ingested loses before subjecting the patients to surgical exploration. 24
25 the protective chitinous layer in the upper digestive tract All the patients were subjected to enzyme‑linked 25
26 of the host. The released hexacanth embryo (oncosphere) immunosorbent assay for hydatid disease. Patients 26
27 gains entry into the portal circulation after passing through were kept fasting overnight, and informed consent 27
28 the intestinal wall and develops into cysts in the liver (first was obtained before subjecting them to operation. 28
29 filter). The definitive host (e.g., dog) eats the infected viscera After opening the abdominal cavity, the operative field 29
30 of the intermediate host and the cycle is completed.[10,11] was protected against the spills by packs soaked with 30
31 10% of povidone‑iodine, the cystic fluid was removed 31
32 Radiological investigations such as ultrasonography using a closed suction system, and the cystic cavity was 32
33 and contrast‑enhanced computed tomography (CECT) filled with 10% of povidone‑iodine for about 10  min. 33
34 identify the cyst in >90% of the cases. CECT provides After incising the ectocyst, the endocyst containing 34
35 characteristic images based on its wall features, daughter the daughter cysts was completely removed. The 35
36 cysts, septations, calcification, and communication with cyst cavity was cleaned by dry gauze, and any biliary 36
37 the biliary channels.[12‑14] communication was looked for. Visible communications 37
38 between the remaining cavity and the biliary ducts were 38
39 Surgery is the basic treatment for hepatic hydatid disease. closed with fine sutures. 39
40 The main objectives of surgical treatment are: 40
41 a. Eradication of the parasite These two techniques were compared with reference 41
42 b. To prevent spillage of contents during the surgical to average length of hospital stay, average days taken 42
43 procedure for resumption of normal activities, complications such 43
44 c. Obliteration of the residual cyst cavity. as infection (wound infection and abscess formation), 44
45 45
46 Various surgical procedures exist to achieve these 46
47 goals.[15‑17] Till date, surgical exploration remains the 47
48 treatment of choice in the management of hydatid 48
49 disease.[16,17] The treatment of the residual cyst cavity 49
50 of the hepatic hydatid disease is a debatable issue 50
51 and generally has not produced any consensus. Two 51
52 main operative approaches have been described: 52
53 (a) drainage procedures and (b) the obliteration of 53
54 the residual cyst cavity after evacuation of the cyst a b 54
55 content (omentoplasty). The main objective of our study Figure 1: (a and b) Contrast‑enhanced computed tomography scan pictures of
55
56 was to compare these two procedures (omentoplasty hydatid cyst liver 56

2 International Journal of Health & Allied Sciences - Volume XX, Issue XX, Month 2020
 Bhat, et al.: Surgical treatment of hydatid cyst liver

1 jaundice, and recurrence of hydatid liver disease. that statistics of average days of hospital stay and average 1
2 The recurrence was checked by clinical examination, days to resume normal work in Group A were 8.7 ± 2 2
3 ultrasonography (USG), and serological tests every and 14.6 ± 3 and in Group B were 18.4 ± 4.5 and 21.2 ± 5, 3
4 3 months. respectively. The comparison of these parameters among 4
5 groups was also statistically significant with P = 0.0001 5
6 Statistical analysis for average days of hospital stay and P = 0.004 for average 6
7 All the data collected were analyzed using IBM SPSS days to resume normal work. 7
8 Statistics for Windows, Version 23.0. (IBM Corp., Armonk, 8
9 NY, USA) and MedCalc Software 18.11.3 (Acacialaan 22, Wound infection occurred in 1 (3.4%) patient of Group A 9
10 8400 Ostend, Belgium). Unpaired Student’s t‑test and and 3  (11.2%) patients of Group  B, and statistical 10
11 Fisher’s test were used to compare data and derive relation of this complication was significant with 11
12 P value. P < 0.005 was considered statistically significant. P = 0.002. Intraabdominal abscess formation occurred in 12
13 1 (3.4%) patient of Group A and in 2 (7.4%) patients of 13
14 Results Group D again, statistically relation with respect to this 14
15 complication was also significant (Value 0.0014 ≤ 0.005). 15
16 Out of 57 patients included in our study, 35 were male Jaundice occurred in 2 (6.8%) in Group A patients and 16
17 and 22 were female with a mean age of 34.2 ± 6.5 years for 3  (11.2%) of Group  B patients. However, comparison 17
18 males and 33.6 ± 5.9 years for females. Age was compared of jaundice in both groups shows no statistical 18
19 and showed no statistical difference. The sizes of the cysts significance  (value 0.073  ≥  0.005). No patient in 19
20 ranged from 6 to 10 cm. Thirty patients (Group A) were Group  A and 1  (3.7%) patient in Group B  developed 20
21 treated with omentoplasty technique and 27 (Group B) biliary fistula. However, the comparison of the 21
22 with the tube drainage. The average length of hospital development of this complication showed no statistical 22
23 stays, average days taken for resumption of normal significance (P = 0.072). 23
24 activities, postoperative complications such as wound 24
25 infection, abscess formation and jaundice, and recurrence On follow‑up, the recurrence of hydatid cyst in the 25
26 over follow‑up period of 4 years were compared in these liver after operation was not reported in any patient in 26
27 two groups [Table 1]. Group A and 2 (7.7%) of the patients of Group B with 27
28 statistical significance (P = 0.001). 28
29 Mortality was recorded in no patient during intraoperative 29
30 and postoperative period. However, one patient did Overall complication rate in Group A patients was 13.3% 30
31 not reported to follow‑up after 6 months because of and in Group  B was 41.2%. The complication rate in 31
32 unknown reason as shown in Table 1. Table 1 also shows Group A was lower as compared to Group B and showed 32
33 statistical significance with P = 0.012 [Table 1]. 33
34 Table 1: Comparative parameters of two surgical 34
35 techniques for hydatid cysts (Group A omentoplasty Discussion 35
36 patients and Group B tube drainage patients) 36
37 Parameter Group A Group B P Due to poor sanitation, hepatic hydatid cyst is still 37
38 (Total 30) (Total 27) 38
an endemic health problem in many countries of the
39 Gender 39
developing world.[18] Clinical symptomatology varies
40 Males 18 17 40
considerably depending on the size and anatomical
Females 12 10
41 location of the cyst. Most common presenting symptoms 41
Mean age 34.2±6.5 33.6±5.9 0.098
42 in our series were pain in the right upper quadrant, 42
Mortality Nil Nil
43 nausea, and vomiting. Physical examination showed 43
Average length of hospital stay 8.7±2 18.4±4.5 0.0001
44 (days) minimal findings. Hepatic hydatidosis is one of the 44
45 Average days taken for 14.6±3 21.2±5 0.004 differential diagnoses of patients of endemic areas 45
46 resumption of normal activities presenting with vague symptoms of pain and mass in 46
47 Complications upper abdomen, nausea, and vomiting.[19,20] 47
48 Infections 48
49 Wound infection 1 (3.4) 3 (11.2) 0.002 In our study, we found that the average hospital stay 49
50 Abscess formation 1 (3.4) 2 (7.4) 0.0014 and average days taken to resume normal routine work 50
51 Jaundice 2 (6.8) 3 (11.2) 0.073 were both shorter in omentoplasty group as compared 51
52 Biliary fistula Nil 1 (3.7) 0.072
to drainage procedure group. Similar findings were 52
53 Recurrence over 4 years Nil 2 (7.7)® 0.001 53
reported by Akin et al.,[21] Gourgiotis,[22] and Wani et al.[23]
54 Percentage of total 13.3 41.2 0.012 54
complications
55 In our study, complication rate and formation of the 55
®
This percentage was derived from 26 patients because after 6 months one
56 girl of 20 years age did not came for follow‑up because of unknown reasons biliary fistula was high in drainage procedure group as 56

International Journal of Health & Allied Sciences - Volume XX, Issue XX, Month 2020 3
 Bhat, et al.: Surgical treatment of hydatid cyst liver

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15 An important finding which we noted in our study is 10. Kern P. Echinococcus granulosus infection: Clinical presentation, 15
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