Hydatid disease of the liver

See article in J. Gastroenterol. Hepatol. 2005; 20: 352-359. Although hydatid disease is endemic in the Middle East, the areas bordering the Mediterranean Sea, South Africa, Northern Canada, Australia and New Zealand, with the immigration and widespread traveling, it can also be observed in other countries. Naturally, most studies about hydatid disease originate from these endemic countries. Dr Kjossev and Dr Losanoff emphasize a serious point on hydatid liver disease. They are trying to classify the disease with its natural course and complications. This effort may help us to understand the clinical course better, to compare the results of different treatment modalities more accurately and to make algorithms for different forms of the disease. Although percutaneous treatment (PAIR) has some encouraging results, surgery still the primary mode of treatment for patients with hydatid cysts and several surgical procedures are described. Hydatid disease of the liver can be managed surgically by radical or conservative methods. The radical method involves total excision of the cyst by pericystectomy or hepatectomy. The conservative method includes removal of cyst contents and management of the residual cavity. Although there is no randomized study to compare radical and conservative surgery, generally surgeons in the nonendemic areas prefer radical surgery whereas surgeons in the endemic areas prefer conservative methods. I believe that radical methods should not be used routinely for a benign disease with its attendant increase in operative risk. Additionally, most hydatid liver cysts can be treated successfully by conservative surgery. Despite these advantages, conservative techniques have the increased risk of cavity complication. There have been efforts to reduce these complications by performing the correct cavity management method since the 1970s. Although the surgical approach is important, the more important point is the stage of the disease. In non-complicated cases, conservative treatment methods are almost effective. Contrary, in complicated cases omentopexy or introflexion techniques seem partly effective. The case in point looks like the approach to acute pancreatitis in the past. Three or four decades ago, all acute pancreatitis cases were treated in the same manner. Later, we learned that there were mainly two clinical forms; severe necrotizing and self-limited edematous. Today, we accept that the treatment modalities of two forms of the same disease are quite different. I believe that different forms of hydatid liver cysts should be evaluated separately. Unfortunately, most of the studies on hydatid liver disease do not separate the cases and try to find the best surgical technique. Here, Dr Kjossev and Dr Losanoff create a detailed classification system to evaluate and treat the cysts with different ways. I think this study does have some weak points. First, the classification system is complicated. A detailed classification system may be ideal, but in daily practice a simple one may be better and more practical. Second, statistical analyses between the cyst's topographic locations with postoperative complications are not clear enough to create an algorithm. Third, T, N and R stages do not effect making clinical decisions in the algorithm. The main determinant of the treatment decision is complicated and non-complicated cysts. Last, there is no comparative data to make the treatment decision between medical treatment, open surgery, PAIR or laparoscopy. I strongly support the efforts of using a uniform nomenclature and international hydatid disease registry to allow more rational comparisons of different management strategies. I believe that the study of Dr Kjossev and Dr Losanoff will help to support these efforts as well, and in the future everybody with an interest in hydatid liver cysts will first stage them.

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