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Ann Thorac Surg 2002;74:889-892
© 2002 The Society of Thoracic Surgeons
evval Eren, MDaa Department of Thoracic and Cardiovascular Surgery, Dicle University School of Medicine, 21280 Diyarbakir, Turkey
Accepted for publication May 13, 2002.
* Address reprint requests to Dr Balci, Department of Thoracic and Cardiovascular Surgery, Dicle University School of Medicine, 21280, Diyarbakir, Turkey
e-mail: abalci{at}dicle.edu.tr
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Abstract |
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Methods. Sixty-three children with a total of 68 ruptured lung hydatid cysts were operated on between 1980 and 2000. Mean age was 12.3 years (range, 1 to 15 years). Radiographic findings were hydropneumothorax (20.6%) and air-fluid level (19%). Mean follow-up was 19.3 months.
Results. Transthoracic needle aspiration was responsible for the rupture in 3 children. The interval between cyst rupture and operation was less than 24 hours in 10 patients (15.9%), 1 to 4 days in 36 (57.1%), and more than 4 days in 17 (27%). Resection rate was 22.1%. The most frequent operative method was cystotomy and capitonnage (38%). Morbidity was 25.4% (extended air leak 5, empyema 3, bronchopleural fistula 3, atelectasis 3, pneumonia 2). Mortality was 4.7% (hemoptysis 1, pneumonia and sepsis 1, aspiration of hydatid material 1). Morbidity and mortality seem to be more frequent in late cases.
Conclusions. Early surgical intervention with single-lung ventilation and maximum parenchyma preservation are recommended.
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Introduction |
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There are several reports about hydatid cysts in children [2–5] but none especially about ruptures, if one excludes those about complications such as rupture into the pleura [6], tension pneumothorax [7], or airway obstruction [8]. The purpose of this study was to document the specifications of ruptured cysts in children.
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Material and methods |
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Most frequent respiratory symptoms were cough in 23 (36.5%) and fetid expectoration in 23 (36.5%; Table 1). All patients had a chest radiograph. An image on the chest roentgenogram with a very round appearance and decreasing density from the center to periphery was known as pathognomonic for intact lung hydatid cyst, especially for the endemic region. In conditions including turbid intracystic fluid, degenerated germinative membrane, or calcification or gross infection of the cyst, it was considered to be ruptured. Radiograph findings of the 63 children were hydropneumothorax in 13 (20.6%), air-fluid level mimicking lung abscess in 11 (17.5%), total pneumothorax in 11 (17.5%), air cysts in 12 (19%), localized empyema in 9 (14.3%), and water lily sign in 7 (11.1%). Other diagnostic methods used were thoracic and liver ultrasonography in 34 patients (54%), computed tomography in 38 (60.3%), and thoracentesis in 12 (19%). Because of their lack of specificity, Weinberg and Casoni tests were not used. Blood tests showed eosinophilia in most patients. On the other hand, no pathognomonic radiologic or serologic findings were found to establish a clear perforated hydatid cyst diagnosis. Any acute symptom (such as cough, hemoptysis, fever, chest pain, vomiting, or membrane expectoration) or sudden aggravation in a present symptom was referred to as cyst rupture.
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The primary method for repairing the part of the lung with the perforated cyst was to close the bronchial openings after removing the germinative membrane, if present, and capitonnage. Median sternotomy was not used because of the risk of infection. For cysts that ruptured to the bronchus, rather than to the pleura, a cystotomy was required to visualize the cystic cavity. The lung tissue next to the cyst was observed and evaluated with ventilation of the lung. If the parenchyma was hepatized and not ventilated with insufflations by the anesthesiologist, a resection was considered. Indications for resection were advanced parenchyma destruction resulting from infection or compression of the cyst to the lung. Determining the extent of the resection was related to intraoperative findings and the surgeon’s opinion. Thus, if the lesion involved at least two thirds of the lobe, a lobectomy was performed. No stapler was used. In empyema cases (5 children) with trapped lung caused by pleural peel, a decortication was performed to reexpand the lung.
All patients received antibiotic therapy in the preoperative and postoperative periods. Mebendazole or albendazole was used postoperatively as an antihelmintic, but not routinely, because of the high dose needed, the lack of a proven effect on hydatid disease and poor patient tolerability. There was no standard protocol for antibiotics such as anthelmintics. In general, first-generation and second-generation cephalosporins were empirically used if the special culture was not available. Any air leak continuing more than 10 days was considered prolonged or extended. Atelectasis was diagnosed with postoperative roentgenograms and decreased respiratory sounds by auscultation associated with a sudden increase in body temperature.
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Results |
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2 test), probably resulting from infection.
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In patients who received separate lung ventilation (19 cases), there was no mortality and there were only complications that needed no or relatively less invasive intervention. There was no correlation between operation type and complications or mortality.
Recurrent transthoracic needle aspirations performed during diagnosis in another hospital were responsible for the rupture in 3 children. No specific cause was identified in the remaining children.
The interval between cyst rupture and operation was less than 24 hours in 10 patients (15.9%), 1 to 4 days in 36 (57.1%), and more than 4 days in 17 (27%).
The period of postoperative antibiotic treatment (mean, 3.6 days; range, 2 to 10 days) was adjusted according to the clinical findings of the patients.
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Comment |
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We observed more complications and higher mortality in cysts operated on late. In addition, some symptoms, especially fever, were resistant to medical treatment with antibiotic and analgesic or antipyretic drugs. Surgery was the only method that effectively reduced the fever. The same antibiotics were used postoperatively and stopped generally within 2 to 4 days. It may be speculated that infection with fever may lead to pneumonia and sepsis. In other series, as in ours, complication and resection rates, as well as mortality, have been higher in complicated cysts [11, 12]. In the pediatric age group, because of the low resistance of the lung to cysts, expansion may cause a tension pneumothorax as a result of the rapid growth of the cyst, advocating early surgical removal of any suspected cyst to avoid further complication [7]. The mortality rate was as high as 4.2% in some series that included both complicated and uncomplicated cysts [13]. We have to emphasize that, like intact cysts, ruptured ones must be operated on as soon as the diagnosis is established, in elective conditions (not emergency), and that separate lung ventilation is important for decreasing morbidity and mortality. The better cases in our series involved children operated on before 4 days and with separate lung ventilation.
Complicated hydatid cysts, especially those that ruptured into the pleura, are difficult to diagnose radiologically. In 3 patients, cysts had ruptured into the pleura but these were misdiagnosed as empyema (roentgenogram, computed tomography, and ultrasonography had been performed). After chest tube insertion, hydatid material was observed within the tube, and thoracotomy was performed. Although computed tomography has been reported to be currently the most sensitive diagnostic tool for demonstrating liver hydatid cyst rupture [14], further studies may be useful to elucidate specific radiologic signs for diagnosing ruptured lung hydatid cysts. In complicated (ruptured, infected) or undiagnosed cases, all the findings are suggestive, not diagnostic. Although the computed tomographic diagnosis of ruptured pulmonary hydatid cyst was the most difficult [15] because of infection, in the planning of the operation it was successful in detecting the localization, contents, and borders of the lesion.
Medical treatment of intact cysts is not effective, but may be useful for ruptured ones. Our patients did not take any antihelmintic drug before the operation. There was no recurrence during the follow-up period. Transthoracic needle aspiration may cause rupture of cysts and spillage of their contents; hydatid fluid with scolices and daughter cysts could cause severe anaphylactic reaction or later development of new cysts in the contaminated tissues. In 3 children, needle aspiration was responsible for the rupture. We advise against puncture when a hydatid cyst is suspected because this may result in rupture, which in turn leads to more complications. In intact cysts, our resection rate was 7% versus a relatively high rate of ruptured ones (22.1%). This high resection rate for ruptured cysts is wholly because of the complication of hydatid disease (rupture), which causes significant destruction of the lung tissue. Similarly, morbidity and mortality are also less in intact cysts (14.4% and 1.5%, respectively). Only the recurrence rate is higher in intact ones (2.5% versus 0%), probably not only because of successful operation but also because of ruptured or infected cysts having a much lower reinfection capacity.
Bronchi opening into the pericyst cavity allow the discharge of fluid matter but not the escape of solid remnants of the collapsed parasite in patients with ruptured lung hydatid cysts [8]. Operative manipulation of chronic ruptured pulmonary hydatids can force fragments of the laminated membrane or small daughter cysts into the bronchial tree, resulting in acute obstruction of airways and the need for intraoperative bronchial aspiration [8]. We have encountered these complications in some adults and 9 children, of whom 5 had intact cysts and 4 had ruptured cysts. All exhibited respiratory failure with a decrease in arterial oxygen pressure or saturation, ventilation difficulty during operation, and prolonged ventilatory support in the postoperative period. Two children, one with an intact cyst and the other with a ruptured cyst, died on the third and fifth postoperative days, respectively, of respiratory failure. We used continuous positive airway pressure delivered by an anesthesiologist during cystotomy routinely to prevent the escape of cyst content to the bronchi. This method may be useful but is not sufficient and dependable because the duration of positive pressure is time-limited and excessive pressure produced by surgical manipulations rather than by ventilation can cause escape of hydatid fluid into the bronchial tree. In addition, before the cystotomy or other surgical method, cyst rupture can occur and force fragments into the tree. Thus, we prefer a double-lumen intubation tube or ordinary cuffed tracheal tube introduced into the main bronchus of the healthy side and single-lung ventilation. No similar complications have been caused by single-lung ventilation in recent years, possibly because of better anesthesiologic and postoperative facilities.
Surgical treatment is effective in children with complicated cysts as well as uncomplicated ones, with low mortality and no late complications or recurrence for this relatively high-risk group. Operation must be performed early because of the high complication rate in patients who were operated on late. The choice of surgical technique depends on the conditions encountered during the operation. When parenchymal destruction is present, resection must be performed. Only the destroyed parenchyma should be removed. Under other conditions, cystotomy and capitonnage are the main surgical methods. In cases of trapped lung caused by infection (empyema), decortication of the pleural peel must be performed. The type of operation was not correlated with morbidity or mortality. Single-lung ventilation is preferred to prevent aspiration of cystic material and respiratory complications, and, in turn, morbidity and mortality. Although postoperative morbidity seems to be high, perforation or infection were responsible rather than the operation itself.
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References |
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C., Tau
tepe ., et al. Surgical treatment of pulmonary hydatid cysts in children. J Thorac Cardiovasc Surg 2000;120:1097-1101.
an R., Yüksel M., Çetin G., et al. Surgical treatment of hydatid cysts of the lung: report on 1055 patients. Thorax 1989;44:192-199.This article has been cited by other articles:
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  M. Sokouti and M. Nazemieh Thoracoscopy in diagnosis of ruptured pulmonary hydatid cyst BMJ Case Reports, November 20, 2008; 2008(nov12_1): bcr0620080133 - bcr0620080133. [Abstract] [Full Text]
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 M. Aghajanzadeh, F. Safarpoor, H. Amani, and A. Alavi One-Stage Procedure for Lung and Liver Hydatid Cysts Asian Cardiovasc Thorac Ann, October 1, 2008; 16(5): 392 - 395. [Abstract] [Full Text] [PDF]
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M N. Eren, A. E Balci, and S. Eren Non-Capitonnage Method for Surgical Treatment of Lung Hydatid Cysts Asian Cardiovasc Thorac Ann, March 1, 2005; 13(1): 20 - 23. [Abstract] [Full Text] [PDF]
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 A. Kuzucu, O. Soysal, M. Ozgel, and S. Yologlu Complicated hydatid cysts of the lung: clinical and therapeutic issues Ann. Thorac. Surg., April 1, 2004; 77(4): 1200 - 1204. [Abstract] [Full Text] [PDF]
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