Experience with Extra Hepatic Intra Abdominal Hydatid Cyst

Introduction: Hydatid disease is a significant health problem with their location at Extrahepatic Intra abdominal sites is a very rare disease. Disease in these sites usually found concurrently with liver hydatid disease. Diagnosis is based blood tests & imaging studies. Surgery is the mainstay of treatment. This study will help us in determining the frequency of Extra Hepatic Intra Abdominal Hydatid Disease. Also different methods to diagnose & treat the disease will be evaluated. Methods: It includes patients of extra hepatic intra abdominal Hydatid cyst above 13 years and underwent surgery from 2009 to 2014. Variables include age, sex, clinical findings, diagnostic investigations, operative findings, operative procedure, post operative complications. results: Eleven patients; 07 male & 04 female; mean age 37.54 years. Most common symptoms were mass in abdomen in 11 patients & dull pain abdomen in 09 (81.8%) patients. Examination revealed non tender mass in epigastric & umbilical region in 04 (36.3%) patients. Ultrasound Abdomen showed hydatid cyst spleen in 02 (18.1%) patients, epigastrium in 04 (36.3%) patients, beneath left crus of diaphragm in 02 (18.1%) patients & right iliac fossa & pelvis in 1 (9.09%) patient. In 02 (18.1%) patients multiple Hydatid cysts were noted. Hydatid cysts liver found in 07 (63.6%) patients. C.T scan Abdomen was performed in 09 (81.8%) patients. Surgical procedures performed include Saucerization & omental packing in liver Hydatid cysts; Splenectomy for Splenic disease & complete excision of remaining intra-abdominal Hydatid cysts. Postoperative complications noted in 05 (45.4%) patients. conclusion: Extra hepatic intra abdominal is an infrequent disease presents significant diagnostic & therapeutic challenge for surgeons. _______________________________________________________________________________________


INtrODUctION
Hydatid disease is a significant health problem in many parts of the world with annual incidence of 18 to 20/100,000 people. 1,2 Liver is the commonest viscera involved followed by lung. 3 Other areas rarely involved are peritoneal cavity, kidney, spleen, bone, retroperitoneum. 4 Disease in these sites usually found concurrently with liver Hydatid disease. 1,5 Diagnosis is based on Anti-echinococcal antigens & antibodies. 6 Ultrasound Abdomen typically demonstrates daughter cysts. CT Scan & MRI are more helpful in delineating futher details related to diagnosis. 7,8 Surgery is the mainstay of treatment. 9 There is no data available in literature on extrahepatic Hydatid disease from this country despite having a sizeable number of Patients which produces significant impact on the life & health of the individual.
This study will help us in determining the frequency of Extra Hepatic Intra Abdominal Hydatid Disease. Also different methods to diagnose & treat the disease will be evaluated.

MEtHODs
This was a descriptive case series study conducted at public and private sector hospitals of Hyderabad, Pakistan from 1 st July, 2009 to 30 th June ,2014. All patients of either sex above the age of 13 years who were diagnosed as cases of extra hepatic Abdominal Hydatid cyst and underwent surgery were included in the study. Patients of extra hepatic Abdominal Hydatid cyst below the age of 13 years, not operated due to serious co morbid illness like Ischemic heart disease (ASA-3), severe chronic obstructive airway disease requiring ventilator support, and complicated chronic liver disease were excluded. Also patients who did not consented for study or lost to follow-up were excluded.
These patients were admitted in ward. Detailed history was taken especially in data related to age, sex, clinical presentation, co morbid illness, animal contact history, past history of same disease & family history of Hydatid cyst. Thorough examination was performed with special focus on variables like anemia, jaundice, general health of the individual & findings of swelling in abdominal examination. Investigations like complete blood count, blood sugar, blood urea and where required ECG and chest x-ray were performed to assess general fitness. In addition investigations required to diagnose pathology like ultrasound of Abdomen, C.T scan of Abdomen & Anti Echinococcus antibodies were performed to establish diagnosis. Diagnosis was made and patients were briefed about the diagnosis and procedure to be performed. Patients were informed and consent was granted. They were assured that their participation is voluntary with no harms to them in terms of getting due treatment. They were also given right to withdraw from study without putting any reasons. Permission for the study was granted from Head Department of Surgery in Public sector hospitals.
Preoperatively patients were put on antihelminth therapy (Albendazole 10mg/kg/per day in divided doses) for 30 days prior to surgery & repeated the same drug postoperatively for 1 month. Laparotomy was performed under General anesthesia. Abdominal cavity opened. Green towels soaked in hypertonic saline were applied all around the swelling. In case of Hepatic Hydatid disease aspiration of fluid & then instillation of hypertonic saline for 3 -5 minutes was performed before opening the cyst. Cyst opened & all contents removed. Communication with the biliary tree ascertained & if found it was closed with Vicryle. Cavity washed & omentum applied in the cyst cavity after deroofing surface of the cyst (Saucerization). In case of Splenic Hydatid disease Splenectomy was performed. In patients with other intra-abdominal hydatid disease complete excision of cyst was performed. Drain was placed in sub hepatic space for Hepatic Hydatid cyst & at the site of cyst excision in other cases. Postoperatively patients received I/V antibiotics. Patients were started orally once gut activity resumed. Drain was removed when less than 10 ml discharge was coming in the drain. Patients were discharged when tolerated diet well, fully mobilized. Follow-up visits were advised at 10 days, 3, 6 & 12 months to assess complications associated with the disease & procedure which includes recurrence of disease.
Data was collected on preformed proforma for variables including age, sex, clinical presentation, abdominal examination findings, diagnostic investigation findings; operative findings, operative procedure performed, any post-operative complications and hospital stay. Sampling strategy used in this study was non probability purposive method. Data were summarized using statistical package for social sciences version 16

DIscUssION
Primary peritoneal Hydatid cyst is a very rare disease and mostly it is secondary in origin with primary site being the Liver. Pedrosa I et al 10  patients during the period 3 months to 20 years which was significantly lower after radical surgical procedures (p= 0.03) and after complete removal of the cyst (p= 0.04) 18 .
Michael OP & collaegues 19 treated a patient of recurrent retro rectal pelvic hydatid cyst with three courses of Albendazole. Sixteen weeks later review CT scan performed before planned surgical procedure showed disappearance of the cyst with a decrease in the IgG anti-echinococcal antibody titers to lower level.

cONcLUsIONs
Extra hepatic intra-abdominal is an infrequent disease presents significant diagnostic & therapeutic challenge for surgeons. It should be included in the differential diagnosis of mass Abdomen. Most commonly it is secondary in origin with primary site is usually Liver. Every effort should be made to avoid spillage of contents during surgery to prevent recurrence of disease.