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Management of Management of Hepatic Cysts

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 Management of
   Hepatic Cysts
     Sybile Val,
     S bil V l MD
    Department of Surgery
SUNY Downstate Medical Center
       August 15, 2008
             www.downstatesurgery.org
                        Questions
1.    Ultrasonography demonstrates a liver cyst with a thick wall
        d       i     Th       i    h ld b d i d
      and septations. The patient should be advised
     a. To have repeat sonograms every 6 months for 2 years
     b. Interventional radiologist for aspiration and biopsy
     c. Surgical referral for laparoscopic fenestration
     d. Surgical referral for complete resection

2.    Cyst wall in cases of cystadenomas should be
     a. Partially resected
     b. Completely resected
     c. Suture ligated
     d. Fenestrated
             www.downstatesurgery.org
                        Questions
3.    Sclerotherapy with alcohol leads to
     a. Necrosis of cyst wall
     b. Fixation of the cells lining the cyst cavity thus disabling
         their ability to secrete fluid
     c. Is never performed because it leads to cholangitis
     d. Has 100% success rate

4.    Polycystic liver disease is a contraindication for laparoscopic
      fenestration
     a. True
     b. False
     c. I don’t know
     d. All of the above
             www.downstatesurgery.org
                       Questions
5.     Laparoscopic fenestration
     a. Has lower recurrence rates than open unroofing
     b. Is considered the procedure of choice for congenital cysts
     c. Is less morbid than traditional unroofing
     c
     d. A is the only incorrect answer!
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               Case Presentation
                    History
                    Hi t
• HPI:                   • PSH:
  – 56 YOF 5 week h/o      – TAH/BSO
    RUQ pain
                              y     p
                           – Cyst aspiration


                         • Meds:
• PMH:
                           – Hyzaar
  – HTN
  – Endometrial cancer
  – No allergies
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    Case Presentation
       Imaging
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    Case Presentation
       Imaging
       I   i
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              Case Presentation
     Physical E    L b
     Ph i l Exam & Labs
• Physical Exam
  – 7/06: RUQ mass, non-tender
    Pre-Op:
  – Pre Op: Unremarkable
• Labs:
    CBC     / / /
  – C C - 4/11/38/248
  – Chem – 140/3.4/100/27/17/0.87/88
  – LFTs - 7.6/4.6/25/22/65/0.2
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    Case Presentation
       Imaging
       I   i
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                   Case Presentation
   Operation C st
   Operation: Cyst Fenestration
• Pneumoperitoneum
  created via open
  technique
• Followed by
  placement of ports for
  puncture, aspiration
  and deroofing of cyst




    Operative Techniques in General Surgery, Vol 4 (March), 2002 76-87
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                   Case Presentation
   Operation Cyst
   Operation: C st Fenestration
• Cyst wall is incised
• Contents are drained
• Flaccid cyst wall is
  resected




    Operative Techniques in General Surgery, Vol 4 (March), 2002 76-87
           www.downstatesurgery.org
             Case Presentation
 Operation: Cyst Fenestration
 O    ti    C tF      t ti
• Residual cyst wall
  carefully inspected
• Ablation of remnant
  cyst lining performed
• (Omentum can be
  placed within cyst
  remmant)




    Operative Techniques in General Surgery, Vol 4 (March), 2002 76-87
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           Case Presentation
                  Pathology
                  P th l
• Benign cyst
  – Fibrous tissue
    Single layer of
  – Si l l        f
    cuboidal epithelium
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           Case Presentation
            Post     ti l
            P t operatively
• POD#0               • POD#6
  – Tolerated diet      – Clinic f/u
  – Pain controlled     – No complaints
  – Discharged home
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Questions??
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    Simple
 Hepatic Cysts
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    Classification
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              Congenital Cysts
     p          y y
• Simple/Solitary Cysts             y y
                               • Polycystic Disease
   – Abnormal development        – Autosomal Dominant
     of intrahepatic BDs         – Also affects kidneys
   – Lined with                        g
                                 – Progressive
     cuboidal/columnar             hepatomegaly
     epithelium                  – Variable and numerous
   – No malignant                  cysts
     transformation              – Liver function preserved
   – 60% solitary                – Prognosis directly
   – Rarely communicate with       related to severity of
     biliary tree                  kidney disease
   – 90-95% asymptomatic         – Associated with
                                   intracranial aneurysms
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                Acquired Cysts
• Neoplastic Cysts
     p        y                •   Traumatic Cysts
  – Slow growing                    – Pt w h/o trauma
  – SYMPTOMATIC                     – Parenchymal injury with
  – May have solid                    disruption of vascular or
                                            p
    component or calc                 biliary structures
  – Cystadenomas                    – Most resolve
                                      spontaneously
                                       p             y
        Lined ith
     • Li d with mucus
        secreting epithelium
  – Cystadenocarcinoma
     • Result of malignant
        transformation
  – All treated surgically
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             Acquired Cysts
• Infectious Cysts
   – Echinococcal (hydatid)
   – Rare in US
   – Caused by tapeworm larvae
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       Presentation




 Symptoms usually result from mass effect,
        caused by enlarging cyst



Blonski, World J Gastroenterology 2006
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       Presentation




 Blonski, World J Gastroenterology 2006
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Differential Diagnosis




 Blonski, World J Gastroenterology 2006
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          Diagnostic Evaluation
• Ultrasound
  –   10 imaging modality
  –               p
      >90% sen/spec
  –   Anechoic
  –   Smooth margins
  –   Diff b/w solid lesions
  –   Unilocular vs. septae
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        Diagnostic Evaluation
• Computed
  Tomography
  – Defines relationship
    of cyst to structures
  – Non-enhancing
    Thin if
  – Thi uniform wall ll
  – No intracystic
    septations
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        Diagnostic Evaluation
• Magnetic
  Resonance
  – More detailed
    anatomic picture
  – T1 – hypointense
         hyperintense
  – T2 – h    i t
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Diagnostic Evaluation




 Blonski, World J Gastroenterology 2006
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                      Treatment



         Only indicated when symptoms are
         present and can be attributed to the
                        cyst




Cowles and Mulholland Journal American College Surgery Vol 191 2000
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          Treatment




Blonski / World J Gastroenterology 2006
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          Treatment Algorithm




M.F. Hansman et al / The American Journal of Surgery 181 (2001) 404-410
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          Treatment


Surgical management has replaced
    non-operative management




    Morino / Annals of Surgery 1994
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          Treatment


 Laparoscopic fenestration is an
       ll t t    t   t f hi hl
   excellent treatment for highly
symptomatic non-parasitic solitary
           hepatic cysts




    Morino / Annals of Surgery 1994
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       Laparoscopic Fenestration
•   First described by Z’geggen   •   Goal is to decompress cyst
    in 1991                           and limit recurrence
•   Indicated for:                     – Careful patient selection
               y y
     – Solitary cysts or                          p
                                       – Widest possible excision
     – PCLD characterized by             of cystic wall
        large superficial cysts        – Careful hemostasis of
•   Reported complications:              cyst edge
                                          y       g
     – Pleural effusion                – Electrocautery/argon
     – Ascities                          beam of cavity
     – Bil l k
        Bile leak                      – Ligation of obvious
                                         biliary leaks
     – Bleeding
                                       – Omental packing as
                                         necessary
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  Optimal Surgical Management
• Retrospective review
• 38 patients b/w 1988 and 1997
        i l      t
  – 23 simple cysts
  – 15 PCLD
• Mean f/u 41 months
• Goal:
  – Determine morbidity rates
              g
  – Assess long term recurrence
       Martin / Annals of Surgery 1998 Vol 228 167-172
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Optimal Surgical Management




   Martin / Annals of Surgery 1998 Vol 228 167-172
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Optimal Surgical Management




   Martin / Annals of Surgery 1998 Vol 228 167-172
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 Optimal Surgical Management
• Conclusions
  – Percutaneous aspiration should be reserved
    for patients with questionable symptoms
  – Recurrence may be expected even if
    meticulous and radical fenestration of all
    available cyst is performed
       p        p           g
  – Laparoscopic deroofing in PCLD p  patients is
    unlikely to be successful when only the
    largest cysts are dealt with

        Martin / Annals of Surgery 1998 Vol 228 167-172
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 Optimal Surgical Management
• Conclusions
  – Laparoscopic technique was associated with
    a reduced morbidity (25%) and shorter
    hospital stay (3 days) compared with open
    deroofing (              y )
             g (36% and 8 days)
  – With respect to recurrence, radical deroofing
    is key



        Martin / Annals of Surgery 1998 Vol 228 167-172
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Well, what about the long term
           results?
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                      Long term results
• Retrospective review over 15 years
• Total of 78 patients
           had i l        t
      – 57 h d simple cysts
      – 8 hydatid cysts
      – 8 hepatobiliary cystadenomas
      – 1 hepatobilary cystadenocarcinoma



Regev et al Large cystic lesions of the liver in adults: A 15 year experience in a tertiary
center Journal of American College of Surgery, 2001 Vol 193 36-45
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                      Long term results
• Retrospective review over 15 years
• 57 had simple cysts
              f    d b/c i
      – 88% referred b/ pain
      – 96.5% had normal hepatic biochemical profile
          %
      – 49% underwent perc aspiration
      – 84% (48) managed surgically
           • 30 laparotomy
           • 18 laparoscopically
Regev et al Large cystic lesions of the liver in adults: A 15 year experience in a tertiary
center Journal of American College of Surgery, 2001 Vol 193 36-45
         www.downstatesurgery.org
             Long term results
• Results:
  – Recurrence seen in all pts s/p aspiration
  – No operative deaths or major complications
  – 2 pts continued to have pain post operatively
    12.5%
  – 12 5% (6/48) demonstrated recurrence
     • 2/18 in laparoscopic group
     • 4/30 in open group
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           Long term results
• Concluded:
  – Cyst aspiration is associated with high rates
    of recurrence
  – Surgical treatment (wide unroofing or
    resection) is associated with good outcomes
  – Laparoscopic unroofing has become the
    p                          g      p    y
    procedure of choice for large simple cysts and
    is associated with low complication and
    recurrence rates
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Location of cyst is a key factor
 influencing surgical outcome




Bia et al / Hepatobiliary Pancreatic Dis Int 2007
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Adjuncts to lap fenestration?
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The role of laparoscopic ultrasound in the
   minimally invasive management o
          a y    as e a age e t of
       symptomatic hepatic cysts




    Schachter et al / Surg Endosc 2001 15; 364-367
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   The role of laparoscopic ultrasound in the
      minimally invasive management o
             a y    as e a age e t of
          symptomatic hepatic cysts

  Advantages of l
• Ad     t                    i lt
                  f laparoscopic ultrasoundd
   – Allows the precise definition of the structure of the
     cyst wall component
   – Identifies presence of cyst wall nodules,
     irregularities and solid papillary growths
   – Allows for US guided biopsies intraoperatively
   – Allow differentiation between the portal and venous
     structures and the cystic lesions



         Schachter et al / Surg Endosc 2001 15; 364-367
           www.downstatesurgery.org
                      Conclusion
Management of liver cysts should be individualized by cyst type,
symptoms and associated complications
Percutaneous aspiration/ablation therapy may be a feasible option in
         i l     did t
poor surgical candidates
Laparoscopic approaches have proven efficacious for simple cysts
and are the treatment modality of choice
Management of specific diseases such as PCLD is more complicated
                                         p         y
and dictates treatment in centers with hepatobiliary and
transplantation expertise
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                        Questions
1.    Ultrasonography demonstrates a liver cyst with a thick wall
        d       i     Th       i    h ld b d i d
      and septations. The patient should be advised
     a. To have repeat sonograms every 6 months for 2 years
     b. Interventional radiologist for aspiration and biopsy
     c. Surgical referral for laparoscopic fenestration
     d. Surgical referral for complete resection

2.    Cyst wall in cases of cystadenomas should be
     a. Partially resected
     b. Completely resected
     c. Suture ligated
     d. Fenestrated
             www.downstatesurgery.org
                        Questions
3.    Sclerotherapy with alcohol leads to
     a. Necrosis of cyst wall
     b. Fixation of the cells lining the cyst cavity thus disabling
         their ability to secrete fluid
     c. Is never performed because it leads to cholangitis
     d. Has 100% success rate

4.    Polycystic liver disease is a contraindication for laparoscopic
      fenestration
     a. True
     b. False
     c. I don’t know
     d. All of the above
             www.downstatesurgery.org
                       Questions
5.     Laparoscopic fenestration
     a. Has lower recurrence rates than open unroofing
     b. Is considered the procedure of choice for congenital cysts
     c. Is less morbid than traditional unroofing
     c
     d. A is the only incorrect answer!
www.downstatesurgery.org




      The End
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                          References
1.                                     p      p                             y
     P. Schachter et al “The role of laparoscopic ultrasound in the minimally
     invasive management of symptomatic hepatic cysts” Surgical Endoscopy
     15; 364-367, 2001
2.   A. Regev et al “Large cystic lesions of the liver in adults: A 15 year
                              center                   193:36-45,
     experience in a tertiary center” J Am Coll Surg 193:36 45 2001
3.   J.F. Gigot wt al “The surgical management of congenital liver cysts”
     Surgical Endoscopy 15: 357-363, 2001
4
4.       H
     MF Hansman et al “M
                   t l “Management and l
                                     t d long t
                                              term f ll       f hepatic
                                                   follow up of h   ti
     cysts” The American Journal of Surgery 181; 404-410, 2001
5.   I. Martin et al “Tailoring the Management of nonparasitic liver cysts”
                               167 172,
     Annals of surgey 228; 167-172 1998
6.   M. Morino et al “Laparoscopic management of symptomatic nonparasitic
     cysts of the liver” Annals of Surgery 219, 157-164, 1994

				
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