Surgical Management of a Complex Pulmonary Hydatid Cyst

In this video, the authors present the case of a thirty-seven-year-old Peruvian man who served as a veterinary assistant and presented with acute bilateral lower extremity pain. He had a history of an echinococcal cyst in the right chest after a thoracotomy with resection 30 years ago in Peru.

Upon admission, CT and MRI cross-sectional imaging revealed a multiloculated cystic lesion in the apex of the right chest with extension into the neural foramina from the level of T2 to T6. This resulted in compression of the dural sac. CT imaging didn’t show involvement of pulmonary parenchyma, bronchus, or vessels. Three-dimensional reconstruction was used for preoperative planning for cyst resection and is shown in the video.

In the operating room, the patient’s prior posterolateral thoracotomy incision was used to access the right chest via the sixth intercostal space. Following adhesiolysis, the pericyst cavity was exposed and dissected free from the surrounding right upper lobe.

After complete exposure, 14 percent sodium-chloride-soaked sponges were packed around the pericyst as a scolicidal agent to prevent recurrence in the event of contamination with cyst contents. The pericyst was entered with a 12 mm trocar to evacuate the contents of the cyst in a controlled fashion.

The goal of this operation was to preserve parenchyma and avoid spinal cord damage while achieving complete resection of the cyst contents without spillage to prevent anaphylaxis and recurrence. It should be noted here that surgeons irrigated the cyst cavity with normal saline as opposed to hypertonic saline given evidence of extension through the neural foramina.

It is important to note the multidisciplinary care that was necessary for the treatment of this patient involving the thoracic surgery, neurosurgery, and infectious disease teams at the institution. Additionally, the team sought international consultation with Dr. Thomas Junghans and Dr. Marija Stojkovic from the University of Heidelberg. They contributed to the WHO informal working group on echinococcus’s recommendations for management of echinococcal cysts.

Traction sutures were then placed to facilitate the controlled opening of the pericyst after removal of the trocar. There was a clear delineation between the host pericyst layer, and the parasite generated cyst cavity. Daughter cysts in the cavity were removed with care not to rupture or spill the cysts within the pleural cavity.

The cyst cavity was then explored. The cyst cavity extended through the neural foramen with boney erosion of the vertebrae. The dura matter was seen through the neural foramen. A Valsalva maneuver was performed with no resultant leak of cerebrospinal fluid. This confirmed the dura was not violated during the operation or by the cyst itself.

The remaining daughter cysts were removed, and the cavity was irrigated thoroughly with normal saline. The cyst itself was dissected free from the chest wall and resected. Chest drains were placed, and the lung was re-expanded. The patient was extubated and drains were removed serially postoperatively. The patient experienced immediate improvement in his neurologic symptoms and was postoperatively placed on albendazole indefinitely. He had no evidence of recurrence one year following this operation.

References

1. Brunetti E, Kern P, Vuitton DA; Writing Panel for the WHO-IWGE. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop. 2010;114(1):1-16. doi:10.1016/j.actatropica.2009.11.001
2. Nabi MS, Waseem T. Pulmonary hydatid disease: What is the optimal surgical strategy? Int J Surg. 2010; 8(8): 612-616. https://doi.org/10.1016/j.ijsu.2010.08.002.

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