Hydatid cysts remain a major health challenge in many countries of the world, including Iran (12, 18, 19). In this study, the clinico-hematological and therapeutic features of hydatid cyst cases admitted to university-affiliated hospitals, from 2004 to 2018, in Fars province, southern Iran was reviewed.
Based on our findings, abdominal pain followed by fever, anorexia, nausea, and vomiting were the most common symptoms of patients before admission. Other studies reported almost the same results with abdominal pain being the most common symptom of liver hydatid cyst (20–22). Motie et al. reported that patients with liver hydatid cyst presented with abdominal pain followed by fever in most cases (23). In their study organomegaly and palpable mass were considered as the most common finding in physical examination, while in our study the most common finding in the examination was abdominal tenderness (23).
As liver CE is a chronic disease and symptoms would show up when the cystic structure becomes large enough to be complicated or pushes the adjacent organs, patients usually do not develop the acute symptoms. In this study, most of the patients had symptoms more than 90 days before the admission which is similar to the findings of Tagliacozzo et al., study in Italy which reported duration of symptoms of 2 up to 72 months (mean 16 months) for patients with liver CE before the admission to the hospital (20).
The establishment of the correct diagnosis of hepatic hydatid cyst is essential before the operation and is based upon clinical, radiological and laboratory data. Differential diagnosis relies greatly on imaging techniques such as ultrasonography, X-rays and computed tomography scans. Ultrasonography is considered to be the gold standard method for diagnosis of the disease while the CT scan is often used in emergency presentations (4). In a study by Prousalidis and colleagues, the liver hydatid cyst was found in 92% and 95% of the ultra-sonographies and CT scans which is in line with our findings (24). In Prousalidis et al., study leukocytosis was found in all cases and hypereosinophilia in 14.3% of them while in our study, almost half of the patients had leukocytosis and more than half of them had hypereosinophilia (24).
New procedures have been used in recent years for the management of hydatid cyst including total cystectomy and percutaneous and perendoscopic procedures, which improved the treatment efficacy as well as the quality of life of CE patients (23). Management of liver hydatid cysts includes percutaneous sterilization practices, surgery, drug treatment, a 'watch-and-wait' approach or a combination of these (24). In our study, most of the cases (82.3%) underwent conservative surgery. Patients who were treated with radical surgery method had a lower recurrence rate but longer duration of hospital stay. Motie et al., and Gomez et al., recommended the radical surgery treatment because of the shorter length of hospital stay and its lower rate of complications and recurrence (25, 26). Tagliacozzo and collogues reported that although radical surgery can reduce the rate of complications, recurrence and hospital stay, performing a radical surgery must be done only in an exceptional case to avoid removing healthy hepatic parenchyma (20).
The effectiveness of radical treatment in comparison with conservative treatment has been documented in several studies. In Georiou et al., study the therapeutic features of 232 patients who underwent surgery for liver hydatid disease was evaluated. Those patients who underwent a radical procedure had no mortality and no recurrence and a low rate (10.95%) of morbidity. Those patients who treated with conservative method had a mortality rate of 2.76% and morbidity of 24.13% and 6.9% of relapse at three-year complete follow-up. The authors concluded that radical surgical treatment are better tolerated by patients and yielded better results in terms of mortality and the rate of recurrence (27). In Secchi et al., study in Argentina, a relatively large group of CE patients (1412) with radical, or conservative surgical procedures have been evaluated. The complication rate has been significantly lower in patients with radical surgery compared with the other procedures. Moreover, the rate of reoperation and recurrence has been significantly lower in patients with radical surgery treatment (28).
Biliary spillage is the foremost common cause of postoperative morbidity after conservative liver CE surgery. In Surmelioglu et al. study, postoperative leakage was detected in 36 out of 186 (19.4%) patients with solitary liver hydatid cyst with conservative surgery (27). While conservative surgery with omentoplasty is reducing the postoperative complications, radical surgery along with administration of albendazole has been considered as the best management option for liver hydatid cysts owing to its low complication and recurrence (29).
Recurrence remains one of the main complications in the management of hydatid disease. In the current study, recurrence of hydatid cyst was recorded in 15% of cases, of which 10% occurred once, 0.01% and 0.006%) cases occurred twice and three times, respectively. In the recurrence cases, 23.7% had been treated with radical surgery while 76.3% with conservative surgery. In another study by the authors in Yasuj district in southwest of Iran, recurrence has been reported in 14% of hydatid cysts (19). In Spain, among the 217 patients with liver hydatid cyst, 25 (11.5%) had a hydatid recurrence after curative treatment. (30).
Anthelmintic drugs (mostly albendazole) are the drug of choice which are often used in liver CE and it appears to have greater efficacy (20–60%) for shrinkage or disappearing the cystic structure than any other agent used so far (31, 32). In a systematic review and meta-analysis, Gomez et al. reported that anthelmintic drugs alone are not considered as ideal treatment for hydatid cyst of the liver (26). In our study, the main drugs that have been used were albendazole and third-generation cephalosporins. The use of third-generation cephalosporin (especially ceftriaxone) is because of their prophylactic effects, after the surgery, for the prevention of wound infection and complications.
Given the nature of any retrospective study, our study also had shortcomings. These limitations included some missing data and the inability to follow up the patients.