**8. General principles of the treatment**

#### **8.1. Surgery methods**

#### *8.1.1. Conventional surgery*

Initially, the surgical treatment of pulmonary hydatidosis involved the marsupialization of the cyst when it was attached to the wall, or an atypical pulmonary resection consist‐ ing of two stages: first pleurodesis was produced, followed by marsupialization in a sec‐ ond procedure. Evidently, these techniques have since been abandoned exceptly when the diagnosis of hydatid cyst rupture was carried later. We have treated young women with chronic pleuritis by marsupialization discovered one month after hydatid cyst rup‐ ture. (Fig 18, 19, 20)

**Figure 18.** Complicated hydatid cyst with chronic pleuritis.

**Figure 20.** Outcomes of marsupialization after 1 year for complicated hydatid cyst

uid during evacuation.

Actually the aim of surgery in pulmonary hydatid cyst is to remove the cyst completely while preserving the lung tissue as much as possible. Lung resection is performed only if there is an irreversible and disseminated pulmonary destruction. Careful manipulation of the cyst and adherence to the precaution to avoid the contamination of the operative field with the cyst content is the imperative part of the operation. Different surgical pro‐ cedures have been described such as the enucleation of intact cyst, and needle aspiration for the evacuation of the cyst with serious risk by spillage of hydatid fluid around the puncture site. Cyst spillage may release a large number of viable scolices that implant elsewhere and produce secondary cysts [16]. Sood et al [17] reported a case of anaphylac‐ tic reaction following aspiration of a hydatid cyst in the liver during an operation under general anesthesia. The risks cited after fluid rupture by enucleation and needle aspira‐ tion are rare but serious, and prompted surgeons in endemic countries to develop a nov‐ el procedure to contain the cyst during surgery, preventing any spillage of hydatid fluid around the puncture; Santini et al [18] assembled a device using a transparent plastic cyl‐ inder used by nurses to perform venous blood harvesting. The top of the cylinder con‐ tains a hole that allows for the connection of two needles (Fig. 21). The base of the plastic cylinder was placed on top of the cyst. They penetrated the cyst using Needle A, and Needle B to create a negative depression in the plastic cylinder, thus allowing the te‐ nacious adhesion of the cyst to the cylinder to eliminate the risk of extravasation of liq‐

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**Figure 19.** Marsupialization of the cyst

**Figure 20.** Outcomes of marsupialization after 1 year for complicated hydatid cyst

**Figure 18.** Complicated hydatid cyst with chronic pleuritis.

208 Principles and Practice of Cardiothoracic Surgery

**Figure 19.** Marsupialization of the cyst

Actually the aim of surgery in pulmonary hydatid cyst is to remove the cyst completely while preserving the lung tissue as much as possible. Lung resection is performed only if there is an irreversible and disseminated pulmonary destruction. Careful manipulation of the cyst and adherence to the precaution to avoid the contamination of the operative field with the cyst content is the imperative part of the operation. Different surgical pro‐ cedures have been described such as the enucleation of intact cyst, and needle aspiration for the evacuation of the cyst with serious risk by spillage of hydatid fluid around the puncture site. Cyst spillage may release a large number of viable scolices that implant elsewhere and produce secondary cysts [16]. Sood et al [17] reported a case of anaphylac‐ tic reaction following aspiration of a hydatid cyst in the liver during an operation under general anesthesia. The risks cited after fluid rupture by enucleation and needle aspira‐ tion are rare but serious, and prompted surgeons in endemic countries to develop a nov‐ el procedure to contain the cyst during surgery, preventing any spillage of hydatid fluid around the puncture; Santini et al [18] assembled a device using a transparent plastic cyl‐ inder used by nurses to perform venous blood harvesting. The top of the cylinder con‐ tains a hole that allows for the connection of two needles (Fig. 21). The base of the plastic cylinder was placed on top of the cyst. They penetrated the cyst using Needle A, and Needle B to create a negative depression in the plastic cylinder, thus allowing the te‐ nacious adhesion of the cyst to the cylinder to eliminate the risk of extravasation of liq‐ uid during evacuation.

through this trocar. There was another suction ready to be used by the assistant to remove any fluid leaking around the trocar. After evacuating the cyst contents, the cyst wall col‐ lapsed. Then the pericyst was incised and opened. All of the remaining contents including portions of the laminated membrane and the remaining fluid were removed under direct vi‐ sion (Figure 24), followed by a partial resection of the pericystic area, the residual cavities were carefully treated with hypertonic saline solution, at this time, the anesthesiologist was asked to ventilate the operated lung to detect the exact location of all bronchial openings by observing air bubbles in the saline solution and all bronchial leaks found were closed indi‐ vidually with absorbable sutures (Fig 25). The cavity was obliterated with purse-string su‐

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**Figure 23.** adjacent tissues were covered by towels soaked in 20% hypertonic saline solution (arrow)

**Figure 24.** Simple cystectomy of germinative membrane (arrow)

tures of absorbable material (capitonnage).

**Figure 21.** The photograph illustrates the home-made device of Mario Santini *Naples.*;With permission

Personally, Cystotomy and capitonnage, our preferred technique, was carried out in 95 % of our patients, we employed a trocar-suction device for needle aspiration (Fig. 22). The use of this instrument prevents the rupture of the cyst, eradicates the parasite and makes it possi‐ ble to excise the residual cavity.

**Figure 22.** Trocar-suction device for needle aspiration

Thoracotomy was carried out under General anesthesia with double lumen endotracheal tubes for producing ipsilateral lung collapse during the procedure. After opening the chest wall and releasing the adhesions, we avoided any manipulation of the lung until evacuation of the cyst is not finished; the adjacent tissues were covered by towels soaked in 20% hyper‐ tonic saline solution (Fig. 23). We preferred sterilizing the cyst by aspiration of some fluid and its replacement with hypertonic saline for fifteen minutes before the cyst was aspirated by a trocar at a place and the contents of the cyst were evacuated by a powerful suction through this trocar. There was another suction ready to be used by the assistant to remove any fluid leaking around the trocar. After evacuating the cyst contents, the cyst wall col‐ lapsed. Then the pericyst was incised and opened. All of the remaining contents including portions of the laminated membrane and the remaining fluid were removed under direct vi‐ sion (Figure 24), followed by a partial resection of the pericystic area, the residual cavities were carefully treated with hypertonic saline solution, at this time, the anesthesiologist was asked to ventilate the operated lung to detect the exact location of all bronchial openings by observing air bubbles in the saline solution and all bronchial leaks found were closed indi‐ vidually with absorbable sutures (Fig 25). The cavity was obliterated with purse-string su‐ tures of absorbable material (capitonnage).

**Figure 23.** adjacent tissues were covered by towels soaked in 20% hypertonic saline solution (arrow)

**Figure 24.** Simple cystectomy of germinative membrane (arrow)

**Figure 21.** The photograph illustrates the home-made device of Mario Santini *Naples.*;With permission

ble to excise the residual cavity.

210 Principles and Practice of Cardiothoracic Surgery

**Figure 22.** Trocar-suction device for needle aspiration

Personally, Cystotomy and capitonnage, our preferred technique, was carried out in 95 % of our patients, we employed a trocar-suction device for needle aspiration (Fig. 22). The use of this instrument prevents the rupture of the cyst, eradicates the parasite and makes it possi‐

Thoracotomy was carried out under General anesthesia with double lumen endotracheal tubes for producing ipsilateral lung collapse during the procedure. After opening the chest wall and releasing the adhesions, we avoided any manipulation of the lung until evacuation of the cyst is not finished; the adjacent tissues were covered by towels soaked in 20% hyper‐ tonic saline solution (Fig. 23). We preferred sterilizing the cyst by aspiration of some fluid and its replacement with hypertonic saline for fifteen minutes before the cyst was aspirated by a trocar at a place and the contents of the cyst were evacuated by a powerful suction

age of causing distortion of the pulmonary parenchyma, especially after removal of multiple or large cysts. However, there is no clear consensus on the use of capitonnage in surgical

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**Figure 26.** residual cavity after aspiration of hydatid cyst (capitonnage technique) (arrow)

Rarely, hydatid cysts can occur in other thoracic structures such as pulmonary artery, chest

Most authors agree that the attempt should be made to remove as little lung tissue as possi‐ ble and that resection of pulmonary parenchyma is only indicated when the adjacent tissue is seriously damaged or infected, when the atelectatic areas are presumably irrecoverable or

when a big cyst or numerous cysts had destroyed a certain anatomical substrate [10].

series of lung hydatid cyst. (Fig 26)

wall or diaphragm. (Fig 27, 28)

**Figure 27.** CT scan of rib hydatid cyst (arrow)

**Figure 25.** bronchial leaks found were closed individually with absorbable sutures

In our opinion, hypertonic saline solution 20% is effective to killing the ova (cyst injection) and for protection of the operation field with imbibed hypertonic saline pads. These precau‐ tions can limit disastrous complications of any spillage or per operative rupture.

Only 5 % of the patients with complicated cyst underwent wedge resection, segmentectomy, lobectomy, pneumonectomy or marsupialization.

#### *8.1.2. Others conventional procedures [19, 20]*

A number of methods have been described for the surgical removal of hydatid cysts of the lung.

**The Barrett technique** (Barrett and Thomas, 1952) which allows the removal of the parasite intact; the pericyst was incised and dissected carefully without rupturing the cyst. This pro‐ cedure is eminently safe and free of risk of contamination of the pleural space, it's widely applicable, involves the loss of no appreciable pulmonary tissue or function. The technique is ideal for enucleation of all uncomplicated pulmonary hydatid cysts, even of the largest size, and after obliteration of the remaining cavity the inflated lobe looks normal

**The Perez Fontana method:** the cyst being removed with the pericyst (cystopericystectomy) and the residual cavity obliterated.

**The Ugon technique:** When the cyst is small and there is no risk of rupture', its com‐ plete removal can be attempted, aided by an increase in the airway pressure provided by the anesthetist.

However, the bronchial openings in the cavity must be closed by sutures in all techniques.

Capitonnage which is the folding of the pericystic zone by sutures for obliteration of the re‐ sidual cavity is usually advocated to prevent air leak from residual bronchial openings. Without capitonnage, the wall of the pericystic cavity is supposed to be covered by epithe‐ lial cells for an uncertain length of time. On the other hand, capitonnage has the disadvant‐ age of causing distortion of the pulmonary parenchyma, especially after removal of multiple or large cysts. However, there is no clear consensus on the use of capitonnage in surgical series of lung hydatid cyst. (Fig 26)

**Figure 26.** residual cavity after aspiration of hydatid cyst (capitonnage technique) (arrow)

Rarely, hydatid cysts can occur in other thoracic structures such as pulmonary artery, chest wall or diaphragm. (Fig 27, 28)

**Figure 25.** bronchial leaks found were closed individually with absorbable sutures

lobectomy, pneumonectomy or marsupialization.

*8.1.2. Others conventional procedures [19, 20]*

212 Principles and Practice of Cardiothoracic Surgery

and the residual cavity obliterated.

the anesthetist.

lung.

In our opinion, hypertonic saline solution 20% is effective to killing the ova (cyst injection) and for protection of the operation field with imbibed hypertonic saline pads. These precau‐

Only 5 % of the patients with complicated cyst underwent wedge resection, segmentectomy,

A number of methods have been described for the surgical removal of hydatid cysts of the

**The Barrett technique** (Barrett and Thomas, 1952) which allows the removal of the parasite intact; the pericyst was incised and dissected carefully without rupturing the cyst. This pro‐ cedure is eminently safe and free of risk of contamination of the pleural space, it's widely applicable, involves the loss of no appreciable pulmonary tissue or function. The technique is ideal for enucleation of all uncomplicated pulmonary hydatid cysts, even of the largest

**The Perez Fontana method:** the cyst being removed with the pericyst (cystopericystectomy)

**The Ugon technique:** When the cyst is small and there is no risk of rupture', its com‐ plete removal can be attempted, aided by an increase in the airway pressure provided by

However, the bronchial openings in the cavity must be closed by sutures in all techniques.

Capitonnage which is the folding of the pericystic zone by sutures for obliteration of the re‐ sidual cavity is usually advocated to prevent air leak from residual bronchial openings. Without capitonnage, the wall of the pericystic cavity is supposed to be covered by epithe‐ lial cells for an uncertain length of time. On the other hand, capitonnage has the disadvant‐

tions can limit disastrous complications of any spillage or per operative rupture.

size, and after obliteration of the remaining cavity the inflated lobe looks normal

Most authors agree that the attempt should be made to remove as little lung tissue as possi‐ ble and that resection of pulmonary parenchyma is only indicated when the adjacent tissue is seriously damaged or infected, when the atelectatic areas are presumably irrecoverable or when a big cyst or numerous cysts had destroyed a certain anatomical substrate [10].

because clinicians tend to adopt longer courses. We believe that the response of the ther‐ apy differs according to age (children and adults), cyst size, cyst structure (presence of daughter cysts inside the mother cysts and thickness of the pericystic capsule allowing penetration of the drugs), and localization of the cyst [23]. We think that selected pedia‐ tric patients with uncomplicated pulmonary hydatid cysts sized less than 5 cm, with thin pericystic capsule respond favorably to treatment. However a large pulmonary hydatid cyst should not be treated medically, because incomplete expectoration of the cyst con‐ tents after the parasite death may lead to infection through bronchial communication. Medical therapy may cause in some cases rupture of the lung cyst, and respiratory dis‐ tress. We suggest that in patients with hydatid disease of the lungs associated with mul‐ tiple organ involvement, medical treatment should not be given before the removal of

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We thought that medical treatment should be given after surgical therapy, patients surgical‐ ly treated for complications following medical treatment are hospitalized twice as long as patients surgically treated in the first place. Postoperative Albendazole treatment (400 mg twice a day for the first 15 days of the month) was administered to patients for a period of 3

Necessary to strictly observe good personal hygiene when the content of the dogs and care for them, and be sure to wash your hands after contact with the dog, not to allow dogs to the food of man and his pot, limit direct exposure of children and dogs. Stray dogs are ev‐ erywhere to be catching. In addition to current (and past) hydatid control campaigns, there have been significant technological improvements in the diagnosis and treatment of human and animal cystic echinococcosis, the diagnosis of canine echinococcosis, and the genetic characterization of strains and vaccination against *E. granulosus* in animals. Incorporation of these new measures could increase the efficiency of hydatid control programmes, potential‐ ly reducing the time required to achieve effective prevention of disease transmission to as

We are of the view that surgical treatment of the lung cyst should be preferred firstly in cases of lung hydatid cyst disease. The diversity of the pathological process offers vari‐ ous tactics and approaches in the surgical treatment which must be individually tailored in each and every case. The goal of surgical therapy is to remove the cyst while preserv‐ ing as much lung tissue as possible and medical treatment may be useful only in no op‐

hydatid cyst of lung.

to 6 months.

**9. Prevention**

little as 5 - 10 years.

**10. Conclusion**

erable patients.

**Figure 28.** specimen of parietectomy for rib hydatid cyst with hydatid cyst material cotenant (arrow)

#### *8.1.3. Video assisted thoracoscopic surgery*

In adult, some authors [21] have reported the successful use of thoracoscopic procedures for the treatment of pulmonary hydatid disease. Sporadic cases were founded in the French and the other in the English literature. In our experience, we have treated three patients through this procedure. Postoperative course was uneventful in all cases. The thoracoscopic approach in pulmonary hydatid cysts must follows the same principles of the open technique, which include sterilization of the cyst with scolicidal agents (eg. hy‐ pertonic saline), complete excision of the endocyst, and closure of bronchial fistula, if present. The main advantage offered by thoracoscopy is less trauma and discomfort for the patient. The lack of intercostal muscle incision and the lower risk of rib fracture re‐ duce the postoperative pain and when compared to thoracotomy, thoracoscopy reduces the chest tube duration and length of hospital stay. Conversion to thoracotomy is mainly related to major pleural adherences.

#### **8.2. Medical therapy**

Although surgery remains the treatment of choice for hydatid disease, the usefulness of drug therapy has been reported in many studies. Medical treatment is an alternative to sur‐ gery where a surgical approach is not recommended in risk patients, and in cases with small and multiple lesions in one or more organs, or proximity of cysts to major vascular struc‐ tures. Antihelminthic agents, Mebendazole, and more recently albendazole, and praziquan‐ tal, reduce recurrence post-operatively, particularly where there has been spillage of cyst contents [22].

Many and substantial questions still remain unanswered, however. What is the optimum duration of treatment? Clearly, duration of treatment of < 3 months produces less than optimal response, whereas results of extension beyond 6 months have yet to be gauged because clinicians tend to adopt longer courses. We believe that the response of the ther‐ apy differs according to age (children and adults), cyst size, cyst structure (presence of daughter cysts inside the mother cysts and thickness of the pericystic capsule allowing penetration of the drugs), and localization of the cyst [23]. We think that selected pedia‐ tric patients with uncomplicated pulmonary hydatid cysts sized less than 5 cm, with thin pericystic capsule respond favorably to treatment. However a large pulmonary hydatid cyst should not be treated medically, because incomplete expectoration of the cyst con‐ tents after the parasite death may lead to infection through bronchial communication. Medical therapy may cause in some cases rupture of the lung cyst, and respiratory dis‐ tress. We suggest that in patients with hydatid disease of the lungs associated with mul‐ tiple organ involvement, medical treatment should not be given before the removal of hydatid cyst of lung.

We thought that medical treatment should be given after surgical therapy, patients surgical‐ ly treated for complications following medical treatment are hospitalized twice as long as patients surgically treated in the first place. Postoperative Albendazole treatment (400 mg twice a day for the first 15 days of the month) was administered to patients for a period of 3 to 6 months.
