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TRANSDIAPHRAGMATIC HYDATID DISEASE

Rajeev M Joshi*, Ashfaq A Tapia**, Prasad K Wagle***, Ashutosh A Darbari****, Sm Navadgi**
*Associate Professor; **Registrar; ***Lecturer; ****Resident; Department of Surgery, BYL Nair Charitable Hospital,
  Mumbai 400 008.
Hydatid disease is a common entity in India. The most frequently affected organs are the liver and the lung but simultaneous involvement of both liver and lungs is rare. We describe a case of hydatid disease involving the left lobe of liver bursting transdiaphragmatically into the right chest. The interesting fact about this case is that both the pulmonary and hepatic cysts were removed with a single right thoracotomy incision thus avoiding the morbidity of a separate laparotomy incision.

CASE REPORT

A 60 year old male patient presented with the symptoms of cough with mucopurulent expectoration since 10 years and haemoptysis since 8 months. He had dyspnoea on exertion and low grade fever since the past 2 months.

X-ray chest showed an opacity in the middle lobe of the right lung. USG abdomen showed an ill-defined cystic septate mass in the left lobe of the liver measuring about 8 x 6 x 7 cm. CT thorax and abdomen showed a hydatid cyst in the left lobe of the liver and another cyst in the middle zone of the right lung with a transdiaphragmatic extension between the two lesions. The LFT's were normal, thus ruling out extrahepaticobiliary involvement.

After Albendazole treatment for one month, the patient was taken up for surgery. Through a right postero-lateral thoracotomy, the pulmonary hydatid cyst was removed. Since the right middle lobe was diseased, a right middle lobectomy was also done. The transdiaphragmatic extension was excised to expose a 2 x 2 cm rent in the diaphragm. Through the rent, the daughter cysts and the laminated membrane of the hepatic lesion was removed. The liver cavity was irrigated with the scolicidal agent betadine. The rent in the diaphragm was closed in two layers with polypropylene sutures. The chest cavity was rinsed with betadine. The chest was closed after leaving two intercostal drains.

Post operative recovery was uneventful.

DISCUSSION

Hydatid disease is caused by the larval stage of taenia echinococcus. The definitive host is the dog and man is the intermediate host. The mode of spread is the faeco-oral route. Hydatid cysts are commonly found in the liver and lung though cysts have been found in many other organs of the body.[2]

The simultaneous involvement of the liver and lung is quite uncommon1 but when it occurs, the right lung is involved in 97% of the cases.[3]

Fig. 1
Fig 1 : X-ray chest showing lesion in the middle zone of the right lung.


Fig. 2
Fig 2 : CT scan showing the pulmonary hydatid cyst.

Transdiaphragmatic hydatid disease has been very seldom reported. The general condition of the patient is seriously affected in cases of ruptured and infected cysts. When the cysts break open into the tracheobronchial tree, the patient coughs up profuse quantities of pus and his condition may improve to a certain degree. The spitting of bile is evidence of biliary obstruction. This obstruction has to be treated first to avoid recurrence of the process. Thus in cases of simultaneous liver and thoracic hydatid disease, it is important to exclude extrahepatic biliary obstruction.[4]

Gomez et al[5] have classified transdiaphragmatic hydatid disease into five grades depending upon the degree of involvement. They have described thoracophrenolaparotomy and right subcostal approaches for excision of the cysts.

Freixinet et al[6] have operated on patients through a thoracolaparotomy or a thoracotomy alone.

The abdomen must be opened to deal with the hepatic cyst when the cyst wall is predominantly below the right costal margin, in case the cyst has ruptured or in the presence of co-existing extra-hepatic biliary obstruction. In the absence of these above complications, a right thoracotomy alone will usually suffice as has been shown in the case presented here.

The main principles involved in the surgery of transdiaphragmatic hydatid cyst are the correct drainage of the cystic intra-hepatic cavity under the diaphragm, separating the pleural cavity completely from the intra-hepatic extension of the transdiaphragmatic fistulous tract, conservative pulmonary resection in certain cases of non - salvageable diseased lung and ruling out the possible existence of biliary hypertension before and after operation.[7]

REFERENCES
  1. Joshi MJ. Hydatid disease. In : Joshi MJ ed. Surgical disease in the tropics. Macmillan India Ltd. 1992; 151-69.
  2. Gupta JC, Nagrath CL, Salgia KM. Hydatid disease in man. J IMA June, 1966; 46 (12) : 641-51.
  3. .Tierris EJ, Argeropules K, Kourtis K, et al. Bronchobiliary fistula due to echinococcosis of the liver. WJ Surg 1997; 1 : 99-104.
  4. Matar K, Gardener MA, Courtice BH, Lonas C. Bronchobiliary fistula due to hydatid disease : a case report. Aus NZJ Surg Oct., 1978; 48 (5) : 559-61.
  5. Gomez R, Mareno E, Loinaz C, et al. Diaphragmatic or transdiaphragmatic thoracic involvement in hepatic hydatid disease : Surgical trends and classification. WJ Surg Sep.-Oct., 1995; 19 (5) : 714-9.
  6. Freixinet JL, Mestro CA, Cugat E, et al. Hepaticothoracic transdiaphragmatic echinococcosis. Ann Thoracic Surg Apr., 1988; 45 (4) : 426-9.
  7. Reventes J, Nagueras FM, Ruis X, Lorenzo T. Hydatid disease of the liver with thoracic involvement. Surg Gynaecol Obstet Oct., 1976; 143 (4) : 570-4.
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