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J Thorac Cardiovasc Surg 1996;111:1280-1281
© 1996 Mosby, Inc.

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THORACOSCOPIC EVACUATION OF DEAD HYDATID CYST

Durban, South Africa

From the Department of Cardiothoracic Surgery, Wentworth Hospital, Durban, South Africa.

Received for publication August 22, 1995 Accepted for publication August 30, 1995. Advances in video-assisted thoracoscopic surgery allow investigation and management of a wider range of pleural and pulmonary diseases. After percutaneous cavernostomy, a thoracoscope may be used for removal of foreign material from within an intrapulmonary cavity. A case of a dead hydatid cyst treated by such thoracoscopic evacuation is described. The procedure is simple and effective and is recommended for use when there is a delay in spontaneous resolution.

Case report

A 13-year-old black boy came to his local hospital with a productive cough and a fever. Chest radiography revealed a right pulmonary cavity with a fluid level and a left lower lobe spherical opacity. Percutaneous needle aspiration of the lesion on the right side resulted in empyema. The patient was referred for further management.

At the referral hospital, it was concluded from radiographic examination that the opacity on the left side was an uncomplicated hydatid cyst ¹ and the proven right empyema had resulted from aspiration of a hydatid cyst complicated by infection. Tube thoracostomy effectively drained the right pleural space. By means of the Seldinger technique aided by fluoroscopy, the pulmonary cavity on the right side was intubated and drained of pus. The patient's fever subsequently subsided, and his general condition improved. Something resembling the crumpled remains of a dead hydatid cyst within the pulmonary cavity on the right side could be seen on a chest radiograph (Fig. 1). Despite the presence of a bronchocutaneous fistula, as evidenced by the production of purulent sputum and the cavernostomy tube air leak, the residual remnants of this cyst were not evacuated during a 2-week period. The uncomplicated hydatid cyst on the left side was removed through a left thoracotomy, followed by capitonage. The right intrapulmonary tube was removed, and the cavity on the right side was entered thoracoscopically through the cavernostomy track. This allowed inspection of the space and easy removal of the dead hydatid cyst, with the cavity being left clean after suction. Open tube cavernostomy drainage was instituted for a further 2 weeks, by which time there was a satisfactory reduction in the size of the cavity. The tube was removed, and after a further short period of clinical and radiologic surveillance, the patient was discharged. When he was seen 1 month later, the patient was entirely well and his chest radiograph showed satisfactory resolution of the empty cavity.

View larger version (125K): [in this window] [in a new window]   Fig. 1. Crumpled remains of ruptured cyst are seen in right pulmonary cavity after percutaneous drainage. Live hydatid cyst is seen in left lung.

An extraordinary number of management options for pulmonary hydatid disease have been offered, ranging from radical procedures such as lobectomy and pneumonectomy ² to the more favoured enucleation technique with capitonage. ³ More recently, medical therapy with benzimidazole drugs, such as albendazole, ⁴ have been tried. The presence of complications may further dictate the procedure to be considered. Spontaneous rupture of a hydatid cyst may result in complete endobronchial expectoration of the cyst wall and contents. Where endobronchial clearance is incomplete, however, the residual cyst wall should be removed to enable more rapid resolution of the intrapulmonary cavity. This can be done easily if thoracotomy is undertaken for removal of other ipsilateral cysts. The establishment of a cavernostomy track followed by thoracoscopic removal of the cyst remnants provides a suitable alternative to thoracotomy, especially when the space is infected. Thoracoscopic removal of live or uncomplicated hydatid cysts does not afford the advantage of capitonage for control of bronchial air leaks and may lead to spillage and pleural recurrence, ⁵ although we have not seen this, and so this procedure was not attempted for the cyst on the left side. It is anticipated that as expertise with and instrumentation for video-assisted thoracoscopic surgery continue to improve, such management may be preferred for live hydatid cysts as well.

Footnotes

J THORAC CARDIOVASC SURG 1996;111:1280-1

References

1. Le Roux BT. Pulmonary hydatid disease. Thorax 1972;27(3):365-367.[Medline]
   
2. Aytac A, Yurdakul Y, Ikizler C, et al. Pulmonary hydatid disease: report of 100 cases. Ann Thorac Surg 1977;23:145-51.[Abstract]
   
3. Dogan R, Yuksel M, Cetin G, et al. Surgical treatment of hydatid cysts of the lung: report on 1055 patients. Thorax 1989;44:192-9.[Abstract]
   
4. Aggarwal P, Wali JP. Albendazole in the treatment of pulmonary echinococcosis. Thorax 1991;46:599-600.[Abstract]
   
5. Barrett NR, Thomas D. Pulmonary hydatid disease. Br J Surg 1952;40:222-44.[Medline]
   

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