J Thorac Cardiovasc Surg 2006;132:560-564
© 2006 The American Association for Thoracic Surgery
Effect of capitonnage and cystotomy on outcome of childhood pulmonary hydatid cysts
Altug Kosar, MDa,*,
Alpay Orki, MDa,
Gokhan Haciibrahimoglu, MDa,
Hakan Kiral, MDa,
Bulent Arman, MDb
a Thoracic Surgery, Sureyyapasa Thoracic and Cardiovascular Surgery Research and Teaching Hospital, Istanbul, Turkey
b Thoracic Surgery, Dr. Lutfi Kirdar Kartal Research and Teaching Hospital, Istanbul, Turkey.
Received for publication February 15, 2006; revisions received May 22, 2006; accepted for publication May 23, 2006.
* Address for reprints: Altug Kosar, MD, Thoracic Surgery, Sureyyapasa Thoracic and Cardiovascular Surgery Research and Teaching Hospital, Ataturk cad. 46/16 Erenkoy, Istanbul 34734, Turkey. (Email: altugkosar{at}yahoo.com).
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Abstract
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OBJECTIVE: In this clinical retrospective study cystotomy and capitonnage were compared in patients with childhood pulmonary hydatid cysts with regard to postoperative period.
METHODS: Between 1990 and 2004, 60 children with pulmonary hydatid cysts were treated surgically. There were 33 boys and 27 girls aged from 3 to 16 years. Cystotomy and closure of bronchial openings were performed in all patients. The patients were divided into 2 groups. While the residual cyst cavity was closed by means of capitonnage in group A (n = 37), cystotomy was applied in group B (n = 23).
RESULTS: There was no mortality in either group. Chest tubes were removed after 3.59 ± 1.04 days in group A and 5.83 ± 2.84 days in group B. The hospital stay was 4.86 ± 1.43 days for group A and 7.22 ± 3.34 days for group B. Prolonged air leak was found in 2 children in group A and 7 children in group B. There was a significant difference between group A and group B with regard to chest tube removal time (P = .001), hospital stay (P = .003), development of prolonged air leak (P = .004), and all complications (P = .031). Follow-up information was available for 49 children, ranging from 13 to 86 months (mean, 56 months). Recurrence was seen in 2 children of group A and 1 child of group B during the follow-up period (P = .698).
CONCLUSION: Capitonnage for pulmonary hydatid cysts is superior to cystotomy because it reduces morbidity (especially prolonged air leak) and hospital stay.
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Introduction
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Drs Kosar, Orki, Haciibrahimoglu, and Kiral (left to right)
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Hydatid disease caused by Echinococcus granulosus is frequently encountered in the sheep- and cattle-raising regions of Australia, New Zealand, South Africa, South America, and the Mediterranean countries of Europe, Asia, and Africa.1,2
It is still a major public health issue in Turkey. The incidence of hydatid disease is 4.9/100,000 in the Turkish population.3 The dog–sheep cycle is the underlying theory for the life cycle of the parasite. People become involved in this cycle when they come into contact with infected dogs or by consuming contaminated vegetables.4 In the present study we have comparatively investigated the affects of cystotomy and capitonnage on childhood pulmonary hydatid cysts with regard to chest tube removal time, hospital stay, and complications.
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Patients and Methods
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Between 1990 and 2004, 237 patients with pulmonary hydatid cysts were operated on in our clinic. Sixty (25.7%) of these patients were of pediatric age (a patient treated by means of wedge resection was excluded in the present study). There were 33 boys and 27 girls. The ages of the children ranged from 3 to 16 years (mean, 12.2 years).
We frequently used posterolateral thoracotomy in 54 (90%) children, 3 requiring additional phrenotomy and 1 requiring laparotomy because of liver hydatid cysts. Median sternotomy was performed in 6 children because of existing bilateral hydatid cysts, and one of them required additional phrenotomy because of liver hydatid cysts.
Operative Techniques
A classic posterolateral thoracotomy (mostly used for muscle sparing) through the fifth or sixth intercostal space or a median sternotomy was applied after achievement of general anesthesia. A double-lumen endotracheal tube was used in older children (n = 28) to avoid the spillage of infected cyst material into the contralateral bronchus. After entering the hemithorax, the lung was freed from all adhesions to the chest wall. After identification of the cyst, the operative field and pleura were covered with wet sponges diluted with 10% povidone-iodine solution to prevent seeding of possible daughter cysts. By using needle aspiration, hydatid fluid was aspirated from the uppermost part of the cyst. Then a large suction apparatus was inserted into the cyst, and the fluid was completely aspirated. No antiscolicidal agent was used. The most prominent part of the cyst was opened with scissors or electrocautery, and the cyst membrane was removed with ring forceps or another instrument. Then the residual cavity was irrigated with 10% povidone-iodine solution and was cleaned with the suction apparatus. Closure of bronchial openings was performed in all patients. In 37 patients (group A, capitonnage), after closure of bronchial openings, the residual cavities were obliterated with separate purse-string sutures starting from the deepest level to the surface by using absorbable 3-0 polyglactin 910 sutures (Vicryl; Ethicon, Edinburg, Scotland; Figure 1). In 23 patients (group B, cystotomy) the cavities were left open after closure of the bronchial openings (Figure 2). One or 2 chest tubes were inserted into the pleural space for underwater drainage (–15 to 20 cm H2O), and chest tubes were removed when no air leak was determined and when the drainage was less than 100 mL in 24 hours.
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Figure 1. Chest radiographs of a patient undergoing capitonnage preoperatively (A) and on the fifth day after the operation (B).
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Figure 2. Chest radiographs of a patient undergoing cystotomy preoperatively (A) and on the sixth day after the operation (B).
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Statistical Analysis
Statistical evaluation was performed by using SPSS 10.0 for Windows. The Fisher exact test or Mann-Whitney U test was used for comparison between groups.
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Results
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The most common symptoms were cough (64%), expectoration of sputum (27%), and thoracic pain (23%), respectively. Other symptoms were fever, hemoptysis, and hydatoptysis (expectoration of the germinative membrane or cystic fragments). Seven (11.7%) patients were asymptomatic. Allergic reactions were not observed in any patient.
A total of 60 patients with 87 pulmonary hydatid cysts were given diagnoses. Five patients had coexisting liver cysts. There was only 1 pulmonary hydatid cyst in 49 (81.7%) patients, 4 had unilateral multiple cysts, and 7 had bilateral multiple cysts. The majority of pulmonary hydatid cysts were located in the right lower lobe (35.6%). Localizations of the cysts are summarized in Table 1. Among these 87 cysts, 58 (66.7%) were intact. There were 29 (33.3%) perforated cysts. All perforated cysts were opened into the bronchial system. The mean size of the cysts was 7 cm (range, 2-20 cm). In 16 (26.7%) patients with giant pulmonary hydatid cysts were found to be 10 cm or greater in diameter. Cystotomy was performed in 7 of 16 patients with giant cysts, and capitonnage was performed in 9 of 16 patients with giant cysts. There was no statistically significant difference between giant cysts undergoing cystotomy and giant cysts undergoing capitonnage with regard to chest tube removal time (P = .020), hospital stay (P = .042), and complications (P = .126).
In all patients chest tube removal time ranged between 2 and 11 days (mean, 4.5 days). The chest tube removal time in group A (n = 37, capitonnage) was 3.59 ± 1.04 days, whereas that in group B (n = 23, cystotomy) was 5.83 ± 2.84 days. The chest tube removal time in group A was shorter than that in group B (P = .001).
Postoperative complications occurred in 14 (23.3%) children: 5 (13.5%) children were of group A, and 9 (39.1%) children were of group B (P = .031). Prolonged air leak (>7 days) was found in 2 children in group A and 7 children in group B. Atelectasis, pneumonia, and wound infection developed in 1 child in group A. Residual pleural space occurred in 2 children in group B. All these complications resolved with conservative treatment, such as chest physiotherapy, nasotracheal aspiration, and bronchoscopy. Complications of the cysts are summarized in Table 2. The frequency of prolonged air leak in group B was significantly higher than that in group A (P = .004). For all patients, hospital stay ranged between 3 and 13 days. The hospital stay in group A was 4.86 ± 1.34 days, whereas that in group B was 7.22 ± 3.34 days (P = .003). There were relations between chest tube removal time, hospital stay, overall postoperative complications, prolonged air leak, and applied operative techniques (Table 3). There was no perioperative or postoperative mortality in either group.
Long-term follow-up information for 49 children was available for 13 to 86 months (mean, 56 months) postoperatively. Eleven (18.3%) patients were excluded from the recurrence calculations because of poor follow-up. Accordingly, recurrence was seen in 2 (6.5%) children of group A (n = 31; 5 months and 2 years after the operation) and in 1 (5.6%) child of group B (n = 18; 14 months after the operation) during the follow-up period. They were treated with rethoracotomy. There was no apparent statistical difference between group A and group B (P = .698). Postoperatively, albendazole, 10 mg/kg per day, was given as 3 sequential 21-day courses, with 7-day intervals between courses for at least 3 months, to almost all the patients (except for 3 patients because of drug side effects).
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Discussion
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Hydatid cysts can be seen in every part of the body and at almost all ages; however, although the lung is the most commonly affected organ in children, in adults it is the liver. It is not clear whether children are more susceptible to pulmonary hydatid cysts compared with liver hydatid cysts.1,5 Hydatid cysts can reach gigantic size by staying asymptomatic because of the structure of the lungs allowing compression.6,7 Pulmonary hydatid cysts can be located on any pulmonary lobe, but right and lower lobes are the most frequently affected lobes of the lung.1,2,4 In our study, although the right lung was affected in 60.9% of patients, the right lower lobe was affected in 35.6%.
The current treatment of pulmonary hydatid cysts is surgical. Different surgical procedures have been described in the literature, such as resection by means of enucleation without needle aspiration, removal of the intact cyst after needle aspiration, pericystectomy (Perez-Fontana), wedge resection, segmentectomy, and lobectomy.1,2,4 There are 2 different techniques for management of the residual cavity for intact or complicated cysts. The first is described by Posadas, which is the suturing of only the bronchial openings (cystotomy), and the other has been advised by Délbét, which is the folding of the pericystic zone with sutures, a method called capitonnage.1 After the closure of the bronchial openings in some way, we carefully (air bubbles were determined through infusion of saline into the cavity during the inflating of lungs) applied the capitonnage technique (in group A) for closing the residual cavity in 37 patients. In 23 patients only the bronchial openings were closed (group B). The hospital stay and chest tube removal time were found to be significantly longer in group B (in which no capitonnage was applied) compared with those in group A. Furthermore, the complications occurring in the postoperative period, especially prolonged air leak, were higher in group B than in group A. The higher complication (P = .031) and prolonged air leak (P = .004) rates in group B were statistically significant. We consider all complications, especially prolonged air leak, as factors prolonging the chest tube removal time and hospital stay. Bilgin and colleagues8 have found the postoperative hospital stay and complication rates significantly long in the cystotomy group of their series and have underlined capitonnage as a necessary procedure. Moreover, Sonmez and associates9 have concluded that capitonnage shortens the postoperative chest tube drainage period by low morbidity rates. However, Saidi10 contended that elimination of the residual cavity by means of capitonnage is not necessary because the pulmonary parenchyma automatically obliterates the space, and subsequently, the surface of the lung at the site of the residual cavity is covered by the pleura. However, Turna and coworkers11 have reported that capitonnage does not present any advantages in hospitalization period, intensive care unit stay, duration of air leak and chest tubes, or prevention of complications (eg, empyema, recurrence, or prolonged air leak).
Some authors have claimed that capitonnage can cause atelectasis by obliterating the major bronchi surrounding the cyst cavity12 and present a potential risk of pulmonary parenchymal distortion.8 However, Erdogan and colleagues13 have reported that they saw no atelectasis in any of the 44 patients with hydatid cysts who had undergone capitonnage. In the present series the capitonnage group revealed only 1 atelectasis case and 1 pneumonia case (3%). Both of these complications were treated conservatively. We think an application of the capitonnage technique by experienced and careful persons, as in our series, would cause a very low rate of atelectasis or distorsion. As mentioned in the majority of the studies, prolonged air leak is the most frequently seen complication, both in the capitonnage and the cystotomy groups.6,8,11,13,14 In the present study the most frequently seen complication in both the capitonnage and cystotomy groups was prolonged air leak. The rate of prolonged air leak was 5.4% (2/37) and 30.4% (7/23) in group A and group B, respectively. We observed air leak presence or increase in previously present air leak rate after the operation in patients with or without air leak belonging to the noncapitonnage group. We think bronchial openings, which were unnoticed during the procedure because of visual obstruction of blood clots and secretion, were the causative factors of this situation. As Eren and associates14 have pointed out, the closure of bronchial openings is very important. Thus we consider capitonnage a better technique because of its role as a second barrier against prolonged air leak in the prevention of bronchial air leak. In the present study the lower rates of prolonged air leak (P = .004) and overall complications (P = .031) were statistically significant.
In the literature there is no collectively agreed on precise definition of a giant pulmonary hydatid cyst size. We defined a giant pulmonary hydatid cyst when the cyst diameter was more than 10 cm. Both Halezeroglu and associates15 and Karaoglanoglu and coworkers7 have reported that patients with giant cysts presented with more postoperative complications and longer hospital stays compared with patients with normal-sized cysts. In the present study the postoperative complication rate was higher in patients with giant cysts compared with that seen in the patients with normal-sized cysts (31.3% and 20.5%, respectively). However, in terms of chest tube removal time (P = .020), hospital stay (P = .042), and complications (P = .126), there was no statistically significant difference between the patients with giant cysts undergoing cystotomy and the patients with giant cysts undergoing capitonnage.
As certain authors have mentioned,2,7,11,12,15-17 because of the higher risk of intraoperative rupture and contamination, we did not apply the enucleation procedure in our patients, except in patients with small and peripherally localized cysts. In addition, contamination and recurrence can be seen in patients in whom enucleation was not applied as well. Furthermore, the inefficient prethoracotomy assessment and the cysts that have not been noticed during the procedure might be evaluated as recurrence. In the present study recurrence was seen in 2 (6.5%) children of group A and in 1 (5.6%) child of group B during the follow-up period, but there was no apparent statistical difference between groups A and B (P = .698).
In conclusion, a childhood pulmonary hydatid cyst should be treated surgically as soon as it is diagnosed. We believe that capitonnage is a more reliable technique with lower complication rates (especially in terms of prolonged air leak) compared with those of cystotomy.
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Acknowledgments
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We thank Sedat Ziyade, MD (Medical Faculty of Istanbul University), for his valuable efforts to gather the statistical data in our manuscript.
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References
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Abstract
Introduction
