One reason for the hopeless prognosis is based on the fact that these tumors are apt to spontaneously rupture. Our experience suggests that appropriate ...
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Letters to the editor portal thromboses and metastases to the left gastric vein. However, we found no previous reports of PHAs that metastasized into the left gastric vein that were curatively resected. These cases should be accumulated, because this may contribute to a better understanding of this phenomenon and lead to a new strategy for the treatment of this disease. Hisashi Nakayama, Hideki Masuda Department of Surgery, Nihon University Nerima Hikarigaoka Hospital, 2-11-1 Hikarigaoka, Nerima-ku, Tokyo 179-0072, Japan Masahiro Fukuzawa First Department of Surgery, Nihon University School of Medicine, Tokyo, Japan Tadatoshi Takayama Third Department of Surgery, Nihon University School of Medicine, Tokyo, Japan Akihiro Hemmi Department of Pathology, Nihon University School of Medicine, Tokyo, Japan
a
References 1. Naka N, Ohsawa M, Tomita Y, Kanno H, Uchida A, Aozasa K. Angiosarcoma in Japan. A review of 99 cases. Cancer 1995;75:989–96. 2. Lee FI, Smith PM, Bennett B, Williams DMJ. Occupationally related angiosarcoma of the liver in the United Kingdom 1972–1994. Gut 1996;39:312–8. 3. Wachsberg RH, Simmons MZ. Coronary vein diameter and flow direction in patients with portal hypertension: evaluation with duplex sonography and correlation with variceal bleeding. AJR Am J Roentgenol 1994;162:637–41. Received: February 18, 2003 / Accepted: August 22, 2003 Reprint requests to: H. Nakayama DOI 10.1007/s00535-003-1274-9
b Fig. 2. a Three-dimensional computed tomography (CT) revealed a lowdensity nodule (large arrows) in the left gastric vein, arising from the confluence of the portal trunk (small arrows) with the splenic vein (arrowheads). b Resected specimen of the left gastric vein
Disseminated abdominal echinococcosis as a late complication of traumatic rupture of liver echinococcal cyst
One reason for the hopeless prognosis is based on the fact that these tumors are apt to spontaneously rupture. Our experience suggests that appropriate surgical treatment, including repeat resections, will be able to result in a favorable prognosis. What was the mechanism of metastasis into the left gastric vein? Because the portal trunk connects the liver and left gastric vein anatomically, the metastasis must have been caused by hematogenous implantation. The typical blood flow of the portal trunks is hepatopetal. In some patients with portal hypertension, it has been reported that the portal flow is hepatofugal.3 In our patient, the exact causes of the metastasis are unknown, but they may be related to factors such as the blood flow in the left gastric vein, tumor histocompatibilty, or angiogenetic factors. Several patients with gastric or hepatic cancer have been reported to have serial
To the Editor: Traumatic rupture of an echinococcal cyst is a serious complication, which may acutely threaten the patient’s life due to anaphylactic schock. If the patient survives, the development of disseminated abdominal echinococcosis is an extremely rare and difficult-to-treat situation. A 39-year-old man was admitted with diffuse abdominal pain, nausea, and fever. Clinical examination revealed generalized tenderness of the abdomen and a palpable mass in the right hypochondrium. The general condition of the patient progressively worsened, with oliguria, hypotension, and dyspnea. Laboratory examination revealed severe leukocytosis (WBC, 21 000/dl), polymorphopyrinosis, and elevation of hepatic enzymes. The patient mentioned that he had suffered a traffic accident 9 years previously, which led to the rupture of an asymptomatic liver
Letters to the editor echinococcal cyst. The patient had undergone external drainage of the remainder of the cyst. Abdominal computed tomography (CT) showed at least six hydatid cysts, the greatest of which occupied the right retrohepatic space and contained air (intrabiliary rupture) (Fig. 1). Exploratory laparotomy revealed: (a) a 5-cm, partially calcified cyst between the right and left liver lobes, which was resected; (b) an 8-cm suppurating cyst within the mesocolon, which was evacuated, irrigated, and externally drained; (c) a 5-cm cyst in the Douglas pouch, which was resected; (d) a 4-cm cyst inside the round ligament, which was also resected; (e) a 15-cm large cyst within the lesser omental pouch between the left liver lobe and the posterior surface of the stomach—reaching the hilum of the spleen—which was evacuated, irrigated, and drained; and (f) a cyst almost 20 cm in diameter, which was situated in the right retrohepatic space and contained pus and bile. This cyst was evacuated and two tubes were placed in the residual cavity for postoperative drainage and irrigation. The extrahepatic biliary tree was drained through a cholecystostomy. The postoperative course of the patient was long but without any major complications. Culture of the pus revealed the presence of Escherichia coli. All drains were gradually removed. The
Fig. 1. Computed tomography (CT) of the upper abdomen, showing three echinococcal cysts, one of which contains air (intrabiliary rupture)
195 residual cavity of the cyst that had ruptured in the biliary tree was irrigated twice daily for 2 weeks, with normal saline. Cholangiography, which was performed on the 14th postoperative day, confirmed the communication of the residual cavity with the biliary tree (Fig. 2). The cholecystostomy tube and the drains of the residual cavity were maintained for 1 month after the operation. Cholangiography performed on the 30th postoperative day showed no communication between the residual cavity and the biliary tree (Fig. 3). Subsequently, both the cholecystostomy tube and the drains of the residual cavity were removed.
Fig. 2. Cholangiography (14th postoperative day) through the cholecystostomy tube, confirming the communication between the biliary tree and the residual cavity
Fig. 3. Cholangiography (30th postoperative day), showing no communication to the residual cavity
196 The patient received antihelminthic treatment with albendazole, 10 mg/kg, for 6 months postoperatively. At followup, 1 year after the operation, ultrasonography revealed no increase in the diameter of the residual cavities nor the development of new cysts. The frequency of disseminated echinococcosis after traumatic intraperitoneal rupture of echinococcal cysts cannot be easily estimated, because almost all data in the literature are derived from individual case descriptions.1–3 The surgical management of disseminated intraabdominal echinococcosis after intraperitoneal spillage always poses a challenge for the surgeon. Ideally, total resection of the cysts would be the treatment of choice. However, this is not always possible. Conservative methods, including external drainage, unroofing, and cavity-obliterating techniques are preferred when the cysts are infected or their locations and size do not allow their safe resection.1,3,4 Free abdominal echinococcal cysts can be almost always easily resected (cystectomy) because they usually do not adhere tightly to other organs. It is noteworthy that the pericystic reactive layer, which is typically present around echinococcal cysts in the liver, is not observed around free echinococcal cysts in the abdominal cavity.1,5,6 In our patient, only three of the six echinococcal cysts could be safely resected. The other three were externally drained, because the size and location of the cysts could not allow a more radical approach, given the compromised general condition of the patient. Disseminated echinococcosis is an absolute indication for antihelminthic drug therapy. Unfortunately, drug therapy still remains an adjunct to surgical procedures. Albendazole, the most commonly used drug, is administered at a dose of 10 mg/kg per day for at least 3 to 6 months.7
Letters to the editor Basilios Papaziogas, John Makris, Athanasios Alexandrakis, Ioannis Galanis, Grigorios Chatzimavroudis, John Koutelidakis, George Paraskevas, George Vretzakis, and Thomas Papaziogas Second Surgical Clinic of the Aristotle University of Thessaloniki, Thessaloniki, Greece
References 1. Gunay K, Taviloglu K, Berber E, Ertekin C. Traumatic rupture of hydatid cysts: a 12-year experience from an endemic region. J Trauma 1999;46:164–7. 2. Sozuer EM, Ok E, Arslan M. The perforation problem in hydatid disease. Am J Trop Med Hyg 2002;66:575–7. 3. Sato N, Namieno T, Takahashi H, Yamashita K, Matsuhisa T, Aoki S, et al. A long-surviving patient with recurrences of hepatic alveolar echinococcosis after traumatic intra-abdominal rupture. J Gastroenterol 1996;31:885–8. 4. Lazaridis C, Makris J, Papaziogas B, Alexandrakis A, Souparis A, Pavlidis T, et al. Drainage of the echinococcal residual cavity with Roux-en-Y cystojejunal anastomosis. Viszeralchirurgie 2001;36:334–6. 5. Dar MA, Shah OJ, Wani NA, Khan FA, Shah P. Surgical management of splenic hydatidosis. Surg Today 2002;32:224–9. 6. Balik IAA, Celebi F, Basglu M, Oren D, Yildirgan I, Atamanalp SS. Intra-abdominal extrahepatic echinococcosis. Surg Today 2001;31:881– 4. 7. Senyuz OF, Yesildag E, Celayir S. Albendazole therapy in the treatment of hydatid liver disease. Surg Today 2001;31:487–91.
Received: May 13, 2003 / Accepted: August 15, 2003 Reprint requests to: B. Papaziogas Fanariou str. 16, 551 33 Thessaloniki, Greece DOI 10.1007/s00535-003-1253-1
