Management of Hepatic Cysts

1. Management of Hepatic Cysts Suen PY Department of Surgery PMH 11 February 2012

2. Case Presentation

3. Case Presentation • Ms Cheung OL • F/62 • PMH: HT • Past Surgical Hx: nil • Social Hx: lives with daughter

4. Case Presentation • C/O: abdominal distension and right upper quadrant discomfort for 5 years with increase in severity in recent 6 months • Decrease in appetite • weight loss (5 pounds in recent 1 year)

5. Case Presentation-Physical Exam • no jaundice, no pallor, no cervical lymphadenopathy • Abdomen: grossly distended, hepatomegaly with liver span about 25 cm, smooth edge and no shifting dullness

6. Case Presentation-Laboratory Results • LFT normal (TB 22 umol/L, ALP 64 U/L, ALT 17U/L, albumin 41 g/L) • CEA: 6.1 • AFP: 1.89 • HbsAg: –ve • Hb 12.1g/dL, WBC 4.4x10⁹/L

7. Case Presentation-Imaging • Bedside USG abdomen: huge cystic lesion in liver • USG abdomen in x-ray dept. (19/4/11): a huge liver cyst with well-circumscribed, thin and regular wall, about 24 cm in diameter over left lobe, no other liver mass

8. Case Presentation-imaging • CT abdomen (15/8/11): a huge liver cyst (near water density) with size of 24x15x24cm over left lobe with significant mass effect, no significant contrast enhancement in the lesion

9. Case Presentation • Laparoscopic liver cyst fenestration (marsupialization/unroofing) offerred; patient opted for OT • Operation done on 23/11/11 • Findings: a large left hepatic cyst (ab0ut 25 cm in diameter); about 3 litres of serous fluid inside and drained

10. Case Presentation-Procedure • Sub-umbilical port made under direct vision with pneumoperitoneum created; 10mm epigastric and 5mm right subcostal ports created • Cyst wall punctured and cystic fluid drained • Cyst wall partially excised • Inner lining of cyst wall cauterized • A piece of omentum anchored into cystic cavity

11. Case Presentation • Post-operatively: uneventful • Discharged on D5 • Followed up 1 mouth later: • Well, no more abdominal distension nor discomfort • Abdomen: soft and not distended • Wound healed • Pathology: a single layer of cuboidal epithelium, suggestive of simple hepatic cyst

12. Hepatic Cysts

13. Hepatic Cysts • Simple hepatic cysts (majority) • polycystic liver disease • Neoplastic cysts (benign or malignant) • Traumatic cysts • Parasitic (hydatid) cysts • Pyogenic cysts

14. Simple Hepatic Cysts

15. Simple hepatic cysts-definition cystic formations of the liver, containing serous fluid, usually not communicating with biliary system

16. Simple hepatic cysts • Most common cystic lesions of the liver • 2nd most common incidental findings of benign lesions in the liver after hemangioma • prevalence : 5% • 90-95% asymptomatic

17. Simple hepatic cysts • For asymptomatic , female to male ratio about 1:1 • For symptomatic, female to male ratio 9:1 • No malignant potential • About half of patients have a single cyst, whereas the other half have two or more

18. Simple hepatic cysts • Pathology: Lined by a single layer of cuboidal or low columnar epithelium • Pathogenesis: regarded as a congenital malformation of aberrant bile duct, usually lost communications with biliary tree and may gradually dilate

19. Simple hepatic cysts-clinical presentation • Majority : asymptomatic • Commonly discovered as incidental finding during radiographic studies for unrelated symptoms or for other diseases • Common symptoms: abdominal discomfort, abdominal distension, nausea or vomiting • Rare symptoms: fever, sweating, back or shoulder pain

20. Simple hepatic cysts-complications • Rare • Intra-cystic haemorrhage (most common; sudden onset of increase in abdominal pain or distension ) • Spontaneous rupture • Infection • Biliary compression with obstructive jaundice • torsion

21. Simple hepatic cysts-diagnosis • Usually diagnosed by USG or CT • USG findings of simple hepatic cysts • Well-circumscribed • Thin and regular wall • Homogeneously anechoic • No septation, mural nodules or projections

22. Simple hepatic cysts-diagnosis • CT findings • Well-defined • Thin and regular wall • Homogenous, hypoattenuated fluid with density similar to water

23. Simple hepatic cysts-diagnosis • MRI may be considered when the diagnosis is equivocal • Well-defined, thin and regular wall • Fluid signal intensity: low on T1-weighted images and high on T2-weighted image • No wall enhancement, nodules or projections; and no internal signals

24. Simple hepatic cysts-diagnosis • Cyst fluid analysis ( percutaneous fluid aspiration for analysis) may also be considered in cases with difficulty in diagnosis • Cytological analysis: acellular fluid and absence of mucin • Chemical analysis: normal CEA, CA19.9 and bilirubin level

25. To differentiate from neoplastic cysts Neoplastic cysts’ characteristics: • Multi-locular ,septated • Thick irregular wall • Mural nodules, projections present • Thick fluid • Mucinous material in fluid • Elevated CEA or CA19.9 in fluid

26. Neoplastic cysts • Rare • Cystadenomas or cystadenocarcinoma • Most are cystadenomas -A benign cystic tumour with potential malignant transformation to cystadenocarcinoma (very rare) • Radiologically : complex cystic lesions

27. Simple hepatic cysts-treatment • Majority of patients require no treatment, just for observation

28. Simple hepatic cysts-indications for treatment • Symptomatic condition (most common) • Intracystic hemorrhage • Diagnostic uncertainty

29. Simple hepatic cysts-treatment modality • Simple percutaneous aspiration • Percutaneous aspiration followed by injection of a sclerosing agent • Fenestration (unroofing or marsupialization) • Enucleation (rarely applied)

30. Treatment-simple percutaneous aspiration • Percutaneous aspiration associated with very high recurrence rate (75-100%) • repeated aspiration can result in cyst infection • usually not for definitive treatment

31. Treatment-cyst aspiration with injection of sclerosing agent • sclerosing agents : ethanol, minocycline hydrochloride, tetracycline hydrochloride • Recurrence rate: 20-30% • contraindicated if there is communication with biliary tract • generally reserved for patients with high operative risk

32. Treatment-fenestration • lowest (5 %) recurrence rate • Should be considered and offered for most of symptomatic patients • A laparoscopic approach is favoured (lots of evidence demonstrates it’s treatment results equivalent to that of an open approach, while it has the advantages of a laparoscopic surgery)

33. Treatment-laparoscopic fenestration procedure • Laparoscopic approach adopted • Resection of a portion of the cyst wall allows drainage into the peritoneal cavity and access to its interior • Ablation of remaining inner lining of cyst wall by cauterization will minimize recurrences and the risk of ascites • A piece of omentum can be anchored into the cavity of cyst to avoid reformation of cyst

34. Treatment Algorithm Cystic lesion(s) Simple cystic lesion(s) complex cystic lesion(s) M.F. Hansman et al/ The American Journal of Surgery 181 (2001) 404-410 symptomatic asymptomatic polycystic liver disease simple hepatic cyst(s) Dominant cysts multiple small cysts Resect. Obs. Fenest. Fenest. Obs. Resect.

35. Summary (management of hepatic cysts) 1. Making a definitive diagnosis of the nature of the cystic lesion -DDx: simple hepatic cysts/neoplastic cysts/others -Inx: US/CT +/- MRI or cystic fluid analysis 2. Determining whether the patient’s symptoms are related to the cystic lesion or not -careful history taking -relevant investigations or procedures

36. Summary 3. Deciding whether to intervene or not -assessing the severity of symptoms, occurrence of complications, certainty of the diagnosis, pre-morbid state and the operative risks 4. Deciding the treatment modality -laparoscopic fenestration, percutaneous aspiration followed by injection of a sclerosing agent, simple aspiration or enucleation

37. The end

38. Reference • Current Surgical Therapy by John L. Cameron, 10th ed. • Surgery of the liver and biliary tract by L.H. Blumgart, 3rd ed. • Hansman MF et al: Management and long-term follow-up of hepatic cysts, Am J Surg 181: 404-410, 2001 • Fabiani P et al: long-term outcome after laparoscopic fenestration of symptomatic simple cysts of the liver, Br J Surg 92: 596-597, 2005 • Mazza OM et al: Magagement of non-parasitic hepatic cysts, Am J Surg 209: 733-739, 2009 • www.medscape. com