Suen PYDepartment of Surgery

PMH11 February 2012

Ms Cheung OLF/62

PMH: HT Past Surgical Hx: nil Social Hx: lives with daughter

C/O: abdominal distension and right upper quadrant discomfort for 5 years with increase in severity in recent 6 months

Decrease in appetiteweight loss (5 pounds in recent 1 year)

no jaundice, no pallor, no cervical lymphadenopathy

Abdomen: grossly distended, hepatomegaly with liver span about 25 cm, smooth edge and no shifting dullness

LFT normal (TB 22 umol/L, ALP 64 U/L, ALT 17U/L, albumin 41 g/L)

CEA: 6.1 AFP: 1.89HbsAg: –veHb 12.1g/dL, WBC 4.4x10⁹/L

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

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

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

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 excisedInner lining of cyst wall

cauterizedA piece of omentum anchored

into cystic cavity

Post-operatively: uneventfulDischarged on D5

Followed up 1 mouth later:Well, no more abdominal

distension nor discomfortAbdomen: soft and not

distendedWound healedPathology: a single layer of

cuboidal epithelium, suggestive of simple hepatic cyst

Simple hepatic cysts (majority)

polycystic liver disease Neoplastic cysts (benign or malignant)Traumatic cystsParasitic (hydatid) cysts Pyogenic cysts

cystic formations of the liver, containing serous fluid, usually not communicating with biliary system

Most common cystic lesions of the liver2nd most common incidental findings of

benign lesions in the liver after hemangiomaprevalence : 5% 90-95% asymptomatic

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

Pathology: Lined by a single layer of cuboidal or low columnar epitheliumPathogenesis: regarded as a congenital malformation of aberrant bile duct, usually lost communications with biliary tree and may gradually dilate

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

RareIntra-cystic haemorrhage (most common;

sudden onset of increase in abdominal pain or distension )

Spontaneous ruptureInfectionBiliary compression with obstructive jaundicetorsion

Usually diagnosed by USG or CT

USG findings of simple hepatic cysts

Well-circumscribedThin and regular wallHomogeneously anechoic No septation, mural

nodules or projections

CT findingsWell-definedThin and regular wallHomogenous,

hypoattenuated fluid with density similar to water

MRI may be considered when the diagnosis is equivocal

Well-defined, thin and regular wallFluid signal intensity: low on T1-weighted

images and high on T2-weighted imageNo wall enhancement, nodules or projections;

and no internal signals

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

Neoplastic cysts’ characteristics:

Multi-locular ,septatedThick irregular wallMural nodules, projections present

Thick fluidMucinous material in fluidElevated CEA or CA19.9 in fluid

Rare Cystadenomas or cystadenocarcinomaMost are cystadenomas -A benign cystic tumour with potential

malignant transformation to cystadenocarcinoma (very rare)

Radiologically : complex cystic lesions

Majority of patients require no treatment, just for observation

Symptomatic condition (most common)

Intracystic hemorrhageDiagnostic uncertainty

Simple percutaneous aspirationPercutaneous aspiration followed by injection

of a sclerosing agent

Fenestration (unroofing or marsupialization)

Enucleation (rarely applied)

Percutaneous aspiration associated with very high recurrence rate (75-100%)repeated aspiration can result in cyst infectionusually not for definitive treatment

sclerosing agents : ethanol, minocycline hydrochloride, tetracycline hydrochloride

Recurrence rate: 20-30%contraindicated if there is communication

with biliary tractgenerally reserved for patients with high

operative risk

lowest (5 %) recurrence rateShould be considered and offered for most

of symptomatic patientsA 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)

Laparoscopic approach adoptedResection 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

M.F. Hansman et al/ The American Journal of Surgery 181 (2001) 404-410

Cystic lesion(

s) Simple cystic

lesion(s)

symptomatic

simple hepatic cyst(s)

Fenest.

polycystic liver disease

Dominant cysts

multiple small cysts

Fenest.

Resect.

asymptomatic

Obs.

complex cystic

lesion(s)

Obs.Resec

t.

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

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

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

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