Ultrasound guided percutaneous injection of alcohol as scolicidal agent for treatment of liver Hydatid cysts: Our experience in a tertiary level hospital

OBJECTIVES: To assess the efficiency of the percutaneous sclerotherapy as an effective method of non – surgical management of liver Hydatid cysts using sterile absolute alcohol as the injected scolicidal agent. METHODS: All the patients referred to the department of Radiology were included in the study over a period of 17 months. All of them underwent pre-procedural imaging to enable us to classify the type of cyst and also to plan access for percutaneous injection sclerotherapy. The patients who returned after medical therapy underwent percutaneous therapy attempts and the ones where there was evidence of cystobiliary communication according to cyst fluid bilirubin levels were excluded for final analysis. The others underwent successful injection. They were followed up with imaging and data were tabulated in Microsoft Excel sheet and the results were analyzed. RESULTS: Among the 23 patients in whom the percutaneous alcohol injection sclerotherapy was attempted, 10 of had evidence of cystobiliary communication. The other 13 of them underwent injection. Minor complications like pain and fever were managed conservatively. One developed severe hypotension, was managed intensively and recovered. On follow up, 83 % showed more than 60% reduction in the cyst volume. Similarly 83% showed imaging appearances indicating good response. Hence percutaneous therapy using alcohol is a safe, effective and cheaper procedure for liver hydatid cysts and minimizes the duration of hospital stay. CONCLUSIONS In conclusion, in our experience of treating patients with liver Echinococcal cysts with percutaneous injection of absolute alcohol using either aspiration needles or pigtail catheters, we showed that this procedure has been a very safe and effective procedure for this condition. However this has to be done as an in-patient procedure and not as an out-patient procedure as complications need to be managed promptly and some might require intensive management. The World Health Organization – Informal Working Group on Echinococcosis [WHO - IWGE] described the various types of the liver Echinococcal cysts and the recommended guidelines on how to perform the procedure. Various techniques have been studied and practiced by different centres, some involving percutaneous puncture, aspiration, injection and reaspiration [PAIR], the same with catheter drainage [PAIRD], just injection of scolicidal agent without reaspiration [PAI] etc. with good comparable results. Any of these techniques could be followed. Different scolicidal agents are also being used for the purpose varying from 20% hypertonic saline, absolute alcohol [95% ethanol], povidone iodine solution, and Albendazole solution etc. all of them showing reasonably good results. This study shows that absolute alcohol can be used as a very good scolicidal agent for the same purpose. However, the procedure requires certain skill in performing ultrasound guided liver puncture and should be carried out only by personnel with proper training in performing ultrasound guided procedures. All the necessary equipments and a good surgical unit specialized in Hepatobiliary surgery and also a good intensive care unit should also be present in the centre where such procedures are carried out for backup in case the patient needs to be taken to theatre immediately or needs intensive care in an ICU setting if major complications arise as was seen in one of our patients. Although this procedure has been described well in the literature, it is still not well established and more prospective studies are required to establish the efficacy and safety of the procedure. More studies in future will also show that the percutaneous injection therapy for liver Echinococcal cysts is also very cheaper compared to surgical therapy, lessens the duration of hospital stay and is also more tolerable for the patients. Hence more prospective studies with long duration follow ups are required to show the long term efficiency and other long term outcomes of this method of treatment for liver Echinococcal cysts