The problems and advantages of one lung ventilation during surgical intervention in pulmonary hydatid cyst disease

Abstract

BackgroundHydatid disease is the most severe helminthic zoonosis, with an important public health problem especially in rural areas
in Turkey. The aim of this study was to review the problems and advantages encountered in surgical treatment of 43 patients
who were ventilated with one-lung ventilation during last four years.

MethodsPatients, operated with one-lung ventilation, constitute the study group. Data related to symptoms, radiographic findings,
performed surgical procedures, perioperative and postoperative morbidity, hospitalization time, and cyst recurrence were collected
from each individual's records.

ResultsCystotomy and capitonnage were performed in all cases. Perioperative complications were seen in 5 patients. Four of these
5 patients had double-lumen endotracheal tube malpositioning. In one patient hypoxemia developed. The most common postoperative
complication was atelectasis. One patient had recurrent cysts. There was no perioperative or postoperative death.

ConclusionsWe prefer cystotomy and capitonnage because it is a fast and effective technique with limited postoperative complications.
One-lung ventilation prevents the exposure of lower lung areas from massive aspiration, which may cause acute obstruction
of airways, and contamination by cyst contents from the operative part of the lung that causes recurrent disease. One-lung
ventilation in pulmonary hydatid cyst surgery may be preferred owing to lower mortality and morbidity rates.

Full text

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IJTCVS
2006; 22: 137–140
Hidir et al
Hydatid cyst
137
The problems and advantages of one lung ventilation during
surgical intervention in pulmonary hydatid cyst disease
Hidir Esme1, MD, Huseyin Fidan2, MD, Ahmet Cekirdekci3, MD
Department of Thoracic Surgery1, Anaesthesia2 and Cardiovascular Surgery3, Afyon Kocatepe University School
of Medicine, Afyon, Turkey
Address for correspondence:
Hidir Esme
Afyon Kocatepe University, Faculty of Medicine
Department of Thoracic Surgery
Pembe Hastane, 03200/ Afyon/ Turkey
e-mail: hesme@aku.edu.tr
Phone: +90 533 6471729
Fax: +90 272 2172029
©IJTCVS 097091342202606/ 40
Received- 20/05/05; Review Completed- 10/06/05; Accepted- 21/04/06.
Introduction
Hydatid disease is the most severe helminthic
zoonosis, with an important public health problem
especially in rural areas in Turkey. The incidence of
hydatid disease is 1:2000 in Turkey.1 The goal of surgical
therapy is to remove the cyst while preserving as much
lung tissue as possible. One-lung ventilation (OLV) is a
must under certain circumstances and provides safety
for the patient and better operative conditions for
surgeons. The experience of OLV during surgical
treatment of pulmonary cyst disease has been reported
only in a few studies.
The aim of this study was to review the problems
and advantages encountered in surgical treatment with
OLV of 43 patients with pulmonary hydatid cysts during
the last four years.
Patients and Methods
The records of 43 patients who had surgical treatment
with OLV between 2000 and 2004 were reviewed.
Twenty-two were male and 21 were female. The mean
age was 26.4 years (18 to 82 years). Fifteen patients
(34.8%) had a long history of close contact with animals,
such as tending of domestic animals or sheep-farming.
The follow-up times for all 43 patients ranged from 3
months to 3 years. Although chest pain, cough, purulent
sputum and fever were common presenting symptoms,
5 patients (11.6%) were symptom free. Asymptomatic
cysts were diagnosed incidentally on chest radiography
Abstract
Background: Hydatid disease is the most severe helminthic zoonosis, with an important public health
problem especially in rural areas in Turkey. The aim of this study was to review the problems and advantages
encountered in surgical treatment of 43 patients who were ventilated with one-lung ventilation during last
four years.
Methods: Patients, operated with one-lung ventilation, constitute the study group. Data related to
symptoms, radiographic findings, performed surgical procedures, perioperative and postoperative morbidity,
hospitalization time, and cyst recurrence were collected from each individual’s records.
Results: Cystotomy and capitonnage were performed in all cases. Perioperative complications were seen in
5 patients. Four of these 5 patients had double-lumen endotracheal tube malpositioning. In one patient
hypoxemia developed. The most common postoperative complication was atelectasis. One patient had
recurrent cysts. There was no perioperative or postoperative death.
Conclusions: We prefer cystotomy and capitonnage because it is a fast and effective technique with limited
postoperative complications. One-lung ventilation prevents the exposure of lower lung areas from massive
aspiration, which may cause acute obstruction of airways, and contamination by cyst contents from the
operative part of the lung that causes recurrent disease. One-lung ventilation in pulmonary hydatid cyst
surgery may be preferred owing to lower mortality and morbidity rates. (Ind J Thorac Cardiovasc Surg, 2006;
22: 137–140)
Key words: Lung, Hydatid cyst, Cysts
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Hydatid cyst
Hidir et alIJTCVS
2006; 22: 137–140
done for other purposes. Cystic hydatid disease was
confirmed by postoperative pathological assessment,
additional supporting serological and radiological
evidence of the disease.
A posterolateral thoracotomy was used in all patients.
Two patients with bilateral disease were managed with
staged thoracotomies after an interval of four weeks.
There were concomitant liver cysts in six patients. Four
weeks after surgery for thoracic cysts, laparotomy was
performed in the patients with hepatic cysts, except two
in whom a thoracic transdiaphragmatic approach was
used. Thoracic transdiaphragmatic approach was used
in liver-dome cysts. Cystotomy and capitonnage were
carried out in all patients. Wedge resection was carried
out in one patient with destroyed pulmonary areas.
Lung decortication was performed in two patients who
had empyema.
A ll patients who had infected cysts (n=4) and
empyema (n=2) received preoperative antibiotic
therapy. The course of treatment was a minimum of 7
days (mean, 11 days; range, 7 to 21 days). β-lactamase
antibiotics were empirically used if the special culture
was not available. β-lactamase antibiotics were
administered as postoperative prophylactic treatment
with a duration ranging from 4 to 15 days (mean, 6 days).
Albendazole treatment was given to 8 patients with
multiple intrathoracic cysts or additional hepatic cysts.
The albendazole was given 800 mg daily for 21-days
three times with 10-day rest periods between courses.
After induction of anaesthesia, the trachea and the
main bronchus of the healthy side were intubated with
a 37F (French) or 39F polyvinylchloride double-lumen
left-sided or right-sided endobronchial tube (DET).
Bilateral and one lung ventilation were checked and
confirmed by auscultation and fiberoptic bronchoscope
(Karl Storz Company, Tuttlingen, Germany). The DET
positioning was again confirmed by auscultation after
the patients were placed in the lateral decubitus position
for thoracotomy. End-tidal carbon dioxide (ETCO2),
peripheral oxygen saturation (SpO2), electrocardiogram
(ECG) and blood pressure were continuously
monitored. A irway pressures were monitored
throughout the operations. And, also arterial blood gases
were monitored when peripheral oxygen saturation
decreased below 90%.
Results
One cystic lesion was detected in the mediastinum,
the others were detected in the lung. The lung cysts were
intact and uncomplicated in 34 patients and were
ruptured in 9 patients (20.7%). Four of nine ruptured
cysts were infected. A total of 48 cysts were found in 43
patients. The hydatid cysts were located in the right lung
in 22 patients, in the left lung in 16, and in both lungs in
2. The patient with the most abundant intrapulmonary
cysts had 3 in the left lung. The most common cyst
localizations were the lower lobes of both lungs.
Radiograph findings of the 43 patients outlined
spherical smooth opacity in 25 (58%), multiple cysts in
2 (4.6%), bilateral in 2 (4.6%), mediastinal hydatid cyst
in 1 (2%), giant pulmonary hydatid cyst (12 cm in
diameter) in 1 (2%) (Fig. 1), air-fluid level mimicking
lung abscess in 4 (9%), localized empyema in 2 (4.6%),
and water lily sign in 3 (6.9%) (Fig. 2).
Fig. 2. The entrance of free air into the cyst and the perivesicular
space following the complete rupture of the laminated menbrane
and floating membranes on the surface of the cyst.
Fig. 1. Lobulated giant hydatid cyst in the right lung.
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Perioperative complications were seen in 5 patients
(11%). Four of these 5 patients had DET malpositioning
which probably took place during patient positioning.
The patients were placed supine again and the DETs
were placed once again. In fifth patient hypoxemia
developed as a result of surgical compression of the
mediastinum and airways. SpO2 gradually decreased
from 99% to 85%. Inspired oxygen was increased to
100%, two-lung ventilation was resumed and positive
end-expiratory pressure 10 cm H2O2 was applied.
Oxygen saturation increased to 99% in approximately 3
minutes. Tracheobronchial trauma or hemorrhage was
not observed in any of the procedures.
In the postoperative course we encountered 9
complications in 8 patients (18.6%) (Table 1). The most
common complication was atelectasis. A telectasis
developed in four patients (9%). A telectasis was
managed by nasotracheal aspiration and intensive
respiratory exercises as well as negative suction. In one
patient, bronchoscopy was needed on the 3rd
postoperative day and atelectasis resolved. Wound
infections developed in two patients and resolved with
local treatment. Extended air leakage was observed in
one patient and was managed by continuous negative
aspiration. Hemoptysis was observed in one patient
after 8 months from operation and managed with
conservative treatment. There was no perioperative or
postoperative death. The mean postoperative unit stay
was 3.3 days and the mean hospital stay was 8.1 days.
In the follow-up period, there were no late
complications, but there was a recurrent hydatid cyst
in one patient who had ruptured cyst. Recurrent cyst
was diagnosed 18 months after operation and was
reoperated with thoracotomy.
preserving as much lung as possible. However, the
presence of complications, the risk of dissemination, the
size of the cyst, and the vital importance of the involved
organ are the other most commonly accepted criteria2.
Most authors do not advocate enucleation (the Ugon
method) because of the higher risk of contamination due
to rupture and cystectomy (the Perez-Fontana method)
because it increases the risk of air leaks and
postoperative bleeding2, 3. Some authors recommend
leaving the cavity open without capitonnage. It is clear
that leaving a potential cavity might allow infection,
hematoma and abscess formation4-6. We used the
capitonnage technique after removal of all hydatid cysts.
Radical pulmonary resections may also be carried out
when lung tissue is diffusely involved as in the form of
multiple intralobular cysts, large cysts involving more
than 50% of the lobe, extensive lobar destruction
resulting from infection unresponsive to preoperative
treatment and sequelae of hydatid disease such as
pulmonary fibrosis, bronchiectasis, or severe
haemorrhage7-9. Thameur et al. reported a lung resection
rate of 14.1%9. Isitmangil et al. reported a lung resection
rate of 6.2%7. We carried out wedge resections in only
one patient with destroyed pulmonary areas (2.3%), no
lobectomy or pneumonectomy procedures were
required. This low ratio may be explained by low
ruptured cyst number.
Bronchi opening into the pericyst cavity allow for
discharge of hydatid liquid. Furthermore, operative
manipulation of chronic ruptured pulmonary hydatid
cysts can force fragments of the laminated membrane
or small daughter cysts into the bronchial tree. Such
extruded solid fragments lodge in bronchi of the same
or opposite lung with resulting in acute obstruction of
airways10. Balci et al. reported that these complications
were encountered in some adults and 9 children (14.2%),
of whom 5 had intact cysts and 4 had ruptured cysts11.
Two of them died. Saidi et al. reported that
intraoperative bronchial aspiration of hydatid material
was seen in 7 patients with ruptured hydatid cysts of
the lung and they had unexplained difficulty in
ventilation10. Monies-Chass et al. reported that the
massive aspiration of hydatid liquid during operation
for excision of hydatid cyst of the lung was seen in 5 of
42 patients (11.9%) and among them, one patient died12.
We did not encounter similar complications during OLV
which may be the preventive reason of these
complications.
Uncontrolled spillage of cyst contents may cause
secondary pleural or bronchogenic hydatidosis. Tor et
al. reported that recurrent hydatid cysts were observed
in 11 % of the patients13. Montaggian and Saidi reported
Table 1. Perioperative and postoperative complications
Complications
Perioperative
DET malpositioning
Hypoxemia
Postoperative
Atelectasis
Wound infections
Extended air leakage
Hemoptysis
Recurrent hydatid cyst
Patients (n)
4
1
4
2
1
1
1
Discussion
Several operative techniques are used to manage
hydatid cyst of the lung, and their main objective is
resection of the intact or complicated cyst, while
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a recurrence rate of 11.3%14. The operation and
anaesthetic approach could play a predisposing role in
the pathogenesis of this complication. Therefore, we
preferred the OLV to prevent the patients from this
complication. We had a recurrent hydatid cyst in one
patient who had ruptured cyst before the first operation
in our series.
Intentional collapse of the lung on the operative side
facilitates most thoracic procedures but some
complicates anesthetic management. The most frequent
complication of OLV is hypoxemia. Most commonly this
event is due to ventilation-perfusion mismatch resulting
from the combination of position, OLV, and lung disease.
Moreover, the DET can be malpositioned. Difficulties
resulting from improperly positioned endobronchial
tubes include failure to collapse the operative lung;
difficulty in ventilating one or both lungs; air entry into
the wrong lung; and air trapping and unsatisfactory
deflation of the lung15. Fiberoptic bronchoscopy can
significantly reduce such malpositioning, and it is
commonly recommended. Tracheobronchial trauma
and hemorrhage are the other complications. In our
series severe hypoxemia requiring treatment developed
in one patient and DET malpositioning in 4 patients.
We resolved easily these complications by using
fiberoptic bronchoscope and conservative interventions.
In our series the most common postoperative
complication was atelectasis and was in right upper lobe
in 3 of 4 patients. This complication was related to the
right-sided DET. Proper positioning of right-sided DET
is technically more difficult because of the short,
variable-length of right main stem bronchus. We think
that bronchial cuff blockes the orifice to the right upper
lobe bronchus. Extended air leakage was observed in
one patient (2.3%). Balci et al. and Topcu et al. reported
that the most common complication was extended air
leakage (7.9 and 7.3%, respectively)11, 16. These surgeons
used capitonnage in 38% and 80% of operations,
respectively. Turna et al. reported that extended air
leakage was observed in 15% (5 to 32 patients) of patients
treated without capitonnage17. We suggest that our low
extended air leakage ratio is related to using capitonnage
in all our patients.
In summary, cystotomy and capitonnage are
preferred in hydatid cyst disease because they are fast
and effective techniques with limited postoperative
complications. OLV may have some complications
related to the isolation of lungs but these complications
can be solved easily with intervention. OLV prevents
the exposure of lower lung areas from massive
aspiration, which may cause acute obstruction of
airways, and contamination by cyst contents from the
operative part of the lung that causes recurrent disease.
In addition, OLV provides safety for the patient and
better operative conditions for the surgeon. OLV in
pulmonary hydatid cyst surgery may be preferred
owing to lower mortality and morbidity rates.
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