Anesthetic challenges in a case of hydatid cyst of liver posted for laparoscopic-assisted excision of the cyst

Ramyavel Thangavelu; Vikasini Raman; RV Ranjan; Sampath Kumar Poral

doi:10.4103/jcrsm.jcrsm_73_21

CASE REPORT

Year : 2022 | Volume : 8 | Issue : 1 | Page : 72-74

Anesthetic challenges in a case of hydatid cyst of liver posted for laparoscopic-assisted excision of the cyst

Ramyavel Thangavelu¹, Vikasini Raman¹, RV Ranjan¹, Sampath Kumar Poral²
¹ Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Puducherry, India
² Department of General Surgery, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission	23-Sep-2021
Date of Acceptance	14-Jan-2022
Date of Web Publication	18-May-2022

Correspondence Address:
Dr. Ramyavel Thangavelu
Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Kalathumettupathai, Ganapathichettikulam, Village 20, Kalapet, Puducherry
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcrsm.jcrsm_73_21

Abstract

Hydatid cyst caused by Echinococcus granulosus is a common health problem in developing countries. The rupture of hydatid cyst can cause anaphylactic shock or even death during the surgical treatment. We present a report regarding anaphylactic reaction due to surgery to the liver for a hydatid cyst. Clinical examination and contrast-enhanced computed tomography preoperatively revealed a large hydatid cyst measuring 18 cm × 13 cm × 11 cm with few thin septations in the right lobe causing mass effect and splaying of intrahepatic vessels. Intraoperatively, the patient was successfully managed with antihistamines, steroids, crystalloids, and a small dose of vasopressor. After the surgery, she was transferred from the Intensive care unit to the surgical ward on the first postoperative day. The possibility of anaphylactic reactions should be kept in mind, and close monitoring for early diagnosis and appropriate management of anaphylaxis is essential for a favorable perioperative outcome in the case of hydatid cyst surgery.

Keywords: Anaphylactic reactions, hepatic hydatid, laparoscopy

How to cite this article:
Thangavelu R, Raman V, Ranjan R V, Poral SK. Anesthetic challenges in a case of hydatid cyst of liver posted for laparoscopic-assisted excision of the cyst. J Curr Res Sci Med 2022;8:72-4

How to cite this URL:
Thangavelu R, Raman V, Ranjan R V, Poral SK. Anesthetic challenges in a case of hydatid cyst of liver posted for laparoscopic-assisted excision of the cyst. J Curr Res Sci Med [serial online] 2022 [cited 2023 May 30];8:72-4. Available from: https://www.jcrsmed.org/text.asp?2022/8/1/72/350140

Introduction

Hydatid cysts are most commonly found primarily in the liver (50%–70%) followed by lungs (20%–30%), kidneys, brain, bones, and other organs (10%).^[1] The management of a hydatid cyst of the liver usually involves surgical management including evacuation, excision of endocyst, or marsupialization.^[2]

One of the major issues that concern the anesthesiologist intraoperatively is the rupture/leakage of hydatid antigenic fluid into the systemic circulation leading to anaphylaxis/anaphylactic shock.^[3] Anticipation and preparedness, with close monitoring for early diagnosis and appropriate management of anaphylaxis, play an important role in anesthetic management. Here, we report the successful anesthetic management of a case of hydatid cyst of the liver posted for laparoscopic excision.

Case Report

A 70-year-old female, a known hypertensive on regular medications presented with complaints of pain in the right hypochondrium for approximately 4 months. The patient had no significant findings on physical examination in the cardiovascular or respiratory systems. Laboratory, biochemical, and hematological tests were within the normal limits. Contrast-enhanced computed tomography revealed a well-defined non-enhancing hypodense lesion measuring 18 cm × 13 cm × 11 cm with few thin septations in the right lobe of the liver causing mass effect and splaying of intrahepatic vessels [Figure 1].

Figure 1: Preoperative contrast-enhanced computed tomography showing a massive hydatid cyst in the right lobe of the liver

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The patient was started on tablet albendazole 800 mg OD and was posted for laparoscopic assisted hydatid cyst excision. Informed anesthesia consent was obtained from the patient after explaining the possibility of anaphylactic reaction intraoperatively and postoperative intensive care (ICU) requirement.

The patient was premedicated with Injection glycopyrrolate 0.2 mg, Injection fentanyl 100 micrograms, and Injection midazolam 2 mg before induction. Induction was performed with Injection thiopentone 200 mg and paralyzed with Injection vecuronium 6 mg. Both induction and intubation were uneventful. The right radial artery was cannulated after induction in anticipation of hemodynamic disturbances that might occur in the event of anaphylaxis intraoperatively. Injection hydrocortisone 100 mg iv and Injection chlorpheniramine maleate 45.5 mg were administered before skin incision as prophylaxis. Anesthesia was maintained with O₂: N₂O mixture with sevoflurane and controlled ventilation. The patient was continuously monitored by electrocardiogram, Invasive blood pressure (BP), pulse oximetry (SpO2), and end-tidal capnography (EtCO2). Abdominal inflation with carbon dioxide for laparoscopy was done and intra-abdominal pressure was maintained between 11 and 14 mm Hg. On reaching the cyst, the surgeons packed the walls with 10% betadine gauze [Figure 2] followed by incision and aspiration of the hydatid fluid from the cyst. During the process of aspiration of the cyst, there was a sudden drop in BP to 80/50 mmHg with an increase in heart rate to about 100/min. However, SpO2 and EtCO2 remained stable. About 300 ml crystalloids were pushed along with Injection phenylephrine 50 μg, following which BP improved to 100/60 mmHg. An additional dose of Injection Hydrocortisone 50 mg iv was also administered. Around 2–2.5 L of hydatid fluid was aspirated. The patient remained stable afterward throughout surgery with no evidence of bronchospasm or desaturation. Following aspiration, marsupialization of the cyst wall was done following the placement of two subhepatic drains. At the end of the surgery, the inhalational agent was stopped, and after reversing the muscle relaxant and thorough oral suctioning, the patient was extubated. Then, the patient was shifted to ICU for postoperative observation after which she was transferred to ward on the first postoperative day (POD). Deep breathing exercises were started on POD 2 and the patient did well and was discharged subsequently.

Figure 2: Perihepatic packing with betadine soaked gauze

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Discussion

Anaphylactic and anaphylactoid reactions during anesthesia are a major cause of concern for anesthesiologists.^[4] Infection with Echinococcus granulosa or echinococcus multilocularis leads to cystic lesions in the liver and lungs. Surgical removal of hydatid cyst is one such scenario where anaphylaxis is common as it might get ruptured, releasing high antigenic contents in the circulation, causing IgE-mediated anaphylactic reactions. Incidence of intraoperative anaphylaxis due to hydatid cyst has been reported to be 2%–3.3%.^[5] The allergic reaction might range from a mild hypersensitivity reaction to a fatal anaphylactic shock. Sudden onset of hemodynamic collapse or increase in airway pressure should raise the suspicion of anaphylaxis intraoperatively. Under anesthesia, cardiovascular signs such as hypotension, tachycardia, and arrhythmias occur predominately with bronchospasm or fall in saturation.

The literature review has revealed several case reports, where there were incidents of anaphylaxis with severe hypotension, desaturation, and bronchospasm on hydatid cyst manipulation and aspiration.^[6] It occurred mainly due to the diffusion of highly antigenic hydatid fluid directly into the bloodstream which triggers an IgE-mediated anaphylactic reaction.^[7] The mainstay of treatment in such reactions is early aggressive therapy with intravenous fluids, iv adrenaline, and steroids.^[8] The inhalational agent should be stopped, 100% oxygen administered and the use of vasopressors may be considered.^[9] The aim should be to restore both adequate cardiac output and circulatory competency.

In our case, though there was an episode of hypotension with a fall in BP to 80/50 mmHg, it reverted with a dose of iv phenylephrine and fluid bolus. Full-blown anaphylaxis was not encountered. The episode of hypotension might have been due to aspiration of a large amount of Hydatid fluid (2–2.5 L) with sudden decompression of cyst, and thus it responded to fluids and a small dose of vasopressor. Also, we had administered steroids and H1 receptor blockers as prophylaxis at the beginning of skin incision, which prevented mast cell activation and basophil mediator release, thereby attenuating the severity of reaction when it occurred. Antihistamines are known to prevent further histamine binding after the development of an anaphylactic reaction. Corticosteroids are given prophylactically to diminish airway swelling and prevent recurrence of symptoms.^[3] Reports available in the literature have recommended that the usage of prophylactic corticosteroids and antihistamines (H1 and H2 receptor blockers) could avoid anaphylactic reactions.^[10] The patient in our report had an episode of hypotension with tachycardia following cyst aspiration intraoperatively which reverted with treatment followed by an uneventful course intraoperatively and recovered well in the postoperative period.

Surgical considerations such as avoiding overdistension and spillage of cystic fluid, gentle manipulation of cyst during the procedure, injecting scolicidal agents, and choice of laparoscopy over open technique are the mainstay in preventing the incidence of anaphylactic reactions.^[11] Thus, any episode of hemodynamic instability in a hydatid cyst surgery should suggest a high degree of suspicion regarding the possibility of an anaphylactic reaction and hence, immediate specific measures should be initiated by the anesthesiologist to attenuate its severity and further management.

Conclusion

A high degree of anticipation of anaphylaxis with adequate prophylactic measures, early diagnosis, and correct management is the cornerstone in anesthetic management for hydatid cyst excision surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank the Department of Radiodiagnosis of our institute for providing the CT image and interpretation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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