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|Year : 1982 | Volume
| Issue : 2 | Page : 112-4B
Primary retroperitoneal hydatid cyst (a report of 3 cases and review of the literature).
Sekar NN, Madhavan KK, Yadav RV, Katariya RN
|How to cite this article:|
Sekar N N, Madhavan K K, Yadav R V, Katariya R N. Primary retroperitoneal hydatid cyst (a report of 3 cases and review of the literature). J Postgrad Med 1982;28:112-4B
|How to cite this URL:|
Sekar N N, Madhavan K K, Yadav R V, Katariya R N. Primary retroperitoneal hydatid cyst (a report of 3 cases and review of the literature). J Postgrad Med [serial online] 1982 [cited 2019 Nov 21];28:112-4B. Available from: http://www.jpgmonline.com/text.asp?1982/28/2/112/5582
Hydatid disease is one of the oldest diseases known to mankind. In 85-95% of the cases, the liver and/or the lung is involved and in only 5-15% the cyst occurs at other sites. Primary retroperitoneal hydatid cyst is extremely rare and only occasional case reports have appeared since Lockhart and Sapinza first reported this entity in 1958. We are reporting here 3 cases of primary retroperitoneal hydatid cysts with a review of the literature.
A 77 year old man was admitted to a peripheral hospital with a swelling in the left iliac fossa, of 30 years' duration and another swelling in the back of the left thigh, of 13 years' duration. An incision was given over the thigh swelling and 800 ml of pus, necrotic material and intact daughter cysts were removed. The abdominal swelling was then noticed to have become small. He was later referred to the Nehru hospital attached to the Post graduate Institute of Medical Education and Research, Chandigarh. Examination here revealed a firm mass in the left iliac fossa. Intact daughter cysts and necrotic material came out of the sinus in the thigh on pressing the abdominal swelling. He was febrile and had psoas spasm. Plain X-ray of the abdomen revealed circum-linear calcification on the left side corresponding to the palpable mass [Fig. 1]. X-ray of the chest was normal and the liver scan showed no space occupying lesion. A sinogram done through the sinus in the thigh revealed a large cavity in the thigh which was communicating with the retroperitoneal mass [Fig. 2 ]. A diagnosis of infected retroperitoneal hydatid cyst with extension along the psoas sheath into the thigh was made and the patient was explored through an oblique iliac incision. There was a large hydatid cyst with calcified walls in the retroperitoneum on the left side containing 1.5 litres of pus, necrotic tissue and intact daughter cysts. The cyst was extending behind the inguinal ligament into the thigh along the psoas sheath. Marsupialisation of the cyst was done after thorough curettage and irrigation. Post-operatively, discharge of necrotic material through the sinus came down gradually. When seen 6 months later, all the sinuses had healed up and the patient was completely asymptomatic.
A 53 year old female was admitted with a gradually increasing painless lump in the right lumbar area of 4 years' duration. Four years prior to admission, a similar swelling had been removed from the right gluteal region at another hospital. On examination, a 12 x 10 cm sized non-tender fixed lump was felt in the right lumbar area. Plain X-ray of the abdomen showed a soft tissue mass on the right side and the X-ray of the chest was normal. Intravenous pyelogram revealed normally positioned kidneys but the right ureter was shifted medially by the mass. Laparotomy was done with the diagnosis of retroperitoneal tumour. Two large hydatid cysts were found in the retroperitoneum on the right side displacing the ureter medially. Enucleation of the cysts was done observing the usual precautions and the residual cavity was drained externally with a wide bore Foley's catheter. The rest of the peritoneal cavity and the liver were thoroughly examined to rule out any other hydatid cyst. The patient had an uneventful postoperative period and the drainage catheter was removed after a few days.
A 35 year old man was admitted with a painless swelling in the right iliac fossa present since 8 months. The mass was 10 cm in diameter and was cystic to feel. Plain X-ray of the abdomen revealed a soft tissue mass. Exploratory laparotomy revealed a large hydatid cyst in the retroperitoneum adherent to the iliacus muscle. Rest of the peritoneal cavity was normal. The cyst was excised in toto without difficulty.
Man is an accidental host in the life cycle of Ecchinococcus granulosus. Human infestation occurs when the ova are swallowed. In the stomach the outer protective coat of the ovum is digested and the larvae are liberated. These penetrate the mucosa of the proximal bowel to enter the portal system. About 85-95% of the larvae are trapped in the liver and the lung and only about 5-15% of them escape into the systemic circulation to involve other organs, mainly the muscles, the kidney, bone and the brain. Retroperitoneal involvement was always thought to be secondary to rupture or spillage during surgery of liver hydatids. Primary retroperitoneal hydatid cysts without other organ involvement was first reported by Lockhart and Sapinza, in 1958 and till 1973, only 9 cases had been reported in the literature. We did not find any other case report in the English literature after 1973.
Various modes of spread have been suggested to explain the escape of liver and lung involvement-via lymphatics or via veno-venous shunts within the liver and in the space of Retzius. Dew and Waddel had favoured airborne transmission and direct implantation of the embryo in the bronchial mucosa as another possible mode of entry. This raises the possibility of an embryo of the parasite entering a venule after penetrating the bronchial mucosa and reaching the left side of the heart to involve other sites and thus bypassing the lung. But this remains largely theoretical and needs to be proved.
Correct pre-operative diagnosis is difficult to make unless circumlinear calcification is seen in the plain X-ray of the abdomen. Of the 9 earlier reported cases, 2 had died due to anaphylactic reaction resulting from spillage during excision or biopsy done with the mistaken diagnosis of a retroperitoneal tumour. Hence one must have a high index of suspicion and rule out hydatid cyst in every case of retroperitoneal cystic swelling especially in endemic areas and adequate precaution should be taken to avoid anaphylaxis. Excision of the cyst may not be possible because of dense adhesions. It is preferable to evacuate the parasite and excise the redundant portion of the pericyst leaving the rest of the cavity open or to drain it externally with a wide bore catheter. A careful search for other abdominal and liver hydatids should be made because secondary retroperitoneal hydatids far outnumber primary retroperitoneal hydatids.
|1.||Barret, N. R.: The anatomy and the pathology of multiple hydatid cysts in the thorax. Arris and Gale lecture. Ann. Roy. Col. Surg. Engl.. 26: 362-379, 1960. |
|2.||Dew, H. R.: "Hydatid Disease-Its pathology, Diagnosis and Treatment". 1st edition The Australasian Medical Publishing Company, Ltd, Sydney, 1928, pp. 304-315. |
|3.||Lockhart, J. and Sapinza, V. C.: Primary retroperitoneal hydatid cyst, Excerpta Med. (Surg)., 12(2): 4513, p. 968, 1958. |
|4.||McPhail, J. L. and Arora, T. S.: Intra thoracic hydatid disease. Dis. Chest, 52. 772-781, 1967. |
|5.||Mukherjee, S., Nigam, M. and Saraf, J. C.: Primary retroperitoneal hydatid cyst. Brit. J. Surg., 60: 916-918, 1973. |
|6.||Saidi, F.: "Surgery of Hydatid Disease". 1st edition, W. B. Saunders Company Ltd., Philadelphia, 1976, p, 32. |
|7.||Waddle, N.: Pulmonary hydatid disease. Aust. N. Z. J. Surg., 19: 273-278, 1950. |