Complex Hydatid Cyst in a Differently Abled Lady: Managing the Perioperative and Surgical Challenges
53-year-old lady was referred to me for evaluation of a liver mass. The preliminary sonography had raised suspicion of a large hydatid cyst. The lady had Down’s syndrome and was living in an assisted living facility. She was extremely anxious about visiting hospitals and clinics. This posed significant challenges in evaluation and treatment. In the first OPD consultation it was apparent that we could not treat her the same way as others.
Complex head and neck surgeries can be performed safely even in high risk patients when necessary care is taken. Innovative and unique approaches are sometimes necessary for successful surgical outcomes. Optimizing patients’ health before surgery ensures safety and reduces post-operative complications.
Since she was not very cooperative with evaluation, family and care givers wanted to know how to proceed further. They also wanted to know if this needs a surgical treatment.
They also wanted to know If surgery had to be performed, how to manage her in the perioperative period, considering her mental status.
I suggested that the patient needs to be evaluated by a psychiatrist who can give suitable medicines to calm her down and then we can carry out the desired tests. This was necessary since a CT scan was needed to understand the extent of the disease and she was not in a condition to cooperate for the same. After 7days of new medications by psychiatrist we could perform the CT scan.
CT scan showed a large mass in the region of the liver. However, it was seen to be arising from the upper pole of right kidney rather than the liver. Based on the features of imaging it was diagnosed to be a hydatid cyst.
I advised surgery for this cyst since it was the best treatment for such large hydatid cysts. The clinical scenario was such that everything had to be meticulously planned for the surgery. The location of the cyst was such that it could not have been removed with an abdominal incision and required a thoracoabdominal incision.
There was a possibility of removing the upper part right kidney and significant blood loss as the cyst was going into the liver. Large incision meant significant post-operative pain. The patient would also be having multiple tubes connected to her which had to remain in place for 5-7 days after surgery.
There was a possibility of aggressive behavior during hospital stay where she could have pulled out any of the tubes attached and harmed herself. At the same time keeping her completely pain free was also important to keep her calm.
I started the patient on Albendazole tablets till the family and caregivers took a decision.
After much deliberation family and her care givers decided to go ahead with surgery.
I got the patient admitted 2 days prior to the planned surgery and she was under constant care of the psychiatrist and the physician. Our chief anesthetist visited her twice before surgery to establish a rapport with her.
On the day of the surgery, to our surprise, patient was extremely cooperative in the operating room. In our practise epidural catheter ( for pain control) is inserted before induction. However, this time ,anticipating less cooperation from the patient ,anaesthesia was given first and then epidural catheter was inserted.
As anticipated, based on the CT scan, the cyst was deeply infiltrating the diaphragm.
To gain excess to the area without rupturing the cyst, I had to resect part of diaphragm. Since the cyst was arising from the kidney, I was prepared for a partial nephrectomy. Hence renal vessels were also dissected and looped. The cyst was large enough to restrict my access to some places which meant slow and meticulous dissection.
The cyst was carefully separated from the liver without much blood loss. Some amount of liver tissue had to be taken along with the cyst to prevent rupture. We could remove the entire cyst without a partial nephrectomy.
The diaphragmatic defect was partially closed. Drains were placed.
Post operatively patient was kept in ICU. Her pain was manged with epidural analgesia. She started having liquids on the first day after surgery and by fifth day she was on soft diet. Her drains were removed on 7th day. Her post-operative recovery was smooth.
She was discharged on 9th day. She was advised to continue taking albendazole tablets.
Take Home message:
Different patients pose different clinical challenges. Choosing the right kind of team makes dramatic differences in the outcomes. The psychiatrist in this case played a vital part in helping the patient remain calm throughout the treatment.
The anaesthetist deviated from normal pathways to ensure patient safety and cooperation. The surgery was planned meticulously to ensure complete removal the cyst without complications.
Hydatid cyst arising in kidney is very unusual. Surgery is the best treatment for this condition.