LAUSR

I recently read with great interest the article by Kahriman et al. published in the June 2017 issue of Acta Radiologica, evaluating the outcomes of percutaneous treatment of hepatic hydatid cysts (1). Hydatid cyst disease is a highly prevalent disease in the Mediterranean region and the authors reported their experience in a large series of patients. They reported a high clinical success; however, their major complication rate was 6.3% which was higher than some recent reports (2). Thus, I have several comments about the procedure technique. In our department, we prefer catheter placement and injection of sclerosing agents (PAIDS) in all cysts suitable for catheter placement. We suggest performing the procedures with a 5.7-French single step trocar catheter (Choice Lock, TCD Single Step, Argon Medical devices, TX, USA) instead of an 18-gauge needle or an 8-French catheter. The PAIR procedure with an 18-gauge needle bears the risk of displacement and opposite wall puncture, especially after aspiration (3). In contrast to 8-French catheters, it is easier to place the 5.7-French with the trocar technique and the risk of seeding with the trocar technique is obviously lower than the Seldinger technique. Single step catheter eliminates the risk of displacement and fluid leakage; therefore, the risk of seeding or anaphylaxis is reduced. We have not experienced any seeding or anaphylaxis so far and previous studies reporting one step technique in hydatid disease showed 0–0.5% major complication rates compatible with our experience (2,4). In addition, failure to aspirate after membrane detachment is a potential difficulty using an 18-gauge needle. Besides the advantages of faster aspiration and injection, single step catheter also enables aspiration of all cyst content in almost all cases. Some authors suggested not removing the single step catheter after the procedure owing to increased anaphylaxis risk (2). In our experience, single step 5.7-French catheter can be removed safely after the procedure. We think overnight hospitalization is not necessary in most patients as we have not experienced any bleeding or anaphylaxis so far. Lastly, we prefer administering more alcohol (60–70% of the aspirated cyst volume instead of 20–30 %) in the cavity. We prefer administering alcohol twice, for 10min each in the left and right decubitus positions. Because the success of sclerosing agents are proportional to the contact time and the area, we believe administering more alcohol twice and changing the patient position enable longer and more effective contact of alcohol with the anterior wall of the cyst. In conclusion, I suggest PAIDS using a low profile single step trocar catheter instead of PAIR with an 18-gauge needle or PAIDS with an 8-French catheter for percutaneous treatment of hepatic hydatid cysts. Low profile single step catheters decrease the risk of seeding and anaphylaxis and enable comfortable procedure. They can be safely removed after the procedure and procedures can be performed on an outpatient basis.