Aspiration sclerotherapy of hepatic cysts

Contains fulltext : 175279.pdf (publisher's version ) (Open Access)Hepatic cysts are fluid-filled lesions in the liver that generally arise as congenital anomalies. Prevalence is estimated between 3 and 18%. Overall, cysts are benign and asymptomatic. However, hepatic cysts can increase to a volume of several liters as a result of continuous fluid production by the cyst wall. This may lead to symptomatic disease due to mechanic pressure on surrounding organs and tissue. Treatment is indicated in these cases. Aspiration sclerotherapy is a minimally invasive procedure that includes percutaneous cyst drainage (aspiration) followed by injection of a sclerosing agent which destroys the epithelium of the cyst (sclerotherapy). This procedure results in cyst volume reduction aiming to relief the patient clinically. Since the early seventies, studies have been published with results of different approaches of aspiration sclerotherapy. Generally, these reports show high rates of efficacy and safety. Nevertheless, efficacy and safety remain source of debate and more invasive surgical alternatives are proposed as primary treatment strategy of large hepatic cysts. In the first part of this thesis, we focus on efficacy and safety of aspiration sclerotherapy. By systematically reviewing the literature, we found a median cyst volume reduction between 76 and 100%. Symptomatic relief is reached in 72 to 100% of patients. No severe morbidity or mortality is reported. In the second part of this thesis, we evaluate possible new modalities to optimize efficacy and safety of aspiration sclerotherapy. We have performed a randomized, placebo-controlled trial to evaluate the combined approach of aspiration sclerotherapy with a somatostatin analogue pasireotide. We found no beneficial effect in the pasireotide-arm. Finally, we explored penetration levels of the antibiotic drug cefazolin into hepatic cyst fluid. We observed low to absent concentrations of cefazolin in cyst fluid which suggests that cefazolin is inadequate as prophylaxis for postprocedural cyst infections after aspiration sclerotherapy.Radboud University, 28 september 2017Promotor : Drenth, J.P.H. Co-promotor : Gevers, T.J.G.166 p

Hepatic cyst infection following aspiration sclerotherapy: a case series

Contains fulltext : 138159.pdf (publisher's version ) (Open Access)Mass-related symptoms caused by hepatic cysts are effectively treated by aspiration sclerotherapy (AS). This minimal-invasive intervention is regarded as a safe procedure. Hence, occurrence of complications is low. Transient fever is commonly reported as a side effect. However, documentation on a post-procedural hepatic cyst infection as a complication of AS is limited. We present five cases in which a tentative diagnosis of post-procedural hepatic cyst infection was made. Patients typically presented with abdominal pain and fever, had to be admitted to our hospital, and were treated with long term antibiotics. Ultimately, the cyst infection successfully resolved with ciprofloxacin in all cases

Aspiration sclerotherapy combined with pasireotide to improve reduction of large symptomatic hepatic cysts (SCLEROCYST): study protocol for a randomized controlled trial

Contains fulltext : 154569.pdf (publisher's version ) (Open Access)BACKGROUND: Aspiration sclerotherapy is an effective therapeutic option for large symptomatic hepatic cysts. However, incomplete cyst reduction following aspiration sclerotherapy is frequently reported. Strong post-procedural cyst fluid secretion by cholangiocytes, which line the epithelium of the hepatic cyst, seems to be associated with lower reduction rates. Previous studies showed that somatostatin analogues curtail hepatic cyst fluid production. This trial will evaluate the effect of aspiration sclerotherapy combined with the somatostatin analogue pasireotide on cyst reduction. By combining treatment modalities we aim to improve cyst reduction leading to greater symptomatic relief and reduced rates of cyst recurrence. METHODS/DESIGN: This single center, randomized, double-blind, placebo-controlled clinical trial evaluates the additional effect of pasireotide when combined with aspiration sclerotherapy in patients with a large (>5 cm) symptomatic hepatic cyst. A total of 34 participants will be randomized in a 1:1 ratio. In the active arm, patients will receive pasireotide (long-acting release, 60 mg injection) two weeks prior to and two weeks following aspiration sclerotherapy. Patients in the control arm will receive placebo injections at corresponding intervals. The primary outcome is proportional cyst diameter reduction four weeks after aspiration sclerotherapy compared to baseline measurements, obtained by ultrasonography. As secondary outcomes, proportional volume reduction, recurrence, symptomatic relief and improvement of health-related quality of life will be assessed. Furthermore, safety and tolerability of the combination of pasireotide and aspiration sclerotherapy will be evaluated. DISCUSSION: This trial aims to improve efficacy of aspiration sclerotherapy by a combined approach of two treatment modalities. We hypothesize that pasireotide will decrease fluid re-accumulation after aspiration sclerotherapy, leading to effective hepatic cyst reduction and symptomatic relief. TRIALS REGISTRATION: This trial is registered with ClinicalTrials.gov (identifier: NCT02048319 ; registered on 6 January 2014) and EudraCT (identifier: 2013-003168-29; registered on 16 August 2013)

Pasireotide does not improve efficacy of aspiration sclerotherapy in patients with large hepatic cysts, a randomized controlled trial

Contains fulltext : 191334.pdf (publisher's version ) (Open Access)OBJECTIVES: We tested whether complementary use of the somatostatin analogue pasireotide would augment efficacy of aspiration sclerotherapy of hepatic cysts. METHODS: We conducted a double-blind, placebo-controlled trial in patients who underwent aspiration sclerotherapy of a large (>5 cm) symptomatic hepatic cyst. Patients were randomized to either intramuscular injections of pasireotide 60 mg long-acting release (n = 17) or placebo (sodium chloride 0.9 %, n = 17). Injections were administered 2 weeks before and 2 weeks after aspiration sclerotherapy. The primary endpoint was proportional cyst diameter reduction (%) from baseline to 6 weeks. Secondary outcomes included long-term cyst reduction at 26 weeks, patient-reported outcomes including the polycystic liver disease-questionnaire (PLD-Q) and safety. RESULTS: Thirty-four patients (32 females; 53.6 +/- 7.8 years) were randomized between pasireotide or placebo. Pasireotide did not improve efficacy of aspiration sclerotherapy at 6 weeks compared to controls (23.6 % [IQR 12.6-30.0] vs. 21.8 % [9.6-31.8]; p = 0.96). Long-term cyst diameter reduction was similar in both groups (49.1 % [27.0-73.6] and 45.6 % [29.6-59.6]; p = 0.90). Mean PLD-Q scores improved significantly in both groups (p < 0.01) without differences between arms (p = 0.92). CONCLUSIONS: In patients with large symptomatic hepatic cysts, complementary pasireotide to aspiration sclerotherapy did not improve cyst reduction or clinical response. KEY POINTS: * Complementary pasireotide treatment does not improve efficacy of aspiration sclerotherapy. * Cyst fluid reaccumulation after aspiration sclerotherapy is a transient phenomenon. * Aspiration sclerotherapy strongly reduces symptoms and normalizes quality of life

Predictors of treatment response following aspiration sclerotherapy of hepatic cysts: an international pooled analysis of individual patient data

OBJECTIVES: To identify predictive variables of treatment response following aspiration sclerotherapy of large symptomatic hepatic cysts. METHODS: We collected individual patient data from two tertiary referral centres and included all patients treated with aspiration sclerotherapy of a large (>5 cm), symptomatic hepatic cyst. At six months, clinical response was defined as complete or incomplete. Secondary, suboptimal technical response was defined as lower quartile of cyst reduction. Predictive variables of clinical and technical response were analyzed by logistic regression analysis. RESULTS: We included 86 patients (58 +/- 10 years; female 90 %). Complete clinical response rate was 55 %. Median cyst diameter and volume reduction were 71 % (IQR 50-87 %) and 98 % (IRQ 88-100 %), respectively. Patients with complete clinical response had a significantly higher cyst reduction compared to incomplete responders (OR 1.02, 95 % CI 1.00-1.04). Aspiration of haemorrhagic cyst fluid (OR 4.39, 95 % CI 1.34-14.39) or a lower cyst reduction at one month (OR 1.06, 95 % CI 1.02-1.10) was associated with a suboptimal technical response at six months. CONCLUSION: Complete clinical response is associated with effective cyst reduction. Aspiration of haemorrhagic cyst fluid or a restricted diameter reduction at one month predicts a suboptimal technical treatment response, however, these variables did not predict symptom disappearance. KEY POINTS: * Aspiration sclerotherapy of hepatic cysts shows excellent clinical and technical efficacy. * Optimal clinical responders have a markedly higher cyst reduction. * Haemorrhagic aspirate and a strong fluid reaccumulation predict suboptimal cyst reduction

Evaluating health-related quality of life in patients with polycystic liver disease and determining the impact of symptoms and liver volume

Item does not contain fulltextBACKGROUND & AIMS: Polycystic liver disease (PLD) follows a progressive course ultimately leading to severe hepatomegaly and mechanical complaints in a subset of patients. It is still unknown to what extent this compromises health-related quality of life (HRQL). Our aim was to determine HRQL in PLD patients and investigate its association with concurrent abdominal symptoms and liver volume. METHODS: Pooled data of 92 severe PLD patients from two randomized clinical trials were used for our cross-sectional analysis. HRQL was assessed using the generic short-form health survey (SF-36) resulting in eight scale scores and the summarizing physical (PCS) and mental component score (MCS). Subsequently, these were compared with the general population. Abdominal symptoms were measured with a standardized, 7-point scale questionnaire in 54 patients. We dichotomized symptoms for absence or presence and compared them with the component scores. Finally, a possible correlation between liver volume and HRQL was explored. RESULTS: Demographics showed severe polycystic livers (mean 4906 +/- 2315 ml). PCS was significantly lower compared with the general population (P < 0.001), in contrast with a similar MCS (P = 0.82). PLD patients had statistically significant (P < 0.05) diminished physical functioning, role physical, general health, vitality and social functioning scores. Upper- and lower abdominal pain and dyspnoea were significantly associated with a reduced PCS (P < 0.01). No correlation was found between liver volume and HRQL. CONCLUSION: Polycystic liver disease patients had significantly lower HRQL in the physical dimension compared with the general population. Abdominal pain and dyspnoea had a significant impact on this physical dimension of HRQL

Ethanol sclerotherapy or polidocanol sclerotherapy for symptomatic hepatic cysts

Contains fulltext : 195655.pdf (publisher's version ) (Open Access)Background: Over the past decades, multiple approaches to aspiration sclerotherapy of large symptomatic hepatic cysts have been investigated. However, comparative data are scarce. Objective: The objective of this article is to compare cyst reduction, symptomatic relief, and adverse events between ethanol sclerotherapy and polidocanol sclerotherapy. Methods: This retrospective study included adults having a symptomatic hepatic cyst treated at a European tertiary referral center with ethanol sclerotherapy (Center 1) or polidocanol-sclerotherapy (Center 2). We compared cyst diameter reduction (%) and symptom improvement (yes/no) within 12 months' post-treatment between centers using multivariate regression analyses adjusted for confounding factors. Finally, we compared adverse events using Fisher's exact test. Results: We included 71 patients from Center 1 and 66 patients from Center 2 (median age 57 years; 126/137 (92%) female). Cyst reduction was comparable between Centers 1 and 2: 37.5% (IQR 15.7-61.0%) versus 44.2% (IQR 24.6-60.5%), respectively (p = 0.35). Correspondingly, symptomatic relief was comparable: 30/53 (56.6%) versus 43/66 (65.2%), respectively (p = 0.88). Center 1 reported significantly more (11 versus 3; p = 0.047) adverse events than Center 2. Conclusion: We found comparable cyst reduction and symptomatic relief rates between ethanol- and polidocanol sclerotherapy, while adverse events occurred more often in the ethanol group. Prospective studies focused on clinical response are needed to further explore differences between approaches