Hydatid cyst, caused by larval stages of Echinococcus granulosus, is a zoonotic parasitic disease with public health importance. The disease is cosmopolitan and endemic in Iran. We conducted a retrospective study of the records of Milad Hospital, Tehran, Iran to establish the proportion of lung and liver surgical procedures that were performed for removal of hydatid cyst and to investigate the demography of the population undergoing lung and liver hydatid cyst surgery in this hospital. A retrospective cross-sectional study was conducted of records of 682 patients who underwent liver (n = 404) or lung (n = 278) surgery from April 2009 to March 2013. In 404 liver surgeries, 111 (27.5) diagnoses of hydatid cyst were verified. Liver hydatid infection demonstrated a significant age-related difference (p < 0.05). Cysts were found in 64 of 217 females (29.5) and 47 of 187 males (25.1). While in both sexes, more cysts were found in liver, the liver/lung ratio in females was significantly higher than in males (p < 0.001). Hydatid cyst was verified in 59 (21.2) of 278 lung surgeries: 27 of 105 females (25.7) and 32 of 173 males (18.5). There was a significant relationship between sex and organ site (p < 0.001) with the proportion of hydatid cysts in males occurring in lung higher than seen in females. In the five investigated years, approximately 25 of liver and lung surgeries conducted at Milad Hospital were related to hydatidosis. Increasing public awareness of principles of avoiding infection could reduce the risk of nearly a quarter of liver and lung surgeries and costs associated with the treatment of hydatid cysts. Â© 201

Moradi, M.

Rampisheh, Z.

Razmjou, E.

Roozbehani, M.

eprints Iran University of Medical Sciences

Heliyon 5 (2019) e01897Contents lists available at ScienceDirectHeliyonjournal homepage: www.heliyon.comA retrospective study of hydatid cysts in patients undergoing liver and lungsurgery in Tehran, IranMaryam Moradi a, Zahra Rampisheh b,c, Mona Roozbehani d, Elham Razmjou d,*a Department of Parasitology and Mycology, School of Medicine, International Campus, Iran University of Medical Sciences, Tehran, Iranb Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iranc Department of Community Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Irand Department of Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, IranA R T I C L E I N F OKeywords:SurgeryInfectious diseaseCystic echinococcosisHydatid cystLungLiverEchinococcus granulosus* Corresponding author.E-mail address: razmjou.e@iums.ac.ir (E. Razmjhttps://doi.org/10.1016/j.heliyon.2019.e01897Received 3 March 2019; Received in revised form2405-8440/© 2019 Published by Elsevier Ltd. ThisA B S T R A C THydatid cyst, caused by larval stages of Echinococcus granulosus, is a zoonotic parasitic disease with public healthimportance. The disease is cosmopolitan and endemic in Iran. We conducted a retrospective study of the recordsof Milad Hospital, Tehran, Iran to establish the proportion of lung and liver surgical procedures that were per-formed for removal of hydatid cyst and to investigate the demography of the population undergoing lung andliver hydatid cyst surgery in this hospital. A retrospective cross-sectional study was conducted of records of 682patients who underwent liver (n ¼ 404) or lung (n ¼ 278) surgery from April 2009 to March 2013. In 404 liversurgeries, 111 (27.5%) diagnoses of hydatid cyst were verified. Liver hydatid infection demonstrated a significantage-related difference (p < 0.05). Cysts were found in 64 of 217 females (29.5%) and 47 of 187 males (25.1%).While in both sexes, more cysts were found in liver, the liver/lung ratio in females was significantly higher than inmales (p < 0.001). Hydatid cyst was verified in 59 (21.2%) of 278 lung surgeries: 27 of 105 females (25.7%) and32 of 173 males (18.5%). There was a significant relationship between sex and organ site (p < 0.001) with theproportion of hydatid cysts in males occurring in lung higher than seen in females. In the five investigated years,approximately 25% of liver and lung surgeries conducted at Milad Hospital were related to hydatidosis. Increasingpublic awareness of principles of avoiding infection could reduce the risk of nearly a quarter of liver and lungsurgeries and costs associated with the treatment of hydatid cysts.1. IntroductionHuman infection with hydatid cyst occurs via consumption of food orwater contaminated with Echinococcus granulosus eggs or by ingestingeggs picked up by direct contact with dogs infected with E. granulosus.Hydatidosis is an important parasitic disease in humans and domesticlivestock of Iran (Kamali et al., 2018; Rokni, 2009) and is categorized as aneglected disease by the World Health Organization (Da Silva, 2010;Deplazes et al., 2017). It is cosmopolitan, especially in sheep breedingregions of Asia, Australia, South America, and Southern Europe (Depla-zes et al., 2017; Mastrandrea et al., 2012). Hydatid cyst infection isendemic in Iran (Zeinali et al., 2017) and has been reported in allprovinces (Shafiei et al., 2016) at a prevalence rate of 1% of surgeries(Rokni, 2009).Diagnosis of hydatid cyst is primarily based on imaging and sero-logical methods including direct hemagglutination, latex agglutination,ou).14 May 2019; Accepted 31 Mayis an open access article under timmune-electrophoresis, and ELISA (Hernandez-Gonzalez et al., 2018),and surgery is the only reliable treatment for the disease in its final stagesin humans. Pezeshki et al. (2007) studied prevalence of hydatid cyst for2001–2004 in Milad Hospital, Tehran and reported 78 cases, 69.2% inliver and 11.5% in lung, in patients ranging from 14 to 76 years, with thehighest occurrence (31.5%) in the 32–40 years age group.We conducted a retrospective cross-sectional study of the lung andliver surgery records of Milad Hospital to determine the proportion of thesurgical procedures that were performed for removal of hydatid cyst. Asecondary goal was to analyze the data with respect to the demographicaspects of infected patients including, sex, age, surgery site, and place ofresidence.2. Materials and methodsThe retrospective cross-sectional study was conducted of 682 patients2019he CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Table 2Age of patients undergoing liver and lung surgery for hydatid cyst removal2009–2013.Age years LiversurgeryNo. (%)Liver hydatidcystNo. (%)LungsurgeryNo. (%)Lung hydatidcystNo. (%)15 3 (0.7) 2 (1.8) 3 (1.1) 0 (0.0)16–25 33 (8.2) 13 (11.7) 29 (10.4) 10 (16.9)26–35 70 (17.3) 31 (27.9) 37 (13.3) 11 (18.6)36–45 45 (11.1) 16 (14.4) 50 (18.0) 12 (20.3)46–55 69 (17.1) 12 (10.8) 54 (19.4) 8 (13.6)56–65 71 (17.6) 21 (18.9) 39 (14.0) 5 (8.5)66–75 48 (11.9) 5 (4.5) 22 (7.9) 2 (3.4)76 14 (3.5) 2 (1.8) 4 (1.4) 0 (0.0)Unknown 51 (12.6) 9 (8.1) 40 (14.4) 11 (18.6)Total 404 (100) 111 (100) 278 (100) 59 (100)M. Moradi et al. Heliyon 5 (2019) e01897undergoing liver (n ¼ 404) and lung (n ¼ 278) surgery from April 2009through March 2013. Three-hundred-sixty patients were male and 322were female. Age ranged from 5 to 85 years (mean 46.8  16.6). Themean age for liver surgery was 47.9  17.1 (<9 to >85) years and forlung surgery was 45.1 15.8 (<5 to >80) years (Table 1). The age range26–35 years was most common in liver surgeries and 36–45 years in lungsurgeries (Table 2).Data were analyzed using SPSS software v. 20.0 (SPSS Inc., Chicago,IL, USA). Means and standard deviations are reported for age, sex, sur-gery site, and frequency of hydatid cyst in pathology reports. Chi-Squaretests were used for evaluation of relationships between two qualitativevariables. We used t-tests to investigate differences in mean age of malesand females and between lung and liver patients. A p-value of <0.05 wasconsidered significant.3. ResultsOf the 682 patients undergoing surgery, 170 (24.9%) were forremoval of hydatid cyst, of whom 46.5% (79/170; 95% CI 39.1–54.0)were male and 53.5% (91/170; 95% CI 46.0–60.9) were female. Of 404liver surgeries, 111 (27.5%; 95% CI 23.3–32.0) were for hydatid cystremoval. The proportion of males undergoing liver surgery thatdemonstrated hydatid cyst was 25.1% (47/187; 95% CI 19.5–31.8), andfor females the proportion was 29.5% (64/217; 95% CI 23.8–35.9). Meanage of hydatidosis patients was 41.5 16.5 years (Table 1). Liver hydatidcyst increased with age to its highest prevalence in the 26-35-year groupand demonstrated a significant age-related difference (p< 0.05) with thelowest number of cases in the 15 and 76-year group (Table 2).Although both sexes showed higher levels of infection in liver than inlung, in females, that proportion was significantly greater than observedin males (p < 0.001). The average age of liver hydatid cyst patients wassignificantly lower than that of those with other liver diagnoses (p <0.001).Of 278 cases of lung surgery, 59 (21.2%; 95% CI 16.8–26.4) were toremove hydatid cysts, 32 of the 173 males (18.5%; 95% CI 13.4–24.9)and 27 of the 105 females (25.7%; 95% CI 18.3–34.8). Mean age was39.2  13.6 years (Table 1). The highest occurrence of lung hydatid cystwas seen in the age group 36–45 years, and the fewest in patients 15and 76 years (Table 2). There was a significant relationship betweensex and organ site (p < 0.001) with lung hydatid cyst more prevalent inmales than in females.Tehran Province contributed the highest number of patients under-going surgery for liver and lung hydatid cyst with 61 and 31 cases,respectively, followed by nine and eight cases, respectively, from AlborzProvince and one to three cases in each of the other representedprovinces.4. DiscussionHospital records are a valuable resource for investigating the inci-dence of certain diseases (McManus et al., 2003). This study revealed thathydatid cyst was the reason for nearly a quarter of liver and lung sur-geries during the study period. The proportion of liver surgeriesTable 1Demographic characteristics of patients undergoing liver and lung surgery 2009–201Surgery site LiverDiagnosis Hydatid cyst p TotalYes No111 293 404aMale 47 140 187Female 64 153 0.372 217Mean age 41.5  16.5 50.5  16.7 <0.001 47.9  1a significant relationship between sex and surgery site (p < 0.001).b significant difference in age of patients based on surgery site (p ¼ 0.04).2conducted for hydatid cyst removal was higher than in lung surgeries,consistent with reported results in Iraq (Abdulhameed et al., 2018),China (Li et al., 2008), Turkey (Aribas et al., 2002), Italy (AgudeloHiguita et al., 2016), and Iran (Fallah et al., 2017; Islami Parkoohi et al.,2018; Pezeshki et al., 2007; Rokni, 2009). This seems likely due to therole of liver as central to the system that provides initial filtering ofingested ova from the blood (McManus et al., 2003).We found the highest occurrence of liver and lung hydatid cyst sur-gery in patients 26–45 years, similar to observations in New Zealand(Burridge et al., 1977). The highest rate of hydatid cyst was reported tobe in the age range of 44–54 and 70–79 years in Tasmania (Thompsonand McManus, 2002) and Uruguay (Perdomo et al., 1997). In Yemen, thehighest incidence was seen in individuals younger than 20 years old, andthe age range of 41–60 years showed the lowest (Al-Shaibani et al.,2015). As hydatid cyst growth is generally one to five centimeters/yearor may persist unchanged for years (McManus et al., 2003; Siracusano etal., 2009), duration of infection is likely the principle reason for thesedifferences.An association of sex and organ site (p < 0.001) was observed in ourstudy, with males exhibiting lung/liver cysts showing a higher propor-tion of lung infection than did females, similar to previous reports fromIran (Kamali et al., 2018) and Italy (Cappello et al., 2013). In females, wefound a significantly higher fraction of the hydatid cysts to occur in theliver compared to that proportion in the males (p < 0.001). These find-ings are similar to those reported in Iran (Fati and Nawazi, 1992; Kakhiand Rouhani, 1994; Nourjah et al., 2004) and other areas includingJordan (Amr et al., 1994; Kamhawi, 1995), Austria (Schneider et al.,2010), Sudan (Omer et al., 2010), and Yemen (Al-Hureibi et al., 1992).Overall, hydatid cyst is more prevalent in females compared to males.The differences could be the result of the lifestyle of women, who may bemore likely to be in direct contact with a source of infection, such asvegetables and soil contaminated with eggs of E. granulosus (Rao et al.,2012).The study was conducted in patients referred to a single center, whichmight limit generalization of results to all patients undergoing liver andlung surgery in Iran, although Milad Hospital is a referral center andreceives patients from all areas of the country. In addition, limited access3.LungHydatid cyst p TotalYes No59 219 27832 141 17327 78 0.174 1057.1b 39.2  13.7 46.6  16.0 0.003 45.1  15.8M. Moradi et al. Heliyon 5 (2019) e01897to information precluded categorizing the diagnoses and background ofthe patients as well as surgical management. Further studies in a multi-referral center with increased access to patient documents could pro-vide more information and expand on the findings of this investigation.5. ConclusionOver the five-year study period, nearly 25% of liver and lung sur-geries in Milad Hospital were related to hydatidosis. A health educationprogram to increase awareness of how hydatidosis is transmitted, alongwith regular anthelminthic treatment of dogs, would help to reduceinfection rates and the need for surgical intervention with its attendantcosts and associated risk.DeclarationsAuthor contribution statementElham Razmjou: Conceived and designed the experiments; Analyzedand interpreted the data; Wrote the paper.Maryam Moradi: Performed the experiments; Analyzed and inter-preted the data; Contributed analysis tools or data; Wrote the paper.Zahra Rampisheh: Analyzed and interpreted the data; Contributedanalysis tools or data.Mona Roozbehani: Contributed analysis tools or data.Funding statementThis research did not receive any specific grant from funding agenciesin the public, commercial, or not-for-profit sectors.Competing interest statementThe authors declare no conflict of interest.Additional informationNo additional information is available for this paper.AcknowledgementsWe would like to thank all hospital staff assisting us in this study.Special thanks are extended to the manager of Milad Hospital Laboratoryand the Medical Records Department, Mr. Hashemi and Dr. Delavari.ReferencesAbdulhameed, M.F., Habib, I., Al-Azizz, S.A., Robertson, I., 2018. 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A retrospective study of hydatid cysts in patients undergoing liver and lung surgery in Tehran, Iran

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A retrospective study of hydatid cysts in patients undergoing liver and lung surgery in Tehran, Iran

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