Cetrimide

Major Brian J. Dubois*

Lieutenant Colonel Ian B. Anderson^

Major Russell J. Brown^^

The Canadian Armed Forces have been deployed to the republics of the former Yugoslavia since 1992 as part of the United Nations Protection Force and the NATO-led Implementation Force. Most of the combat arms units have been supported by small, self-contained surgical teams for essential surgery. Considerable benefit is gained by cooperating with civilian surgeons. The experience of treating five patients with complicated hydatid disease endemic to the area is examined. Treatment of these patients requires performing major surgical procedures under austere conditions and must be undertaken with care. Careful selection and communication with the surgical nursing team and civilian surgeons is essential. Well selected cases can also pay tremendous dividends in terms of maintaining the skills of personnel who must be prepared for any emergency in addition to providing vital surgical assistance to these patients.

Introduction

Hydatid disease is very common in the Balkan peninsula, with the former republics of Yugoslavia having one of the highest prevalence rates.1 The outbreak of the civil war in this area has had a disastrous effect on the health care of the civilian population, with hospitals and medical personnel singled out for ethnic cleansing and destruction, a breakdown in normal public health issues, and widespread malnutrition. The restrictions on civilian movement and the diversion of what little health resources are left to support the military operations of the various factions has resulted in much less surgical care to the civilian population.

The Canadian Armed Forces have been involved with the United Nations Protection Force since its inception and have been stationed in Visoko, a small town approximately 25 km northeast of Sarajevo, since March 1993. During the period from November 1994 to January 1995, four patients were treated for hydatid disease; a fifth was operated on in Bihac as part of the NATO-led Implementation Force after the Dayton Accord had brought peace to the region. The cases serve to illustrate several points about the treatment of hydatid cysts and the provision of care in an austere environment.

Case Reports

Case 1

A 40-year-old Bosnian female presented with a 2-week history of epigastric and right upper-abdominal fullness and pain. She reported being intermittently jaundiced and was found to have a moderately enlarged liver (5 cm below the costal margin) but no splenomegaly. Ultrasound examination done in Visoko showed a huge, complex cyst of what appeared to be the right lobe. At surgery, there were hundreds of cysts, some of which had spontaneously deflated; others were daughter cysts within larger brood cysts. The posterior cavity was in fact continuous with the larger cavity containing considerable membranous material. The gallbladder had not been visible on the sonogram but was displaced to the right of the specimen. The remainder of the abdominal cavity was packed off with sponges soaked in hypertonic saline placed around the specimen. An initial attempt to remove the entire pericyst caused profuse bleeding, necessitating the placement of deep hemostatic sutures that resulted in devascularization of segment VI. The remainder of the cyst material was removed (Fig. 1), the internal surface of the pericyst was examined, and one or two areas of bile staining were secured with suture. There was no obvious opening to the biliary tract, and it was felt that the intermittent jaundice was caused by mass effect and compression of bile ducts. By this time, the devascularized area had demarcated, and a limited segmental resection was performed by one of the authors (I.B.A.) without further blood loss. The patient was ventilated overnight and given an epidural catheter to assist with pain control. She was transferred to Visoko Hospital on day 4 taking a normal diet. Follow-up was limited, but she was afebrile and taking a normal diet at 1 month.

Case 2

A 14-year-old male had been reported as always having trouble with his liver and presented with slowly worsening jaundice for 1 month. Ultrasonography demonstrated two large cysts in the posterior right lobe of the liver. A computed tomographic scan obtained in Tuzla demonstrated two 10-cm cysts and an enlarged gallbladder. Although less than 100 km by road, this journey required a day to travel through several checkpoints, a day in Tuzla, and another day to return through a war zone, all while the patient was seriously ill. He was seen by two surgeons who refused to consider surgery. The Canadian team was asked to provide whatever care was possible for this child. He was thin, deeply jaundiced, and septic, with a fever of 38.5 deg C and a pulse of 150 beats per minute. After treatment with antibiotics for 18 hours, he was operated on at Visoko Hospital to conserve Canadian nursing resources limited by leave. A thoracoabdominal incision was used because of the location of the cysts. The gallbladder was found to be distended and inflamed. After cholecystectomy, the common bile duct was explored and found to contain pus and membranous material. The duct was closed over a T-tube. The cysts were then opened, and 1 to 21 of purulent bilious fluid and membranous material was extracted. The right hepatic duct had a 1-cm hole in it, and this was repaired. The cavity was irrigated with hypertonic saline, the omentum was mobilized and placed in the defect, and drains were placed. Postoperatively, the patient did well and resumed a normal diet on day 3. He developed a bile fistula that drained for 4 weeks and closed spontaneously. He was discharged 1 month postoperatively and was doing well when last seen 1 month later.

Case 3

A 19-year-old male was found on routine examination to have an 8-cm right lower lung mass. Ultrasonography of the abdomen showed a coincidental 8-cm cyst with daughter cysts in the inferior aspect of the right lobe of the liver. Because of the limited resources of the civilian facility, it was decided by all to deal with these simultaneously at the Canadian facility. The patient underwent a right posterolateral thoracotomy, with the pulmonary lesion being entirely removed as a right lower lobectomy. The incision was then closed, the patient was repositioned, and a right subcostal incision was used to gain access to the abdomen. As suggested by the sonogram, the cyst was in the anterior aspect of segment VI; after a pericystectomy of the surface was performed, the cyst was removed intact. The patient did well and was transferred to Visoko Hospital the next day and was discharged on day 7.

Case 4

A 54-year-old male had a hydatid cyst of the liver removed 14 years earlier transdiaphragmatically through a right thoracotomy. He presented with abdominal pain, and ultrasonography revealed a 13-cm cyst with daughter cysts thought to be superficial in the right lobe of the liver. He was otherwise well. A laparotomy was made through a right subcostal incision, and the cyst, contrary to all tests, was posterior and superior in segment VII. The right lobe was mobilized with difficulty because of numerous adhesions to the diaphragm. The pericyst was opened, and the cyst and its contents were easily dissected and removed. Irrigation with hypertonic saline was performed, large drains were placed, and omentoplasty was performed. The patient did well and was discharged on postoperative day 7.

Case 5

A 7-year-old female was admitted to Bihac Hospital with abdominal pain and an asthmatic attack after falling at home. The child remained on the pediatric ward for 1 month. The Bosnian surgeon was consulted because of fever; ultrasonography demonstrated two 8-cm cysts of the right lobe of the liver, one anterior and one posterior. The patient was brought to surgery after stabilization, and the lesion was approached through a right subcostal incision. The liver and remaining peritoneal contents were packed off with gauze soaked with 1% cetrimide solution,2 and the anterior cyst was unroofed. Unfortunately, the cyst leaked and there was gross spillage of contents, including what was thought to be viable scolecoidal "sand." This fluid was aspirated and the germinal layer easily stripped off. The cavity was irrigated with cetrimide, but at this time the patient's condition deteriorated, with increased airway pressures, bronchospasm, and urticaria. She improved with the administration of hydrocortisone. The posterior cyst was explored after repacking of the liver, and numerous adhesions to the diaphragm were taken down. This cyst was grossly infected, containing a large amount of creamy yellow pus. The germinal capsule came away easily. The patient likely suffered an anaphylactic reaction at surgery; in retrospect, the original reason for admission to the pediatric unit may have been a small leak and a similar anaphylactic reaction.

Discussion

Hydatid disease is caused by cestode worms of the species Echinococcus granulosis. The adult worm resides in the intestine of carnivore mammals such as foxes, wolves, and dogs. Secreted eggs are ingested by herbivores, and on emerging from the egg case, the larval embryophore penetrates the intestine and lodges in fine circulatory beds, most commonly in the liver followed in frequency by the lung, spleen, bone, and brain.1,3 The intermediate host goes on to form a cystic mass consisting of compressed host tissue forming the pericyst, with an internal parasitic ectocyst and a thin inner germinal layer that produces large numbers of brood capsules4 (see Fig. 2). The sylvatic form is common in the caribou, moose, and deer populations of northern Canada and Alaska,1,5 where the cysts tend to be small, simple, and calcified.6 Associated with agricultural herding communities, the pastoral form is widely distributed around the world. Dogs form the definitive host, with cattle and sheep acting as intermediate hosts. Humans are accidental intermediate hosts of the parasite because of the close relationship of dogs in those societies. These cysts are frequently complicated by brood capsules forming daughter cysts and eventually reaching great size.5,7

Diagnosis

Symptoms are related to mechanical pressure of the cystic mass or toxicity of the fluid. Small cysts are usually asymptomatic and can be seen on sonograms or as calcified masses on chest X-ray films. Large cysts cause pain and jaundice, erode into vital structures (as in case 2),8 and may become infected (as in cases 2 and 5). The cysts are susceptible to trauma and rupture,9 resulting in a severe anaphylactic reaction (as in case 5), peritonitis, and intraperitoneal seeding. This disease must be distinguished from the invasive alveolar hydatid disease caused by the species Echinococcus multlocularis. A case of this has not been seen by a Canadian Forces surgical team. There are several immunological means of confirming the diagnosis, none of which were available in Bosnia. Unfortunately, these have a high false-positive cross-reactivity with other hepatic diseases and helminthic infections or false-negative rates.3

Treatment

Medical therapy is limited, although some drugs (mebendazole and albendazole) may slow the growth of the parasite in inoperable cases and E. muiltilocularis infections and may prevent the recurrence of daughter cysts after accidental spillage. Surgical options include liver resection if the cyst is small and peripherally located or removal of the cyst. Viable cysts are under pressure and should be aspirated under controlled circumstances, if possible, before removal of the cyst contents. Various scolicidal agents have been used to pack off the operative site and instill into the cavity to limit spillage of sand: 3% saline,4 0.5% silver nitrate, 2% formalin, chlorhexidine, 80% alcohol, and 0.5% cetrimide.10 The cyst is usually unroofed and the germinal layer easily separated from the surrounding pericyst. Controversy exists regarding what to do with the resulting cavity, which can be extremely large. The cavity can be marsupialized, although this has a high rate of infection. Omentoplasty fills and obliterates the remaining cavity, reducing the risk of sepsis.4 Some authors have recommended excision of the surrounding pericyst11; although radical, this is perceived as reducing the risk of postoperative sepsis. However, unless it is very small the pericyst should not be excised because it is essentially compressed liver and can result in profuse bleeding (as was seen in case 1). Compression of venous outflow, a rich collateral circulation, and displacement of intrahepatic structures from the mass effect of these large cysts make resection dangerous.10 Small cysts can be found in the complex internal structure of the pericyst and must be completely removed. Surgeons should look for small biliary leaks (as was seen in case 2) and be prepared to oversew small ones with absorbable sutures.4,11,12 Discussion of these cases is obviously confined by the limited long-term follow-up. Several of these patients are at high risk of recurrence from implanted scolices. Recurrence rates are reported to exceed 50%.13

One of the highest incidences in the world for these parasites is in the Balkan peninsula. Canadian military medical officers try to establish close professional relations with local practitioners to ensure familiarity with local medical problems that may affect the health of Canadian soldiers. Just as important is the professional exchange of views, experience, and skills that enriches a tour with the United Nations. Canadians are encouraged to contribute to humanitarian projects and can benefit the peace process significantly. There are guidelines to prevent inappropriate or wasteful projects: provision of this care should not interfere with the original mission or compromise the preparedness of a surgical team. Any assistance provided is at the request of the local medical authorities (when they exist) as a cooperative project. It is inappropriate to start a project or a course of treatment that cannot be completed in the time available before returning to Canada.14

Canadian Surgical Teams

The Canadian surgical teams have been described in detail.ls To summarize, they are small and mobile but well equipped. Normally, their role is to perform essential surgery, including emergencies and procedures that permit the soldier to carry out his or her duties without evacuation. These teams have a minimum of personnel and can be quickly overwhelmed with casualties. Similarly, a critically ill patient who cannot be evacuated would quickly exhaust the two intensive care nurses of the team. On the other hand, surgical teams working in these areas are not normally busy because they are on standby for emergencies. The provision of humanitarian surgical care ensures maximum readiness of staff and equipment. Some backup plan is necessary in case casualties arrive during these operations. They must be scheduled when the military situation is quiet. When possible, the patients should be operated on in the local civilian hospital even when that requires the temporary loan of equipment and provision of supplies. There are usually two surgeons present, and the facility in Visoko was equipped with a field portable McVicar operating table that could be set up in the same room. Two patients could have been operated on simultaneously in the same room. These plans must be discussed before assistance is provided and should include the commander of the battle group. As an example, the patient presented in case 1 was operated on just after a new unit had rotated into the United Nations Protection Force. After some hesitation, the commander authorized the procedure. The result was a successful operation and a surgical-nursing team that was not only at peak proficiency but was able to demonstrate this to the commander and his soldiers. Another advantage of regular use of these surgical teams is training and skills maintenance of medical assistants; by assisting the anesthetist, their airway management and intravenous skills are highly developed.

Health Care in Bosnia Working with a foreign medical system requires some adaptation, and this is especially true in Bosnia. The amount of damage to public and private property is staggering; what is especially disturbing is the destruction of medical and hospital facilities that has resulted in the suspension of medical care in many areas. After working with medical professionals from various parts of the former Yugoslavia, one becomes aware that there was some variation in the provision of health care to civilians in the various republics that made up the country. There are some customs that take getting used to and that in many ways reflect different training and cultures. One must not be too quick to criticize, because there are often local reasons for policies being as they are. Patients are frequently admitted long before surgery (in some cases weeks). However, transportation is extremely unreliable, and some patients may stay waiting for a space in a busy surgical schedule. Much of the equipment of these hospitals is old, broken, or lacking in parts. Monitors are uncommon, certain drugs and oxygen are in short supply, and postoperative care is certainly austere compared with what Canadian patients would expect. One must keep in mind that these people had just finished a bloody war, showing courage and fortitude regardless of their politics. Both Visoko and Bihac Hospital bear the scars of mortar and artillery shells landing in the grounds and on the buildings.

When treating Bosnian patients in cooperation with civilian colleagues, a certain amount of tact and diplomacy is necessary. Local medical personnel are much appreciative of learning new techniques and therapeutics. The slow, subtle approach is often better. An example is the universal indiscriminate use of multiple antibiotics postoperatively. Persistent gentle persuasion will usually result in a change of prescribing habits; doctrinal statements usually result in alienation of the team. The local medical personnel can also pass on a lot of knowledge based on their own experience.

Several patients were regarded by the civilian surgeons as hopeless (case 2) and would have died had surgery been refused. Other patients would have been operated on in local facilities under very austere conditions regardless of Canadian involvement (cases 1 and 3), there being no oxygen on the wards and no intensive care for this type of patient. Preoperative investigations varied and depended on the threat to civilians by belligerents, freedom of movement, available transportation, and the greater priority placed on urgent war wounds. As seen in cases 1 and 4, the results of tests must be treated with some flexibility because the original hard copy may not be available and many of the laboratory machines have not seen a medical engineer/ technician or standardization controls for months or years. With the large numbers of wounded and the lack of resources, these civilian institutions must practice some triage. Involvement of the military medical team should be avoided if there is no cooperation with local health care workers or when the patients require follow-up or extended procedures after the team has left. During the period in which Canadian surgeons have been deployed in the former Yugoslavia, many improvements have been seen in the provision of health care to the civilian population. There is a highly professional group of civilian surgeons who recognize the need to evolve into a peacetime medical community and update an aging infrastructure.

Conclusions

The provision of humanitarian care in war-torn areas of the world can provide a worthwhile service to the local medical community, stimulate a healthy exchange of professional knowledge, and maintain a surgical team in a high state of readiness. One must be careful and objective to not exceed one's capabilities or start a project that cannot be finished. Although local surgeons may have experience in treating local diseases, common sense and clear communication are necessary to avoid complications that would unfairly tarnish the reputation of the visiting surgical team and the United Nations. One must try to obtain as many investigations as possible under the circumstances and insist that the actual reports or results (X-ray films and sonograms) are available and not take the word of a translation or a verbal result. Even so, one must keep an open mind regarding the accuracy of these tests that are not subject to the same quality control that we are accustomed to.

Small sylvatic cysts are seen occasionally in North America. The nature of military service will bring surgeons into contact with the larger, more complicated cysts when treating indigenous patients or in military patients who have been infected with these during military service abroad. These patients may present years after infection. The risk of these parasitic infections reinforces the requirement for preventive medicine programs and vigorous "no pets" policies in units in operational theaters.

Acknowledgment

We thank Major General W. Clay, Surgeon General and Chief of Health Services for the Canadian Armed Forces, for reading the manuscript and suggesting several improvements.

References

Kune GA, Morris DL: Hydatid disease. In Maingot's Abdominal Operations, Ed 9, pp 1225-40. Edited by Schwartz ST, Ellis H. Norwalk, CT, Appleton-CenturyCrofts, 1989.

Reynolds JEF (ed): Martindale The Extra Pharmacopoeia, Ed 30. London, UK, The Pharmaceutical Press, 1993.

Gottstein B: Molecular and immunology diagnosis of echinococcosis. Clin Micro

biol Rev 1992; 5: 248-61.

Sayek I, Yalin R, Sanic Y: Surgical treatment of hydatid disease of the liver. Arch Surg 1980;115: 847-50.

Wilson JF, Diddams AC, Rausch RL: Cystic hydatid disease in Alaska: a review of 101 autochthonous cases of Echinococcus granulosis infection. Am Rev Respir Dis 1968; 98: 1-15.

Moore RD, Urschel JD, Fraser RE, Nakai Geeraert AJ: Cystic hydatid lung disease in northwest Canada. Can J Surg 1994; 37: 20-2.

Debakey ME, Jordan GL. Surgery of the liver. In Diseases of the Liver. Ed 6, pp 1203-21. Edited by Schiff L, Schiff ER. Philadelphia, PA, Lippincott, 1987. Akkiz H, Akinoglu A, Colakoglu S, Demiryurek H, Yagmur 0: Endoscopic management of biliary hydatid disease. Can J Surg 1996; 39: 287. 9. Leiav S, Weissberg D: Traumatic rupture of hydatid cysts. Can J Surg 1996; 39: 293. 10. Ozman V, [gci A, Kebudi A, Kecer M, Boztakioglu Y, Parlak M: Surgical treatment

of hepatic hydatid disease. Can J Surg 1992; 35: 423-7. 11. Belli L, del Favero E, Marni A, Romani F: Resection versus pericystectomy in the treatment of hydatidosis of the liver. Am J Surg 1983; 145: 239-42.

12. Demirci S, Eraslan S, Anadol E, Bozatli L; Comparison of the results of different surgical techniques in the management of hydatid cysts of the liver. World J Surg 1989; 13: 88-91.

13. Wilcocks C, Manson-Bahr PEC: Manson's Tropical Diseases, Ed 17. London, Balliere-Tindell, 1972.

14. Medical directive 3/94. Guidelines on humanitarian activities for the medical

services. Ottawa, National Defence Headquarters, 1994. 15. Mehran R, Connelly P, Boucher P, Berthiaume E, Cote M: Modern war surgery, the experience of Bosnia. 1. Deployment. Can J Surg 1995; 38: 266-74.

Canadian Forces Medical Services, Department of National Defence, Canada. *Canadian Forces Medical Group Detachment Edmonton, 201 Boudreau Road, St. Albert, Alberta T8N 6C4, Canada.

^Chief of Surgery, Formation Health Services, Maritime Forces Atlantic, P.O. Box 99000 STN Forces, Halifax, Nova Scotia, B3K 5X5, Canada.

^^Department of Anesthesia, Canadian Forces Medical Group Detachment Ottawa, 1745 Alta Vista Drive, Ottawa, Ontario, K1A 0K2, Canada.

The content of this paper represents the views of the authors only and does not represent official policy of the Department of National Defence or the Canadian Government. The methods of treating the cases presented are based on individual and austere medical conditions. Practitioners treating hydatid disease should be familiar with the various treatment modalities and surgical procedures before embarking on a course of treatment.

This manuscript was received for review in July 1997. The revised manuscript was accepted for publication in January 1998.

Copyright Association of Military Surgeons of the U.S. Sep 1998
Provided by ProQuest Information and Learning Company. All rights Reserved