Outstanding ,complete surgical removal of Hydatid cysts and ectopic pregnancy

Jaipur, 26th September 2017: A 21 year old female from Ganganagar presented with C/o easy fatiguability and shortness of breath on exertion episodically since the last 2 years with an increase in the severity of symptoms dating recently about a week back. Investigated and diagnosed by an astute physician locally and referred to us for surgical intervention. Detailed investigations revealed that she had a huge Hydatid cyst occupying the Right ventricle measuring about 8 x 6 cms and at the same time another cyst in the right lower lobe of the liver measuring 10×8 cms. The patient also had a 4 day prior report of positive urinary pregnancy test which had been followed up with serial Beta HCG levels and a Transvaginal USG, but conceptus could not be detected. Obstetrics review at RBH recommended follow up Beta HCG levels.
A combined team discussion involving the Dr. Budhaditya Chakraborti from CTVS team, Dr. Vipin Jain, Laparoscopic General surgeon, Dr. Vibha Chaturvedi, Obstetrician & Dr. Sunil Beniwal, Cardiologist was carried out. We debated about operating both cysts concomitantly in one sitting but in favor of patient safety decided to stage the surgery taking care of the critical cardiac pathology first. Since the cardiac presentation was a potential emergency, we moved ahead with cardiac surgery planning to follow up on the pregnancy issue immediate post op.
Presentation in the intra cardiac right ventricular cavity bears the potential risk of rupture causing anaphylactic reaction and pulmonary embolism, mechanical obstruction to the right ventricular outflow into the lungs and significant right ventricular failure.
Dr. Budhaditya Chakraborti, Senior Consultation – Caridac Surgery said “the surgery is complicated since the cyst containing the fluid may rupture or leak while handling and is known to cause severe fall in BP, increased airway spasm, rashes etc. The patient was operated on cardiopulmonary bypass and the entire cyst and its contents evacuated”. She has had a relatively uneventful post operative course. Post operative labs showed an increase in Beta HCG levels again and a TV USG confirmed the suspicion of an ectopic pregnancy in the right ovary.
5 days following her cardiac operation, the patient was operated laparoscopically for the ectopic pregnancy and was found to have incomplete abortion of the conceptus through the fallopian tube. Since the patient was nulliparous, the conceptus was recovered by milking the fallopian tube in order to preserve her chances of a future conception. Laparoscopic intervention for the liver cyst revealed a huge 10×8 cms cyst which was drained and cappitonaged.
The patient had an uneventful recovery and was discharged a day after with follow up.
Hyatid cysts are a parasitic infestation by a tapeworm echinococcus. Humans are an intermediary from a primary infestation in dogs, pigs, sheep or cattle. Exposure to food and water contaminated by the feces of an infected definitive host or poor hygiene in areas of infestation can lead to echinococcosis.
Commonly reported sites of infection are the liver and lungs. spleen, kidney, peritoneal cavity, skin and muscles is about 2% each and incidence of the heart, brain, vertebral column, ovaries, pancreas, gallbladder, thyroid gland, breast, and bones involvement is about 1% each.
Such a combined surgical approach complicated by an ectopic pregnancy is probably a first of its kind reported. Literature search to our knowledge does not reveal any similar case.