Aim: To investigate the effect of the brief mindfulness practice (MP) on fatigue, kinesiophobia, and quality of life (QoL) in patients with acute myocardial infarction (MI) was the purpose of the study.

Material and Methods: This study was designed as a randomized controlled study. The study was carried out with 56 MI patients. Participants were randomly assigned to the mindfulness group (MG) or a control group (CG). The MG patients received a 15 min MP session during eight weeks, comprising sitting and breathing for a total of eight weeks, while the CG patients received only a single-time attention-matched education.

Results: After completion of the MP, any significant difference was not found in the fatigue scores of the patients (p>0.05). The kinesiophobia scores in the MG were significantly lower in the 4th, 8th and 12th weeks (p<0.05). The QoL scores were significantly higher in the MG in the 8th week (p<0.05).

Discussion: The MP practice can significantly improve the QoL, and this beneficial effect of MP is maintained particularly in the emotional aspect. Furthermore, the MP may decrease kinesiophobia in patients with MI. Based on the results of the study, MP may be recommended as mind-body-based complementary approaches within the scope of post-MI management.

Keywords: Fatigue, Kinesiophobia, Mindfulness, Myocardial Infarction, Quality of Life

Introduction

Myocardial infarction (MI) is the most frequent manifestation of coronary artery disease (available at: https://www.tkd.org.tr/TKDData/Uploads/files/Turkiye-kalp-ve-damar-hastaliklari-onleme-ve-kontrol-programi.pdf). In recent years, the survival rate after MI has increased due to the advances in MI treatment, including the widespread use of defibrillators in the coronary intensive care units (CICU), reperfusion algorithms, and additional treatments such as the coronary artery bypass graft [1]. However, patients continue to experience symptoms such as anxiety, depression, sleep disturbances, pain, and fatigue afterward [2,3]. Fatigue is experienced by nearly half of the patients after MI, and it lasts for about two months to a year during the post-treatment period [4,5]. Fatigue and other symptoms such as pain, palpitations, and dyspnea may cause difficulties in daily activities, which may decrease the functional independence of the patients due to stress, anxiety, and fear [4,6]. In the behavioral fear-avoidance model, the fear of movement situation is called “kinesiophobia” [7]. Kinesiophobia is an avoidance behavior and a natural and emotional adaptation reaction demonstrated after acute injuries. Perpetuating fear and avoidance behaviors after cardiac events may lead to negative physiological and psychological consequences [7].
Considering the symptom burden and reduced QoL after MI, supporting the patients through interventions is necessary. Psychosocial adaptation, lifestyle changes, cardiac rehabilitation interventions, and various complementary and integrative approaches have been applied for symptom management and increasing the QoL of the patients after MI [8,9]. Among complementary and integrative approaches, mindfulness-based approaches have drawn increasing attention in recent years for the treatment of various chronic diseases [10]. Mindfulness practice (MP), developed by Kabat-Zinn et al. (2013), is defined as a present-centered and purposive non-judgmental awareness. MP involves bringing an individual’s attention to the experience of the present moment, including their thoughts, feelings, and physical sensations, with certain openness, curiosity, and acceptance [11]. The control of emotional response and the effective use of the breath reduce the tension in the body and increase the blood oxygen saturation in the patients. Therefore, MP may prove to be effective in reducing fatigue and kinesiophobia and improving the QoL in patients after MI. The present randomized controlled study aimed to investigate the effect of the MP on fatigue, kinesiophobia, and the QoL in patients with acute MI. The present study hypothesized that MP would (1) alleviate the fatigue severity, (2) decrease the kinesiophobia, and (3) improve the QOL in patients with acute MI.

Material and Methods

Trial design

The study was designed as a randomized controlled trial with two parallel groups and a 4-week follow-up period to investigate the effect of the MP on fatigue, kinesiophobia, and the QoL in patients with acute MI. The patients were divided into two groups: the mindfulness group (MG) and the control (CG) group.

Inclusion and exclusion criteria

The inclusion criteria were as follows: (a) age between 18 and 75 years; (b) having received pharmacological reperfusion therapy after acute MI or the percutaneous coronary intervention (PCI); (c) no temporary or permanent pacemaker; (d) no diseases that would affect the breathing exercise; (e) no physical or mental health problems that could interfere with communication; (f) no diagnosis of cognitive, mental, or psychological illness; (g) no learning disabilities or difficulties; (h) ability to use a telephone; and (i) consent to participate in the study. The exclusion criteria were: (a) planned coronary artery bypass graft (CABG); (b) having experienced cardiogenic shock caused due to acute MI; (c) having hearing impairment; (d) living in a nursing home after discharge from the hospital; (e) currently not using any complementary therapy modalities known for stress-reducing.

Participants and sample size

The study was conducted in November 2018-June 2020, in the CICU of a university hospital, Turkey. A total of 163 patients were contacted and 104 patients who did not fulfill the inclusion criteria were excluded. The remaining 59 patients were randomly divided into two study groups, following which three patients withdrew from the study due to discharge before receiving the MP education (n=1), refusal to share communication information (n=1), and withdrawal after the first interview (n=1). Therefore, the study was completed with a total of 56 patients with acute MI [MP (n=28) and CG (n=28)] (Figure 1).
As there were no similar studies available in the literature, it was not possible to calculate the required sample size in advance. Therefore, the power analysis was performed using the G-Power 3.0.10 program, based on the mean change in the MacNew Quality of Life Scale (MacNew) score between the 0th week and the 8th week (MG: from 5.04±0.70 to 5.76±0.47; CG: from 5.17±0.85 to 5.37±0.51). Accordingly, the power of the study was determined to be 89.8% with a significance level of 0.05 and an effect size of 0.79.

Randomization, allocation, and blinding

The patients were evaluated for participation in the study within 24h of admission to the CICU, and the participants who met the inclusion criteria were selected. Stratified randomization was used to balance the age (≤50 years and >50 years) and number of MI events (first-time MI and recurrent) between the study groups. After the stratification, the patients were assigned randomly into two groups (Group 1: 28; Group 2: 28) using “Random Number Generator” (1: Mindfulness group; 2: Control group) by the senior (4th) co-author who was not involved in the intervention procedures conducted afterward. All the training sessions were conducted by the principal investigator (PI), who was not blinded to the study groups.

Recruitment

Study Procedure

The MP is, originally, a part of the mindfulness-based stress-reduction program [11]. Mindfulness interventions usually include yoga, walking meditation, guided imagery, body scans, and sitting meditation. In the present study, the research team included only mindful breathing and sitting meditation in the MP intervention.
The intervention procedures were performed at the CICU by the PI, who is certified and experienced in MP interventions. Each patient received the MP training individually on the day of discharge, with face-to-face sessions conducted while they were in their beds with a dim light. Bed curtains were drawn prior to the sessions to ensure patient privacy and reduce distracting stimuli. The patients in the MP group were first provided with a description of mindfulness and its effects on the body. These theoretical sessions lasted for 15 min. After the completion of the theoretical sessions on MP, all the MP steps were practiced by the patients under the supervision of the PI for 15 min. The PI asked the participants to sit in a comfortable position on a chair with their backs straight and eyes closed. Then, the PI requested the participants to breathe deeply and focus on their breathing and the present moment throughout the session. Therefore, each participant in the MP group received a total of 30 min of training, including theoretical as well as practical sessions on MP. The PI also recorded the MP instructions using a voice recorder, generating an audio file for practicing the MP sessions at their home. The MP groups continued to practice the MP session for 15 min each day, for a total of eight weeks, at home. Daily reminders (text messages or phone calls) were sent to participants to motivate them to practice the MP and to evaluate their compliance with the study protocol.
The patients in the CG received only a one-time attention-matched education on the structure and function of the heart, including the heart anatomy, heart functions, coronary arteries, and the diseases of the heart. The attention-matched education was provided face-to-face and lasted for 15 min.

Outcome Measures

Patient Information Form: This form was originally developed by the researchers based on previous literature. It contains 14 questions regarding the socio-demographic characteristics and the current and previous health status [3,5,8].
Piper Fatigue Scale (PFS): This scale was originally developed by Piper et al. and the latest revision contains four sub-dimensions and 27 items, with a 0–10 scale for each item [12]. The total fatigue score, calculated by averaging 22 items, ranges from 0 to 10. The Turkish validity and reliability study was performed by Can et al. (2004), who reported Cronbach’s alpha coefficient of 0.94 [13]. In the present study, the Cronbach alpha value was 0.96.
Tampa Scale for Kinesiophobia for Heart (TSK-H): Tampa Scale for Kinesophobia (TSK) was adapted for cardiac diseases and named the TSK-Heart scale by Bäck et al. [14]. TSK-H comprises 17 items that assess the subjective rating of kinesiophobia, and each item is rated on a four-point Likert scale with scoring options ranging from “strongly disagree” to “strongly agree”. Acar et al. performed the Turkish validity and reliability study of the TSK-H and reported Cronbach’s alpha value of 0.75 [15]. The Turkish version ranges between 17 and 68, with high values indicating a higher level of kinesiophobia. In the present study, Cronbach’s alpha value was 0.67.
MacNew Quality of Life Questionnaire (MacNew): The MacNew tool was developed to measure the QoL of the patients with heart disease and comprises 27 questions containing three subscales. The MacNew sub-dimensions include the emotional functioning sub-dimension (EFS) (14-items), the physical functioning sub-dimension (PFS) (13-items), and the social functioning sub-dimension (SFS) (14-items). The total score is calculated by averaging the scores of all the questions and sub-dimensions and ranges between from 1 to 7, with higher scores representing better QoL. The Turkish validity and reliability study was conducted by Daskapan et al., who reported Cronbach’s alpha value of 0.80 and the internal content index of 0.60 [16]. In the present study, the Cronbach’s alpha value was obtained as 0.83.

Data Collection

The baseline data were collected during the first interview with the participants using the patient information form, PFS, TKS-H, and MacNew. The patients in both groups were re-assessed (follow-up assessment) in the 4th, 8th, and 12th weeks using the PFS, TKS-H, and MacNew.

Ethics statement

The study was approved by the clinical trials ethics committee [(Decision number: 2018/18–29 (KA-180075)]. The authors of the present study thoroughly explained the study to all the participants, who were also asked to sign written informed consent.

Statistical analysis

Data were analyzed using the IBM SPSS version 23.0 (IBM Corp., Armonk, NY, USA). Data analysis was performed independently by a statistician from the research group. Comparisons of the MacNew, PFS, and TSK-H scores between the study groups were performed using Student’s t-test. The statistical significance threshold for the two-tailed test and the analyzes was set at p<0.05.

Results

The mean age of all participants was 55.0±10.0 years. Among the patients, 67.9% of patients in the MG were 50 years and older and 78.6% experienced MI for the first time, while 67.9% of the patients in the CG were 50 years and older and 85.7% experienced MI for the first time. The majority of the participants in both groups were male (82.1% in MG; 85.7 in CG) and married (96.4%).
Both groups were similar in terms of age and previous MI history (p>0.05). The analysis of the clinical characteristics revealed that 57.1% of the patients had at least one co-morbid disease in both study groups. ST-segment elevated MI type was observed at a 53.6% rate in MG and 67.9% in CG. Almost all the patients (92.9%) had a stent implanted (Table 1). Although not presented in any table, antiplatelet agents were the most prescribed agents in both groups (89.3% in the MG and 78.6% in the CG).
Study groups were homogeneous in terms of fatigue scores at baseline assessment (t:1.004, p=0.32). The mean total PFS scores of the participants in the MM group were 2.08 at the baseline, 0.9 at week 4, 0.47 at week 8, and 0.44 at week 12 of the study. The corresponding scores for the CG were 1.56, 1.12, 0.98, and 0.76, respectively. These scores represented that the patients in both groups experienced mild fatigue after MI. When comparing the total PFS scores between the study groups, no significant difference was observed for the baseline assessment and all the assessments (p>0.05) (Table 2).
Concerning the kinesiophobia scores, the TSK-H score was 40.25 for MG and 41.71 for CG at the baseline assessment. The study groups were homogeneous in terms of the kinesiophobia scores at the beginning of the study (t:−0.875, p=0.39). The TSK-H scores were 36.18 in the 4th week, 34.39 in the 8th week, and 34.96 in the 12th week in the MG, and the corresponding scores in the CG were 41.71, 41.89, 41.82, and 41.00, respectively. The TSK-H scores obtained for the MG were significantly lower than those obtained for the CG in the 4th week (t:−3.734, p=0.001), 8th week (t:−5.279, p=0.000), and 12th week (t:−4.390, p=0.000) (Table 2).
In terms of the QoL scores, the study groups were homogenous at the baseline assessment (t:−0.640, p=0.53). After the completion MP sessions, the QoL scores were significantly higher in the MG compared to the CG at 8th week (t:2.933, p=0.005). In the all sub-dimensions of MacNew presented significant differences in favor of MG at week 8 (t:3.257, p=0.002 for EFS; t:2.694, p=0.01 for PFS; and t:3.130, p=0.003 for SFS). Only the EFS sub-dimension continued to present significantly higher differences in the follow-up assessment at week 12 (t:2.118, p=0.039) (Table 3).

Discussion

The current study was designed as a randomized controlled trial that investigated the effects of 8-week MP interventions on fatigue, kinesiophobia, and the QoL in patients with acute MI. Although the literature contains studies investigating the effects of MP in heart failure patients, to the best of our knowledge, no study investigating the effects of MP on acute MI patients has been conducted so far. Consistent with our hypothesis, MP decreased kinesiophobia and improved the QoL in patients with MI. The other hypothesis, that “MP can reduce fatigue”, was not confirmed by the results of the present study.
Fatigue is considered an important determinant of the health status in acute MI patients [4,5]. However, studies investigating the association between MP and fatigue in patients with MI are limited. In several systematic reviews evaluating the effectiveness of MP in heart diseases, it was concluded that MP increases the functional capacity and effectively reduces fatigue [3,17]. However, contrary to the findings reported in the literature, the MP intervention did not prove to be effective in reducing fatigue in the present study. The literature emphasizes that fatigue is influenced by various factors, such as patient characteristics, repeated MI, MI severity, and the treatment applied (PCI, CABG, or implanting cardiac battery) for MI [2,4,5]. Since our study sample comprised mostly middle-aged and male patients, with no diseases and a high QoL before the MI, and the participants also reported a mild fatigue level at the beginning of the study, the authors presumed patient characteristics as the possible reason for the ineffectiveness of the MP intervention in fatigue.
The importance of encouraging patients to perform physical activity during the early period after MI is well-recognized as secondary prevention [7,18]. However, kinesiophobia presents a striking barrier to the implementation of cardiac rehabilitation, including body movements or exercises. Several studies have reported that heart disease patients largely experience kinesiophobia [7,19]. Throughout the study, the kinesiophobia scores remained significantly lower in the MG. In the present study, the mean kinesiophobia scores were significantly decreased in the MG, with this positive effect lasting for four weeks after the completion of the MP intervention. Therefore, it is proposed that MP can reduce kinesiophobia and could, therefore, be applied as a complementary intervention in cardiac rehabilitation programs.
The American Heart Association published a scientific statement based on a systematic review of the studies on meditation, suggesting a possible benefit for the CAD patients [20]. In support of our third hypothesis, the MP intervention in the present study improved the QoL and all its sub-dimensions in the intervention group compared to the control group. The positive effect of MP on the emotional dimension was maintained in the follow-up assessment, while the achievements in the physical and social dimensions could not be sustained after the intervention was terminated. Recent studies have also reported significant improvements in the QoL and its sub-dimensions immediately after the mindfulness intervention and after three or six months in MI and other cardiac patients [21]. Gotink et al. (2017) reported that a 12-week online MP intervention improved the patients’ QoL in the intervention group [22]. Nijjar et al. (2019) reported improvements, even though statistically insignificant, in the health-related QOL at three months in the intervention group compared to the controls [23]. The MP may increase selective and sustainable attention and awareness, thereby reducing the negative processes and consequently, the emotional vulnerability, contributing to improving the QoL. In other words, the efficacy of MP in the QoL might be based on the patient’s self-realization of automatic thoughts.

Limitation

Despite the encouraging findings, the present study also had certain limitations. One of the limitations is the difficulty in masking the patients’ groups due to the nature of the intervention presented as a barrier to a double-blind, randomized control trial. The PI collected the data for both groups and also administered all the interventions. Lastly, the generalizability of the study findings to all MI patient populations is low as our sample consists mostly of young and male patients.

Conclusion

In conclusion, the present study demonstrated that the MP intervention can significantly improve the QoL in patients with MI, and this effect is maintained, particularly in the emotional aspect. Moreover, the MP is effective in decreasing kinesiophobia, and this beneficial effect was sustained for one month after the intervention was terminated. On the contrary, the MP intervention could not affect the fatigue scores. On the basis of these findings, it is recommended to integrate the MP intervention into clinical practice as an integrative and complementary intervention within the scope of secondary prevention after acute MI. The study procedure should be replicated in different study samples, including the patients with low ejection fraction and those requiring CABG or pacemaker following acute MI.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.

Funding: None

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

References

1. Gong FF, Vaitenas I, Malaisrie SC, Maganti K. Mechanical complications of acute myocardial infarction: a review. JAMA Cardiol. 2021;6(3):341-49.
2. Puymirat E, Simon T, Cayla G, Cottin Y, Elbaz M, Coste P, et al. Acute myocardial infarction: changes in patient characteristics, management, and 6-month outcomes over a period of 20 years in the FAST-MI Program (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) 1995 to 2015. Circulation. 2017;136(20):1908-19.
3. Zou H, Cao X, Geng J, Chair SY. Effects of mindfulness-based interventions on health-related outcomes for patients with heart failure: a systematic review. Eur J Cardiovasc Nurs. 2020;19(1):44-54.
4. Hirsch S, Stephens AR, Crane PB. Fatigue, depression, cardiovascular risk, and self-rated health: comparing a community sample of adults to those with a history of myocardial infarction. Clin Nurs Res. 2022;31(2):174-82.
5. Gecaite-Stonciene J, Hughes BM, Burkauskas J, Bunevicius A, Kazukauskiene N, van Houtum L, et. al. Fatigue is associated with diminished cardiovascular response to anticipatory stress in patients with coronary artery disease. Front Physiol. 2021;12(692098):1-12.
6. Mansilla-Chacón M, Gómez-Urquiza JL, Martos-Cabrera MB, Albendín-García L, Romero-Béjar JL, Canadas-De La Fuente GA, et. al. Effects of supervised cardiac rehabilitation programmes on quality of life among myocardial ınfarction patients: a systematic review and meta-analysis. J Cardiovasc Dev Dis. 2021;8(12):1-17.
7. Brunetti ND, Guerra A, Ieva R, Correale M, Santoro F, Tarantino N, et al. Scared for the scar: fearsome impact of acute cardiovascular disease on perceived kinesiophobia (fear of movement). Clin Cardiol. 2017;40(7):480-4.
8. Johnston N, Bodegard J, Jerström S, Åkesson J, Brorsson H, Alfredsson J, et al. Effects of interactive patient smartphone support app on drug adherence and lifestyle changes in myocardial infarction patients: a randomized study. Am Heart J. 2016;178(8):85-94.
9. Peixoto TC, Begot I, Bolzan DW, Machado L, Reis MS, Papa V, et al. Early exercise-based rehabilitation improves health-related quality of life and functional capacity after acute myocardial infarction: a randomized controlled trial. Can J Cardiol. 2015; 31(3):308-13.
10. Chen X, Zhang B, Jin SX, Quan YX, Zhang XW, Cui XS. The effects of mindfulness-based interventions on nursing students: A meta-analysis. Nurse Educ Today. 2021;98,104718:1-8.
11. Kabat-Zinn J. Full catastrophe living, revised edition: how to cope with stress, pain and illness using mindfulness meditation. UK: Hachette; 2013.p.2-198.
12. Piper BF, Dibble SL, Dodd MJ, Weiss MC, Slaughter RE, Paul SM. The revised Piper fatigue scale: psychometric evaluation in women with breast cancer. Oncol Nurs Forum. 1998;25:677–84.
13. Can G, Durna Z, Aydiner A. Assessment of fatigue in and care needs of Turkish women with breast cancer. Cancer Nurs. 2004; 27(2):153-61.
14. Bäck M, Jansson B, Cider Å, Herlitz J, Lundberg M. Validation of a questionnaire to detect kinesiophobia (fear of movement) in patients with coronary artery disease. J Rehabil Med. 2012; 44(4):363-9.
15. Acar S, Savci S, Keskinoğlu P, Akdeniz B, Özpelit E, Kahraman BÖ, et al. Tampa Scale of Kinesiophobia for Heart Turkish Version Study: cross-cultural adaptation, exploratory factor analysis, and reliability. J Pain Res. 2016;9:445–51.
16. Daskapan A, Höfer S, Oldridge N, Alkan N, Muderrisoglu H, Tuzun EH. The validity and reliability of the Turkish version of the MacNew heart disease questionnaire in patients with angina. J Eval Clin Pract. 2008;14(2):209-13.
17. Kwekkeboom KL, Bratzke LC. A systematic review of relaxation, meditation, and guided imagery strategies for symptom management in heart failure. J Cardiovasc Nurs. 2016;31(5):457–68.
18. Norman J, Fu M, Ekman I, Björck L, Falk K. Effects of a mindfulness-based intervention on symptoms and signs in chronic heart failure: A feasibility study. Eur J Cardiovasc Nurs. 2018;17(1):54-65.
19. Bäck M, Cider Å, Herlitz J, Lundberg M, Jansson B. Kinesiophobia mediates the influences on attendance at exercise-based cardiac rehabilitation in patients with coronary artery disease. Physiother Theory Pract. 2016; 32(8):571-80.
20. Levine GN, Lange RA, Bairey-Merz CN, Davidson RJ, Jamerson K, Mehta PK, et al. Meditation and cardiovascular risk reduction: a scientific statement from the American Heart Association. J Am Heart Assoc. 2017;6(10):e002218.
21. Ghahnaviyeh LA, Bagherian B, Feizi A, Afshari A, Darani FM. The effectiveness of acceptance and commitment therapy on quality of life in a patient with myocardial infarction: A randomized control trial. Iran J Psychiatry. 2020;15(1):1-9.
22. Gotink RA, Younge JO, Wery MF, Utens EM, Michels M, Rizopoulos D, et al. Online mindfulness as a promising method to improve exercise capacity in heart disease: 12-month follow-up of a randomized controlled trial. PloS one. 2017;12(5):e0175923.
23. Nijjar PS, Connett JE, Lindquist R, Brown R, Burt M, Pergolski A, et al. Randomized trial of mindfulness-based stress reduction in cardiac patients eligible for cardiac rehabilitation. Sci Rep. 2019; 9(1):1-11.

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Canan Demirci, Metin Oksul, Necla Ozer, Leyla Ozdemir. Effect of mindfulness on fatigue, kinesiophobia and quality of life in patients with acute myocardial infarction. Ann Clin Anal Med 2023;14(2):110-115

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Aim: The aim of this study was to examine the role of conservative therapy in cavitary lesions secondary to capitonnage suturing in the postoperative period for giant hydatid cyst cases within the context of the literature.

Material and Methods: The files of 346 patients who had been operated in our clinic due to a hydatid cyst between 01 May 2010 and 30 June 2020 were analyzed retrospectively. Epicrisis reports and operation notes of 52 cases that had been operated due to a giant hydatid cyst were examined. Files of 7 giant hydatid cyst cases with postoperative cyst cavity were included in the study.

Results: Cases were followed up for six months following the medical treatment. Surgical intervention was not performed for any of the seven patients whose treatment was completed, and their cavities closed spontaneously. The length of stay in the hospital was determined as 10-15 days (mean=13.1 days). Mortality and morbidity were not encountered in any of our cases.

Discussion: In case of cavity opening in the post-operative period in giant hydatid cyst cases, unless complications such as bronchopleural fistula, pneumothorax, empyema or fluid retention giving air-liquid level inside the cavity occur, it must be assumed that capitonnage sutures were opened. We assume that implementation of infection treatment as the first option before surgery for the closure of the cavity may be more effective for spontaneous recovery of the patients without increasing their risks of mortality and morbidity.

Keywords: Hydatid Cyst, Conservative Therapy, Cavitary Lesion, Capitonnage, Giant Hydatid Cyst

Introduction

Cyst Hydatid is the most common parasitic disease of the lungs. It is usually caused by Echinococcus granulosus and rarely by Echinococcus multilocularis. Carnivorous animals such as dogs and wolves are the primary hosts in the lifecycle of echinococcus, whereas humans, sheep and cattle are the intermediate hosts. While hydatid cyst disease in humans is frequently seen in the liver and lungs, it can be seen wherever the blood reaches when it is considered that scolex are carried by the blood. It is endemic in Mediterranean and Middle East countries, including Turkey. Hydatid cyst disease frequently presents with the involvement of the lower lobes of the lungs, especially the right lower lobes [1-5].
Hydatid cysts with a diameter larger than 10 cm are defined as giant cysts [6]. Giant cyst hydatid disease is more common in childhood compared to adults due to the elastic structure of the lungs [7]. Its clinical symptoms show a parallel with the size of the cyst. Chest pain, cough, shortness of breath and hemoptysis are among the most common symptoms [8]. Casoni and Weinberg complement fixation tests, which were previously used in diagnosis, are now replaced by serological tests. We did not apply these tests to the patients in our clinic.
Imaging procedures are frequently used for diagnosis. Giant hydatid cysts cause a more severe clinical picture by creating more pressure on the surrounding lung tissues compared to smaller cysts. When giant cysts are ruptured, they can cause obstruction in respiratory airways due to excess cyst liquid and the size of the cyst membrane requiring emergency intervention.
The basic treatment of cyst hydatid disease is parenchyma protective surgery [9]. Surgical procedures are more difficult with giant cysts compared to smaller cysts and they cause more problems in the post-operative period.
The aim of this study was to examine the role of conservative therapy in cavitary lesions secondary to capitonnage suturing in the postoperative period in giant hydatid cyst cases within the context of the literature.

Material and Methods

This retrospective study was approved by the Institutional Review Board (2011-KAEK-25 2020/09-09) and the informed consents were waived by approval of the Institutional Review Board.
The files of the patients who had been operated in our clinic due to a hydatid cyst between 01 May 2010 and 30 June 2020 were analyzed retrospectively. Complications requiring surgical intervention, such as prolonged air leak, pneumothorax, bronchopleural fistula (BPF) or empyema were not included in the study.
PA chest radiography and thorax computed tomographies (BT) were used in the diagnosis as clinical imaging techniques. All patients were hospitalized and were followed up. All patients underwent rigid bronchoscopy and fiberoptic bronchoscopy (FOB) and were assessed in terms of BPF. Moreover, complete blood count, sedimentation, C-reactive protein (CRP) and blood biochemistry examinations were applied for each patient and active infection and organ function disorders were investigated. Broad-spectrum antibiotherapy was initiated in all cases, and they were followed up with daily PA chest radiographies. After discharge, the patients were followed up in 10 day-periods in the first month and then once a month for six months.

Results

The files of 346 patients who had been operated in our clinic due to a hydatid cyst were analyzed. Epicrisis reports and operation notes of 52 cases that had been operated due to a giant hydatid cyst were examined. Files of 7 giant hydatid cyst cases with postoperative cyst cavity were included in the study (Figure 1).
The age and gender distribution of the cases and general characteristics of the cysts are given in Table 1. The age distribution of our cases was 21-40 (mean 30.7) years old.
Application complaints of the patients were non-specific respiratory system symptoms, such as cough, expectorating, shortness of breath, fever and fatigue.
The cyst was located in a single lung in all of the seven cases with cavity-opening complication in the post-operative period. The cyst was most frequently detected in the right lung (n=5; 71.4%) and in the lower lobe (n=5; 71.4%) (Figure 2). Giant cyst hydatid diagnosis was made by measuring the cavity diameter using thorax BT in all cases. The measured cyst cavity diameter was 10-15 cm (mean 12.4 cm). Posterolateral thoracotomy + cystotomy + capitonnage were applied in all cases as operation methods.
The mean time of postoperative complication development time was 48.8 (30-65) days. Application complaints of the patients were frequent cough and expectorating. In the first PA chest radiography it was detected that the cyst cavity recurred in the operated lung lobe but there was no air-liquid level inside the cyst. On the other hand, complications such as pneumothorax, empyema or abscess were not detected radiologically. Complete blood count, biochemistry, sedimentation and CRP were determined for all patients. Infection parameters such as leukocyte count, sedimentation and CRP levels were measured.
All patients were examined in terms of clinical, radiologic and bronchoscopic BPF. There was no evidence of fistula in any of the cases. Broad spectrum antibiotics were initiated in cases referring to infectious diseases. Patients whose treatment was completed in ten days were followed up with daily PA chest radiography. Cases were followed up for six months following medical treatment. The cavity closed spontaneously without surgical intervention in the seven patients whose treatment was completed (Figure 3). The length of stay in the hospital was determined as 10-15 days (mean 13.1 days). Mortality and morbidity were not encountered in any of our cases.

Discussion

Giant cyst hydatid disease can reach a large extent to cover the entire lobe of the lung. This situation is explained by the higher elasticity of lung tissue compared to other tissues. Giant pulmonary cysts are more common in children compared to adults due to the higher lung elasticity in children [10]. Symptoms and findings of giant pulmonary cyst hydatids are not different from those of simple cyst hydatids. Depending on the cyst size, its location, and the presence of complications, patients may experience dyspnea, chest pain, hemoptysis, fever, membrane expectoration (hydoptysis) and allergic reactions. Enlargement of the pulmonary giant cyst hydatid from 10 cm in diameter to a diameter that fills the entire hemithorax can only be explained by the elastic structure of the cyst and its location away from mediastinal structures [11,12].
Cyst hydatid diagnosis is made with radiologic examinations and serologic methods. PA chest radiography, thoracic ultrasonography, thorax computed tomography, thorax magnetic resonance and echocardiography for cardiac involvement in case of necessity are among the most preferred radiologic methods [13]. Basic treatment in cyst hydatid cases is parenchyma protective surgery [13,14]. The aim in surgery is the eradication of the parasite, prevention of intraoperative rupture and closing of the residual cavity. Surgical options include cystectomy, cystotomy, enucleation wedge resection, segmentectomy and lobectomy in case of cysts causing parenchyma destruction by covering more than 50% of one lobe or causing chronic abscess, bronchiectasis or severe hemoptysis. Lobectomy was not applied to any of the cases included in this study.
Cystotomy and capitonnage are the most preferred methods of surgical treatment. We also preferred this method of surgery in all our cases. Medical treatment is applied in small uncomplicated cysts, in patients who do not tolerate surgical operation and in cases that reject surgical treatment [13-14]. Surgical treatment was applied in all our cases. In a previous study it was mentioned that medical treatment should begin at least 4 days prior to surgery, and albendazole should be used for at least one month, while mebendazole should be used for at least three months [16]. Despite this, other studies assert that the use of albendazole and mebendazole in the control of this disease in the pre-operative period may cause cyst perforation [13,17]. In our clinic, we did not apply routine albendazole treatment in non-perforated cyst hydatid cases in the pre-operation period. In the postoperative period, we used 10mg/kg of albendazole for three months to prevent recurrence and checked routine liver functions each month.
There was no liver or any other organ involvement in any of the seven cases that had been operated due to giant cyst hydatid and cavity opening complication had developed after surgery. Untreated cysts may open into the bronchus and pleura, causing serious complications requiring invasive intervention. Complications such as atelectasis, prolonged air leak, pneumothorax, empyema, recurrence, BPF and cavity opening can develop after surgery [18]. The recurrence rate in the post-operation period in cyst hydatid cases varies from 4.6% to 12%. The first place in etiology is occupied by surgery that is performed inattentively to prevent pleura spread [19]. According to one study, the most frequent post-operation complication was atelectasis (17.5%) [20]. In another study, it was emphasized that the most common complication was prolonged air leak [1]. Considering all of our cyst hydatid cases, our most common post-operative complication was atelectasis with a rate of 13.7%. We applied medical treatment to all of our seven giant cyst hydatid cases that developed very annoying complications such as opening of the cavity under capitonnage after surgery. The common feature of our cases was that we detected a complication of BPF, which plays role in cavity opening.

Study limitations

The retrospective design was the main limitation of this study.

Conclusion

In case of cavity opening in the post-operative period in giant hydatid cyst cases, unless complications such as BPF, pneumothorax, empyema or fluid retention giving air-liquid level inside the cavity occur, it must be assumed that capitonnage sutures were opened. We assume that implementation of infection treatment as the first option before surgery for closure of the cavity may be more effective in spontaneous recovery of patients without increasing their risk of mortality and morbidity.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.

Funding: None

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

References

1. Yekeler E, Karaarslan K, Yazıcıoğlu A, Kaya S, Karaoğlanoğlu N. Lobectomy for pulmonary hydatid cyst. Turk J Med Sci. 2013; 43(6):1024-9.
2. Çobanoğlu U, Sayır F, Şehitoğlu A, Bilici S, Melek M. Therapeutic strategies for complications secondary to hydatid cyst rupture. Int J Clin Exp Med. 2011;4(3):220-6.
3. Arslan S, Özşahin SL, Doğan T, Akkurt İ. Multiple complicated lung hydatid cyst associated with interatrial septal hydatid cyst. Ege Journal of Medicine. 2009; 48(2):135–7.
4. Aydin Y, Ulas AB, Ince I, Kuran E, Keskin H, Kirimli SN, et al. Modified capitonnage technique for giant pulmonary hydatid cyst surgery. Interact Cardiovasc Thorac Surg. 2021;33(5):721-6.
5. Lodhia J, Chugulu S, Sadiq A, Msuya D, Mremi A. Giant isolated hydatid lung cyst: two case reports. J Med Case Rep. 2020;14(1):200.
6. Halezeroglu S, Celik M, Uysal A, Senol C, Keles M, Arman B. Giant hydatid cysts of the lung. J Thorac Cardiovasc Surg. 1997;113(4):712-7.
7. Dincer SI, Demir A, Sayar A, Gunluoglu MZ, Kara HV, Gurses A. Surgical treatment of pulmonary hydatid disease: a comparison of children and adults. J Pediatr Surg. 2006; 41(7): 1230-6.
8. Haberal MA, Akar E, Sengoren Dikiş O, Kaya M. Surgical treatment of childhood pulmonary hydatidosis: An analysis of 25 cases. Tanaffos. 2018;17(4):208-84.
9. Salamone G, Licari L, Randisi B, Falco N, Tutino R, Vaglica A, et al. Uncommon localizations of hydatid cyst. Review of the literature. G Chir. 2016;37(4):180-5.
10. Symbas PN, Aletras H. Hydatid disease of the lung. In: Shields TW, editor. General thoracic Surgery. Philadelphia: Williams and Wilkins; 1994.p.1021-31.
11. Demirhan R, Onan B, Kıral H, Yalçınkaya I. Surgical treatment of giant hydatid cyst in childhood. Türk Göğüs Kalp Damar Cer Derg. 2010;18(2):121-5.
12. Aletras H, Symbas PN. Hydatid disease of the lung. In: Shields TW, Lo Cicero J III, Ponn RB, editors. General thoracic surgery. 5th ed. Philadelphia: Lippincott Williams &Wilkins; 2000. p. 1113–22.
13. Ülkü R, Eren N, Çakır O, Balci A, Onat S. Extrapulmonary intrathoracic hydatid cysts. Can J Surg. 2004;47(2):95-8.
14. Onal O, Demir OF. The relation between the location and perforation rate of lung hydatid cysts in children. Asian J Surg. 2018;41(5):422-6.
15. Hasdiraz L, Oğuzkaya F, Bilgin M. Is lobectomy necessary in the treatment of pulmonary hydatid cysts? ANZ J Surg. 2006;76(6):488-90.
16. Usluer O, Ceylan KC, Kaya S, Sevinc S, Gursoy S. Surgical Management of pulmonary hydatid cysts. Tex Heart Inst J. 2010;37(4):429-34.
17. Velasco-Tirado V, Romero-alegría Á, Belhassen-garcía M, Alonso-Sardón M, Esteban-Velasco C, López-Bernúset A, et al. Recurrence of cystic echinococcosis in an endemic area: a retrospective study. BMC Infect Dis. 2017;17(1):455.
18. Umut S, Bartu Saryal S. Türk Toraks Derneği Paraziter Akciğer Hastalıkları Tanı ve Tedavi Rehberi 2009 (Turkish Thoracic Society Diagnosis and Treatment Guidelines for Parasitic Lung Diseases 2009). Turkish Thoracic Journal. 2009; 10(8):1-12.
19. İşıtmangil T, Görür R, Yiyit N, Erdik O, Yıldızhan A, Candaş F, et al. Toraksta kist hidatik hastalığı nedeniyle cerrahi tedavi uygulanan 308 hastanın değerlendirilmesi (Evaluation of 308 patients who underwent surgical treatment for hydatid cyst of the thorax). Türk Göğüs Kalp Damar Cer Derg. 2010;18(1):27-33.
20. Fındık G, Aydoğdu K, Hazer S, Öz G, Küçükbayrak A, Karaoğlanoğlu N, et al. The management of post operative complications in childhood pulmonary hydatid cysts. Türk Göğüs Kalp Damar Cerrahisi Dergisi. 2012;20(4):850-6.

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Miktat Arif Haberal, Erkan Akar, Ozlem Sengoren Dikis, Mehmet Oguzhan Ay, Hakan Demirci, Murat Ersal, Melih Yuksel, Halil Kaya. Role of conservative therapy in complicated giant pulmonary hydatid cyst cases. Ann Clin Anal Med 2023;14(2):135-138

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