Clinical trial NCT05500157: Assessment of Treatment With Laparoscopic Fenestration or Aspiration Sclerotherapy for Large Symptomatic Hepatic Cysts
Official title: Assessment of Treatment With Laparoscopic Fenestration or Aspiration Sclerotherapy for Large Symptomatic Hepatic Cysts (ATLAS): a Randomized Clinical Trial.
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: NA
Conditions: Liver Cyst
Polycystic Liver Disease
Autosomal Dominant Polycystic Kidney
Autosomal Dominant Polycystic Liver Disease
Keywords: polycystic liver disease
aspiration sclerotherapy
fenestration
Lead sponsor: Radboud University Medical Center
Sponsor class: OTHER
First posted: 2022-08-12
Enrollment: 70
Sex: ALL
Minimum age (years): 18
Maximum age (years): 75
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: Patients with large hepatic cysts (\> 5cm) may develop symptoms. These can be captured with the polycystic liver disease questionnaire (PLD-Q). Treatment of large hepatic cysts consists of aspiration sclerotherapy or laparoscopic fenestration.

The safety and efficacy of both procedures has been explored in two recent systematic reviews yet no evident conclusion regarding superiority of either procedure could be drawn.

The main objective of the ATLAS trial is to compare laparoscopic fenestration and aspiration sclerotherapy in patients with large symptomatic hepatic cysts on patient-reported outcomes.

Detailed description: Rationale: Patients with large hepatic cysts(\>5cm) may develop symptoms due to distention of Glisson's capsule and/or compression on other abdominal organs. Frequently reported symptoms include abdominal pain, early satiety, nausea, and dyspnea. These symptoms can be captured in the disease-specific Polycystic Liver Disease Questionnaire (PLD-Q), a validated instrument. The treatment of symptomatic liver cysts is aimed to improve symptoms and quality of life by reducing cyst volume. There are two procedures available to treat symptomatic liver cysts: percutaneous aspiration sclerotherapy and laparoscopic fenestration.

In aspiration sclerotherapy, fluid is evacuated from the liver cyst and subsequently the cyst lining is exposed to a sclerosing agent for a limited period of time. Sclerotherapy causes temporary recurrence of cyst fluid after drainage, but subsequently results in a steady decrease of cyst volume in the majority of patients.

In laparoscopic fenestration the liver is exposed through laparoscopic surgery. In this procedure the cyst is punctured and drained followed by resection of extra-hepatic cyst wall.

The safety and efficacy of aspiration sclerotherapy and laparoscopic fenestration have been explored in two recent systematic reviews. No evident conclusion could be drawn because of the retrospective study design in the vast majority of the studies and the heterogeneity among these. A randomized controlled trial is warranted to identify the possible differences in safety and efficacy in aspiration sclerotherapy and laparoscopic fenestration.

Hypothesis: The investigators expect patients treated with laparoscopic fenestration to have better clinical outcome; i.e. a lower PLD-Q score, compared to aspiration sclerotherapy, when measured 4 weeks after the procedure. The investigators expect this difference to become smaller over time (after 6 and 12 months), with loss of statistical significance.

Objective: The main objective is to compare laparoscopic fenestration and aspiration sclerotherapy in patients with large symptomatic hepatic cysts on patient-reported outcomes. This information can be used to assess cost-effectiveness in both treatments.

Study design: A prospective, randomized clinical superiority trial in which patients will be randomized 1:1 to one of the treatment arms. Patients will be followed for 1 year.

Study population: All patients ≥18 years who are diagnosed with a dominant, simple hepatic cyst (\>5 cm in diameter), that are symptomatic (PLD-Q score ≥20) and have an indication for treatment (both aspiration sclerotherapy and laparoscopic fenestration) are suitable for inclusion in this study. Only patients that are eligible for both treatments can be included in this study. In particular, patients with multiple cysts (\>20 cysts of \>1.5 cm) will be excluded as surgery leads to more complications in these patients.

Intervention: Patients will be randomly allocated to either aspiration sclerotherapy or laparoscopic fenestration. Both procedures are performed according to the standard Radboudumc protocols. Aspiration sclerotherapy consists of ultrasound-guided, percutaneous drainage of the cyst with subsequent sclerosation with ethanol. Laparoscopic fenestration consists of standard abdominal laparoscopy in which the large cyst(s) are drained and deroofed.

Main study parameters: The main study parameter is the PLD-Q score at 4 weeks after treatment. Secondary parameters are among others: PLD-Q score at baseline, 6 months and 12 months; liver volume (CT) at baseline and 4 weeks; cyst volume (ultrasound) at baseline, 4 weeks, 6 months and 12 months; complications according to Clavien-Dindo; admission duration, recurrence and re-intervention rates.

Eligibility criteria: Inclusion Criteria:

* Age ≥18 years
* Hepatic cyst characteristics:

  * Large (\>5 cm),
  * Symptomatic (PLD-Q score ≥20),
  * Non-parasitic on imaging (US/CT/MRI)
  * Non-neoplastic on imaging (US/CT/MRI)
* Providing informed consent

Exclusion Criteria:

* Clinical indication of a complicated hepatic cyst (cyst rupture or active cyst infection)
* Cyst is not laparoscopically accessible for surgery
* Cyst is not percutaneously (ultrasound-guided) accessible for aspiration
* More than 20 cysts of \>1.5 cm
* Age above 75 years
* ASA IV
* ECOG score \>1
* Aspiration sclerotherapy or laparoscopic fenestration of hepatic cysts was performed in the last 6 months.
* Severe renal impairment (eGFR \< 30 ml/min/1,73 m2)
* Coagulopathy (spontaneous INR \>2 or platelet count \< 80 x 109/l)
* Radiologic contrast allergy
* Pregnancy
* Any current or prior medical condition that may interfere with the conduct of the study or the evaluation of its results in the opinion of the investigator (e.g. inability to fill out questionnaires).

Primary outcomes:
measure: PLD-Q 4 weeks
timeFrame: 4 weeks after the procedure
Secondary outcomes:
measure: PLD-Q score 1, 6 and 12 months after intervention
timeFrame: up to 12 months
measure: PLD-Q invididual symptoms
timeFrame: up to 12 months
measure: SF-36 MCS
timeFrame: up to 12 months
measure: SF 36 PCS
timeFrame: up to 12 months
measure: EQ-5D-5L
timeFrame: up to 12 months
measure: Liver and cyst volume
timeFrame: up to 12 months
measure: Liver and cyst volume at recurrence
timeFrame: up to 12 months
measure: Cyst volume with US
timeFrame: up to 12 months
measure: Adverse events
timeFrame: up to 12 months
measure: Technical success
timeFrame: periprocedural
measure: Hospital stay
timeFrame: periprocedural
measure: Re-intervention rates
timeFrame: up to 12 months
measure: Cost-effectiveness iPCQ
timeFrame: up to 12 months
measure: Cost-effectiveness iMCQ
timeFrame: up to 12 months
Other outcomes:
Locations:
city: Nijmegen
country: Netherlands
facility: Radboudumc University Medical Center
state: Gelderland
Study officials:
affiliation: Radboud University Medical Center
name: Joost P.H. Drenth
role: PRINCIPAL_INVESTIGATOR
References: