Percutaneous treatment of hydatid cysts (Echinococcus granulosus)

Cystic echinococcosis of the liver in Kazakhstan: The effectiveness of the PAIR method in comparison with laparoscopic and «open» surgical methods

BACKGROUND

One of the urgent problems of surgical parasitology in the Republic of Kazakhstan is liver cystic echinococcosis. The study aimed to analyze the effectiveness and safety of the percutaneous treatment with different techniques in comparison with the results of laparoscopic and "open" surgical methods.

METHODS

Retrospectively, we analyzed the outcome of 485 patients with active echinococcal cysts in the period from January 2017-July 2023. Indications for surgical treatment and the choice of the intervention method were based on this classification. Patients were conditionally divided into 3 groups: Laparoscopy-33, Laparotomy-319, PAIR-133.

RESULTS

The duration of the operation in the PAIR was significantly shorter compared to the Laparotomy and Laparoscopy groups (55.4vs.225.2 and 215.3, p = 0.0001). There was no intraoperative blood loss in PAIR, whereas in Laparotomy and Laparoscopy there were 146.0 and 111.0. The postoperative stay of patients in PAIR is significantly shorter than in Laparotomy and Laparoscopy (3.8 compared to 7.5 and 6.4, p = 0.0001). The follow-up time averaged 39.8 months ± 21. There were no statistically significant differences in relapses. Laparotomy and PAIR groups had 11 (3.5 %) and 6 (4.5 %) relapses, respectively.

CONCLUSION

In cystic echinococcosis of the liver types CE1, CE3a regardless of the localization, the optimal volume is a PAIR is characterized by a shorter postoperative stay of the patient, early recovery and cure. In the CE2, CE3b stages, laparoscopic pericystectomy is the most effective and safe in individual patients. In case of an intimate arrangement of cysts to tubular structures, the safest method is laparotomy.

Primary Retroperitoneal Hydatid Cyst: A Diagnostic and Treatment Conundrum

Hydatid cysts are caused by accidental egg ingestion of the Echinococcus granulosus parasite. A 24-year-old female was admitted to our hospital for chronic left lumbar pain. Computed tomography (CT) and abdominal ultrasonography identified an 8/12 cm retroperitoneal cyst. The CT results coupled with enzyme-linked immunosorbent assay tests (positive IgG for Echinococcus granulosus) confirmed that the tumor was a hydatid cyst. Treatment consisted of preoperative chemotherapy with albendazole, intraoperative parasite inactivation, laparoscopic partial cystectomy, and drainage. The drain was removed after three days. Chemotherapy was maintained for two years after surgery. No relapse was observed at the six-month reevaluation. In this article, the diagnostic and therapeutic options and resources are discussed and compared with the published literature.

Percutaneous treatment of liver hydatid cysts: to PAIR or not to PAIR

PURPOSE OF REVIEW

The aim is to review recent literature for percutaneous treatment of liver hydatid cysts (cystic echinococcosis: CE) via different techniques such as PAIR (puncture, aspiration, injection, and reaspiration), standard catheterization, and modified catheterization technique (MoCaT).

RECENT FINDINGS

PAIR is an established technique and considered to be safe and effective for CE1 and CE3a as it is associated with lower morbidity, mortality, recurrence, and shorter hospital stay as compared with surgery. Standard catheterization is also dedicated for the treatment of CE1 and CE3a. PAIR should be preferred for treatment of liver CE1 and CE3a cysts, since PAIR is associated with lower major complication rates and shorter hospital stay. However, standard catheterization technique is indicated when cysto-biliary fistula develops or any technical difficulty arises during the PAIR. In these cases it is needed to switch PAIR to standard catheterization to complete the procedure.

SUMMARY

For CE1 and CE3a cysts, PAIR and standard catheterization are the choice for percutaneous treatments, while MoCaT is a treatment option for CE2 and CE3b cysts.

Historical changes in surgical strategy and complication management for hepatic cystic echinococcosis

Echinococcosis is a zoonotic parasitic disease caused by Escherichia larvae. It frequently involves the liver (70%-75%), followed by the lungs (15%-20%), and occasionally the brain, heart, spleen, bone, and other organs. The main pathogenic forms of human echinococcosis currently include cystic echinococcosis (CE) and alveolar echinococcosis (AE). CE is globally distributed, while the distribution of AE is generally restricted to the northern hemisphere. In China, CE accounts for 75% of all echinococcosis cases. With rapid advances in surgical techniques in recent decades, the surgical strategy for CE has changed, especially with the continuous improvement of surgical methods and the expansion of surgical contraindications. To further understand the changes in surgical treatment strategies for hepatic CE, we interpreted and analyzed the existing literature addressing the surgical treatment of hepatic CE both domestically and abroad and briefly summarized them in chronological order. This review aims to provide a deeper understanding of the progress in the surgical treatment of hepatic CE to provide clearer avenues for its clinical diagnosis and treatment.

Percutaneous Drainage in Hepatic Hydatidosis-The PAIR Technique: Concept, Technique, and Results

Over decades, surgery has been the only accepted mode of treatment for liver hydatid cysts. It had been a surgical dogma for a long that hydatid disease is an absolute contraindication for needle puncture/aspiration as it can cause anaphylaxis, death, and dissemination. We envisaged prospectively perform percutaneous drainage as a primary form of treatment for hepatic hydatidosis. Through extensive and very careful experimentation, we proved that aspiration of hydatid cysts can be performed safely and is the ideal way to manage a subset of patients with hydatid cysts in the liver. The patient and cyst characteristics good and not good for percutaneous drainage were carefully selected. The procedure of percutaneous drainage of hepatic hydatid cysts involves four sequential steps as defined in the alphabets of the title PAIR, denoting puncture (P), Aspiration (A), Instillation (I), and Reaspiration (R). During and postprocedure, we enforced strict monitoring given the anticipated anaphylaxis. The first PAIR procedure was performed in June 1988. The results of percutaneous drainage of 21 cysts in 12 patients were reported in 1991. Next, a prospective study was done to show that concomitant Albendazole therapy is recommended as an adjuvant to percutaneous drainage for hepatic hydatidosis. In a seminal prospective study comparing percutaneous drainage and surgery, we showed that percutaneous drainage is as good as surgery in the management of uncomplicated hydatid cysts with fewer complications and shorter hospital stays. Lastly, long-term follow-up results of percutaneous drainage on a large cohort of patients with hepatic hydatid cysts were reported, with excellent results and no evidence of local, peritoneal or systemic dissemination. Based on these data percutaneous drainage, the so-called PAIR technique has established itself as a novel therapeutic advance in hepatic hydatid disease.

International consensus on terminology to be used in the field of echinococcoses

Echinococcoses require the involvement of specialists from nearly all disciplines; standardization of the terminology used in the field is thus crucial. To harmonize echinococcosis terminology on sound scientific and linguistic grounds, the World Association of Echinococcosis launched a Formal Consensus process. Under the coordination of a Steering and Writing Group (SWG), a Consultation and Rating Group (CRG) had the main missions of (1) providing input on the list of terms drafted by the SWG, taking into account the available literature and the participants’ experience; and (2) providing independent rating on all debated terms submitted to vote. The mission of the Reading and Review Group (RRG) was to give an opinion about the recommendation paper in terms of readability, acceptability and applicability. The main achievements of this process were: (1) an update of the current nomenclature of Echinococcus spp.; (2) an agreement on three names of diseases due to Echinococcus spp.: Cystic Echinococcosis (CE), Alveolar Echinococcosis (AE) and Neotropical Echinococcosis (NE), and the exclusion of all other names; (3) an agreement on the restricted use of the adjective “hydatid” to refer to the cyst and fluid due to E. granulosus sensu lato; and (4) an agreement on a standardized description of the surgical operations for CE, according to the “Approach, cyst Opening, Resection, and Completeness” (AORC) framework. In addition, 95 “approved” and 60 “rejected” terms were listed. The recommendations provided in this paper will be applicable to scientific publications in English and communication with professionals. They will be used for translation into other languages spoken in endemic countries.

Management of cystic echinococcosis in the last two decades: what have we learned?

Background

Management options for cystic echinococcosis (CE) remain a serious problem. The main aim of this study was to examine the selection and complications of treatment applied in patients with CE. The second aim was to evaluate the mortality rate and causative factors.

Methods

A retrospective descriptive study of patients diagnosed with CE between 1998 and 2015 was conducted, according to ICD-9 (code 122·0 to 122·9) criteria in the Complejo Asistencial Universitario of Salamanca, Spain.

Results

Four-hundred-ninety-one (491) patients were diagnosed with CE disease and the treatment applied in these patients were: 166 (33.8%) patients received only surgery, 176 (35.8%) surgery and drugs, 17 (3.5%) drugs alone, in 131 (26.7%) patients the strategy was 'watch and wait', and only one patient (0.2%) was applied puncture-aspiration-injection-respiration (PAIR). Thus, a total of 342 patients received surgery, either alone (166) or combined with drugs (176), and a total of 193 (39.4%) patients were medically treated, either alone (17) or combined with surgery (176); 123 (63.7%) patients used albendazole alone; and 70 (36.3%) patients used a combination of albendazole and praziquantel. Sixty-five patients (19.0%) had complications after surgery and seven of them (2%) died. Only 15 (7.8%) cases had side effects from anthelmintics. Throughout the study period, 80 (16.3%) patients died, 14 (2.9%) of them due to CE disease.

Conclusions

Complications of CE are one of the most common causes of mortality in CE patients, with size, location, and number of cysts, and the 'watch and wait' treatment strategy being the main factors associated with mortality.

Preliminary Evaluation of Percutaneous Treatment of Echinococcal Cysts without Injection of Scolicidal Agent

Puncture, Aspiration, Injection of scolicidal agent, Re-aspiration is the most widely used percutaneous treatment of cystic echinococcosis (CE). Among its perceived risks is chemical sclerosing cholangitis, a serious complication due to the caustic effect of the scolicidal solution on the biliary tree, when a patent cystobiliary fistula occurs. To simplify the protocol, we decided to omit injection and reaspiration of the scolicidal agent and to implement a full course of albendazole (ABZ) therapy instead of the routine 1-month ABZ prophylaxis. We searched our databases for patients with CL (Cystic Lesion, suspected for CE), CE1, and CE3a cysts treated between October 2007 and January 2017 with percutaneous aspiration followed by at least 1 month of oral ABZ and with an ultrasound follow-up of at least 6 months. Fifteen patients matched our inclusion criteria. Follow-up ranged from 7 to 75 months. The oral ABZ course after the aspiration procedure ranged from 1 to 18 months. Eleven subjects (73.3%) had undergone a course of ABZ before the percutaneous procedure (min 15 days, max 16 months). Ten cysts (62.5%) had reached solidification (stage CE4) in 3 to 69 months. Four other cysts (26.7%) remained stable in stage CE3a, whereas two cysts (13.3%) reactivated to stage CE3b. Procedural perioperative complications occurred in 13.3% of patients, whereas complications during the follow-up occurred in 20% of patients. These proof-of-concept preliminary results are overall comparable with those reported in the literature for other percutaneous treatments, both in terms of response rate, relapse rate, and morbidity.

Abdominal wall Hydatid cyst: A review a literature with a case report

INTRODUCTION

Hydatid cyst (HC) disease is a serious health problem in endemic areas. It is a parasitic infection that commonly involves liver and lungs while muscular HC is rare. HC of abdominal wall was reported only six times. We reported a 39-year-old male presented with HC of the right loin who was managed surgically with brief literature review.

CONCLUSION

HC should be put in the differential diagnosis of the abdominal wall masses. Its pre-operative diagnosis is important to prevent rupture with subsequent anaphylaxis and recurrence. Surgery is the main modality of treatment.

A comparison of imaging guided double percutaneous aspiration injection and surgery in the treatment of cystic echinococcosis of liver

OBJECTIVE

To compare the results and complications of treatment by double percutaneous aspiration injection (DPAI) in cystic echinococcosis (CE) of the liver with those of surgery. To the best of our knowledge, such a study has not been carried out till date.

METHODS

From November 2012 to November 2015, 43 patients were randomly allocated to DPAI group (n = 22) and surgery group (n = 21). After the intervention, patients were evaluated monthly for 3 months, then at the sixth month and 6 monthly thereafter.

RESULTS

Average hospital stay was 2.38 days in DPAI group and 8.23 days in the surgery group. Response to DPAI was categorized as successful in 95.3% (n = 20) patients and incomplete in 4.7% (n = 1) patients. Response to surgery was characterized as successful in 85.7% (n = 18) patients and incomplete in 4.7% (n = 1) patients, and recurrence was seen in 9.5% (n = 2) patients. Using a 10% margin for non-inferiority, treatment response in the DPAI group was non-inferior to that of the surgery group. In the DPAI group, 19 patients had no complications, minor complications were seen in 4.7% (n = 1) patients and a major complication was seen in 4.7% (n = 1) patients. In the surgery group, no complications were seen in 13 patients, major complications were seen in 28.57% (n = 6) patients and minor complications were seen in 9.5% (n = 2) patients.

CONCLUSION

Over a follow-up period of 3 years, DPAI is non-inferior to surgery in the treatment of CE of the liver, while there is a statistically significant difference in the hospital stay and occurrence of complications. Advances in knowledge: DPAI offers advantages such as a short hospital stay, minimal invasiveness and morbidity, while being non-inferior to surgery. Total Immunoglobulin G antibody titres have limited utility in follow-up of patients treated.

The Echinococcoses: Diagnosis, Clinical Management and Burden of Disease

The echinococcoses are chronic, parasitic diseases that are acquired after ingestion of infective taeniid tapeworm eggs from certain species of the genus Echinococcus. Cystic echinococcosis (CE) occurs worldwide, whereas, alveolar echinococcosis (AE) is restricted to the northern hemisphere, and neotropical echinococcosis (NE) has only been identified in Central and South America. Clinical manifestations and disease courses vary profoundly for the different species of Echinococcus. CE presents as small to large cysts, and has commonly been referred to as 'hydatid disease', or 'hydatidosis'. A structured stage-specific approach to CE management, based on the World Health Organization (WHO) ultrasound classification of liver cysts, is now recommended. Management options include percutaneous sterilization techniques, surgery, drug treatment, a 'watch-and-wait' approach or combinations thereof. In contrast, clinical manifestations associated with AE resemble those of a 'malignant', silently-progressing liver disease, with local tissue infiltration and metastases. Structured care is important for AE management and includes WHO staging, drug therapy and long-term follow-up for at least a decade. NE presents as polycystic or unicystic disease. Clinical characteristics resemble those of AE, and management needs to be structured accordingly. However, to date, only a few hundreds of cases have been reported in the literature. The echinococcoses are often expensive and complicated to treat, and prospective clinical studies are needed to better inform case management decisions.

Current status of diagnosis and treatment of hepatic echinococcosis

Echinococcus granulosus (E. granulosus) and Echinococcus multilocularis (E. multilocularis) infections are the most common parasitic diseases that affect the liver. The disease course is typically slow and the patients tend to remain asymptomatic for many years. Often the diagnosis is incidental. Right upper quadrant abdominal pain, hepatitis, cholangitis, and anaphylaxis due to dissemination of the cyst are the main presenting symptoms. Ultrasonography is important in diagnosis. The World Health Organization classification, based on ultrasonographic findings, is used for staging of the disease and treatment selection. In addition to the imaging methods, immunological investigations are used to support the diagnosis. The available treatment options for E. granulosus infection include open surgery, percutaneous interventions, and pharmacotherapy. Aggressive surgery is the first-choice treatment for E. multilocularis infection, while pharmacotherapy is used as an adjunct to surgery. Due to a paucity of clinical studies, empirical evidence on the treatment of E. granulosus and E. multilocularis infections is largely lacking; there are no prominent and widely accepted clinical algorithms yet. In this article, we review the diagnosis and treatment of E. granulosus and E. multilocularis infections in the light of recent evidence.

The Comparison of 2 New Promising Weapons for the Treatment of Hydatid Cyst Disease: PAIR and Laparoscopic Therapy

BACKGROUND

To compare the effectiveness and safety for hydatid disease treatment, the 2 new minimally invasive therapies: laparoscopic and PAIR (puncture, aspiration, injection, and reaspiration) were compared by systematic meta-analysis.

METHODS

A comprehensive analysis of published cases from 1990 to 2014 was performed using PubMed database. A total of 231 publications on laparoscopic treatment of hydatid cysts and 298 publications on the PAIR treatment were identified. Thirty-eight studies involved 1230 laparoscope-treated subjects and 41 involved 2686 PAIR-treated subjects in this review. The effectiveness and safety of emphasis is placed on the recurrence, insufficient response, death, cure, and postoperative complications. Operation time and hospital stay are also discussed as new evaluation index. The stages of cyst are summarized to determine which stage is suitable for PAIR.

RESULTS

Clinical and parasitological cure occurred in 98.7% of patients undergoing laparoscopic intervention and in 97.5% of patients receiving PAIR plus chemotherapy (P<0.014). Recurrence occurred in 1.0% and 1.6%, respectively (P<0.087). Insufficient response occurred in 0.16% and 0.9%, respectively (P<0.009); 2 patients died in each group (P<0.594). Allergic reaction/urticarial/anaphylactic shock occurs in 0.14% and 4.24% of patients receiving laparoscopic intervention and PAIR plus chemotherapy, respectively (P<0.001). Infection/abscess (5.37% and 2.57%; P<0.001) and surgical-related complications (7.32% and 3.43%; P<0.001) were seen more frequently in laparoscopic intervention subjects than PAIR plus chemotherapy subjects.

CONCLUSIONS

Laparoscopic therapy and PAIR intervention are shown to be safe and effective alternative for open surgery with suitable indication such as cyst type and location. They have different postoperative complication features. The biliary fistula/bile leakage was more frequent in laparoscopic intervention (P<0.001) and fever occurred more in PAIR plus chemotherapy patients.

Do the Hydatid Cysts Have Unusual Localization and Dissemination Ways in the Chest Cavity?

We wanted to report our two cases of intrathoracic extrapulmonary hydatid cyst in pleural cavity due to its rarity. Our first case is a 24-year-old male patient who was admitted with a cystic mass lesion consistent with hydatid cyst which was incidentally detected in inferior lobe of the right lung neighboring to thoracic wall and diaphragm. Our second case is a 32-year-old male patient who was admitted with chest pain and a cystic lesion in apex of the right hemithorax and intercostal field in basal after he had been medically treated due to hydatid cyst of the dome of the liver for two years. The cysts were removed with thoracotomy. Extrapulmonary intrathoracic hydatid cysts were evaluated with regard to invasion ways and treatment indications and methods.

Non-surgical and non-chemical attempts to treat echinococcosis: do they work?

Cystic echinococcosis (CE) and alveolar echinococcosis (AE) are chronic, complex and neglected diseases. Their treatment depends on a number of factors related to the lesion, setting and patient. We performed a literature review of curative or palliative non-surgical, non-chemical interventions in CE and AE. In CE, some of these techniques, like radiofrequency thermal ablation (RFA), were shelved after initial attempts, while others, such as High-Intensity Focused Ultrasound, appear promising but are still in a pre-clinical phase. In AE, RFA has never been tested, however, radiotherapy or heavy-ion therapies have been attempted in experimental models. Still, application to humans is questionable. In CE, although prospective clinical studies are still lacking, therapeutic, non-surgical drainage techniques, such as PAIR (puncture, aspiration, injection, re-aspiration) and its derivatives, are now considered a useful option in selected cases. Finally, palliative, non-surgical drainage techniques such as US- or CT-guided percutaneous biliary drainage, centro-parasitic abscesses drainage, or vascular stenting were performed successfully. Recently, endoscopic retrograde cholangiopancreatography (ERCP)-associated techniques have become increasingly used to manage biliary fistulas in CE and biliary obstructions in AE. Development of pre-clinical animal models would allow testing for AE techniques developed for other indications, e.g. cancer. Prospective trials are required to determine the best use of PAIR, and associated procedures, and the indications and techniques of palliative drainage.

Predictive factors of recurrence after surgical treatment for liver hydatid cyst

BACKGROUND

Hydatid recurrence after surgery is about 10 %. It still constitutes a problem both in terms of pathophysiology and management of recurrence.

AIM

The aim of this study was to assess the management of abdominal hydatid recurrence after surgical treatment for liver hydatid cyst and to identify the predictive factors of recurrence.

METHODS

We retrospectively included all the patients operated on between January 1, 2008, and December 31, 2012, in the Department "B" of Charles Nicolle Hospital (Tunisia), for abdominal hydatid recurrence. Sixteen men and 33 women, with a median age of 45 years, were included. For all patients, clinical variables and morphological and intra-operative characteristics concerning both the hydatid cysts previously treated and the recurrent cysts were collected. Surgical procedures were recorded as well as the immediate and long-term outcomes. Comparative studies were performed: "extrahepatic recurrence versus No," "peritoneal recurrence versus No," and "open approach versus laparoscopic approach." A univariate analysis followed by a multivariate analysis was carried out to determine predictive factors of hydatid recurrence.

RESULTS

Comparative analysis showed that laparoscopic approach, segments II and III localization, and postoperative complications during the first intervention were associated with a greater number of both peritoneal and extrahepatic hydatid recurrence. Multivariate analysis retained the laparoscopic approach as a predictive factor of both peritoneal recurrence (OR 5.5; 95 % CI 1.56; p = 0.008) and abdominal extrahepatic recurrence (OR 3.54; 95 % CI 1.08; p = 0.035).

CONCLUSION

Laparoscopic approach for the treatment of liver hydatid cysts was associated with a higher rate of extrahepatic and peritoneal recurrence than open.

Cystic echinococcosis of the liver: A primer for hepatologists

Cystic echinococcosis (CE) is a complex, chronic and neglected disease with a worldwide distribution. The liver is the most frequent location of parasitic cysts. In humans, its clinical spectrum ranges from asymptomatic infection to severe, potentially fatal disease. Four approaches exist in the clinical management of CE: surgery, percutaneous techniques and drug treatment for active cysts, and the ”watch and wait” approach for inactive cysts. Allocation of patients to these treatments should be based on cyst stage, size and location, available clinical expertise, and comorbidities. However, clinical decision algorithms, efficacy, relapse rates, and costs have never been properly evaluated. This paper reviews recent advances in classification and diagnosis and the currently available evidence for clinical decision-making in cystic echinococcosis of the liver.

Abdominal wall hydatid cyst: case report and review of literature

A 60-year-old woman presented with a swelling in right paraumbilical region of one-year duration. Examination revealed a painless cystic swelling 15 × 10 cm with cough impulse. Ultrasound and CECT abdomen showed a subcutaneous cystic swelling with intramuscular extension. No other intraabdominal cystic lesions were found. Surgical exploration showed a cystic lesion adherent to peritoneum without any intraperitoneal extension. Cyst was carefully excised without any spillage. Gross specimen on opening showed multiple daughter cysts consistent with hydatid cyst, confirming the diagnosis of solitary abdominal wall hydatid cyst.

Justified concern or exaggerated fear: the risk of anaphylaxis in percutaneous treatment of cystic echinococcosis-a systematic literature review

Percutaneous treatment (PT) emerged in the mid-1980s as an alternative to surgery for selected cases of abdominal cystic echinococcosis (CE). Despite its efficacy and widespread use, the puncture of echinococcal cysts is still far from being universally accepted. One of the main reasons for this reluctance is the perceived risk of anaphylaxis linked to PTs. To quantify the risk of anaphylactic reactions and lethal anaphylaxis with PT, we systematically searched MEDLINE for publications on PT of CE and reviewed the PT-related complications. After including 124 publications published between 1980 and 2010, we collected a total number of 5943 PT procedures on 5517 hepatic and non-hepatic echinococcal cysts. Overall, two cases of lethal anaphylaxis and 99 reversible anaphylactic reactions were reported. Lethal anaphylaxis occurred in 0.03% of PT procedures, corresponding to 0.04% of treated cysts, while reversible allergic reactions complicated 1.7% of PTs, corresponding to 1.8% of treated echinococcal cysts. Analysis of the literature shows that lethal anaphylaxis related to percutaneous treatment of CE is an extremely rare event and is observed no more frequently than drug-related anaphylactic side effects.

The risk of anaphylactic shock is the objection most often raised by opponents of percutaneous treatments for cystic echinococcosis, but there are no updated figures on the actual occurrence of anaphylaxis as a complication of this treatment.

To assess the number of lethal and non-lethal anaphylactic reactions following percutaneous aspiration of echinococcal cysts, we systematically reviewed the literature published from 1980–2010.

The analysis of the available literature shows that the risk of severe anaphylactic reactions resulting from percutaneous treatment of echinococcal cysts has been widely exaggerated and the actual risk may be lower than that following administration of certain antibiotics.

Provided adequate stand-by resuscitation measures are available, each time an echinococcal cyst is punctured, fear of anaphylactic shock is no longer justified as an argument to avoid this therapeutic option.

Percutaneous aspiration and drainage with adjuvant medical therapy for treatment of hepatic hydatid cysts

AIM: To determine the efficacy and success of percutaneous aspiration irrigation and reaspiration (PAIR) in the management of hepatic hydatidosis.

METHODS: Twenty-six patients with 32 hepatic hydatid cysts had PAIR. Twenty-two patients received at least 2 wk of drug therapy before the procedure was carried out to reduce the risk of recurrence from spillage during the procedure. The procedure was performed under local anesthesia with a 19-gauge 20 cm long needle, the cyst was punctured, cystic content (approximately 30 mL) was aspirated by a 12-14 F pigtail catheter and aspirated fluids were sent for analysis. Once the cyst was almost empty, two-thirds of the net amount of material aspirated was replaced by hypertonic saline and left in the cavity for about 30 min, with the catheter left in place for reaspiration of most of the fluid. When the amount of fluid drained was less than 10 mL per 24 h, the drainage catheter was removed.

RESULTS: All 32 cysts showed evidence of immediate collapse after completion of the procedure, and before discharge from hospital, ultrasound examination showed fluid reaccumulation in all cysts. Serial follow-up showed a progressive decrease in the size and change in the appearance of cysts. To confirm the sterility of these cystic cavities, seven cysts were reaspirated on average 3 mo after the procedure. Investigations revealed no viable scolices.

CONCLUSION: PAIR using hypertonic saline is very effective and safe with proper precautions.

Percutaneous needle aspiration, injection, and re-aspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts

BACKGROUND

Hepatic hydatid cyst is an important public health problem in parts of the world where dogs are used for cattle breeding. Management of uncomplicated hepatic hydatid cysts is currently surgical. However, the puncture, aspiration, injection, and re-aspiration (PAIR) method with or without benzimidazole coverage has appeared as an alternative over the past decade.

OBJECTIVES

To assess the benefits and harms of PAIR with or without benzimidazole coverage for patients with uncomplicated hepatic hydatid cyst in comparison with sham/no intervention, surgery, or medical treatment.

SEARCH STRATEGY

The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, DARE, and ACP Journal Club and full text searches were combined (all searched October 2010). Reference lists of pertinent studies and other identified literature were scanned. Researchers in the field were contacted.

SELECTION CRITERIA

Only randomised clinical trials using the PAIR method with or without benzimidazole coverage as the experimental treatment of uncomplicated hepatic hydatid cyst (ie, hepatic hydatid cysts, which are not infected and do not have any communication with the biliary tree or other viscera) versus no intervention, sham puncture (ie, performing all steps for puncture, pretending PAIR being performed, but actually not performing the procedure), surgery, or chemotherapy were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, and the risk of bias in each trial was assessed by the authors. Principal authors of the trials were contacted to retrieve missing data.

MAIN RESULTS

We found no randomised clinical trials comparing PAIR versus no or sham intervention. We identified only two randomised clinical trials, one comparing PAIR versus surgical treatment (n = 50 participants) and the other comparing PAIR (with or without albendazole) versus albendazole alone (n = 30 participants). Both trials were graded as 'adequate' for allocation concealment; however, generation of allocation sequence and blinding methods were 'unclear' in both. Compared to surgery, PAIR plus albendazole obtained similar cyst disappearance and mean cyst diameter with fewer adverse events (32% versus 84%, P < 0.001) and fewer days in hospital (mean + SD) ( 4.2 + 1.5 versus 12.7 + 6.5 days, P < 0.001). Compared to albendazole, PAIR with or without albendazole obtained significantly more (P < 0.01) cyst reduction and symptomatic relief.

AUTHORS' CONCLUSIONS

PAIR seems promising, but there is insufficient evidence to support or refute PAIR with or without benzimidazole coverage for treating patients with uncomplicated hepatic hydatid cyst. Further well-designed randomised clinical trials are necessary to address the topic.

Human echinococcosis: a neglected disease

Echinococcosis is among the most neglected parasitic diseases. Development of new drugs and other treatment modalities receives very little attention, if any. In most developed countries, Cystic Echinococcosis (CE) is an imported disease of very low incidence and prevalence and is found almost exclusively in migrants from endemic regions. In endemic regions, predominantly settings with limited resources, patient numbers are high. Whole communities do not have access to appropriate treatment. The choice of treatment modalities is limited because of poor infrastructure and shortage of equipment and drugs. In this context, CE meets the criteria for a neglected disease. Furthermore, the terminology related to the designations around the parasite, its evolution and some therapeutic procedures is not uniform and sometimes inappropriate terms and wrong designations are used based on incorrect concepts. Although all of us know the different aspects of the disease it is pertinent to remember some important points and, above all, to clarify some aspects concerning the hydatid cyst's nomenclature in order to understand better the therapeutic options in the liver locations, particularly the different surgical approaches.

Predisposing factors and surgical outcome of complicated liver hydatid cysts

AIM: To evaluate the predisposing factors for peritoneal perforation and intrabiliary rupture and the effects of these complications on surgical outcome in liver hydatid disease.

METHODS: A total of 372 patients with liver hydatid cysts who had undergone surgical treatment were evaluated retrospectively. Twenty eight patients with peritoneal perforation, 93 patients with spontaneous intrabiliary perforation, and 251 patients with noncomplicated hydatid cysts were treated in our clinics.

RESULTS: When the predisposing factors for complications were evaluated, younger age, superficial position, and larger cyst dimensions (P < 0.05; range, 0.001-0.017) increased peritoneal perforation rates. It was shown that older age increased cyst dimensions, and presence of multiple and bilobar cysts increased intrabiliary rupture rates (P < 0.05; range, 0.001-0.028). Partial pericystectomy and drainage was the most frequent surgical procedure in all groups (71.6%). The incidence of post-operative complications in the peritoneal perforated group, in the intrabiliary ruptured group, and in the noncomplicated group was 25%, 16.1% and 5.5%, respectively. When compared, complication rates were significantly different (P = 0.002). When length of hospital stay was compared, there was no significant difference between the groups (P > 0.05). The overall recurrence rate was 3.8% (14 patients), but there was not any statistical difference among the patient groups (P = 0.13). The early postoperative mortality rate was 1.1%.

CONCLUSION: In peritoneally perforated and intrabiliary ruptured cases, the most important steps are irrigation of the peritoneal cavity and clearance of the cystic material from the biliary tree.

Experience with video-assisted thoracoscopic removal of pulmonary hydatid cysts in children

Pulmonary hydatid disease is prevalent in many parts of world including India. In our small series of 5 pediatric patients, all patients were diagnosed with clinical and radiological findings on plain X-ray chest and CT (Computed Tomography) chest. All of them received oral albendazole 10 mg/kg/day soon after diagnosis except in one patient in which preoperative differential diagnosis was bronchogenic cyst and lung abscess (case 4). All underwent video assisted thoracoscopy. Simple endotracheal intubation was utilized in all cases along with CO(2) insufflation. Complete thoracoscopic removal was successful in 3 cases, while conversion to open thoracotomy was required in 2 cases. All of them showed rapid recovery except for one patient in whom prolonged intercostal drainage was present for 2 weeks. The average duration of procedure was 150 minutes and average length of hospital stay was 4.5 days except case 2, which was discharged on day 15 due to prolonged air leak. Histopathology in all cases was suggestive of hydatid cyst. At mean follow up of 6 months, all patients are asymptomatic and doing well.

Clinical and sonographic management of viable hydatid liver cysts

AIM

The aim of this study was to review our 18-year experience in the treatment of viable hydatid liver cysts (HLCs) with double percutaneous aspiration and ethanol injection (D-PAI) and to provide indications for the clinical management of HLCs.

MATERIALS AND METHODS

From January 1989 to December 2007, 127 patients (100 males; 13-80 years) with 184 viable HLCs (137 univesicular, 47 multivesicular; 2.8-20 cm) underwent D-PAI.

RESULTS

Ultrasonography (US) showed complete disappearance of 125/184 (68%) cysts; in the remaining 59 cases, an inactive solid (37 cases, 20%) or liquid pattern (22 cases, 12%) was observed with volume decreases of 50-80%. The final US pattern was unmodified during the follow-up in 96.8%. Local recurrences were observed in 5 patients (3.9%): 4 patients with 8 multivesicular cysts and 1 patient with a bilocular cyst (with a solid pattern on US) that ruptured into the biliary tree 2 years after the procedure and disappeared after endoscopic sphincterectomy. The mortality rate was 0.8%, and the overall morbidity was 8.6%. The mean hospital stay was 2.9 days. The time of healing for smaller cysts (<5 cm) was shorter than that of large cysts (≥5 cm) (P < 0.001).

CONCLUSION

Our long-term results confirm the high effectiveness of D-PAI in the treatment of HLCs. These results suggest that multilocular cysts require closer follow-up than unilocular cysts.

Long-term results of percutaneous treatment of hydatid liver cysts: a single center 17 years experience

BACKGROUND

Liver cystic echinococcosis is considered a relatively benign disease, nevertheless, treatment is mandatory in symptomatic cysts and recommended in active cysts because of the risk of severe complications. Surgery is still considered the gold standard treatment. In the last two decades percutaneous injection of scolicidal agents has been developed with excellent results in terms of disappearance of the cyst, very low side effects and low mortality rate.

MATERIALS AND METHODS

One hundred sixty eight patients with 225 liver cysts were studied. A total of 108 patients with 151 viable hydatid liver cysts underwent Double Percutaneous Aspiration and Injection of alcohol of the cyst without re-aspiration of the ethanol, which remained in situ.

RESULTS

The mortality rate was 0.9% (1 patient), the overall morbidity was 8.6% with only 2.5% of major side effects. The mean hospital stay was very short (2.9 days). Follow-up ranged from 14 to 204 months (median 48 months). Ultrasonography showed complete disappearance of the cyst with reconstitution of liver parenchyma in 109 out of 225 (48.4%) cysts; in the remaining cysts a solid or a liquid findings were observed in 104 (46.2%) and 12 (5.3%), respectively, with a decreased volume of 50-80%.

CONCLUSION

These data show that Double Percutaneous Aspiration and Injection of alcohol for hydatid liver cysts can achieve comparable results to open surgery. The low incidence of side effects shows that this technique is safe and cost effective, compared to radical or conservative surgery.

Peritoneal perforation of liver hydatid cysts: clinical presentation, predisposing factors, and surgical outcome

The aim of this study was to evaluate the clinical presentation of, predisposing factors in, and early and long-term outcome of patients treated surgically for intraperitoneal ruptured liver hydatid cysts. Medical records of 27 patients with traumatic rupture of hydatid cysts were evaluated retrospectively, as were records of 347 patients with nonperforated hydatid cysts. The ratio of perforation cases to nonperforation cases was 7.8%. Traffic accidents were the most common cause of perforation (n = 16). All patients had abdominal findings, and two patients (7%) had anaphylactic findings. The sensitivities of computed tomography and ultrasonography were 100% and 93%, respectively. Conservative surgical procedures were used for 80.5% of cysts and radical procedures for 19.5%. Associated organ injuries were determined in 10 patients. No significant difference was found between patients with peritoneal perforation and those without perforation in terms of sex (p = 0.403), previous hydatid disease surgery (p = 0.565), localization (p = 0.241), number of cysts (p = 0.537), presence of cystic content infection (p = 0.65), or presence of bile duct communication (p = 0.37). However, there were significant differences in age (p = 0.004), cyst diameter ( > 10 cm) (p = 0.03), and presence of superficially localized cysts (p = 0.011). Three patients developed recurrence. In the group of patients with perforation, the complication and recurrence rates were not statistically different in a comparison of surgical techniques (p = 0.37). No postoperative deaths occurred. The main predisposing factors for cyst perforation are young age and superficial localization. Peritoneal rupture increases the rates of postoperative morbidity and recurrence; in contrast, there was no significant relation between the operative procedure and the morbidity and recurrence rates.

Hydatid disease of the parotid gland: a rare case report

A 40-year-old female suffering from hydatid disease located in the parotid gland is presented. Although Greece remains an endemic area for echinococcosis, this presentation of the disease is rare. Total excision of the cyst with partial parotidectomy was performed. The patient refused to receive general anesthesia and the operation was carried out under local anesthesia. Perioperative adjuvant medical therapy with albendazole was administered. In a two-year follow-up no recurrence has occurred.

Percutaneous treatment of giant abdominal hydatid cysts: long-term results

BACKGROUND

This study aimed to evaluate the efficacy of percutaneous treatment of giant abdominal hydatid cysts.

METHODS

In this study, 15 abdominal giant hydatid cysts were treated with the catheterization technique, which included puncture of the cyst, aspiration of fluid, instillation and respiration of hypertonic saline solution, and catheterization and sclerosant therapy with absolute ethanol followed by free drainage of the cavity. The catheter was removed when the daily drainage was less than 10 ml.

RESULTS

The goals, including inactivation of the parasite and elimination of the mass effect, were achieved in all patients. Catheterization required a mean of 32 days (range, 14-52 days) and hospitalization a mean of 8.73 days (range, 2-30 days). No evidence for recurrence was observed in any patient during a mean follow-up period of 52.8 months (range, 36-72 months).

CONCLUSION

Percutaneous treatment of giant hydatid cysts is effective because it eliminates both the mass effect and the parasite and alleviates the symptoms. Although the long catheterization time associated with the procedure is unfavorable, it is tolerated by the patients.

Percutaneous imaging-guided treatment of hydatid liver cysts: Do long-term results make it a first choice?

AIM

To evaluate the long-term results of percutaneous imaging-guided treatment of hydatid liver cysts.

MATERIALS AND METHODS

Sixty patients with 77 hydatid liver cysts underwent percutaneous treatment with ultrasonography (US) or computed tomography (CT) guidance. Absolute alcohol and hypertonic saline were used for sclerosing the cysts after aspiration. Prophylactic albendazole treatment was given before and after the procedures. Follow-up US and CT were obtained periodically, and changes in cyst morphology were recorded. Minimum follow-up period for the patients included in this study was 12 months. Serological correlation was also available for a group of patients. The outcome of the procedures were categorized into five groups based on morphological changes observed by imaging.

RESULTS

Procedures were regarded as successful in 80% and unsuccessful in 20% of patients. Failures most often occurred with type III cysts; less than half (39%) of the total type III cysts had a successful outcome. On the other hand, all type I cysts ended up with cure. Anaphylaxis, pneumotorax and severe pain interrupting the procedures were also among the reasons of failure.

CONCLUSION

Percutaneous aspiration, injection and reaspiration (PAIR) of types I and II hydatid liver cysts is effective and safe in the long-term. Surgery should no longer be regarded as the first choice treatment in all hydatid liver cysts but should be reserved for type III and certain active type IV cysts.

Cystic Hydatic Disease in Sheep: Treatment with Percutaneous Aspiration and Injection with Dipeptide Methyl Ester

An in vitro and in vivo study was conducted to show the effect of dipeptide methyl ester on the protoscolices of Echinococcus granulosus and in naturally infected sheep. Easily punctured cysts were located by ultrasonography. A PAIR and PAI method were performed by the injection of dipeptide methyl ester into these cysts at a final concentration of 110 mmol/L. Follow-up was conducted monthly by ultrasonography. After injection of the compound, the sheep were sacrificed at different times from 6 to 17 weeks. The size and the morphological aspect of treated cysts were noted. Samples were collected for histology and electron microscopy. In conclusion, these studies revealed significant and rapid detachment of the membrane of the treated cyst and alteration of the inner membrane in less than 5 min after injection of the drug, confirming the effect of the compound on the laminated layer of the parasite.

Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts

BACKGROUND

Hepatic hydatid cyst is an important public health problem in parts of the world where dogs are used for cattle breeding. Management of uncomplicated hepatic hydatid cysts is currently surgical. However, the puncture, aspiration, injection, and re-aspiration (PAIR) method with or without benzimidazole coverage has appeared as an alternative to surgery over the past decade.

OBJECTIVES

To assess the benefits and harms of PAIR with or without benzimidazole coverage for patients with uncomplicated hepatic hydatid cyst in comparison with sham/no intervention, surgery, or medical treatment.

SEARCH STRATEGY

The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Controlled Trials Register in The Cochrane Library, MEDLINE, EMBASE, DARE, and ACP Journal Club and full text searches were combined (all searched October 2004). Reference lists of pertinent studies and other identified literature were scanned. Researchers in the field were contacted.

SELECTION CRITERIA

Only randomised clinical trials using the PAIR method with or without benzimidazole coverage as the experimental treatment of uncomplicated hepatic hydatid cyst (ie, hepatic hydatid cysts which are not infected and do not have any communication with the biliary tree or other viscera) versus no intervention, sham puncture (ie, performing all steps for puncture, pretending that PAIR is being performed, but actually not performing the procedure proper), surgery, or chemotherapy were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and methodological quality of each trial was assessed by the authors. Principal authors of the trials were contacted to retrieve missing data.

MAIN RESULTS

We found no randomised clinical trials comparing PAIR versus no or sham intervention. We identified only two randomised clinical trials, one comparing PAIR versus surgical treatment (n = 50) and the other comparing PAIR (with or without albendazole) versus albendazole alone (n = 30). Both trials were graded as 'adequate' for allocation concealment; however, generation of allocation sequence and blinding methods were 'unclear' in both of them. Compared to surgery, PAIR plus albendazole obtain similar cyst disappearance and mean cyst diameter with fewer adverse events (32% versus 84%, P < 0.001) and fewer days in hospital (mean + SD) ( 4.2 + 1.5 versus 12.7 + 6.5 days, P < 0.001). Compared to albendazole, PAIR with or without albendazole obtain significantly more often (P < 0.01) cyst reduction and symptomatic relief.

AUTHORS' CONCLUSIONS

PAIR seems promising, but there is insufficient evidence to support or refute PAIR with or without benzimidazole coverage for treating patients with uncomplicated hepatic hydatid cyst. Further well-designed randomised clinical trials are necessary to address the topic.

Modified pair technique for treatment of hydatid cysts in the spleen

The aim of this study was to evaluate the results of single-session sclerotherapy with mixture of alcohol and polidocanol and a subsequent injection of albendazole for devisceration of hydatid cysts in the spleen. Eight patients (four women and four men, average age 22.9+/-11.4 with hydatid cyst in the spleen were treated with 10 minutes time of exposure to mixture of ethanol 95% and polidocanol 1%. After that, 2 to 5 ml of albendazole was injected into the cyst cavity. Two patients had 2 cysts. At follow-up the patients were examined with clinical and biochemical examinations, ultrasonography, and serologic test for echinococcal antibody titres. The mean hospital stay was 2.5+/-0.93 days. During the follow-up period, mean cyst diameter decreased from 46+/-16.4 mm to 13.6+/-16.26 mm. In all ten cysts, a reduction of post procedural recolection of fluid over 40% was observed. Five cysts (50%) disappeared during the follow-up period. All cysts (5) smaller then 50 mm in diameter disappeared during follow-up period. After an initial rise, the echinococcal-antibody titres fell progressively and at the last follow-up were negative (< 1: 160) in 7 (88%) patients. No complications were observed, except for pain, fever and urticaria during the first 24-hours after the procedure. Sclerotherapy using only one session and 10 min time of exposure to the mixture of ethanol and polidocanol, and a subsequent injection of albendasole solution represents an effective treatment of hydatid cysts in the spleen. This procedure is even more efficacious for hydatid cyst with diametar smaller then 50 mm.

Percutaneous treatment of liver hydatid cysts: comparison of direct injection of albendazole and hypertonic saline solution

OBJECTIVE

The purpose of this study was to compare the effect of intracystic injection of albendazole and hypertonic saline in patients with liver hydatid disease.

MATERIALS AND METHODS

Fifty-nine patients with a total of 109 hydatid cysts were treated percutaneously. In all cases, local anesthesia was applied. Twenty percent hypertonic saline was used in 31 patients (40 cysts, group 1) as the scolicidal agent, and albendazole solution was used in 28 patients (69 cysts, group 2). The PAIR (percutaneous puncture, aspiration, injection, reaspiration) method was applied in group 1. In group 2, we used a different procedure that could be called the PAI (percutaneous aspiration and injection) method. After this procedure, routine sonography and CT examinations were conducted. The results of both groups were compared.

RESULTS

Follow-up examinations showed that liver hydatids expanded approximately to their original size after a significant reduction during the first month. In the follow-up period, fluid contents totally disappeared; thickening and irregularities were also observed in the cyst walls and a solid, hyperechogenic, heterogeneous pseudotumor appearance representing a degenerated membrane was seen in all patients. Hypertonic saline solution inactivated the scolices from the beginning of the treatment. However, scolices were inactive in the cysts aspirated 1 month after the procedure in group 2. A significant correlation was noted between elapsed time after the treatment and the cyst size using Wilcoxon's signed rank test (p = 0.000). No difference was seen between two groups in the amount of cyst size reduction using the Mann-Whitney test (p =0.521).

CONCLUSION

In addition to its oral use, albendazole may be injected intracystically as we did in our study. It sterilizes the cyst cavity and affects scolices as well.

A New Percutaneous Approach for the Treatment of Hydatid Cyst of the Kidney: Long-term Follow-up

Renal hydatid disease is an uncommon benign parasitic infestation compared to liver hydatid disease. Although the treatment of hydatid cysts depends on surgery which is related with high morbidity and an overall local recurrence rates, the following case reports describing two patients with renal hydatid cysts were successfully treated with this new percutaneous method.

Treatment options for hepatic cystic echinococcosis

A number of surgical and non-surgical options exist to treat cystic echinococcosis of the liver. For decades, surgical excision via a conservative or radical approach was the recommended approach for hepatic hydatid cysts. The availability of chemotherapeutic agents with significant activity against Echinococcus granulosis has made it possible to undertake ultrasound- or computed tomography-guided transhepatic percutaneous drainage (termed puncture, aspiration, injection, and re-aspiration (PAIR)) of hydatid cysts. Pre- and post-intervention chemotherapy with albendazole or mebendazole offers the advantage of reducing the risk of disease recurrence and intraperitoneal seeding of infection that may develop via cyst rupture and spillage occurring spontaneously or during surgery or needle drainage. PAIR appears to have greater clinical efficacy (i.e. a higher incidence of cure), lower rates of major and minor complications, mortality, and disease recurrence, and fewer days of hospitalization compared to patients treated surgically. For patients who fail drug therapy alone, PAIR is a safe and effective procedure of choice for patients with hepatic echinococcosis, and perhaps other anatomic sites of infection such as lung, peritoneum, kidney, and other viscera. Surgery should be reserved for patients with hydatid cysts refractory to PAIR because of secondary bacterial infection or for those with difficult-to-manage cyst-biliary communication or obstruction.

Primary Hydatid Cyst in Adrenal Gland: A Case Report

The hydatid cyst of the adrenal gland is extremely rare pathology of the adrenal gland; here we report an adrenal hydatid cyst that presented as a solitary renal tumor.

Percutaneous treatment of a complex hydatid cyst of the liver under sonographic control Report of the first case

Surgical procedures are considered the gold standard treatment of hydatid cysts. We report the first case of percutaneous treatment of a complex hydatid cyst of the liver, using radio frequency as a scolecidal agent in a 28-year-old man. The procedure was performed under real-time ultrasound control and with the patient under general anesthesia. Injection of alcohol was performed at the end of the procedure to induce retraction of the residual cavity. The percutaneous procedure was associated with oral albendazole therapy. Six months after the procedure, the patient was in very good condition. Liver and blood tests were normal and the cyst cavity was reduced. Further studies are required to define the indication of this new therapeutic strategy of hydatid cyst.

Liver hydatid disease: Morphological changes of protoscoleces after albendazole therapy

Background. Postoperative recurrence of the liver hydatid disease befalls approximately 10?30% of patients. Preoperative or postoperative therapy with albendazole in single therapeutic protocol (800 mg/d, within 28 days) indicated the need to evaluate the hydatid cyst liquid protoscoleces viability. Morphological changes of protoscoleces following the treatment with drugs are not well known. Aim. To estimate the viability of protoscoleces after preoperative or postoperative albendazole therapy, and their ability for cystic metamorphosis. Methods. A prospective, randomized clinical trial included 30 patients with liver hydatid disease, treated with albendazole and surgically (I group), and 30 patients in the control group treated only surgically (II group). The concentration of albendazole and its active metabolite albendazole sulphoxide in the cysts contents were determined using HPLC. Estimation of protoscoleces viability was based on the established micromorphologic criteria, and compared between the patients treated with albendazole, and the patients treated only surgically. Biological assessment of the viability was performed on protoscoleces with uncertain signs of the disturbed viability (unchanged structure, evaginated, without movements) using intraperitoneal injection of 1 ml of protoscoleces prepared suspension to AO type of rats. Results. The concentration of albendazole in cysts' contents ranged from 0 to 64.9 ?g/ml, and of its active metabolite from 0.5 to 40.8 ?g/ml. The presence of fully viabile protoscoleces in the albendazol treated patients was significantly lower than in the control group. A significant difference was noticed in the presence of disintegrated protoscoleces without movements in the albendazol treated group, compared to the control group. Biological assessment of the viability showed incapability of these protoscoleces for cystic metamorphoses. Conclusion. Low viability of parasites due to medicamentous therapy is very useful and important to surgeons, because the fertility of cysts is lower, and the risk of the disease recurrence is reduced.

Surgical treatment of hepatic hydatid cyst

Hydatid disease of the liver is caused by the tapeworm Echinococcus granulosus, and the highest incidence of human infestation occurs in sheep and cattle-raising areas. Although, still an uncommon occurrence, it is being seen with increasing frequency; hence, it is important that surgeons make themselves aware of the pathology and treatment of the disease. The liver is most commonly involved, although many other organs, including lungs and brain may also be affected. An echinococcal cyst of the liver was reported in a patient who is a resident in Northern Ireland but had originally lived and worked in mainland Britain. Details of the lifecycle, pathology, diagnostic techniques and surgical management of hydatid cysts are reviewed.

Biological, epidemiological, and clinical aspects of echinococcosis, a zoonosis of increasing concern

Echinococcosis in humans is a zoonotic infection caused by larval stages (metacestodes) of cestode species of the genus Echinococcus. Cystic echinococcosis (CE) is caused by Echinococcus granulosus, alveolar echinococcosis (AE) is caused by E. multilocularis, and polycystic forms are caused by either E. vogeli or E. oligarthrus. In untreated cases, AE has a high mortality rate. Although control is essentially feasible, CE remains a considerable health problem in many regions of the northern and southern hemispheres. AE is restricted to the northern hemisphere regions of North America and Eurasia. Recent studies have shown that E. multilocularis, the causative agent of AE, is more widely distributed than previously thought. There are also some hints of an increasing significance of polycystic forms of the disease, which are restricted to Central and South America. Various aspects of human echinococcosis are discussed in this review, including data on the infectivity of genetic variants of E. granulosus to humans, the increasing invasion of cities in Europe and Japan by red foxes, the main definitive hosts of E. multilocularis, and the first demonstration of urban cycles of the parasite. Examples of emergence or reemergence of CE are presented, and the question of potential spreading of E. multilocularis is critically assessed. Furthermore, information is presented on new and improved tools for diagnosing the infection in final hosts (dogs, foxes, and cats) by coproantigen or DNA detection and the application of molecular techniques to epidemiological studies. In the clinical field, the available methods for diagnosing human CE and AE are described and the treatment options are summarized. The development of new chemotherapeutic options for all forms of human echinococcosis remains an urgent requirement. A new option for the control of E. granulosus in the intermediate host population (mainly sheep and cattle) is vaccination. Attempts are made to reduce the prevalence of E. multilocualaris in fox populations by regular baiting with an anthelmintic (praziquantel). Recent data have shown that this control option may be used in restricted areas, for example in cities, with the aim of reducing the infection risk for humans.

Echinococcosis

Echinococcosis is a near-cosmopolitan zoonosis caused by adult or larval stages of cestodes belonging to the genus Echinococcus (family Taeniidae). The two major species of medical and public health importance are Echinococcus granulosus and Echinococcus multilocularis, which cause cystic echinococcosis and alveolar echinococcosis, respectively. Both are serious and severe diseases, the latter especially so, with high fatality rates and poor prognosis if managed incorrectly. Several reports have shown that both diseases are of increasing public health concern and that both can be regarded as emerging or re-emerging diseases. In this review we discuss aspects of the biology, life cycle, aetiology, distribution, and transmission of the Echinococcus organisms, and the epidemiology, clinical features, treatment, and diagnosis of the diseases they cause. We also discuss the countermeasures available for the control and prevention of these diseases. E granulosus still has a wide geographical distribution, although effective control against cystic echinococcosis has been achieved in some regions. E multilocularis and alveolar echinococcosis are more problematic, since the primary transmission cycle is almost always sylvatic so that efficient and cost-effective methods for control are unavailable.

Percutaneous aspiration-injection-reaspiration drainage plus albendazole or mebendazole for hepatic cystic echinococcosis: a meta-analysis

Using meta-analysis methodology, we compared the clinical outcomes for 769 patients with hepatic cystic echinococcosis treated with percutaneous aspiration-injection-reaspiration (PAIR) plus albendazole or mebendazole (group 1) with 952 era-matched historical control subjects undergoing surgical intervention (group 2). The rate of clinical and parasitologic cure (P<.0001) was greater in patients receiving PAIR plus chemotherapy. Disease recurrence (P<.0001), major complications (anaphylaxis, biliary fistula, cyst infection, liver/intra-abdominal abscess, and sepsis; P<.0001), minor complications (P<.0001), and death (P<.0824) occurred more frequently among surgical control subjects. Fever (P<.002) and minor allergic reactions subjects (P<.0001) were more common among PAIR-treated subjects. The mean durations of hospital stay were 2.4 days for group 1 and 15.0 days for group 2 (P<.001). Compared with surgery, PAIR plus chemotherapy is associated with greater clinical and parasitologic efficacy; lower rates of morbidity, mortality, and disease recurrence; and shorter hospital stays.

Percutaneous sonographically guided treatment of hydatid cysts in sheep: direct injection of mebendazole and albendazole

OBJECTIVE

The purpose of this study was to investigate the scolicidal effect of intracystic injection of benzimidazolic solutions in naturally infected sheep with hydatid disease.

METHODS

Twenty-four sheep with 37 hydatid cysts were included in this study for percutaneous treatment with benzimidazolic solutions. The animals were divided into 3 groups: group I, treatment group with mebendazole; group II, treatment group with albendazole; and group III, control group with distilled water. All solutions were given percutaneously under sonographic guidance. Cyst contents were aspirated with a needle, and then scolicidal solutions were injected into the cysts; reaspiration was not done. Routine follow-up sonographic images were taken on the 15th day after treatment, then once per month for 3 months, and then at 3-month intervals thereafter. At the 1-month follow-up, the percutaneous aspirate yielded orange juice-like material containing necrotic debris without living scolices.

RESULTS

Sonography showed a reduction in cyst size in the benzimidazolic groups (groups I and II) and progressive changes in echo patterns. An anaphylactic reaction was observed during the procedure in 1 animal. After 12 months of sonographic follow-up, the animals in all groups were killed, and macroscopic and microscopic changes in tissue samples were evaluated. At autopsy, no cysts with living scolices were found in the benzimidazolic groups, and the appearance of the treated cysts was different from that of those in the control group. Microscopic examination showed the degeneration, necrosis, and thickening of the cyst walls in the treatment groups.

CONCLUSIONS

Intracystic injection of benzimidazolic solutions as scolicidal agents may be used for percutaneous treatment of hepatic hydatid cysts in sheep.