Is the Adjuvant Albendazole Treatment Really Needed with PAIR in the Management of Liver Hydatid Cysts? A Prospective, Randomized Trial with Short-Term Follow-Up Results

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.

Treatment of uncomplicated hepatic cystic echinococcosis (hydatid disease)

BACKGROUND

Cystic echinococcosis is a parasitic infection mainly impacting people living in low- and middle-income countries. Infection may lead to cyst development within organs, pain, non-specific symptoms or complications including abscesses and cyst rupture. Treatment can be difficult and varies by country. Treatments include oral medication, percutaneous techniques and surgery. One Cochrane review previously assessed the benefits and harms of percutaneous treatment compared with other treatments. However, evidence for oral medication, percutaneous techniques and surgery in specific cyst stages has not been systematically investigated and the optimal choice remains uncertain.

OBJECTIVES

To assess the benefits and harms of medication, percutaneous and surgical interventions for treating uncomplicated hepatic cystic echinococcosis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, two other databases and two trial registries to 4 May 2023. We searched the reference lists of included studies, and contacted experts and researchers in the field for relevant studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in people with a diagnosis of uncomplicated hepatic cystic echinococcosis of World Health Organization (WHO) cyst stage CE1, CE2, CE3a or CE3b comparing either oral medication (albendazole) to albendazole plus percutaneous interventions, or to surgery plus albendazole. Studies comparing praziquantel plus albendazole to albendazole alone prior to or following an invasive intervention (surgery or percutaneous treatment) were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were symptom improvement, recurrence, inactive cyst at 12 months and all-cause mortality at 30 days. Our secondary outcomes were development of secondary echinococcosis, complications of treatment and duration of hospital stay. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included three RCTs with 180 adults and children with hepatic cystic echinococcosis. Two studies enrolled people aged 5 to 72 years, and one study enrolled children aged 6 to 14 years. One study compared standard catheterization plus albendazole with puncture, aspiration, injection and re-aspiration (PAIR) plus albendazole, and two studies compared laparoscopic surgery plus albendazole with open surgery plus albendazole. The three RCTs were published between 2020 and 2022 and conducted in India, Pakistan and Turkey. There were no other comparisons. Standard catheterization plus albendazole versus PAIR plus albendazole The cyst stages were CE1 and CE3a. The evidence is very uncertain about the effect of standard catheterization plus albendazole compared with PAIR plus albendazole on cyst recurrence (risk ratio (RR) 3.67, 95% confidence interval (CI) 0.16 to 84.66; 1 study, 38 participants; very low-certainty evidence). The evidence is very uncertain about the effects of standard catheterization plus albendazole on 30-day all-cause mortality and development of secondary echinococcosis compared to open surgery plus albendazole. There were no cases of mortality at 30 days or secondary echinococcosis (1 study, 38 participants; very low-certainty evidence). Major complications were reported by cyst and not by participant. Standard catheterization plus albendazole may increase major cyst complications compared with PAIR plus albendazole, but the evidence is very uncertain (RR 10.74, 95% CI 1.39 to 82.67; 1 study, 53 cysts; very low-certainty evidence). Standard catheterization plus albendazole may make little to no difference on minor complications compared with PAIR plus albendazole, but the evidence is very uncertain (RR 1.03, 95% CI 0.60 to 1.77; 1 study, 38 participants; very low-certainty evidence). Standard catheterization plus albendazole may increase the median duration of hospital stay compared with PAIR plus albendazole, but the evidence is very uncertain (4 (range 1 to 52) days versus 1 (range 1 to 15) days; 1 study, 38 participants; very low-certainty evidence). Symptom improvement and inactive cysts at 12 months were not reported. Laparoscopic surgery plus albendazole versus open surgery plus albendazole The cyst stages were CE1, CE2, CE3a and CE3b. The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on cyst recurrence in participants with CE2 and CE3b cysts compared to open surgery plus albendazole (RR 3.00, 95% CI 0.13 to 71.56; 1 study, 82 participants; very low-certainty evidence). The second study involving 60 participants with CE1, CE2 or CE3a cysts reported no recurrence in either group. The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on 30-day all-cause mortality in participants with CE1, CE2, CE3a or CE3b cysts compared to open surgery plus albendazole. There was no mortality in either group (2 studies, 142 participants; very low-certainty evidence). The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on major complications in participants with CE1, CE2, CE3a or CE3b cysts compared to open surgery plus albendazole (RR 0.50, 95% CI 0.13 to 1.92; 2 studies, 142 participants; very low-certainty evidence). Laparoscopic surgery plus albendazole may lead to slightly fewer minor complications in participants with CE1, CE2, CE3a or CE3b cysts compared to open surgery plus albendazole (RR 0.13, 95% CI 0.02 to 0.98; 2 studies, 142 participants; low-certainty evidence). Laparoscopic surgery plus albendazole may reduce the duration of hospital stay compared with open surgery plus albendazole (mean difference (MD) -1.90 days, 95% CI -2.99 to -0.82; 2 studies, 142 participants; low-certainty evidence). Symptom improvement, inactive cyst at 12 months and development of secondary echinococcosis were not reported.

AUTHORS' CONCLUSIONS

Percutaneous and surgical interventions combined with albendazole can be used to treat uncomplicated hepatic cystic echinococcosis; however, there is a scarcity of randomised evidence directly comparing these interventions. There is very low-certainty evidence to indicate that standard catheterization plus albendazole may lead to fewer cases of recurrence, more major complications and similar complication rates compared to PAIR plus albendazole in adults and children with CE1 and CE3a cysts. There is very low-certainty evidence to indicate that laparoscopic surgery plus albendazole may result in fewer cases of recurrence or fewer major complications compared to open surgery plus albendazole in adults and children with CE1, CE2, CE3a and CE3b cysts. Laparoscopic surgery plus albendazole may lead to slightly fewer minor complications. Firm conclusions cannot be drawn due to the limited number of studies, small sample size and lack of events for some outcomes.

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.

Percutaneous Treatment of Giant Hydatid Cysts and Cystobiliary Fistula Management

RATIONALE AND OBJECTIVES

To investigate the efficacy and safety of percutaneous treatment in cystic echinococcosis (CE) type 1 and 3a giant cysts (with at least one diameter>10 cm) according to the World Health Organization classification and to evaluate the management of complications, especially cystobiliary fistulas (CBFs).

MATERIALS AND METHODS

This retrospective study included 66 patients with 68 CE1 and CE3a giant cysts treated with percutaneous catheterization between January 2016 and December 2021. The characteristics of the cysts, major and minor complications, time to catheter removal, and length of hospital stay were recorded.

RESULTS

Among the 68 cysts, CBFs occurred in 35 (51.5%), cavity infections in 11 (16.1%), recollection in five (7.4%), and anaphylaxis in three (4.5%). There was no mortality. Biliary drainage was observed intraoperatively in 20 (29.4%) and only postoperatively in 15 (22.1%) of the 35 cysts with CBFs. A plastic biliary stent was placed in 18 (51.5%) of the 35 cysts with CBFs. The patients with CBFs had a longer hospital stay and time to catheter removal than those without fistulas (15.3 ± 10.9 vs. 6.1 ± 2.6 days and 32.7 ± 51.8 vs. 6.2 ± 3.1 days, respectively; P < 0.001). Of the patients who developed recollection, three were treated with secondary catheterization, and two underwent surgery. In total, three patients underwent surgery. The rate of clinical success was 95.4%. All cysts were followed up for an average of 19.1 (range, 12-60) months, and there was an average 88.8% reduction in cyst volume compared to the initial evaluation.

CONCLUSION

CE1 and CE3a giant cysts can be treated effectively and safely with high clinical success using the catheterization technique. Contrary to what has previously been reported for these patients, the rate of CBFs is high, but these patients can successfully be treated with percutaneous drainage and/or endoscopic retrograde cholangiopancreatography without the requirement of surgery.

Percutaneous treatment of giant hydatid cysts: a single-center experience of 58 cysts

PURPOSE

The aim of this study is to evaluate the efficacy of percutaneous treatment in hydatid cysts (HCs) with at least one diameter larger than 10 cm.

MATERIALS AND METHODS

58 CE1 or CE3a HCs with at least one diameter larger than 10 cm which were treated with catheterization between September 2016 and December 2021 were retrospectively analyzed.

RESULTS

Mean age was 40 ± 17.7 (18-80). Majority of HCs were in the liver (89.6%). Median follow-up was 28 months. Technical success rate was 100%; however, a second procedure was needed in 13 cysts due to recollection (n = 4), infection (n = 6), and recurrence (n = 3).

CONCLUSIONS

Giant HCs can be effectively treated with catheterization with low complication rates.

Liver cystic echinococcosis: a parasitic review

Liver cystic echinococcosis (CE), known as hydatid disease, is caused by the tapeworm Echinococcus granulosus sensu lato. Humans are accidental hosts in this zoonotic disease process, and hepatic infection accounts for over two-thirds of all cases. Since signs and symptoms are mainly non-specific, especially in early disease, clinicians should have a low threshold to include CE as a differential diagnosis in patients with positive serology and suggestive radiological findings, especially in endemic regions. The standard management for liver CE depends on the patient's symptoms, the radiological stage, the size and location of the cyst, the presence of complications and the treating clinicians' expertise. In this review, we discuss the lifecycle of Echinococcus granulosus sensu lato and its epidemiology and then focus on discussing the clinical features, diagnosis and treatment options of CE of the liver.

Benign liver lesions 2022: Guideline for clinical practice of Associazione Italiana Studio del Fegato (AISF), Società Italiana di Radiologia Medica e Interventistica (SIRM), Società Italiana di Chirurgia (SIC), Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Associazione Italiana di Chirurgia Epatobilio-Pancreatica (AICEP), Società Italiana Trapianti d'Organo (SITO), Società Italiana di Anatomia Patologica e Citologia Diagnostica (SIAPEC-IAP) - Part I - Cystic lesions

Benign liver lesions are increasingly diagnosed in daily clinical practice due to the growing use of imaging techniques for the study of the abdomen in patients who have non-specific symptoms and do not have an increased risk of hepatic malignancy. They include simple or parasitic cysts and solid benign tumors which differ widely in terms of prevalence, clinical relevance, symptoms and natural history and often lead to significant clinical problems relating to diagnosis and clinical management. Following the need to have updated guidelines on the management of benign focal liver lesions, the Scientific Societies mainly involved in their management have promoted the drafting of a new dedicated document. This document was drawn up according to the present Italian rules and methodologies necessary to produce clinical, diagnostic, and therapeutic guidelines based on evidence. Here we present the first part of the guideline, concerning the characterization of focal hepatic lesions detected by ultrasound, and the diagnosis and clinical management of simple and parasitic hepatic cysts, and of polycystic liver disease.

Case Report: Imaging-Guided Percutaneous Catheterization and Microwave Ablation of a Bone Hydatid Cyst with Soft-Tissue Component

Cystic echinococcosis (CE) of the bone is a rare disease compared with CE of the viscera, and the most involved bony structures are the spine and the pelvis. Both the diagnosis and the treatment of bone CE are challenging for several reasons. The combination of surgery and antimicrobial therapy is the most common approach, the results are far from adequate. Luckily, percutaneous treatment has appeared on the horizon for bone lesions as a more practical option with fewer drawbacks in light of current reports. This article deals with the successful result of ablation-assisted percutaneous treatment of a bone CE lesion and a soft tissue CE lesion treated by modified catheterization technique in a male patient with left hip pain that was unresponsive to previous surgery for CE.

Prospective collection of clinical data on cystic echinococcosis: experience with the European Registry of Cystic Echinococcosis in Pavia, Italy

BACKGROUND

Cystic echinococcosis (CE) is a chronic, complex and neglected infection that may cause serious disease in humans. Given its peculiar epidemiologic and clinical features, collection of clinical data is challenging. Notification systems, when available, fail to record important clinical features, available data are mostly retrospectively collected and no prospectively enrolled uniform surveillance systems exist. The European Register of Cystic Echinococcosis database (ERCE) is the first systematic attempt to address these issues.

METHODS

Here, we describe the demographics and clinical characteristics of 436 patients who accessed the CE clinic at the University of Pavia-San Matteo Hospital Foundation, in Pavia, Italy, from March 2012 to February 2020.

RESULTS

Overall, 436 patients, consisting of 204 (46.8%) males and 232 (53.2%) females were enrolled; the mean age at enrollment was 50 (range 4-88) y. Of the 436 patients, 248 (56.9%) were born in Italy while 188 (43.1%) were foreign-born. In total, 638 CE cysts were counted, most of them in the CE4 (230; 36.1%) and CE3b (131; 20.5%) stages.

CONCLUSIONS

This is the largest cohort of CE patients with detailed clinical and demographic data published to date. We strongly encourage colleagues caring for CE patients in the European Union to join the ERCE.

Percutaneous Versus Surgical Interventions for Hepatic Cystic Echinococcosis: A Systematic Review and Meta-Analysis

Purpose

This systematic review and meta-analysis summarises the current literature on invasive treatment options of cystic hepatic echinococcosis (CE), comparing percutaneous radiological interventions to surgery, still the cornerstone of treatment in many countries.

Methods

A literature search was conducted in Medline and EMBASE databases (PROSPERO registration number: CRD42019126150). The primary outcome was recurrence of cysts after treatment. Secondary outcomes were complications, duration of hospitalisation, mortality and treatment conversion.

Results

The number of eligible prospective studies, in particular RCTs, was limited. In the four included studies, only conventional surgery is compared directly to percutaneous techniques. From the available data, in terms of recurrence, percutaneous treatment of hydatid cysts is non-inferior to open surgery. With regard to complications and length of hospital stay, outcomes favour percutaneous therapy.

Conclusion

Although evidence from prospective research is small, percutaneous treatment in CE is an effective, safe and less invasive alternative to surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00270-021-02911-4.

Renal Cystic Echinococcosis: Long-Term Outcomes of Percutaneous Treatment

PURPOSE

To evaluate the long-term outcomes of percutaneous treatment of renal cystic echinococcosis (CE) stratified by cyst stages according to the World Health Organization (WHO) classification.

MATERIALS AND METHODS

Between January 1997 and February 2019, 34 patients with renal CE (18 women; mean age, 38 years) were treated with 3 different percutaneous techniques. According to the World Health Organization classification, the cysts were classified as CE1, CE2, CE3a, and CE3b. Puncture, aspiration, injection, reaspiration (PAIR) or standard catheterization was used for the dimension-based treatment of CE1 and CE3a cysts. Modified catheterization (MoCaT) was used to treat all CE2 and CE3b cysts. Technical and clinical success, complications, and reduction in cyst cavities were evaluated.

RESULTS

The technical success rate was 100%. PAIR, standard catheterization, and MoCaT were used to treat 12, 9, and 13 cysts, respectively. The only severe adverse event was a bacterial superinfection that occured in the cyst cavity of a patient (3%) treated with MoCaT. Four patients (12%) experienced mild/moderate periprocedural allergic adverse events and were managed conservatively. The mean length of hospital stay was 1, 5, and 7 days for patients treated with PAIR, standard catheterization, and MoCaT, respectively. The clinical success rate was 97%. In 1 of 34 cysts (3%), recurrence was detected and the cyst was successfully re-treated. During the 10.5-year follow-up period, 95% volume reduction was achieved. The median final cyst volume was 10 mL.

CONCLUSIONS

Renal CE can be successfully treated with minimum adverse events and recurrence rates using appropriate percutaneous techniques selected according to their stages as classified according to WHO.

Comparison of the Long-Term Results of Puncture, Aspiration, Injection and Re-aspiration (PAIR) and Catheterization Techniques for the Percutaneous Treatment of CE1 and CE3a Liver Hydatid Cysts: A Prospective Randomized Trial

PURPOSE

To evaluate and compare the results of puncture, aspiration, injection and re-aspiration (PAIR) and catheterization techniques for treatment of CE1 and CE3a liver hydatid cysts according to World Health Organization classification.

MATERIALS AND METHODS

Forty patients (29 females) with 56 liver CE1and CE3a cysts were prospectively randomized and enrolled into 2 groups by sealed envelope method. Procedures were performed under general anesthesia. Several parameters including technical success (completing procedure steps), clinical success (lack of recurrence on follow-up), major and minor complications, long-term changes of cyst cavities and length of hospital stay were compared between two groups.

RESULTS

As in 2 patients with 3 cysts, PAIR technique had to be changed to catheterization technique due to technical reasons. The technical success rates were 91.9% and 100% for PAIR and catheterization groups, respectively. Volume decrease rates were 78.5% and 86.8% in PAIR and catheterization groups, with a mean follow-up of 78.1 and 71 months, respectively. There was no mortality, anaphylactic shock or intraabdominal dissemination. The rate of major complications such as abscess, cysto-biliary fistula and recurrence was 2.94% and 36.84% in PAIR and catheterization groups, respectively (p = 0.002). Median length of hospital stay was shorter in PAIR group (1 vs 4 days) (p = 0.015).

CONCLUSION

PAIR technique should be preferred to catheterization technique for treatment of liver CE1 and CE3a cysts due to lower rates of major complications and length of hospital stay. Catheterization technique should be employed when cysto-biliary fistula was evident.

The combination of Cytokines and albendazole therapy for prophylaxis and treatment of experimental/hydatid cyst

Albendazole is appropriate chemotherapy for treatment and prophylaxis of cystic echinococcosis (CE). The recent studies show Cytokine therapy could be useful for chronic and progressive diseases, therefore, the use of cytokine in prophylaxis and treatment of hydatidosis could be considerable. The aim of this study is to evaluate the efficacy of interleukin-12 + interferon-gamma, in combination with albendazole for prophylaxis and treatment of CE in Balb/c mice. Albendazole and cytokines were administrated for prophylaxis and treatment in CE. The efficacy of this agents were determined by measuring of size, weight, number of cysts, histology and lymphocyte response. Lymphocyte stimulation index and production of interleukin-12 and interferon-gamma were measured by MTT assay and ELISA respectively. Combination of albendazole and cytokines was very effective for prophylaxis and treatment in experimental CE.

Echinococcus granulosus hydatid cyst in rural Manitoba, Canada: Case report and review of the literature

Echinococcal infections are a rare but important disease in Canada. The parasite’s traditional endemic area includes rural, northern communities with wild canines and ungulates. There is evidence that the endemic area is enlarging. Echinococcus can cause significant morbidity, and rarely death. An 18-year-old female presented with right upper quadrant abdominal pain. Computed Tomography (CT) of the abdomen showed a 5.4 × 4 cm cyst with the presence of “water lily sign”. She showed signs of cyst leak including eosinophilia and fever. Therefore, she underwent surgical resection of her cyst with Albendazole cover and was continued post-operatively for three months. CT head, chest, and pelvis failed to identify further sites of cyst formation. She has recovered well from surgery and is no longer followed by Infectious Diseases. The annual incidence and prevalence of Echinococcus disease are very low among the Canadian population. Therefore, there is a paucity of experience with new interventional techniques. Traditional management with surgery and anti-helminthic drugs is a reasonable alternative to percutaneous drainage. Screening communities has previously been determined not to be cost effective. Screening family members with similar risk factors has not been previously documented, and treatment has historically been reserved for symptomatic individuals with the disease.

Sound Around the World: Ultrasound for Tropical Diseases

Ultrasound for diagnosis and staging of schistosomiasis and echinococcosis have paved the way over the past several decades for the application of ultrasound in tropical diseases. Until recently, the size and cost of ultrasound systems limited the application in low-resource settings. The increase in portable ultrasound systems has given more clinicians access to ultrasound, and clinically based protocols for the care of patients have emerged, such as focused assessment with sonography for HIV/TB and tropical cardiac ultrasound. This article explores the history and current use of ultrasound in these diseases and highlights their application in the care of patients.

A systematic review and meta-analysis on the treatment of liver hydatid cyst using meta-MUMS tool: comparing PAIR and laparoscopic procedures

INTRODUCTION

There is an academic debate over surgical treatments of liver hydatid cyst disease. In this study, a systematic review and meta-analysis were carried out in order to evaluate the pros and cons of both PAIR (Puncture, Aspiration, Injection, Respiration) and laparoscopic techniques by considering the outcomes of liver hydatid cysts.

MATERIAL AND METHODS

We designed descriptive Boolean queries to search two databases, PubMed and Scopus, to derive the articles published in the period of January 2000 to December 2016 in order to evaluate the outcomes of these research articles. The outcomes of laparoscopic and PAIR procedures include the rates of cure, postoperative complications, recurrences, and mortality, which were extracted, assessed, and used as their corresponding effect sizes.

RESULTS

Fifty-seven studies including a total of 2832 patients (PAIR group n = 1650 and laparoscopic group = 1182) were analyzed. In this meta-analysis study, a random effect model of correlations of outcomes (postoperative complications, mortalities, recurrences, and cure rates) of PAIR and laparoscopy procedures was used. The meta-analysis and the forest plots of the two procedures show that the PAIR approach is superior in terms of cure, complication, and mortality rates compared with the laparoscopy technique. However, the recurrence rate is low in laparoscopic approaches. Moreover, Egger's tests for determining publication bias and heterogeneity tests were also performed.

CONCLUSIONS

This study shows promising trends toward an advantage of PAIR procedures in treatment of liver hydatid cyst in comparison with laparoscopic procedures. The PAIR procedure is superior to laparoscopy due to having a higher cure rate and lower complication and mortality rates; however, the latter has a lower recurrence rate.

Progress in the pharmacological treatment of human cystic and alveolar echinococcosis: Compounds and therapeutic targets

Human cystic and alveolar echinococcosis are helmintic zoonotic diseases caused by infections with the larval stages of the cestode parasites Echinococcus granulosus and E. multilocularis, respectively. Both diseases are progressive and chronic, and often fatal if left unattended for E. multilocularis. As a treatment approach, chemotherapy against these orphan and neglected diseases has been available for more than 40 years. However, drug options were limited to the benzimidazoles albendazole and mebendazole, the only chemical compounds currently licensed for treatment in humans. To compensate this therapeutic shortfall, new treatment alternatives are urgently needed, including the identification, development, and assessment of novel compound classes and drug targets. Here is presented a thorough overview of the range of compounds that have been tested against E. granulosus and E. multilocularis in recent years, including in vitro and in vivo data on their mode of action, dosage, administration regimen, therapeutic outcomes, and associated clinical symptoms. Drugs covered included albendazole, mebendazole, and other members of the benzimidazole family and their derivatives, including improved formulations and combined therapies with other biocidal agents. Chemically synthetized molecules previously known to be effective against other infectious and non-infectious conditions such as anti-virals, antibiotics, anti-parasites, anti-mycotics, and anti-neoplastics are addressed. In view of their increasing relevance, natural occurring compounds derived from plant and fungal extracts are also discussed. Special attention has been paid to the recent application of genomic science on drug discovery and clinical medicine, particularly through the identification of small inhibitor molecules tackling key metabolic enzymes or signalling pathways.

Human cystic and alveolar echinococcosis (CE and AE), caused by the larval stages of the helminths Echinococcus granulosus and E. multilocularis, respectively, are progressive and chronic diseases affecting more than 1 million people worldwide. Both are considered orphan and neglected diseases by the World Health Organization. As a treatment approach, chemotherapy is limited to the use of benzimidazoles, drugs that stop parasite growth but do not kill the parasite. To compensate this therapeutic shortfall, new treatment alternatives are urgently needed. Here, we present the state-of-the-art regarding the alternative compounds and new formulations of benzimidazoles assayed against these diseases until now. Some of these new and modified compounds, either alone or in combination, could represent a step forward in the treatment of CE and AE. Unfortunately, few compounds have reached clinical trials stage in humans and, when assayed, the design of these studies has not allowed evidence-based conclusions. Thus, there is still an urgent need for defining new compounds or improved formulations of those already assayed, and also for a careful design of clinical protocols that could lead to the draw of a broad international consensus on the use of a defined drug, or a combination of drugs, for the effective treatment of CE and AE.

Percutaneous treatment of hepatic cystic echinococcosis: the success of alcohol as a single endocavitary agent in PAIR, catheterization, and modified catheterization techniques

OBJECTIVES

This retrospective study aims at demonstrating the success rate, effectiveness, and advantages of alcohol as a scolicidal and sclerosing agent for the percutaneous treatment of liver hydatid cysts.

METHODS

A total of 554 liver hydatid cysts obtained from 347 patients admitted between January 2008 and February 2016 were retrospectively investigated. Of these, 435 (78.5%), 91 (16.4%), and 28 (5%) were classified as Gharbi type 1, 2, and 3, respectively. Type 1 and 2 cysts were treated using PAIR (puncture, aspiration, injection, respiration) and single puncture catheterization methods; type 3 lesions were treated using a modified catheterization technique. Alcohol was used as a scolicidal and sclerosing agent in all procedures.

RESULTS

After excluding three lesions (0.5%) because of lack of parenchymal support during catheterization, 274 (49.7%), 250 (45.3%), and 27 (4.9%) of 551 lesions were treated with PAIR, single puncture catheterization, and modified catheterization techniques, respectively. Therefore, a 99.5% of technical success rate was obtained. Major complications in 2 patients (0.5%) and minor complications were observed in 36 patients (10.3%). Mean hospital stay was 1.55±2.3 days (range: 0-23 days). Patients were followed-up for mean 19.6 months (range: 6-83 months), during which recurrences were detected in 19 patients (5.4%).

CONCLUSIONS

The use of alcohol as a scolicidal and sclerosing agent during the percutaneous treatment of liver hydatid cysts is associated with a high success rate and low rates of recurrence and complications, and should be considered an important alternative to surgical procedures.

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.

Percutaneous treatment of liver hydatid cysts in 190 patients: a retrospective study

Background Hydatid liver disease (HLD) is a significant health problem, especially in endemic areas worldwide. Percutaneous treatment is an effective alternative therapeutic option. Purpose To present the clinical and radiological results of percutaneous treatment of HLD in 190 patients. Material and Methods Percutaneous treatment of HLD between April 2005 and March 2015 was analyzed retrospectively. The demographic data, numbers and types of cysts, initial and final volumes of the cysts, types of percutaneous treatment, and procedure-related complications were determined. Results A total of 190 patients (95 male patients and 95 female patients; age range, 5-82 years) with 283 liver hydatid cysts who underwent percutaneous treatment were included in the study. Of the 283 cysts, 234 (83%) were cystic echinococcosis CE1, 31 (11%) were CE3a, and 18 (6%) were CE2 cysts, according to the World Health Organization (WHO) classification. The percutaneous procedure was successful in all patients. A total of 12 (6.3%) major complications, including anaphylaxis, allergic skin reaction, perihepatic hemorrhage, and cavity infection, were seen. No mortality was noted. Recurrence in one patient and an additional cyst in one patient were seen. All patients were asymptomatic during the follow-up period. Mean volume reduction was 77.5%, with a mean follow-up period of 18 months. Conclusion Percutaneous treatment is an effective and safe method for the treatment of HLD. It should be regarded as a first-line treatment method for uncomplicated hydatid cysts.

Comparison of Long-Term Results of Percutaneous Treatment Techniques for Hepatic Cystic Echinococcosis Types 2 and 3b

OBJECTIVE

The purpose of this study was to determine the long-term results of a modified catheterization technique for percutaneous treatment of hepatic cystic echinococcosis (CE) types 2 and 3b and to retrospectively compare the results of puncture, aspiration, injection, and reaspiration (PAIR); standard catheterization; and the modified catheterization technique.

MATERIALS AND METHODS

Seventy-three patients (37 male, 36 female; 75 cysts) with CE types 2 and 3b who underwent percutaneous treatment from March 1991 to August 2008 were included. Informed consent from all patients and approval of the ethics board were obtained. Patients were 6-79 years old. Twenty-three cysts (30.6%) were treated with PAIR, 26 (34.7%) with standard catheterization, and 26 (34.7%) with the modified catheterization technique. The results of the three techniques were statistically compared.

RESULTS

Among all patients, the cysts decreased in volume by 61.1% (range, 5-100%). Cysts recurred in 11 (47.8%) patients treated with PAIR, three (11.5%) treated with standard catheterization, and one (3.8%) treated with the modified catheterization technique. The recurrence rate was not significantly different between standard catheterization and the modified catheterization technique (p > 0.05), whereas significantly more recurrences developed after PAIR than with the other two techniques (p < 0.05). Twelve (16.4%) major and 16 (21.9%) minor complications developed. Significantly fewer major complications occurred with PAIR than with the modified catheterization technique, but the difference between standard catheterization and the other two techniques was not significant.

CONCLUSION

Treatment of CE types 2 and 3b with the modified catheterization technique was associated with a recurrence rate lower than what is seen with other techniques, and therefore it appears to be a safe, reliable, and efficient alternative.

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.

An Unusual Case of Anaphylaxis after Blunt Abdominal Trauma

BACKGROUND

Due to current human migratory patterns, emergency physicians in developed countries are facing emergent clinical presentations of neglected tropical diseases with increasing frequency. In those situations, the clinician's diagnosis is often delayed due to a lack of familiarity with the disease.

CASE REPORT

We present the case of a 25-year-old Peruvian man who presented to the Emergency Department complaining of dyspnea and abdominal pain after upper abdominal trauma. His physical examination revealed mouth and eyelid edema in association with epigastric pain. An abdominal computed tomography scan revealed a liver hydatid cyst. Emergent surgical evacuation of the cyst was required to control the anaphylactic reaction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Anaphylaxis in the setting of a complicated hydatid cyst is a life-threatening disease. Critical care management and emergent surgical evacuation of the cyst are indicated.

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.