A novel modified PAIR technique using a trocar catheter for percutaneous treatment of liver hydatid cysts: a six-year experience

Lung Hydatidosis Unveiled: A Multisystem Mirage of Pathological Rarity

Lung hydatidosis is a zoonotic infection, primarily caused by Echinococcus sp., and has a significant role in the economy and public health. Canines are the predominant hosts of these parasitic tapeworms. Lungs are the most commonly infected organ after the liver. Hepatic pulmonary blood circulation is mainly reported to transport infection to the lungs. The prevalence of hydatid disease has increased over the past decade. In addition, patients with multi-organ involvement of hydatid cysts have been reported in different parts of the world. Hydatidosis can remain asymptomatic for years after infection in some conditions, especially in cases of splenic hydatidosis. Chest radiography and computed tomography findings can be used to confirm the diagnosis of hydatid disease. Hydatid disease is, in general, managed by pharmacological therapy, but if multi-organ involvement is observed, surgery along with medical management is required. Long-term follow-up is recommended in such cases to check the recurrence of the disease.

A case of successful multi-stage surgical treatment of liver echinococcosis

A clinical case of successful radical multi-stage surgical treatment of a patient with bilobar parasitic lesion of the liver with echinococcosis complicated by infection of one of the cysts is presented. The patient was admitted to the clinic with volumetric lesions in both lobes of the liver. At the stage of differential diagnosis, on the basis of process verification by puncture biopsy under ultrasound control, the ethiology of mass lesions was reliably established. At the primary stationary stage, infection of one of the echinococcal cysts was diagnosed, for which the cyst was drained under ultrasound control. After that, the patient was discharged to the outpatient care for compensation, correction of the general level of health and nutritional status. At the next stage of the inpatient examination, the patient was determined to have an insufficient level of functional reserves of the liver to perform a radical operation. For this reason, laparoscopic ligation of the right branch of the portal vein was performed in order to develop vicarious hypertrophy of the contralateral lobe. After 30 days, the increased level of functional reserves of the liver made it possible to plan radical surgical treatment with an acceptable risk for the patient. The operation was performed in the amount of right-sided extended hemihepatectomy with marginal resection of the 3rd segment of the liver. The symptoms of liver failure in the postoperative period according to the ISGLS scale were regarded as Grade A. The patient was discharged from the hospital in a satisfactory condition on day 10 after the operation. In the postoperative period, courses of therapy with albendazole were prescribed according to the standard scheme. The patient is under observation for more than a year after treatment. The condition is satisfactory. No recurrence of the disease was noted.

Turkish HPB Surgery Association consensus report on hepatic cystic Echinococcosis (HCE)

OBJECTIVES

Cystic Echinococcosis (CE) is one of the important problems of the Eurasian region. We aimed to prepare a consensus report in order to update the treatment approaches of this disease. This study was conducted by Turkish HPB Surgery Association.

MATERIAL AND METHODS

This study was conducted with the modified Delphi model. For this purpose, we conducted a three-stage consensus-building approach.

RESULTS

Six topics, including diagnosis, medical treatment, percutaneous treatment, surgical treatment, management of complications and posttreatment follow-up and recurrences in HCE were discussed.

CONCLUSION

The expert panel made recommendations for every topic.

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.

Treatment of Hepatic Hydatid Disease: Role of Surgery, ERCP, and Percutaneous Drainage: A Retrospective Study

INTRODUCTION

Failure to follow the World Health Organization's Informal Working Group on Echinococcosis guidance or having limited experience in the management of cystic echinococcosis (CE) in endemic or nonendemic areas of the world may lead to risky unnecessary procedures.

MATERIALS AND METHODS

Medical records of all patients undergoing surgery for hepatic hydatid disease at the gastroenterologic surgery and general surgery departments of our hospital between December 2014 and October 2019 were collected and reviewed retrospectively. Demographic characteristics, the size and number of the cysts preoperative liver function tests, surgical treatment, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage (PD), morbidity, and treatment outcomes were reviewed.

RESULTS

Of 122 patients included in the study, 77 (63, 1%) were female and 45 (36, 9%) were male individuals and their mean age was 44.95 years. CE1 was identified in 13 patients (10.6%) CE2 in 66 patients (54.1%), CE3a in 7 patients (5.8%), CE3b in 28 patients (22.9%), and CE4 in 8 patients (6.6%). Twenty patients (16.4%) with a cystobiliary fistula in the liver, obstructive jaundice, and postoperative bile leak underwent ERCP. PD was performed in patients with fluid in the hepatic hydatid cyst pouch, increased pouch size because of bile collection, and clinical symptoms postoperatively. Patients presenting with persistent bile leak despite PD underwent ERCP and were treated with endoscopic sphincterotomy and stent placement. Patients with PD were followed by keeping the percutaneous drain open and closed for a while to create pressure difference in the cyst pouch after ERCP. The percutaneous drain was removed in the next 14 to 21 days after checking the pouch size, whereas the common bile duct stents were removed 2 months later after performing a follow-up cholangiography.

CONCLUSIONS

ERCP should be the primary method for the diagnosis and treatment for hepatic hydatid cysts ruptured into the ducts. İn some cases, high-flow hydatid cysts with rupture into the bile ducts or persistent biliary fistulas can be treated with ERCP and endoscopic sphincterotomy, biliary stent, PD, and nasobiliary drainage without the need for surgical intervention.

Zataria Multiflora bois as an auspicious therapeutic approach against Echinococcus granulosus: Current status and future perspectives

Hydatidosis caused by Echinococcus granulosus is a major zoonotic diseases. In addition to imposing heavy economic losses, the disease is a public health problem worldwide. The larval stage of the parasite (hydatid cyst) is formed in a wide range of domestic, wild and human beings as intermediate hosts. On the other, its recurrence has been reported anywhere as a reemerging disease. Although the cysts have some evading mechanisms, both human TH1 and TH2 cells subsets are stimulated. Because of increasing resistance and adverse effects of medications such as abnormalities of liver and other organs functions and abdominal pain, seeking alternative therapeutic approaches to be inexpensive, easy available, with low side effects and toxicity seems essential. However, the lack of information on the social and economic welfares of herbal medicines for the industrial scale application is a limitation. Zataria Multiflora bois (ZMB) has exhibited huge advantages and tremendous protoscolicidal effects as demonstrated by numerous studies and its combination therapies with anti-parasitic drugs have exerted desirable outcomes in vitro and in vivo. Noticeably, the compound confers negligible side effects or toxicity even at high concentrations. ZMB has exhibited promising inhibitory effects against hydatid cyst, particularly when combined with chemical drugs and in formulations of nanoemulsions. Its immunomodulatory effects include increase of nitric oxide production (NO) and protection of hepatic cells (Kupffer cells, fat-storing cells, and endothelial cells), enhancement of macrophages and T cells and increase of cytokines production. This study aimed at assessment of ZMB traits for application against hydatid cyst protoscolices.

[Diagnostics and management of intra-abdominal Echinococcus manifestation]

INTRODUCTION

Cystic and alveolar echinococcosis are two potentially life-threatening diseases caused by the helminthic parasites Echinococcus granulosus or Echinococcus multilocularis, respectively. In central Europe a marked increase in incidence of both forms of echinococcosis has recently been observed.

OBJECTIVE

There is widespread uncertainty with diagnostic and treatment algorithms due to the close genetic relationship of both parasites and the similar presentation; however, since the treatment and prognosis significantly differ between the two diseases, a correct diagnosis is essential. This review summarizes the similarities and differences in the diagnostics and surgical treatment of these two parasites.

RESULTS

The correct diagnosis is mainly based on patient history, radiological imaging and serological testing. In cystic echinococcosis cyst viability and stage determine whether treatment is medicinal, interventional, surgical or a watch and wait strategy. For alveolar echinococcosis surgical resection in combination with perioperative or adjuvant medicinal treatment is the gold standard and the only therapeutic option. As identification of the disease is often delayed due to the oligosymptomatic manifestation, complex resections are frequently necessary that need to be treated by a multidisciplinary team of experts.

CONCLUSION

Echinococcosis is still a neglected disease due to the rarity and thus should be referred to experts in a tertiary hospital to avoid mistreatment or overtreatment. Due to a timely surgical, infectiological and interventional treatment in an interdisciplinary work-up, the prognosis of echinococcosis has significantly improved in recent years.

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.

Experimental Nanopulse Ablation of Multiple Membrane Parasite on Ex Vivo Hydatid Cyst

The impact of ultrashort nanopulse on cellular membrane is of biological significance and thus has been studied intensively. Different from cell study, this ex vivo study aims to investigate the biological effects of nanosecond pulsed electric field (nsPEF) on an independent multimembrane parasite, human hydatid cyst, to observe the unique influence of nanopulse on macromembrane structure, permeabilization, and biochemistry. The 300 ns nsPEF was delivered on an experimental model of single human hydatid cyst ex vivo with eight different parameters. Then pathological changes during 7 days of 48 parasite cysts were followed up after nsPEF. The laminated layer, the germinal layer, the protoscolex, and cyst fluid were evaluated by the morphological, pathological, and biochemical measurements. The parameter screening found that nsPEF can damage hydatid cyst effectively when the field strength is higher than 14 kV/cm. When nsPEF is higher than 29 kV/cm, nsPEF destroy hydatid cyst completely by collapsing the germinal layer, destructing protoscolices, and exhausting the nutrition.

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.

Successful percutaneous treatment of extrahepatic cystic echinococcosis through PAIR and single puncture catheter techniques

PURPOSE

To demonstrate the successful percutaneous treatment of extrahepatic cystic echinococcosis as an alternative to surgical procedures.

MATERIALS AND METHODS

A total of 27 extrahepatic hydatid cysts in 12 patients, the spleen in 8 patients, muscles and soft tissues in 3 patients each and right adrenal gland in 1 patient were treated with PAIR (puncture, aspiration, injection, respiration) or single puncture catheterization methods. As a scolicidal and sclerosing agent, alcohol was used in all patients.

RESULTS

Of 27 extrahepatic lesions of hydatid cysts, 24 (88.9%) were Gharbi type 1 (WHO CE 1), and 3 (11.1%) were Gharbi type 2 (WHO CE 3A). Of hydatid cystic lesions, 20 with PAIR and 7 with single puncture catheterization methods were treated. No major complications developed in any patients. Abscesses were detected in two patients (16.6%). Mean total hospital stay was calculated between 1 and 14 days (mean 2.3 days). Follow-up periods ranged between 10 and 62 months (mean 22.3 months).

CONCLUSION

Percutaneous treatment for extrahepatic hydatid cystic lesions is an important alternative to surgical procedures because of the high therapeutic success rate, lower rate of complications and shorter hospital stays.

Nanosecond pulsed electric field (nsPEF) disrupts the structure and metabolism of human Echinococcus granulosus protoscolex in vitro with a dose effect

The number of interventional treatments for hepatic cystic echinococcosis is increasing, but the chemicals or high temperatures used in these methodologies cause biliary complications, thus limiting their clinical applications. This experimental study aimed to apply a novel, non-thermal, non-chemical ablation method termed nanosecond pulsed electric field (nsPEF) for the treatment of human hepatic cystic echinococcosis. The nsPEF treatment parameters against protoscolices from human hepatic cystic echinococcosis were optimized in vitro. The efficacy and mechanism of nsPEF treatment were also investigated. Fresh protoscolices were isolated from human hepatic cystic echinococcosis and were exposed to 300 ns of nsPEF with different field strengths (0, 7, 14, 21, and 29 kV/cm) and pulse numbers (50 and 100 pulses). Then, the viability of the nsPEF-treated protoscolices was evaluated in vitro. Morphological and ultra-structural changes were visualized with H&E staining and scanning electron microscopy. The membrane enzyme activity of alkaline phosphatase (AP) and gamma-glutamyl-transpeptidase (GGT) was measured. nsPEF caused dose-dependent protoscolex death. One-hundred pulses of nsPEF at 21 kV/cm or higher caused a significant increase in the death rate of protoscolices. nsPEF induced significant lethal damage with 50 pulses at 21 or 29 kV/cm and with 100 pulses at 14, 21, or 29 kV/cm, accompanied by morphological destruction and increased levels of AP and GGT membrane enzymes. Thus, nsPEF induced dose-dependent protoscolex mortality and caused destruction of protoscolices and increased membrane enzymes. The mechanism may involve direct damage to the membrane structures of the protoscolices, promoting enzyme exhaustion and disruption of metabolism.