Echinococcosis surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Mahshid Mir, M.D. [2] ; Cafer Zorkun, M.D., Ph.D. [3]

Overview

Surgery for echinococcosis is indicated if the cyst is non-echoic and greater than 5 cm in diameter (CE1m and l), contains daughter cysts (CE2), and/or is associated with the detachment of membranes (CE3), consists of multiple cysts that are accessible to be punctured, are infected or in the patients who fail to respond to chemotherapy alone. Puncture, aspiration, injection and reaspiration, also known as the PAIR protocol, is utilized for the surgical treatment of echinococcal cysts.

Surgery

World Health Organization classification of cystic echinococcosis and PAIR treatment stratified by cyst stage ^[1]^[2]

Abbreviations: PAIR: puncture, aspiration, injection, reaspiration, CE: cystic echinococcus.

WHO stage	Description	Stage	Size	Preferred treatment	Alternate treatment
CE1	Unilocular unechoic cystic lesion with double line sign	Active	<5 cm	Albendazole alone	PAIR
CE1	Unilocular unechoic cystic lesion with double line sign	Active	>5 cm	Albendazole + PAIR	PAIR
CE2	Multiseptated, “rosette-like” “honeycomb” cyst	Active	Any	Albendazole + either modified catheterization or surgery	Modified catheterization
CE3a	Cyst with detached membranes (water-lily sign)	Transitional	<5 cm	Albendazole alone	PAIR
CE3a	Cyst with detached membranes (water-lily sign)	Transitional	>5 cm	Albendazole + PAIR	PAIR
CE3b	Cyst with daughter cysts in solid matrix	Transitional	Any	Albendazole + either modified catheterization or surgery	Modified catheterization

Indications for PAIR

Patients with:

Non-echoic lesion ≥ 5 cm in diameter (CE1m and l)
Cysts with daughter cysts (CE2), and/or with detachment of membranes (CE3)
Multiple cysts if accessible to puncture
Infected cysts
Patients who fail to respond to chemotherapy alone

PAIR Protocol

The critical points in the PAIR protocol can be summarized below^[3]^[4]^[5]^[6]

PAIR Protocol	Preferred management
Prophylaxis pre- & post procedure	Albendazole To be administered 24 to 4 hours before intervention and 15 days to 30 days after intervention according to cyst size No treatment if pregnant
Communication with biliary tree	ERCP + cystography or cystography alone
Electrolytes in the fluid	Not mandatory; may help for assessing the nature of the cyst
Scolicidal agent to be used	Hypertonic saline (at least 15 % final concentration in cyst) or 95 % alcohol
Quantity of scolicide injected	At least 1/3 of the aspirated quantity
Evaluation of viability	Microscopic examination, staining with methylene blue/eosin red
Needle vs catheter	Needle for cysts < 5 cm or in multiloculated cysts, catheter for cyst > 5 cm (PAIRD)
Follow-up	Every week for the 1st month, then every other month for the 1st year, then every year for 10 years

Contraindications for PAIR

Non-cooperative patients and inaccessible or risky location of the cyst in the liver
Cyst in spine, brain and/or heart
Inactive or calcified lesion
Cysts communicating with the biliary tree
Cysts open into the abdominal cavity, bronchi and urinary tract

Benefits of PAIR

Minimal invasiveness
Reduced risk compared with surgery
Confirmation of diagnosis
Removal of large numbers of protoscolices with the aspirated cyst fluid
Improved efficacy of chemotherapy given before and after puncture
Reduced hospitalization time
Cost of the puncture and chemotherapy usually less than that of surgery or chemotherapy alone

References

↑ Junghanss T, da Silva AM, Horton J, Chiodini PL, Brunetti E (2008). “Clinical management of cystic echinococcosis: state of the art, problems, and perspectives”. Am. J. Trop. Med. Hyg. 79 (3): 301–11. PMID 18784219.
↑ Brunetti E, Kern P, Vuitton DA (2010). “Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans”. Acta Trop. 114 (1): 1–16. doi:10.1016/j.actatropica.2009.11.001. PMID 19931502.
↑ Rajesh R, Dalip DS, Anupam J, Jaisiram A (2013). “Effectiveness of puncture-aspiration-injection-reaspiration in the treatment of hepatic hydatid cysts”. Iran J Radiol. 10 (2): 68–73. doi:10.5812/iranjradiol.7370. PMC 3767020. PMID 24046781.
↑ Gabal AM, Khawaja FI, Mohammad GA (2005). “Modified PAIR technique for percutaneous treatment of high-risk hydatid cysts”. Cardiovasc Intervent Radiol. 28 (2): 200–8. doi:10.1007/s00270-004-0009-5. PMID 15883860.
↑ Nasseri Moghaddam S, Abrishami A, Malekzadeh R (2006). “Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts”. Cochrane Database Syst Rev (2): CD003623. doi:10.1002/14651858.CD003623.pub2. PMID 16625588.
↑ Etlik O, Arslan H, Bay A, Sakarya ME, Harman M, Temizoz O, Kayan M, Bakan V, Unal O (2004). “Abdominal hydatid disease: long-term results of percutaneous treatment”. Acta Radiol. 45 (4): 383–9. PMID 15323389.

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[pmid18784219-1] Junghanss T, da Silva AM, Horton J, Chiodini PL, Brunetti E (2008). “Clinical management of cystic echinococcosis: state of the art, problems, and perspectives”. Am. J. Trop. Med. Hyg. 79 (3): 301–11. PMID 18784219.

[pmid19931502-2] Brunetti E, Kern P, Vuitton DA (2010). “Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans”. Acta Trop. 114 (1): 1–16. doi:10.1016/j.actatropica.2009.11.001. PMID 19931502.

[pmid24046781-3] Rajesh R, Dalip DS, Anupam J, Jaisiram A (2013). “Effectiveness of puncture-aspiration-injection-reaspiration in the treatment of hepatic hydatid cysts”. Iran J Radiol. 10 (2): 68–73. doi:10.5812/iranjradiol.7370. PMC 3767020. PMID 24046781.

[pmid15883860-4] Gabal AM, Khawaja FI, Mohammad GA (2005). “Modified PAIR technique for percutaneous treatment of high-risk hydatid cysts”. Cardiovasc Intervent Radiol. 28 (2): 200–8. doi:10.1007/s00270-004-0009-5. PMID 15883860.

[pmid16625588-5] Nasseri Moghaddam S, Abrishami A, Malekzadeh R (2006). “Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts”. Cochrane Database Syst Rev (2): CD003623. doi:10.1002/14651858.CD003623.pub2. PMID 16625588.

[pmid15323389-6] Etlik O, Arslan H, Bay A, Sakarya ME, Harman M, Temizoz O, Kayan M, Bakan V, Unal O (2004). “Abdominal hydatid disease: long-term results of percutaneous treatment”. Acta Radiol. 45 (4): 383–9. PMID 15323389.

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