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__NOTOC__
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{{Echinococcosis}}
{{Echinococcosis}}
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{{CMG}} '''Associate Editor-In-Chief:''' {{MIR}} ; {{CZ}}
==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 cyst|echinococcal cysts]].
==Surgery==
==== World Health Organization classification of cystic echinococcosis and PAIR treatment stratified by cyst stage <ref name="pmid18784219">{{cite journal |vauthors=Junghanss T, da Silva AM, Horton J, Chiodini PL, Brunetti E |title=Clinical management of cystic echinococcosis: state of the art, problems, and perspectives |journal=Am. J. Trop. Med. Hyg. |volume=79 |issue=3 |pages=301–11 |year=2008 |pmid=18784219 |doi= |url=}}</ref><ref name="pmid19931502">{{cite journal |vauthors=Brunetti E, Kern P, Vuitton DA |title=Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans |journal=Acta Trop. |volume=114 |issue=1 |pages=1–16 |year=2010 |pmid=19931502 |doi=10.1016/j.actatropica.2009.11.001 |url=}}</ref>====
<span style="font-size:85%">'''Abbreviations:'''
'''PAIR:''' puncture, aspiration, injection, reaspiration, '''CE:''' cystic echinococcus.
</span>
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " |WHO stage
! style="background: #4479BA; color: #FFFFFF; " |Description
! style="background: #4479BA; color: #FFFFFF; " |Stage
! style="background: #4479BA; color: #FFFFFF; " |Size
! style="background: #4479BA; color: #FFFFFF; " |Preferred treatment
! style="background: #4479BA; color: #FFFFFF; " |Alternate treatment
|-
! rowspan="2" style="background: #DCDCDC; " |CE1
| rowspan="2" |Unilocular unechoic [[Cystic|cystic lesion]] with double line sign
| rowspan="2" |Active
|<5 cm
|[[Albendazole]] alone
|PAIR
|-
|>5 cm
|[[Albendazole]] + PAIR
|PAIR
|-
! style="background: #DCDCDC; " |CE2
|Multiseptated, "rosette-like" "honeycomb" [[cyst]]
|Active
|Any
|[[Albendazole]] + either modified catheterization or surgery
|Modified [[catheterization]]
|-
! rowspan="2" style="background: #DCDCDC; " |CE3a
| rowspan="2" |[[Cyst]] with detached membranes (water-lily sign)
| rowspan="2" |Transitional
|<5 cm
|[[Albendazole]] alone
|PAIR
|-
|>5 cm
|[[Albendazole]] + PAIR
|PAIR
|-
! style="background: #DCDCDC; " |CE3b
|[[Cyst]] with daughter cysts in solid [[matrix]]
|Transitional
|Any
|[[Albendazole]] + either modified catheterization or surgery
|Modified [[catheterization]]
|}


{{CMG}} '''Associate Editor-In-Chief:''' {{CZ}}
==Surgery==
===Indications for PAIR===
===Indications for PAIR===
Patients with:
Patients with:
* Non-echoic lesion ≥ 5 cm in diameter (CE1m and l)
* Non-echoic lesion ≥ 5 cm in diameter (CE1m and l)
* Cysts with daughter cysts (CE2), and/or with detachment of membranes (CE3)
* [[Cysts]] with daughter [[cysts]] (CE2), and/or with detachment of [[membranes]] (CE3)
* Multiple cysts if accessible to puncture
* Multiple [[cysts]] if accessible to puncture
* Infected cysts
* [[Infected]] [[cysts]]
* Pregnant women
* Patients who fail to respond to [[chemotherapy]] alone
* Children >3 years old
 
* Patients who fail to respond to chemotherapy alone
* Patients in whom surgery is contraindicated
* Patient who refuse surgery
* Patients who relapse after surgery
===PAIR Protocol===
===PAIR Protocol===
The critical points in the PAIR protocol can be summarized below<ref name="pmid24046781">{{cite journal |vauthors=Rajesh R, Dalip DS, Anupam J, Jaisiram A |title=Effectiveness of puncture-aspiration-injection-reaspiration in the treatment of hepatic hydatid cysts |journal=Iran J Radiol |volume=10 |issue=2 |pages=68–73 |year=2013 |pmid=24046781 |pmc=3767020 |doi=10.5812/iranjradiol.7370 |url=}}</ref><ref name="pmid15883860">{{cite journal |vauthors=Gabal AM, Khawaja FI, Mohammad GA |title=Modified PAIR technique for percutaneous treatment of high-risk hydatid cysts |journal=Cardiovasc Intervent Radiol |volume=28 |issue=2 |pages=200–8 |year=2005 |pmid=15883860 |doi=10.1007/s00270-004-0009-5 |url=}}</ref><ref name="pmid16625588">{{cite journal |vauthors=Nasseri Moghaddam S, Abrishami A, Malekzadeh R |title=Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD003623 |year=2006 |pmid=16625588 |doi=10.1002/14651858.CD003623.pub2 |url=}}</ref><ref name="pmid15323389">{{cite journal |vauthors=Etlik O, Arslan H, Bay A, Sakarya ME, Harman M, Temizoz O, Kayan M, Bakan V, Unal O |title=Abdominal hydatid disease: long-term results of percutaneous treatment |journal=Acta Radiol |volume=45 |issue=4 |pages=383–9 |year=2004 |pmid=15323389 |doi= |url=}}</ref>
The critical points in the PAIR protocol can be summarized below<ref name="pmid24046781">{{cite journal |vauthors=Rajesh R, Dalip DS, Anupam J, Jaisiram A |title=Effectiveness of puncture-aspiration-injection-reaspiration in the treatment of hepatic hydatid cysts |journal=Iran J Radiol |volume=10 |issue=2 |pages=68–73 |year=2013 |pmid=24046781 |pmc=3767020 |doi=10.5812/iranjradiol.7370 |url=}}</ref><ref name="pmid15883860">{{cite journal |vauthors=Gabal AM, Khawaja FI, Mohammad GA |title=Modified PAIR technique for percutaneous treatment of high-risk hydatid cysts |journal=Cardiovasc Intervent Radiol |volume=28 |issue=2 |pages=200–8 |year=2005 |pmid=15883860 |doi=10.1007/s00270-004-0009-5 |url=}}</ref><ref name="pmid16625588">{{cite journal |vauthors=Nasseri Moghaddam S, Abrishami A, Malekzadeh R |title=Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD003623 |year=2006 |pmid=16625588 |doi=10.1002/14651858.CD003623.pub2 |url=}}</ref><ref name="pmid15323389">{{cite journal |vauthors=Etlik O, Arslan H, Bay A, Sakarya ME, Harman M, Temizoz O, Kayan M, Bakan V, Unal O |title=Abdominal hydatid disease: long-term results of percutaneous treatment |journal=Acta Radiol |volume=45 |issue=4 |pages=383–9 |year=2004 |pmid=15323389 |doi= |url=}}</ref>
{| class="wikitable"
{| class="wikitable"
!PAIR Protocol
! style="background: #4479BA; color: #FFFFFF; " |PAIR Protocol
!Preferred management
! style="background: #4479BA; color: #FFFFFF; " |Preferred management
|-
|-
|Prophylaxis pre- & post procedure
![[Prophylaxis]] pre- & post [[procedure]]
|Albendazole  
|[[Albendazole]]
* To be administered 24 to 4 hours before intervention and 15 days to 30 days after intervention according to cyst size  
* To be administered 24 to 4 hours before [[Intervention (counseling)|intervention]] and 15 days to 30 days after [[Intervention (counseling)|intervention]] according to [[cyst]] size  
* No treatment if pregnant
* No treatment if [[pregnant]]
|-
|-
|Communication with biliary tree
!Communication with [[biliary tree]]
|ERCP + cystography or cystography alone
|[[ERCP]] + cystography or cystography alone
|-
|-
|Electrolytes in the fluid
![[Electrolyte|Electrolytes]] in the fluid
|Not mandatory; may help for assessing the nature of the cyst
|Not mandatory; may help for assessing the nature of the [[cyst]]
|-
|-
|Scolicidal agent to be used
!Scolicidal agent to be used
|Hypertonic saline (at least 15 % final concentration in cyst) or 95 % alcohol
|[[Hypertonic]] [[saline]] (at least 15 % final concentration in cyst) or 95 % alcohol
|-
|-
|Quantity of scolicide injected
!Quantity of scolicide injected
|At least 1/3 of the aspirated quantity
|At least 1/3 of the aspirated quantity
|-
|-
|Evaluation of viability
!Evaluation of viability
|Microscopic examination Staining with methylene blue/eosin red
|Microscopic examination, staining with [[methylene blue]]/eosin red
|-
|-
|Needle vs catheter
![[Needle]] vs [[catheter]]
|Needle for cysts < 5 cm or in multiloculated cysts Catheter for cyst > 5 cm (PAIRD)
|Needle for [[cysts]] < 5 cm or in multiloculated cysts, catheter for cyst > 5 cm (PAIRD)
|-
|-
|Follow-up
!Follow-up
|Every week for the 1st month, then every other month for the 1st year, then every year for 10 years
|Every week for the 1st month, then every other month for the 1st year, then every year for 10 years
|}
|}
===Contraindications for PAIR===
===Contraindications for PAIR===
* Non-cooperative patients and inaccessible or risky location of the cyst in the liver
* Non-cooperative [[patients]] and inaccessible or risky location of the [[cyst]] in the [[liver]]
* Cyst in spine, brain and/or heart
* [[Cyst]] in [[spine]], [[brain]] and/or [[heart]]
* Inactive or calcified lesion
* Inactive or [[Calcification|calcified]] lesion
* Cysts communicating with the biliary tree
* Cysts communicating with the [[biliary tree]]
* Cysts open into the abdominal cavity, bronchi and urinary tract
* Cysts open into the [[abdominal cavity]], [[Bronchus|bronchi]] and [[urinary tract]]
===Benefits of PAIR===
===Benefits of PAIR===
* Minimal invasiveness
* Minimal invasiveness
* Reduced risk compared with surgery
* Reduced risk compared with [[surgery]]
* Confirmation of diagnosis
* Confirmation of [[diagnosis]]
* Removal of large numbers of protoscolices with the aspirated cyst fluid
* Removal of large numbers of protoscolices with the aspirated [[cyst]] [[fluid]]
* Improved efficacy of chemotherapy given before and after puncture
* Improved efficacy of [[chemotherapy]] given before and after puncture
* Reduced hospitalization time
* Reduced [[hospitalization]] time
* Cost of the puncture and chemotherapy usually less than that of surgery or chemotherapy alone
* Cost of the puncture and [[chemotherapy]] usually less than that of [[surgery]] or [[chemotherapy]] alone


== References ==
== References ==
{{reflist|2}}
{{reflist|2}}
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Latest revision as of 21:32, 29 July 2020

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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
>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
>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:

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
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

Benefits of PAIR

References

  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.
  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.
  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.
  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.
  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.
  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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