Echinococcosis surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Echinococcosis}} | {{Echinococcosis}} | ||
{{CMG}} '''Associate Editor-In-Chief:''' {{CZ}} | {{CMG}} '''Associate Editor-In-Chief:''' {{MIR}} ; {{CZ}} | ||
==Overview== | ==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]] 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== | ==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>==== | ==== 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>==== | ||
PAIR: puncture, aspiration, injection, reaspiration | <span style="font-size:85%">'''Abbreviations:''' | ||
'''PAIR:''' puncture, aspiration, injection, reaspiration, '''CE:''' cystic echinococcus. | |||
</span> | |||
{| class="wikitable" | {| class="wikitable" | ||
!WHO stage | ! style="background: #4479BA; color: #FFFFFF; " |WHO stage | ||
!Description | ! style="background: #4479BA; color: #FFFFFF; " |Description | ||
!Stage | ! style="background: #4479BA; color: #FFFFFF; " |Stage | ||
!Size | ! style="background: #4479BA; color: #FFFFFF; " |Size | ||
!Preferred treatment | ! style="background: #4479BA; color: #FFFFFF; " |Preferred treatment | ||
!Alternate treatment | ! style="background: #4479BA; color: #FFFFFF; " |Alternate treatment | ||
|- | |- | ||
! rowspan="2" |CE1 | ! rowspan="2" style="background: #DCDCDC; " |CE1 | ||
| rowspan="2" |Unilocular unechoic cystic lesion with double line sign | | rowspan="2" |Unilocular unechoic [[Cystic|cystic lesion]] with double line sign | ||
| rowspan="2" |Active | | rowspan="2" |Active | ||
|<5 cm | |<5 cm | ||
|Albendazole alone | |[[Albendazole]] alone | ||
|PAIR | |PAIR | ||
|- | |- | ||
|>5 cm | |>5 cm | ||
|Albendazole + PAIR | |[[Albendazole]] + PAIR | ||
|PAIR | |PAIR | ||
|- | |- | ||
!CE2 | ! style="background: #DCDCDC; " |CE2 | ||
|Multiseptated, "rosette-like" "honeycomb" cyst | |Multiseptated, "rosette-like" "honeycomb" [[cyst]] | ||
|Active | |Active | ||
|Any | |Any | ||
|Albendazole + either modified catheterization or surgery | |[[Albendazole]] + either modified catheterization or surgery | ||
|Modified catheterization | |Modified [[catheterization]] | ||
|- | |- | ||
! rowspan="2" |CE3a | ! rowspan="2" style="background: #DCDCDC; " |CE3a | ||
| rowspan="2" |Cyst with detached membranes (water-lily sign) | | rowspan="2" |[[Cyst]] with detached membranes (water-lily sign) | ||
| rowspan="2" |Transitional | | rowspan="2" |Transitional | ||
|<5 cm | |<5 cm | ||
|Albendazole alone | |[[Albendazole]] alone | ||
|PAIR | |PAIR | ||
|- | |- | ||
|>5 cm | |>5 cm | ||
|Albendazole + PAIR | |[[Albendazole]] + PAIR | ||
|PAIR | |PAIR | ||
|- | |- | ||
!CE3b | ! style="background: #DCDCDC; " |CE3b | ||
|Cyst with daughter cysts in solid matrix | |[[Cyst]] with daughter cysts in solid [[matrix]] | ||
|Transitional | |Transitional | ||
|Any | |Any | ||
|Albendazole + either modified catheterization or surgery | |[[Albendazole]] + either modified catheterization or surgery | ||
|Modified catheterization | |Modified [[catheterization]] | ||
|} | |} | ||
| Line 63: | Line 65: | ||
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]] | |||
|[[Albendazole]] | |[[Albendazole]] | ||
* 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 | * 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]] | |||
|[[ERCP]] + cystography or cystography alone | |[[ERCP]] + cystography or cystography alone | ||
|- | |- | ||
![[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 | |||
|[[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 | |||
|At least 1/3 of the aspirated quantity | |At least 1/3 of the aspirated quantity | ||
|- | |- | ||
!Evaluation of viability | |||
|Microscopic examination, staining with [[methylene blue]]/eosin red | |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) | |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 | |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]] | ||
| Line 109: | Line 112: | ||
== References == | == References == | ||
{{reflist|2}} | {{reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Parasitic diseases]] | [[Category:Parasitic diseases]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Needs content]] | [[Category:Needs content]] | ||
[[Category:Needs overview]] | [[Category:Needs overview]] | ||
[[Category:Emergency medicine]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | |||
[[Category:Hepatology]] | |||
[[Category:Gastroenterology]] | |||
[[Category:Surgery]] | |||
Latest revision as of 21:32, 29 July 2020
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Echinococcosis surgery On the Web |
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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:
- 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
|
| 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.