Echinococcosis surgery

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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]


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.


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


  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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