Treatment of liver cystic echinococcosis (hydatid disease)
Key messages
– We do not know if standard catheterization plus albendazole is more effective or safer compared to puncture, aspiration, injection and re‐aspiration (PAIR) plus albendazole for treating cystic echinococcosis at specific cyst stages (CE1 and CE3a).
– People undergoing laparoscopic (keyhole) surgery plus albendazole may have slightly fewer minor complications and shorter hospital stay than people who receive open surgery plus albendazole. We do not know if laparoscopic surgery plus albendazole may lead to fewer cases of recurrence or major complications. These results also apply to specific cyst stages (CE1, CE2, CE3a or CE3b).
– Healthcare workers caring for people with cystic echinococcosis should consider the safety of different treatment options and patient preferences.
What is cystic echinococcosis?
Cystic echinococcosis, also known as hydatid disease, is a parasitic infection that is caused by a tapeworm. People living in low‐ and middle‐income countries in areas with livestock (sheep, cattle, pigs, goats) are mostly affected as the tapeworm lifecycle involves a stage of livestock infection and a stage affecting dogs.
When a human is infected, cysts may develop in any organ of the body; however, the liver is the most affected organ. The cysts may grow and progress through different stages, in which their composition changes from liquid to semi‐solid to solid content. The cyst stages reflect how active the cyst is, for example, whether it has produced daughter cysts, or whether it is inactive and solid. The cysts may cause no symptoms or lead to symptoms depending on their location in the body. In the liver, cysts can lead to abdominal pain and other non‐specific symptoms. Sometimes complications such as abscesses, cyst rupture with possible serious allergic reactions or secondary echinococcosis (i.e. spread into the abdominal cavity with formation of many new cysts) can occur.
This review focused on cystic echinococcosis in active stages occurring in the liver.
How is cystic echinococcosis treated?
Treatment can be difficult and varies across countries. Treatment options depend on the characteristics of the cyst (stage, number, size, location), the health resources available and the general health of the patient. Treatment options include oral antiparasitic medication (albendazole), surgical removal of the cyst and percutaneous techniques that involve passing a needle through the skin into the cyst within the liver to empty the cyst.
One percutaneous technique is known as PAIR (puncture, aspiration (drawing out the cyst contents), injection of a medicine to kill the parasite and re‐aspiration). After treatment, the patient can usually return home on the same day following the removal of all antiparasitic substances from the cyst. Another percutaneous technique is known as standard catheterization. This is similar to PAIR, except that a larger plastic tube (a catheter) is also inserted into the cyst to help thoroughly evacuate cyst content with antiparasitic substances. The catheter is then left in the cyst to drain out all the fluid over the next 24 hours or longer.
What did we want to find out?
We wanted to find out which treatment led to the most improvement in symptoms, the least recurrence of the disease and fewer side effects/complications.
What did we do?
We searched for studies that compared one treatment option for cystic echinococcosis (oral medication, surgery, percutaneous techniques) with a different treatment option for people with liver cystic echinococcosis at different active stages.
What did we find?
We included three studies. One study of 38 adults and children aged 5 to 72 years in Turkey compared different percutaneous treatments plus albendazole (standard catheterization plus PAIR), and two studies with 142 adults and children aged 6 to 60 years from India and Pakistan compared laparoscopic surgery plus albendazole to open surgery plus albendazole. We found no data on symptom improvement or on whether more cysts became inactive at 12 months after treatment.
The evidence is very uncertain about the effect of standard catheterization plus albendazole on cyst recurrence, deaths and secondary echinococcosis compared to PAIR plus albendazole. Standard catheterization plus albendazole may increase major complications and may make little to no difference on minor complications, but the evidence is very uncertain. Standard catheterization plus albendazole may increase duration of hospital stay, but the evidence is very uncertain.
The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on cyst recurrence, death and major complications compared to open surgery plus albendazole. Laparoscopic surgery plus albendazole may lead to slightly fewer minor complications and may reduce the duration of hospital stay compared to open surgery plus albendazole.
What are the limitations of the evidence?
We are not confident in the evidence because we included only three studies with a small number of participants. The studies did not report all the treatments that we were interested in, and they did not report results on the outcome measures that we were interested in, such as symptom improvement. All results applied to specific cyst stages.
How up to date is this evidence?
The evidence is up to date to 4 May 2023.
Kuehn R, Uchiumi LJ, Tamarozzi F. Treatment of uncomplicated hepatic cystic echinococcosis (hydatid disease). Cochrane Database of Systematic Reviews 2024, Issue 7. Art. No.: CD015573. DOI: 10.1002/14651858.CD015573.
Access the full text article here.
The editorial base of the Cochrane Infectious Diseases Group is funded by UK aid from the UK government for the benefit of low- and middle-income countries (project number 300342-104). The views expressed do not necessarily reflect the UK government's official policies.