Laparoscopic Treatment Strategies for Liver Echinococcosis

Multicenter retrospective study on advancements in diagnosis and laparoscopic treatment of hepatic echinococcosis in Xinjiang China

With the advancement of precise hepatobiliary surgery concepts, the diagnostic and therapeutic approaches for hepatic echinococcosis have undergone significant transformations. However, whether these changes have correspondingly improved patient outcomes remains unclear. A retrospective analysis of these changes will provide crucial guidance for the prevention and treatment of hepatic echinococcosis. Clinical data from 6 hospitals in Xinjiang region of China from January 2009 to December 2023 were collected and systematically random sampling was conducted. The study was divided into the first stage (2009-2013), the second stage (2014-2018), and the third stage (2019-2023) with a 5-year time node to compare the changes in diagnosis and treatment mode and clinical features. There was no significant difference in the age of onset among patients across different phases (P = 0.759). The frequency of open cystectomy gradually decreased [302 (62.3%), 223 (53.0%), 165 (55.7%), P = 0.015], while the rate of total cystectomy increased steadily [82 (16.9%), 88 (20.9%), 94 (23.7%), P = 0.040]. The proportion of patients admitted due to screening also increased [367 (75.7%), 373 (88.6%), 364 (91.9%), P < 0.001]. Preoperative imaging techniques evolved from being singular to diversified. Postoperative recurrence rates declined over time [89 (18.4%), 53 (12.6%), 32 (8.1%), P < 0.001], as did the incidence of grade C bile leakage [88 (18.1%), 51 (12.1%), 20 (5.1%), P < 0.001]. However, the incidence of intraoperative bleeding ≥ 800 ml showed an upward trend [39 (8.0%), 53 (12.6%), 60 (15.2%), P = 0.004]. No significant differences were observed in clinical classification across different periods, but average hospitalization costs increased. The data across all groups indicated that herdsmen remain the most affected population, while the incidence among students gradually decreased. Over the past 15 years, both the diagnostic and therapeutic approaches and the prognosis of patients with hepatic echinococcosis in the Xinjiang region of China have improved. Laparoscopic total cystectomy is gradually becoming the preferred surgical approach for these patients, and early screening efforts have benefited an increasing number of patients.

ASPECTS OF LIVER ECHINOCOCCOSIS SURGERY

According to the WHO, «…at any given time, more than 1 million people worldwide are aff ected by echinococcosis…». Due to the lack of tendency to decrease the number of patients and the existence of endemic regions where the incidence rate varies from 1.2 to 9.0 per 100,000 population, this parasitic disease continues to be a serious medical and social problem. At the present stage, the diagnosis of echinococcosis does not present signifi cant diffi culties, mainly due to the emergence of non-invasive imaging methods, the informative value of the complex application of which reaches 95-100 %.Aim of the study. Improving the treatment results of patients with liver echinococcosis.Research materials. The study included 328 patients with liver echinococcosis admitted to the surgery department of the multidisciplinary clinic of the Samarkand State Medical University in the period from 2005 to 2023. Depending on the choice of treatment, the patients were divided into two groups: the comparison group consisted of 154 (46.9 %) patients treated from 2005 to 2012 and the main group included 174 (53.0 %) patients operated on from 2013 to 2023.Research results. Compared with the comparison group, in the main group of patients, intraoperative complications decreased from 6.5 to 2.3 %, and complications in the early postoperative period from 18.2 to 5.2 %. In the late postoperative period, the recurrence of the disease decreased from 16.2 % to 3.6 %.Conclusions. The introduction of improved surgical instruments into practice – a modifi ed puncture needle, a «basket clamp» allowed to level the risk of seeding of surrounding tissues with embryonic elements. The introduction of a device for the purpose of identifying hidden biliary fi stulas in the residual cavity after echinococcectomy from the liver reduced the number of bile leaks. With the introduction of a modifi ed method for eliminating the residual cavity after echinococcectomy from the liver, the number of complications during surgery and in the early postoperative period was minimized.

Treatment of uncomplicated hepatic cystic echinococcosis (hydatid disease)

BACKGROUND

Cystic echinococcosis is a parasitic infection mainly impacting people living in low- and middle-income countries. Infection may lead to cyst development within organs, pain, non-specific symptoms or complications including abscesses and cyst rupture. Treatment can be difficult and varies by country. Treatments include oral medication, percutaneous techniques and surgery. One Cochrane review previously assessed the benefits and harms of percutaneous treatment compared with other treatments. However, evidence for oral medication, percutaneous techniques and surgery in specific cyst stages has not been systematically investigated and the optimal choice remains uncertain.

OBJECTIVES

To assess the benefits and harms of medication, percutaneous and surgical interventions for treating uncomplicated hepatic cystic echinococcosis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, two other databases and two trial registries to 4 May 2023. We searched the reference lists of included studies, and contacted experts and researchers in the field for relevant studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in people with a diagnosis of uncomplicated hepatic cystic echinococcosis of World Health Organization (WHO) cyst stage CE1, CE2, CE3a or CE3b comparing either oral medication (albendazole) to albendazole plus percutaneous interventions, or to surgery plus albendazole. Studies comparing praziquantel plus albendazole to albendazole alone prior to or following an invasive intervention (surgery or percutaneous treatment) were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were symptom improvement, recurrence, inactive cyst at 12 months and all-cause mortality at 30 days. Our secondary outcomes were development of secondary echinococcosis, complications of treatment and duration of hospital stay. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included three RCTs with 180 adults and children with hepatic cystic echinococcosis. Two studies enrolled people aged 5 to 72 years, and one study enrolled children aged 6 to 14 years. One study compared standard catheterization plus albendazole with puncture, aspiration, injection and re-aspiration (PAIR) plus albendazole, and two studies compared laparoscopic surgery plus albendazole with open surgery plus albendazole. The three RCTs were published between 2020 and 2022 and conducted in India, Pakistan and Turkey. There were no other comparisons. Standard catheterization plus albendazole versus PAIR plus albendazole The cyst stages were CE1 and CE3a. The evidence is very uncertain about the effect of standard catheterization plus albendazole compared with PAIR plus albendazole on cyst recurrence (risk ratio (RR) 3.67, 95% confidence interval (CI) 0.16 to 84.66; 1 study, 38 participants; very low-certainty evidence). The evidence is very uncertain about the effects of standard catheterization plus albendazole on 30-day all-cause mortality and development of secondary echinococcosis compared to open surgery plus albendazole. There were no cases of mortality at 30 days or secondary echinococcosis (1 study, 38 participants; very low-certainty evidence). Major complications were reported by cyst and not by participant. Standard catheterization plus albendazole may increase major cyst complications compared with PAIR plus albendazole, but the evidence is very uncertain (RR 10.74, 95% CI 1.39 to 82.67; 1 study, 53 cysts; very low-certainty evidence). Standard catheterization plus albendazole may make little to no difference on minor complications compared with PAIR plus albendazole, but the evidence is very uncertain (RR 1.03, 95% CI 0.60 to 1.77; 1 study, 38 participants; very low-certainty evidence). Standard catheterization plus albendazole may increase the median duration of hospital stay compared with PAIR plus albendazole, but the evidence is very uncertain (4 (range 1 to 52) days versus 1 (range 1 to 15) days; 1 study, 38 participants; very low-certainty evidence). Symptom improvement and inactive cysts at 12 months were not reported. Laparoscopic surgery plus albendazole versus open surgery plus albendazole The cyst stages were CE1, CE2, CE3a and CE3b. The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on cyst recurrence in participants with CE2 and CE3b cysts compared to open surgery plus albendazole (RR 3.00, 95% CI 0.13 to 71.56; 1 study, 82 participants; very low-certainty evidence). The second study involving 60 participants with CE1, CE2 or CE3a cysts reported no recurrence in either group. The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on 30-day all-cause mortality in participants with CE1, CE2, CE3a or CE3b cysts compared to open surgery plus albendazole. There was no mortality in either group (2 studies, 142 participants; very low-certainty evidence). The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on major complications in participants with CE1, CE2, CE3a or CE3b cysts compared to open surgery plus albendazole (RR 0.50, 95% CI 0.13 to 1.92; 2 studies, 142 participants; very low-certainty evidence). Laparoscopic surgery plus albendazole may lead to slightly fewer minor complications in participants with CE1, CE2, CE3a or CE3b cysts compared to open surgery plus albendazole (RR 0.13, 95% CI 0.02 to 0.98; 2 studies, 142 participants; low-certainty evidence). Laparoscopic surgery plus albendazole may reduce the duration of hospital stay compared with open surgery plus albendazole (mean difference (MD) -1.90 days, 95% CI -2.99 to -0.82; 2 studies, 142 participants; low-certainty evidence). Symptom improvement, inactive cyst at 12 months and development of secondary echinococcosis were not reported.

AUTHORS' CONCLUSIONS

Percutaneous and surgical interventions combined with albendazole can be used to treat uncomplicated hepatic cystic echinococcosis; however, there is a scarcity of randomised evidence directly comparing these interventions. There is very low-certainty evidence to indicate that standard catheterization plus albendazole may lead to fewer cases of recurrence, more major complications and similar complication rates compared to PAIR plus albendazole in adults and children with CE1 and CE3a cysts. There is very low-certainty evidence to indicate that laparoscopic surgery plus albendazole may result in fewer cases of recurrence or fewer major complications compared to open surgery plus albendazole in adults and children with CE1, CE2, CE3a and CE3b cysts. Laparoscopic surgery plus albendazole may lead to slightly fewer minor complications. Firm conclusions cannot be drawn due to the limited number of studies, small sample size and lack of events for some outcomes.

Pitsilka M, Magouliotis D, Zacharoulis D. New Energy Devices in the Treatment of Cystic Echinococcosis

Treatment of cystic echinococcosis of the liver still remains a debatable subject. The method of choice should aim for the total elimination of the parasite with minimum morbidity and mortality. Different approaches have been proposed. Medical treatment as a monotherapy has been abandoned due to the high chances of recurrence and is mostly used as an adjuvant to surgery or minimally invasive methods. Surgical methods are divided into conservative ones, which include cystectomy and partial pericystectomy, and radical ones, total pericystectomy and hepatectomy. Radical procedures are correlated with lower complication and recurrence rates and, therefore, should be attempted when indications are present. On the other hand, conservative surgery can be the first option in endemic areas, performed by non-specialized general surgeons. The development of laparoscopic techniques made their use a possible alternative approach in selected cases. The use of percutaneous treatments is also quite widespread due to their minimally invasive nature. New energy devices seem to play a significant role in the treatment of cystic echinococcosis, although more studies are needed to establish their efficacy. Observation without intervention is an option for inactive uncomplicated cysts.