Percutaneous drainage and combined praziquantel-albendazole therapy: a novel approach for the treatment of simple echinococcal liver cysts

Abstract

Cystic echinococcosis (CE) is a worldwide helminthic zoonosis causing serious disease in humans. The WHO Informal Working Group on Echinococcosis recommends a stage-specific treatment approach of hepatic CE that facilitates the decision on what therapy option is most appropriate. Percutaneous aspiration, instillation of a scolicide, e.g., ethanol or hypertonic saline, and subsequent re-aspiration (PAIR) have been advocated for treating medium-size unilocular WHO-stage CE1 cysts. PAIR can pose a risk of toxic cholangitis because of spillage of ethanol in the case of a cysto-biliary fistula or of life-threatening hypernatriaemia when hypertonic saline is used. The purpose of our study is to develop an alternative, safe, minimally invasive method to treat CE1 cysts, avoiding the use of toxic topic scolicides.

We opt for percutaneous drainage (PD) in four patients: the intrahepatic drainage catheter is placed under CT-fluoroscopy, intracystic fluid is aspirated, and the viability of intracystic echinococcal protoscolices is assessed microscopically. Oral praziquantel (PZQ) is added to albendazole (ABZ) instead of using topical scolicidals.

Protoscolices degenerate within 5 to 10 days after PZQ co-medication at a cumulative dosage of 250 to 335 mg/kg, and the cysts collapse. The cysts degenerate, and no sign of spillage nor relapse is observed in the follow-up time of up to 24 months post-intervention.

In conclusion, PD combined with oral PZQ under ABZ coverage is preferable to PAIR in patients with unilocular echinococcal cysts.

Zusammenfassung

Die zystische Echinokokkose (CE) ist eine weltweit verbreitete zoonotische Helminthose, die schwere Erkrankungen beim Menschen hervorruft. Die WHO Informal Working Group on Echinococcosis empfiehlt einen stadiengerechten Therapieansatz der hepatischen CE, der die Entscheidung über die geeignetste Behandlungsoption erleichtert. Die perkutane Aspiration, Instillation eines Skolizids, beispielsweise von Ethanol oder hypertoner Kochsalzlösung, und darauffolgender Re-Aspiration (PAIR) wurde für einfache Zysten mittlerer Größe im WHO-Stadium 1 empfohlen.

Die PAIR beinhaltet Risiken wie das einer toxischen Cholangitis durch das Verbringen von Ethanol in eine zystobiliäre Fistel oder einer lebensbedrohenden Hypernatriaemie bei Verwendung hypertoner Kochsalzlösung. Das Ziel unserer Studie war es, eine alternative, sichere, minimal invasive Methode für die Behandlung von CE1 Zysten zu entwickeln, bei der der Einsatz topischer Skolizide vermieden werden kann.

Wir entschieden uns für eine perkutanen Drainage (PD) bei vier Patienten: ein intrahepatischer Katheter wurde unter CT-fluoroscopischer Kontrolle eingelegt, die intracystische Flüssigkeit fluid wurde aspiriert und die Vitalität der intracystischen Protoscolices mikroskopisch analysiert. Praziquantel (PZQ) per os wurde zur Albendazolmedikation (ABZ) hinzugefügt anstatt topische Skolizide zu verwenden.

Die Protoscolices degenerierten innerhalb 5 bis 10 Tagen nach PZQ Ko-medikation nach Erreichen einer kumulativen Dosis von 250 bis 335 mg/kg und die Zysten kollabierten. Die Zysten degenerierten ohne ein Zeichen der Disseminierung von Zystenflüssigkeit oder eines Rückfalls über bis zu 24 Monaten nach der Intervention.

Zusammenfassend ist eine PD in Kombination mit PZQ p.o. unter ABZ-Abdeckung einer PAIR bei Patienten mit unilokulären Echinokokkenzysten vorzuziehen.

Keywords

cystic echinococcosis - Echinococcus granulosus - interventional radiology - percutaneous treatment - praziquantel - albendazole

Schlüsselwörter

Zystische Echinococcosis - Echinococcus granulosus - Interventionelle Radiologie - Perkutane Behandlung - Praziquantel - Albendazol

Publikationsverlauf

Eingereicht: 23. März 2023

Angenommen: 29. März 2023

Artikel online veröffentlicht:
20. September 2023

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