Percutaneous vs surgical management of hepatic cystic echinococcosis: A perspective on evolving clinical pathways

Table 1 Classification of hepatic cystic echinococcosis

WHO classification	Lesion characteristics
CL	Cystic lesion, nature to be determined
CE1	Unilocular cystic lesion, fluid-filled, often with characteristic “double-line sign” or “honeycomb sign”
CE2	Multivesicular, multiseptated cyst with internal daughter cysts
CE3a	Collapsed inner cyst membrane presenting as “water lily sign” or “floating membrane sign”
CE3b	Partially detached inner cyst wall floating freely within the cyst fluid, presenting as “tent sign”
CE4	Solidified lesion presenting as “brain-like sign”
CE5	Solid lesion with calcification

WHO: World Health Organization; CL: Cystic lesion; CE: Cystic echinococcosis.

Table 2 Summary of treatment strategies for hepatic cystic echinococcosis based on World Health Organization classification

Ref.	Treatment modality	WHO classification	Recommended treatment	Remarks
[8,11,21,24,25,40,41]	PAIR	CE1/CE3a	PAIR + ABZ	PAIR vs catheterization: Major complications 2.94% vs 36.84% (aP = 0.002); hospital stay: 3.8 days; D-PAI: Cyst disappearance in 64.8%; PD + PZQ + ABZ avoids topical scolicidal toxicity
[20-22,28]	Percutaneous (giant cyst/biliary fistula)	CE1/CE3a	Catheterization + ABZ	Catheterization indicated for PAIR failure or visible fistula
[26,27,29,31]	Percutaneous (complex cysts)	CE2/CE3b	MoCaT + ABZ	Recurrence: 3.85% (all classifications), 4.5% (CE2/CE3b); hospital stay: 3.88 days
[17,18,32,33]	Conservative surgery	CE1/CE3/CE2/CE3b	Endocystectomy, subtotal pericystectomy	Endocystectomy recurrence: 4.8%; subadventitial cystectomy recurrence: 0.7%, spontaneous fistula closure: 100%
[14,15,17,37]	Radical surgery	CE2/CE3/complex	Hepatectomy, total pericystectomy	Recurrence: 1.85% vs 11.9% (conservative) (bP < 0.0001); hospital stay: 8.65 days vs 14.9 days; complications: 13.3% vs 31.4%
[7,15,16]	Laparoscopic surgery	All classifications	Laparoscopic surgery	Hospital stay: MD = -1.9 days; minor complications: RR = 0.13 (cP < 0.05)
[11,27,28,34,36]	Biliary fistula management	All classifications	ERCP + drainage	Risk factors for ERCP: Left lobe cysts (OR = 25.71), PAIR (OR = 29.79), conservative surgery (OR = 3.63); NBD vs BS: Hospital stay 8.3 days vs 16.13 days; BS: 69.5% required second ERCP
[32,38,39]	Watchful waiting	CE4/CE5	Long-term ultrasound follow-up	Naturally inactivated cysts: Stable in 98.5%; post-treatment CE4 reactivation: Up to 50%
[1,32]	Medical therapy	CE1/CE3a (< 5 cm)	ABZ monotherapy	Cyst disappearance: 30%; regression: 30%-50%
[11,34,36]	Cyst volume and biliary fistula risk	All classifications		Fistula group: Initial volume 726.8 mL vs 351.1 mL (dP < 0.001); diameter ≥ 9.5 cm: Sensitivity 70%, specificity 60%; children: > 75 mm associated with fistula (eP = 0.040); hospital stay: 32 days vs 7 days (fP < 0.0001)
[10,17,35]	Patient factors/medical resources	All classifications		Surgical decision predictors: Imaging, cyst stage, symptoms (Cox C-index: 0.94, AUC = 0.950)

^aP = 0.002 vs catheterization group;.

^bP < 0.0001 vs conservative surgery;.

^cP < 0.05 vs open surgery group;.

^dP < 0.001 vs patients without fistula;.

^eP = 0.040 vs children without fistula;.

^fP < 0.0001 vs patients without fistula.

WHO: World Health Organization; PAIR: Puncture, aspiration, injection, re-aspiration; ABZ: Albendazole; D-PAI: Double percutaneous aspiration and ethanol injection; PD: Percutaneous drainage; PZQ: Praziquantel; MoCaT: Modified catheterization technique; MD: Mean difference; RR: Risk ratio; ERCP: Endoscopic retrograde cholangiopancreatography; OR: Odds ratio; NBD: Nasobiliary drainage; BS: Biliary stenting; AUC: Area under the curve.