CardioVascular and Interventional Radiology | 2021
Commentary on “Percutaneous Versus Surgical Interventions for Hepatic Cystic Echinococcosis – A Systematic Review and Meta-Analysis”
Abstract
There are basically four treatment options for the management of liver cystic echinococcosis (CE) cysts, namely surgery, medical treatment, percutaneous treatment, and ‘‘wait and watch’’. The active/viable types according to World Health Organization (WHO) classification (CE1, CE2, CE3a and CE3b) should be treated on the basis of ‘‘stage-specific approach’’, and theoretically non-viable/ inactive types (CE4 and CE5) are managed by ‘‘wait and watch approach’’. Although surgery (conservative, radical or laparoscopic) is the traditional treatment option, a percutaneous approach by different techniques, such as PAIR, standard catheterisation technique and modified catheterisation technique (MoCaT), has gained wide acceptance in the last decades [1]. As a general rule, CE1 and CE3a are treated by PAIR or standard catheterisation technique [2]. In a previous prospective randomised trial comparing PAIR and standard catheterisation technique for liver CE1 and CE3a cysts, it was concluded that it is better to start with PAIR, as the PAIR group is associated with a significantly lower rate of major complications, lower recurrence rate and shorter duration of hospital stays. However, the catheterisation technique should be preferred in the presence of cystobiliary fistulas or any technical difficulty detected during the PAIR procedure [2]. MoCaT is proposed for the treatment of CE2 and CE3b on the basis of evacuation of the cyst content via a catheter [3]. I congratulate Mönnick G. et al. who published a paper in this issue of CVIR on ‘‘a systematic review and metaanalysis to compare the results of percutaneous treatment versus surgical interventions for hepatic cystic echinococcosis’’ [4]. They concluded that ‘‘contrary to popular belief, less invasive treatment methods, using percutaneous evacuation to treat CE, appear to be at least non-inferior in terms of recurrence rate, and significantly show less postoperative complications and shorter hospital stay compared to surgical treatment.’’ Although we know that their results are very much in accordance with the larger published series in the literature, these findings are also similar to a previously published meta-analysis in which percutaneous treatment (PAIR) was found to be associated with lower recurrence, mortality and complication rates as well as a shorter hospital stay [5]. In my opinion, the authors have correctly chosen the two prospective randomised trials to compare. However, one problem in the first study is that the types of treated cysts were classified to be unior multi-vesicular. Although univesicular type cysts could be grouped as CE1, information on multi-vesicular types (9 in each group) was not presented (CE2 or CE3b?) [6]. In the second study, bile was aspirated at the initial puncture in one patient from the DPAI-arm and this patient was excluded from the study [7]. This case is a good example that bile aspiration during PAIR is an indication to convert the PAIR technique to standard catheterisation to complete the treatment [2]. I think there is a close relationship between the type of liver CE cysts (according to WHO classification) and the percutaneous technique applied. This approach can be accepted as a kind of ‘‘stage-specific approach for percutaneous options’’. The best results are obtained when one of & Okan Akhan [email protected]; [email protected]