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

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.