There are several options for treatment, including surgery, PAIR, and chemotherapy. For asymptomatic individuals, as previously mentioned, an observatory approach can be attempted with appropriate supervision, provided that the cysts are considered to be at relatively low risk for rupture, based on size, location, and patient activities. Entire surgical removal of the cyst cures the patient; however, there are both temporary and permanent contraindications to surgery based on the difficulty of reaching the lesion, advanced age or comorbidities, pregnancy, small or calcified cysts, and potentially lack of adequate medical care in certain endemic areas. In these individuals albendazole is the drug of choice, although it is suspected not to be parasiticidal, given recurrence rates after discontinuation.

Although the technical procedure of choice is still debated, given the lack of controlled trials, the accepted objective is the entire elimination of the parasite without intraoperative spillage or compromise of healthy tissue. In light of the concern for recurrent disease, debate exists regarding the importance of removing the pericyst and hepatic tissue (radical resection) versus conservatively evacuating the cyst alone. The level of evidence is inadequate to inform the correct level of aggressiveness; however, there is support for the safety of a laparoscopic approach and the use of omentoplasty to prevent abscess formation. Because spilled cyst fluid may contain viable protoscolices that could implant in the peritoneal cavity during surgery or cause anaphylaxis, protection of the operating field is imperative before emptying or resecting the cyst with either the radical or the conservative approach. The peritoneal and/or pleural cavities should be isolated with dry gauze or gauze soaked with parasiticidal solution or 20% hypertonic saline. After access is established and control of the cyst wall verified, the cyst is punctured and evacuated using a large-caliber suction device, and resection is then performed in either fashion. If there is any question of possible spillage of cyst contents during the case, patients are offered postsurgical treatment with 10 mg of albendazole per kilogram, usually for 8 weeks.

An alternative to surgical intervention is the PAIR technique, in which the cyst is punctured transcutaneously under ultrasound guidance and the parasite is killed through repeated aspiration and injection of scolicidal agents such as 20% hypertonic saline. For simple hydatid liver cysts that do not abut the liver capsule, this appears to be a safe and attractive option, especially in endemic areas without the option for more aggressive intervention. Many infectious disease specialists recommend treating with antiparasitic drugs such as albendazole for up to 8 weeks postprocedure. Chapter 82 provides further details on cyst staging and treatment options.

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