Asymptomatic Liver Hydatid Cysts: Is There a Role for Nonoperative Management?

Liver cystic echinococcosis (CE) is one of the important neglected tropical diseases that have a global distribution and significant implications on public health outcomes. The World Health Organization (WHO) has played an essential role in raising awareness about this chronic parasitic disease and has set the stage for a unified diagnostic and treatment approach. Currently, the management of CE should follow the stage-specific WHO recommendations. Therapeutic options include surgery, percutaneous treatment, drug therapy, and observation. Despite the availability of multiple treatment options, it is necessary to recognize that the evidence to support the best treatment approach is insufficient. Determining the ideal individualized treatment strategy remains controversial, in particular on how best to manage asymptomatic individuals. Invasive treatment options such as surgery or PAIR (puncture, aspiration, injection, reaspiration) have considerable risks as well as risk of relapse. Given that the majority of liver hydatid cysts have a good prognosis, two treatment strategies should be highlighted. First, the “watch and wait” strategy is a safe option to consider in inactive uncomplicated cysts classified as WHO stage CE4 and CE5. Second, medical drug therapy with benzimidazoles is another noninvasive treatment option with an expected favorable outcome in the majority of cases. Antiparasitic drugs work best for small (less than 5 cm) CE1 and CE3a cysts. Both noninvasive treatment strategies should be followed up closely with regular ultrasound monitoring. Patients should be informed about the risks and benefits including the risk of relapse. Evidence from randomized trials comparing different options is needed for better guidance.