Treatment of Hepatic Cystic Echinococcosis in Patients from the Southeastern Rhodope Region of Bulgaria in 2004-2013: Comparison of Current Practices with Expert Recommendations

Abstract

Cystic echinococcosis (CE) is a clinically complex chronic parasitic disease, management options for which include surgery, percutaneous treatments, and treatment with albendazole (ABZ) for active cysts, and the "Watch-and-Wait" approach for uncomplicated, inactive cysts. We examined, retrospectively, the clinical management of 334 patients with hepatic CE from the southeastern Rhodope region of Bulgaria between 2004 and 2013. Cysts were reclassified according to the World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) on the basis of ultrasound reports and images. The majority (62.3%) of uncomplicated cysts were CE1, 66% of which were treated surgically. Of all interventions, 5% were performed on inactive uncomplicated CE4-CE5 cysts. About half (47.6%) of these cysts were therefore treated inappropriately, exposing patients to unnecessary treatment-related risks and the health system to unnecessary costs. No management change was observed after the publication of the WHO-IWGE Expert Consensus recommendations in 2010. In Bulgaria, ABZ is still used in interrupted cycles as this is reimbursed, and peri-interventional chemoprophylaxis was not administered in the majority of surgical patients. Efforts are needed to introduce the WHO-IWGE classification and management recommendations and to encourage reception of state-of-the-art practices by public health regulatory bodies to improve patient quality of care and optimization of health resources.

Figure 1.

The southeastern Rhodope region of Bulgaria comprising Kardzhali, Haskovo, and Smolyan districts.

Figure 2.

Schematic representation of the natural history of hepatic cystic echinococcosis (CE) and suggested clinical approaches according to the World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE). Solid black arrow indicates natural evolution toward inactivation; black dashed arrows indicate evolution of therapy-unresponsive chronic stages. Ultrasound (US) images: cyst US classifications according to WHO-IWGE and Gharbi. Gray boxes suggested stage-specific approach to uncomplicated hepatic CE according to the WHO Expert Consensus. ABZ = albendazole; PAIR = puncture, aspiration, injection of scolecidal agent, reaspiration. (Modified from Ref. 5.)