Percutaneous needle aspiration, injection, and reaspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts

Hepatic hydatid cyst is an important public health problem in parts of the world where dogs are used for cattle breeding. Management of uncomplicated hepatic hydatid cysts is currently surgical. However, the puncture, aspiration, injection, and reaspiration (PAIR) method with or without benzimidazole coverage has appeared as an alternative to surgery over the past decade. To assess the benefits and harms of PAIR with or without benzimidazole coverage for patients with uncomplicated hepatic hydatid cysts in comparison with sham/no intervention, surgery, or medical treatment. The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Controlled Trials Register in The Cochrane Library, MEDLINE, EMBASE, DARE, and ACP Journal Club and full-text searches were combined (all searched October 2004). Reference lists of pertinent studies and other identified literature were scanned. Researchers in the field were contacted.Only randomized clinical trials using the PAIR method with or without benzimidazole coverage as the experimental treatment of uncomplicated hepatic hydatid cysts (i.e., hepatic hydatid cysts which are not infected and do not have any communication with the biliary tree or other viscera) versus no intervention, sham puncture (i.e., performing all steps for puncture, pretending that PAIR is being performed, but actually not performing the procedure proper), surgery, or medical treatment were included.Data were independently extracted and methodologic quality of each trial was assessed by the authors. The principal authors of the trials were contacted to retrieve missing data. We found no randomized clinical trials comparing PAIR versus no or sham intervention. We identified only two randomized clinical trials, one comparing PAIR versus surgical treatment (n = 50) and the other comparing PAIR (with or without albendazole) versus albendazole alone (n = 30). Both trials were graded as ''adequate'' for allocation concealment; however, generation of allocation sequence and blinding methods were ''unclear'' in both of them. Compared with surgery, PAIR plus albendazole obtain similar cyst disappearance and mean cyst diameter with fewer adverse events (32% versus 84%, P = 0.001) and fewer days in hospital (mean + SD: 4.2 + 1.5 versus 12.7 + 6.5 days, P = 0.001). Compared with albendazole, PAIR with or without albendazole obtain significantly more often (P = 0.01) cyst reduction and symptomatic relief. PAIR seems promising, but there is insufficient evidence to support or refute PAIR with or without benzimidazole coverage for treating patients with uncomplicated hepatic hydatid cysts. Further well-designed randomized clinical trials are necessary to address the topic.