Shifting Paradigms in Cholangiohydatidosis: Is Endotherapy Transforming from a Bridge to Definitive Monotherapy?
Cystic echinococcosis (CE), caused by the larval stage of Echinococcus granulosus , is a globally under-recognized zoonosis. An estimated one million people are affected at any given time, with incidence exceeding 50 cases per 100,000 person-years in endemic pockets across the Mediterranean, the Middle East, Central Asia, western China, East Africa, and South America. 1 India carries a substantial share of this burden. National incidence estimates range from 1 to 200 per 100,000 population, with classical high-prevalence foci in Andhra Pradesh and Tamil Nadu. 2 Long-recognized endemic clusters also persist in southern Rajasthan 3 and in the Kashmir Valley, where a large population-based seros-urvey of over 1,400 samples con fi rmed ongoing transmission. 4 Recent seroprevalence data from North India report anti-E. granulosus IgG positivity as high as 46% among clinically suspected patients, suggesting active and possibly intensifying transmission. 5 As elsewhere, the liver remains the most commonly affected organ in Indian series. Despite this burden, India lacks a national CE surveillance framework, leaving tertiary-center case series, such as the one published in this issue of Journal of Digestive Endoscopy from Uttar Pradesh 6 as the principal source of insight into complicated, biliary-penetrating disease in the subcontinent. For symptomatic or complicated active cysts, three broad treatment modalities coexist: benzimidazole chemotherapy (albendazole being the agent of choice, typically 10 to 15mg/kg/d), surgical resection, ranging from conservative cystectomy to formal hepatectomy, and image-guided percutaneous drainage – most commonly PAIR (puncture, aspiration, injection of a scolicidal agent, and re-aspiration