Treatment Of Hepatic Alveolar Echinococcosis Research Articles

Effect and mechanism of reactive oxygen species-mediated NOD-like receptor family pyrin domain-containing 3 inflammasome activation in hepatic alveolar echinococcosis.

The NOD-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome is a significant component of the innate immune system that plays a vital role in the development of various parasitic diseases. However, its role in hepatic alveolar echinococcosis (HAE) remains unclear. To investigate the NLRP3 inflammasome and its mechanism of activation in HAE. We assessed the expression of NLRP3, caspase-1, interleukin (IL)-1β, and IL-18 in the marginal zone and corresponding normal liver of 60 patients with HAE. A rat model of HAE was employed to investigate the role of the NLRP3 inflammasome in the marginal zone of HAE. Transwell experiments were conducted to investigate the effect of Echinococcus multilocularis (E. multilocularis) in stimulating Kupffer cells and hepatocytes. Furthermore, immunohistochemistry, Western blotting, and enzyme-linked immunosorbent assay were used to evaluate NLRP3, caspase-1, IL-1β, and IL-18 expression; flow cytometry was used to detect apoptosis and reactive oxygen species (ROS). NLRP3 inflammasome activation was significantly associated with ROS. Inhibition of ROS production decreased NLRP3-caspase-1-IL-1β pathway activation and mitigated hepatocyte damage and inflammation. E. multilocularis induces hepatocyte damage and inflammation by activating the ROS-mediated NLRP3-caspase-1-IL-1β pathway in Kupffer cells, indicating that ROS may serve as a potential target for the treatment of HAE.

Advances in the pharmacological treatment of hepatic alveolar echinococcosis: From laboratory to clinic.

Hepatic alveolar echinococcosis (HAE) is a zoonotic parasitic disease caused by the larvae of Echinococcus multilocularis. Because of its characteristics of diffuse infiltration and growth similar to tumors, the disability rate and mortality rate are high among patients. Although surgery (including hepatectomy, liver transplantation, and autologous liver transplantation) is the first choice for the treatment of hepatic alveolar echinococcosis in clinic, drug treatment still plays an important and irreplaceable role in patients with end-stage echinococcosis, including patients with multiple organ metastasis, patients with inferior vena cava invasion, or patients with surgical contraindications, etc. However, Albendazole is the only recommended clinical drug which could exhibit a parasitostatic rather than a parasitocidal effect. Novel drugs are needed but few investment was made in the field because the rarity of the cases. Drug repurposing might be a solution. In this review, FDA-approved drugs that have a potential curative effect on hepatic alveolar echinococcosis in animal models are summarized. Further, nano drug delivery systems boosting the therapeutic effect on hepatic alveolar echinococcosis are also reviewed. Taken together, these might contribute to the development of novel strategy for advanced hepatic alveolar echinococcosis.

Effectiveness and safety of ultrasound-guided percutaneous microwave ablation for hepatic alveolar echinococcosis

BackgroundMicrowave ablation (MWA) is a popular therapy for liver malignant tumor in recent years. Few studies have been conducted on its use in the treatment of hepatic alveolar echinococcosis (HAE). The study aims to evaluate the efficacy and safety of MWA in the treatment of HAE.MethodsThis study analyzed the data of 45 patients (mean age, 38 ± 2 years; 24 males) diagnosed with HAE and underwent MWA treatment between June 2014 to December 2019. The patients after MWA were examined by CT or MRI [follow-up: 32 months (IQR 23–48.5)] to determine whether the lesions were relapsed and to evaluate the therapeutic effect of MWA. The safety of MWA was evaluated by monitoring postoperative complications. Clinical data, such as patient demographics, imaging features of the lesions, relevant findings of laboratory tests before and after ablation, and information related to ablation, were collected and analyzed. Paired-sample t tests and paired-sample Wilcoxon signed-rank tests were used to compare relevant laboratory indicators before and after MWA.ResultsMWA was applied to 57 HAE lesions in 45 patients. The median size of lesions was 3.42 cm (IQR2.85–4.41). The rate of complete ablation was 100% (57/57). The median follow-up time was 32 months (IQR 23–48.5). The recurrence rate was 13% (6/45), and the median time of recurrence was 22 months. The rate of minor complications was 11.1% (5/45), and there were no major complications and deaths. Compared to preoperative, ALB, RBC, HBG, and PLT were decreased (p < 0.001); ALT, TB, DB, and WBC were increased (p < 0.001); and no statistically difference in PT, APTT, and INR (p > 0.05).ConclusionsMWA might be a safe and effective way to cure HAE. Meanwhile, it provides a new option and a new way of thinking about treatment for patients with HAE.

Analysis of the efficacy of microwave ablation in the treatment of early hepatic alveolar echinococcosis: A propensity score matching based study

BackgroundTo explore the efficacy of microwave ablation (MWA) in the treatment of hepatic alveolar echinococcosis (HAE) with a diameter of ≤5 cm. MethodFrom June 2014 to January 2020, patients diagnosed with HAE were retrospectively analyzed. After balancing the confounding factors by propensity score matching (PSM) , the patients were divided into MWA group (n = 20) and radical operation group (n = 20) by 1:1 matching. The safety and effectiveness of MWA were assessed by comparing the differences between the two groups in terms of postoperative general laboratory indices, grading of postoperative complications, length of postoperative hospitalization, the outcome of treatment, and disease recurrence. ResultAfter PSM, all confounders were not statistically different (P>0.05) . Compared with the radical surgery group, patients in the MWA group had lower postoperative ALT and WBC elevations (P<0.001) , shorter postoperative hospital stay (P<0.001) ) , lower hospital costs (P<0.001) . The effective rate of the two groups was 100%. There was no statistical difference in the incidence of postoperative complications and recurrence rate (P>0.05). ConclusionMWA is a safe and effective means of treating HAE ≤ 5 cm in diameter.

Current status of the surgical treatment of hepatic alveolar echinococcosis

Hepatic alveolar echinococcosis (HAE) is a zoonotic disease caused by Echinococcus multilocularis. At present, the treatment of HAE is mainly based on radical surgical resection, assisted by drug therapy. This article introduces the current status of the application of radical surgical resection, ablation techniques, and palliative surgery in the treatment of HAE and summarizes the main indications for autologous liver transplantation, so as to provide certain experience and reference for selecting the treatment strategies for HAE.

Value of prognostic nutritional index in predicting the prognosis of patients with hepatic alveolar echinococcosis

Objective To investigate the value of prognostic nutritional index (PNI) in predicting the prognosis of patients with hepatic alveolar echinococcosis. Methods A retrospective analysis was performed for the clinical data of 242 patients who were admitted to Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, from January 2015 to December 2018 and underwent surgical treatment of hepatic alveolar echinococcosis. The results of routine blood test and liver function were collected at 1 week before surgery, and PNI was calculated. X-Tile software was used to determine the cut-off value of PNI, and according to this cut-off value, the patients were divided into high PNI group with 216 patients and low PNI group with 26 patients. The chi-square test was used for comparison of categorical data between groups; the Kaplan-Meier method was used to plot survival curves, and the log-rank test was used for comparison between groups; the Cox regression model was used to perform univariate and multivariate analyses, and hazard ratio (HR) and corresponding 95% confidence interval (CI) were calculated. Results PNI was associated with treatment modality, intraoperative blood loss, stage of echinococcosis, number of lesions, Child-Pugh class, aspartate aminotransferase, total bilirubin, albumin, alkaline phosphatase (ALP), prothrombin time (PT), and lymphocyte count (all P Conclusion PNI can be used to predict the prognosis of patients with hepatic alveolar echinococcosis. The higher the peripheral blood PNI before surgery, the better the prognosis of patients.

Laparoscopic or open treatment for hepatic alveolar echinococcosis: A single-institution experience

ObjectiveThe aim of this study was to evaluate the safety and efficacy of laparoscopy in the treatment of hepatic alveolar echinococcosis (AE). MethodsBetween January 2018 and December 2019, 213 hepatic AE patients were admitted to the authors’ institution. Among them, 165 patients (77.46%, 165/213) underwent surgery. Of 13 patients who underwent laparoscopic treatment, two required conversion to open surgery. The remaining 11 patients (group 1) were analyzed. During the same period, 154 patients underwent open surgery, but only 14 records were compatible with the criteria for the laparoscopic approach and were reviewed retrospectively (group 2). ResultsConversion to open surgery occurred in two cases. Both groups were basically consistent in terms of detailed demographic data, characteristics of the lesions, and surgical strategy (P > 0.05). The laparoscopic group not only achieved the same R0 resection as the open group, but the results were also significantly superior to those of the open group in terms of postoperative complications, postoperative catheterization time, and postoperative hospital stay (P = 0.042, P = 0.046, and P = 0.045, respectively). No recurrences were observed in either group during this period. ConclusionsLaparoscopic surgery provides a safe and efficacious approach for hepatic AE in selected patients. Large, prospective, randomized trials are needed to confirm its superiority.

Laparoscopic hepatectomy for the treatment of hepatic alveolar echinococcosis.

Background: At present, laparoscopy is relatively mature as a minimally invasive technique, but there are few reports on this approach for the radical treatment of hepatic alveolar echinococcosis (AE). In this study, we aimed to evaluate the safety and feasibility of laparoscopic hepatectomy (LH) for AE treatment. Results: A retrospective review of medical records obtained from 13 patients diagnosed with AE between January 2018 and December 2019 and treated with laparoscopic hepatectomy was conducted at the First Affiliated Hospital of Xinjiang Medical University. All patients (n = 13) underwent hepatic resection using laparoscopy and none were transferred to open surgery. The average duration of surgery was 285 min (145–580 min). Intraoperative bleeding was 305 mL (20–2000 mL). The mean duration of postoperative catheterization was 6.9 days (3–21 days), and postoperative hospital stay was 7.2 days (4–14 days). No complication of Clavien-Dindo grade III or above occurred, except for the second patient with acute liver failure post-surgically. No recurrences or deaths were observed at 9–30 months of follow-up. Conclusions: Laparoscopic hepatectomy appears to be safe and effective in selected AE patients. The advantages of this technique for AE treatment need to be further compared with the classical open approach.

Comment on surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients.

Echinococcus multilocularis causes alveolar echinococcosis which is a chronic, progressive zoonotic disease that mainly affects the liver. Hepatic alveolar echinococcosis is insidious and the patients are asymptomatic most of the time. Generally, it is incidentally found on imaging studies performed for other reasons. Specific symptoms may evolve if the vascular and biliary structures of the liver are affected. Hepatic alveolar echinococcosis shows a similar pattern to malignancies in terms of radiologic and clinical features. For this reason, oncological surgical principles should be applied during the resection of hepatic alveolar echinococcosis. The gold standard surgical treatment is resection with negative surgical margin. However, in patients whose radical resection is not possible other therapeutic options include palliative resection which has no benefit to the patient, and other curative major surgical options such as ex vivo liver resection, and autotransplantation and ultimately liver transplantation. The remnant liver volume has paramount importance if resection is going to be performed. For this reason, occasionally, remnant liver volume hypertrophy is induced by employing either two-stage hepatectomy or associating liver partition and portal vein ligation for staged hepatectomy.

Progress of researches on the use of ultrasound in the diagnosis and treatment of hepatic alveolar echinococcosis

The patients with hepatic alveolar echinococcosis have unapparent early symptoms due to invasive and slow growth, and the disease is usually at an advanced stage upon diagnosis, which has a poor prognosis. Early diagnosis of hepatic alveolar echinococcosis is therefore of great importance. The advances in the ultrasound techniques continues to improve the accuracy for the diagnosis of hepatic alveolar echinococcosis, and ultrasound plays a critical role in the treatment and assessment of therapeutic efficacy for hepatic alveolar echinococcosis. This paper mainly reviews the application of ultrasound in the diagnosis and treatment of hepatic alveolar echinococcosis.

Surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients.

Hepatic alveolar echinococcosis (HAE) is a potentially fatal disease caused by the larval growth of Echinococcus multilocularis. We analysed the clinical data of 178 consecutive HAE patients treated with definitive radical surgery at our institution. According to the surgical approach: group A patients underwent direct radical hepatic resection; group B patients first underwent percutaneous puncture external drainage, followed by radical hepatic resection 2 months later; group C patients underwent a two-step hepatic resection; and group D patients underwent liver transplantation. The baseline characteristics, mortality, postoperative complications and recurrence rates were evaluated. Symptoms were present in 79.8% (142/178) patients. Bi-lobar lesion was found in 34 (19.1%, 34/178) patients, 47.2% (84/178) of whom had ⩾2 lesions each. There were no intraoperative deaths. The postoperative mortality was 2.29% in group A, 8.62% in group D and 0% in groups B and C. The main cause of death was a serious postoperative complication (Clavien-Dindo grades III-V). Patients were followed-up systematically for a median of 35.8 months (8-72) without recurrence. Active HAE should be treated by radical liver resection, and the complicated alveolar echinococcosis of the liver has been managed whenever possible using principles of radical liver resection by experienced hepatic surgeons.

Efficacy and safety of ultrasound-guided percutaneous microwave ablation for the treatment of hepatic alveolar echinococcosis: A preliminary study.

The present study aims to assess the efficacy and safety of ultrasound-guided percutaneous microwave ablation (MWA) for hepatic alveolar echinococcosis (HAE) preliminarily.Seventeen patients diagnosed to HAE and treated with MWA (80 watts, 4 min) were retrospectively analyzed. The upper abdominal computed tomography (CT) was performed at 1, 6, 12 months after the MWA treatment. The complications were evaluated to assess the safety.The diameters of the lesions in the HAE patients ranged from 1.9 to 4.7 cm. The patients included 10 males and 7 females, aged 26 to 70 (45.82 ± 13.36) years, 5 patients infecting with chronic hepatitis viral B and 8 patients with positive hydatid antibody (IgG). The lesions observed in the postoperative CT (1, 6, 12 months) were calcified compared with those observed in the preoperative CT and without relapse. No serious treatment-related complications occurred after treatment.MWA is a novel and effective therapeutic method for HAE with a single lesion (diameter≤=5 cm). Further studies based on prospective random control trials to confirm our findings are necessary.

Segment-orientated anatomical liver resection for the treatment of hepatic alveolar echinococcosis in the middle lobe of the liver

Objective To investigate the efficacy and feasibility of segment-orientated anatomical liver resection for the treatment of hepatic alveolar echinococcosis (HAE) in the middle lobe of the liver. Methods The clinical data of a female patient with HAE in the middle lobe of the liver who was admitted to the First Affiliated Hospital of Xi'an Jiaotong University in September 2013 were retrospectively analyzed. Before operation, various surgical plannings were facilitated by a three-dimensional reconstruction system, and then the surgical planning was determined with the assistance of the multivariate analysis (volume measurement of liver, resectability of remnant functional liver, evaluation of vascular resection and reconstruction, Child-Pugh score and indocyanine green retention at 15 minutes ) . Segment-orientated anatomical liver resection(segment Ⅴ, Ⅷ and Ⅳb) was performed on the patient. There was a close relationship between the HAE and the first and the second hepatic portal during operation, and the anatomical liver resection of segment Ⅴ, Ⅷ and Ⅳb was precisely carried out. The patient was followed up by outpatient examination and telephone interview every month up to April 2014. The condition of the liver was observed by B ultrasound and computed tomography examinations. Results The three-dimensional reconstruction of the CT data of the patient clearly displayed the anatomical structure and adjacent relationship between the tumor, abdominal organs and major abdominal vessels. The preoperative evaluation of the anatomy of tumor based on three-dimensional images was confirmed with operative findings. The operation time and volume of blood loss were 410 minutes and 1 000 mL, respectively. The patient did not receive blood transfusion. The intraoperative vital signs of the patient were stable. There were no complications such as hepatic insufficiency. The duration of postoperative hospital stay was 15 days. Surgical incision was healed at discharge. The results of blood routine and blood biochemistry test, daily diet and basic self-care ability were in normal condition. HAE was diagnosed based on the result of pathological examination. Albendazole was administered with 1 200 mg/ d after operation. The patient was followed up for 6 months and returned to work. The weight of the patient increased by 5 kilograms than that at discharge, without complaint of discomfort. There was no recurrence of HAE and hepatic echinococcosis of organs. Conclusions Segment-orientated anatomical liver resection is not only a method for complete resection, but also maximizes the functional remnant of liver on the basis of intraoperative three-dimensional reconstruction system together with selective hepatic inflow occlusion and vessel reconstruction technique. The patient gets a full recovery with satisfactory outcome. Key words: Echinococcosis, hepatic; Hepatectomy; Vessel reconstruction

Diagnosis and treatment of hepatic alveolar echinococcosis after liver transplantation

As a treatment method for advanced hepatic alveolar echinococcosis (AE),liver transplantation has been gradually performed.One patient with hepatic AE recurrence after liver transplantation was admitted to the Fourth Hospital of PLA in November 2012.The patients received liver transplantation in 2006 for the treatment of hepatic AE.Recurrent lesions were found in the head of the pancreas and the right lung.The patient was also associated with liver dysfunction.Liver function was improved obviously after liver-protective treatment,and continuous albendazole treatment was giving to the patient.Based on a full discussion of the patient,we thought that hepatic AE patients who met the following conditions could receive liver transplantation:(1) Severe hepatic insufficiency.(2) Inability to receive radical liver resection.(3) Absence of extra-hepatic metastasis of AE.Albendazole should be administered for at least 2 years after liver transplantation,and the patient should be monitored for a minimum of 10 years for the prevention of possible recurrence of AE. Key words: Hepatic alveolar echinococcosis ; Liver transplantation ; Recurrence ; Diagnosis ; Treatment

Surgical treatment for hepatic alveolar echinococcosis: report of 50 cases.

The purpose of this study is to present the surgical treatment of hepatic alveolar echinococcosis and evaluate the treatment outcomes. A retrospective analysis was made on 50 patients admitted between 2000 and 2008. All the patients were divided into two groups, 26 patients for the radical surgery group and 24 for the palliative surgery group. In the palliative surgery group, 10 patients died during the follow-up period, 2 patients presented with brain metastasis and 4 patients with lung metastasis, 1 patient had multiple lesions in the liver, 1 patient who received left hepatectomy had a new lesion in caudate lobe of the liver, 4 patients had postoperative jaundice, 3 had cholangitis and 4 patients had biliary leaks. There were also 3 patients lost in the follow-up period. In the radical surgery group, 22 patients were alive and asymptomatic without recurrence during the follow-up period, 3 patients had recurrent cholangitis and 4 patients had biliary leaks. Three patients were lost during the followup period in this group. Radical resection appears to be best treatment of hepatic alveolar echinococcosis and palliative operation may cause a series of severe complications leading to death.

Application of a digital three-dimensional reconstruction technique in the diagnosis and treatment of hepatic alveolar echinococcosis

Objective To investigate the value of a digital three-dimensional reconstruction technique in the treatment of hepatic alveolar echinococcosis (HAE).Methods The computed tomography scan data for 13 patients with HAE who were admitted to the First Affiliated Hospital of Xinjiang Medical University from February 2011 to October 2011 were reconstructed and analyzed by a three-dimensional reconstruction system to assess resectability,and to facilitate surgical planning and individualized virtual surgery.The results of preoperative analysis were compared with the results of actual operations.Results The three-dimensional models of the liver were reconstructed successfully,and intrahepatie lesions and vessels were clearly displayed.One patient received an autologous liver transplantation,10 underwent hepatectomy,and 2 received percutaneous transhepatic cholangial drainage.Virtual operation planning was carried out for 11 patients using the three-dimensional reconstruction system.The mean volume of the liver to be resected was predicted to be 920 ml (range,339-2678 ml),and the mean percentage of liver to be resected to the total liver volume was predicted to be 45％ ( range,23％ -68％ ).The mean volume o[ the actual liver resection was 834 ml (range,315-2250 m[),and the mean percentage of actual liver resected to the total liver volume was 42％ (range,22％ -70％ ),which was consistent with the results of preoperative three-dimensional reconstruction.All patients were followed up for 2-8 months,and no severe complications such as liver failure,hemorrhage and bile leakage were detected.Conclusion Digital three-dimen-sional reconstruction is helpful in the diagnosis and treatment of HAE and effectively reduces surgical risks. Key words: Hepatic alveolar echinococcosis; Three-diamensional reconstruction; Surgical planning

Liver transplantation for the treatment of end-stage hepatic alveolar echinococcosis

Objectiye To investigate the value of liver transplantation for the treatment of end-stage hepatic alveolar echinococcosis(HAE).Methods The clinical data of 8 patients with end-stage HAE who received liver transplantation at the First Affiliated Hospital of Xinjiang Medical University from December 2000 to August 2010 were retrospectively analyzed.The operation time,anhepatic phase,infusion of suspension of red blood cells and postoperative complications were observed.Results The median operation time,anhepatic phase and infusion of suspension of red blood cells were 635 minutes(range,490-760 minutes),66 minutes(range,44-240 minutes)and 20 U(range,4-40 U).Liver transplantation was successfully carried out on 7 patients except for 1 patient who received emergent liver transplantation died of severe hepatic encephalopathy,renal failure and coagulation disorder on postoperative day 1.The median follow-up time was 6 months(range,3-29 months).One patient died of septicopyemia in postoperative month 3,1 died of incurable infection of bile duct in postoperative month 5,and 1 died of acute rejection in postoperative month 6.One patient was complicated with stricture of the bile duct anastomosis,and was cured by choledochojejunostomy.The size of the metastatic lesion in the left lung of 1 patient was reduced.One patient who underwent liver autotransplantation had no signs of residual liver disease with good liver function.Conclusion End-stage HAE is an indication for liver transplantation.A minimum dose of immunosuppressive agent and systemic administration of anti-HAE drugs are necessary to prevent the recurrence of HAE and ensure a long-term survival.Liver autotransplantation is the optimal method for the treatment of end-stage HAE,because no immunosuppressive agent is needed after operation. Key words: Hepatic alveolar echinococcosis; Liver transplantation,orthotopic; Liver transplantation,autologous

Analysis of surgical therapy on 43 cases of hepatic alveolar echinococcosis

Objective To study the operative techniques and the surgical results of hepatic alveolar echinococcosis. Methods Forty three patients with hepatic alveolar echinococcosis treated in our Hospital from 2000 to 2008 were studied retrospectively. They were divided into two groups: radical resection group (19 cases) and palliative resection group (24 cases). Results There were 1 surgeryrelated death, 2 patients with remote metastases, 2 patients with intrahepatic dissemination, 4 patients with recurrent jaundice and 3 patients with cholangitis in the palliative resection group. There were 3 patients with biliary fistula, 1 patient with cholangitis and 3 patients with emaciation in the radical resection group. Among the 30 patients followed-up for ≤3-≤8 years, 10 patients died in the palliative resection group and the long-term survival rate was 28.5% (4/14). One patient died from gastric cancer in the cardiac in the radical resection group and the long survival rate was 93. 7%(15/16). Conclusions The first choice of treatment for hepatic alveolar echinococcosis is radical resection. Patients could be cured by radical resection. Palliative surgery is an option for patients not manageable otherwise. Key words: Hepatic alveolar echinococcosis; Radical resection; Palliative resection

Alveolar Echinococcosis in Turkey

Background: Radical resection is the only potentially curative treatment for hepatic alveolar echinococcosis (AE). Although Turkey is an endemic region, population screening is not performed and early diagnosis is rare. Consequently, surgeons are compelled to explore possibilities such as near-total resection and biliodigestive anastomosis for palliation of jaundice. Methods: Surgery was performed in 32 patients with hepatic AE with the following indications: (1) resection; (2) palliation of jaundice; (3) definite assessment of operability; (4) failure in the management of cavity infection by percutaneous methods. Curative resection (R0 = complete resection of all parasitic mass [n = 9], and R1 = a resection in which a small remnant was left on a vital structure [n = 8]) were performed in 17 patients, intrahepatic cholangiojejunostomy in 7, laparotomy-external drainage in 7, and debulking in 1. Results: Perioperative mortality rates were 2/17, 0/7, 2/7 and 1/1, respectively. Twelve patients in the curative resection group are alive without recurrence/progression of the small remnant during a median follow-up of 59 (range 27–116) months. One patient developed an inoperable recurrence that was treated with albendazole. One patient was lost to follow-up. Long-term albendazole treatment was effective in all R1 patients except a patient who had slow asymptomatic progression. Successful palliation of jaundice was achieved in 5 of the 7 intrahepatic cholangiojejunostomy patients. Conclusions: The results of R1 resection in alveolar hydatid disease are similar to those of R0 resection; a small remnant is successfully controlled by albendazole. In patients with jaundice due to hilar invasion, biliary diversion from segment 3 or 5 is effective for palliation of the jaundice and facilitates albendazole treatment.