Clinical Management of Cystic Echinococcosis in Bhutan: Current Practices, Gaps, and Recommendations

BackgroundCystic echinococcosis (CE) is a neglected parasitic zoonosis that primarily affects marginalized populations in rural endemic regions. These populations have limited access to, and availability of, the appropriate infrastructure, resources, and skills required to treat this complex disease. This retrospective study reviewed and analyzed the clinical management of CE patients in Bhutan, based on hospital records from January 2020 to December 2024. MethodsHospital records of 120 patients with hepatic or pulmonary CE treated between January 2020 and December 2024 in the three hospitals caring for CE patients in Bhutan were retrospectively reviewed. Data on clinical presentation, diagnosis, treatment, and outcomes were extracted from hospital records using a standardized questionnaire. Data analysis was performed using R software (version 4.4.3). FindingsThe median age of the patients was 36 years (IQR: 21.75-53), with 60% being female. The liver was the most affected organ (70%), followed by the lungs (8%). US and CT were used in 83% for diagnostic and pre-surgical assessments. WHO-recommended CE cyst staging was performed in only 11% of cases. Pre-intervention complications were reported in 40% of patients. Treatment approaches included surgery (open or laparoscopic partial cystectomy, deroofing, and cyst drainage) combined with albendazole (ABZ) therapy (74%), PAIR in 4%, and ABZ alone in 8% of cases. Antibiotic use beyond standard perioperative prophylaxis was common (44% of cases). Post-treatment complications occurred in 23% of surgical cases, including one death; biliary leakage was the most frequent complication (55%), and more than one-third of surgical patients were discharged with drains in situ. 23% of the cohort were readmissions and 11% of the patients with hepatic CE were due to documented recurrence requiring repeat surgery. Long-term follow-up was absent, limiting the early detection and management of recurrence. Conclusion and recommendationsThe study findings show that the care for CE patients in Bhutan urgently requires implementation of US-based cyst staging and treatment allocation, the development of infrastructure and skills for the major treatment modalities recommended by WHO guidelines and long-term follow-up to improve patient outcomes, including recurrence, and to ensure quality control of CE care. Safe and proven practices, particularly in surgery, must be prioritized over diversification. Such strategies are feasible and cost-effective. Author SummaryCystic echinococcosis (CE) is a neglected parasitic disease that develops silently and can affect people for years before causing serious complications. It is common in rural, livestock-rearing regions, including Bhutan, where access and availability to appropriate care is limited. We reviewed hospital records of 120 patients treated for CE in Bhutan between 2020 and 2024 to understand current clinical practices and treatment outcomes. Most patients had large liver cysts and were diagnosed at a late stage, often only once complications had occurred. US-based cyst staging was very rarely performed, and cyst-staging was not used to inform treatment decisions. Surgery combined with anti-parasitic (albendazole) therapy was the most common treatment. Postoperative complications and disease recurrence were frequent, and most patients had no long-term follow-up to attend complications and recurrences timely. Considerable variation in surgical and medical management was observed. Developing and implementing WHO-guideline-based infrastructure, resources and training for CE patient care is urgently needed.