Surgical excision is the treatment of choice for CE and the only avenue leading to cure of the infestation. A new treatment, called PAIR, is currently being refined. PAIR is an acronym for Puncture, Aspiration, Injection, and Reaspiration. PAIR technique is guided by either ultrasound or computed tomography. It must be accompanied by chemotherapy in the form of benzimidazole for the 4 days preceding the procedure and for 1 to 3 months postprocedure. This technique can be performed on the liver, kidney, or bones, but not in the lungs or brain. Surgical interventions range from radical surgery—a total pericystectomy or partial resection of the affected organ—to conservative procedures, such as open cystectomy, to simple procedures, such as placing a drainage tube to empty infected and communicating cysts. The possibility of relapse decreases with increasing complexity of the surgical treatment.

Radical complete resection of AE cysts, such as lung wedge resection or lobectomy, is the only possible curative intervention for AE patients. Some infestations dictate that total hepatectomy with transplantation be carried out, but only if no extra hepatic disease is present. Parasite re-emergence may occur in the transplanted organ, and distant metastasis may occur in immunosuppressed patients.

Respiratory compromise may result from larger alveolar cysts. Spirometric evaluation preoperatively will indicate reduced volumes secondary to space-occupying lesions.

Resection of the alveolar cyst requires isolation of the affected lung. One-lung ventilation is generally well tolerated. Atelectasis may be present, particularly in the right lower lobe, because of encroachment by the enlarged liver. The atelectasis results in hypoxemia, which will worsen after anesthesia induction. Positive end-expiratory pressure (PEEP) may be an effective treatment to prevent extension of the atelectasis. When one-lung ventilation is anticipated, placement of an arterial pressure catheter is a prudent measure to assess patient tolerance of the method via serial arterial blood gas analysis.

Liver dysfunction may interfere with metabolic functions. As a result, actions of medications may be prolonged, depending on how effectively the liver metabolizes medications.

Good, continuous communication between surgeon and anesthetist is essential. Paralysis is essential, especially during drainage and delivery of the cyst(s), to avoid movement and spillage of the cyst contents. If the cyst contents are spilled, anaphylaxis and shock may result. Because of these extreme consequences, preoperative intravenous access should be established with large-bore catheters. Preoperative administration of diphenhydramine and/or a corticosteroid may help reduce an anaphylactic reaction to spillage of cyst contents. In the event of anaphylactic shock, rapid administration of fluids, epinephrine, additional corticosteroids, and diphenhydramine will require the presence of the large-bore intravenous catheters.

The anesthetist should anticipate large fluid shifts, large volumes of fluid administration, and the potential loss of large volumes of blood, which are also reasons to use large-bore intravenous catheters.