Percutaneous vs surgical management of hepatic cystic echinococcosis: A perspective on evolving clinical pathways

Abstract

The management of hepatic cystic echinococcosis continues to evolve, with percutaneous techniques increasingly challenging traditional surgical approaches. The paper from Tahtabasi et al on the recent issue of World Journal of Gastroenterology present a large-scale retrospective analysis comparing percutaneous and surgical treatments for liver hydatid cysts with a World Health Organization classification of CE1 and CE3a over a 20-year period. Their study, encompassing 989 patients from an endemic region in Türkiye, provides robust real-world evidence that percutaneous methods offer shorter hospital stays, reduced operative times, and lower risks of intraoperative organ injury, while surgical intervention demonstrates marginal advantages in reducing recollection and anaphylaxis. Importantly, the study identifies cyst volume as a key predictor of cystobiliary fistula development, irrespective of treatment modality. This editorial contextualizes these findings within the broader landscape of hydatid disease management, discusses methodological strengths and limitations, and highlights the need for standardized definitions, randomized trials, and individualized treatment algorithms. We argue that a tailored approach - incorporating cyst characteristics, anatomical location, and patient factors - is essential for optimizing outcomes in patients with this complex parasitic disease.

Key Words: Cystic echinococcosis; Percutaneous treatment; Surgical management; Clinical pathways; Zoonotic disease; Echinococcus granulosus; Hydatid cyst

Core Tip: Hepatic cystic echinococcosis management is less challenged by a lack of therapeutic options than by rational, cyst-specific decision-making. Percutaneous interventions are safe and effective for cysts classified by World Health Organization as CE1 and CE3a, offering advantages in efficiency; while surgery remains essential for large cysts and those with complex biliary involvement or high-risk anatomy. Large real-world data further identify cyst volume as a major determinant of biliary complications, independent of treatment modality. Rather than competing strategies, percutaneous and surgical approaches should be integrated into dynamic, risk-adapted clinical pathways guided by cyst biology, anatomy, and procedural burden.

This editorial refers to “Percutaneous vs surgical management of World Health Organization cystic echinococcosis 1 and 3a liver hydatid cysts” by Tahtabasi et al, 2026; https://doi.org/10.3748/wjg.v32.i3.114226.

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INTRODUCTION

Hepatic echinococcosis remains one of the most challenging parasitic diseases in gastroenterology. Its complexity arises not from a lack of therapeutic options but from the difficulty in selecting the most appropriate, sustainable strategy across heterogeneous patients and cyst characteristics[1,2]. As a classical zoonotic disease caused by Echinococcus infection, hepatic echinococcosis comprises two biologically and clinically distinct entities: Cystic echinococcosis caused by Echinococcus granulosus and alveolar echinococcosis caused by Echinococcus multilocularis[2,3]. The liver is the organ most frequently affected, followed by the lungs, brain, bones, kidneys, and other systemic sites[2,4]. Moreover, prognosis depends heavily on the appropriateness of the therapeutic strategy. In the absence of timely and appropriate treatment, hepatic alveolar echinococcosis is associated with a dismal prognosis, with reported mortality rates approaching 90% within 10-15 years after diagnosis; by contrast, hepatic cystic echinococcosis (HCE) generally carries a substantially lower mortality, typically reported at approximately 2%-4%[5,6].

For several decades, surgery has been considered the definitive treatment for HCE. However, with the continuous expansion of minimally invasive techniques, particularly percutaneous interventions, the selection of optimal therapies for HCE continues to be constrained by three major challenges: Marked heterogeneity in cyst biology, variability in anatomy-related procedural risk, and established institutional preferences shaped by local practice patterns[7-10]. Collectively, these factors contribute to persistent complexity and uncertainty in clinical decision-making. As percutaneous techniques gradually reach maturity, contemporary debate has shifted away from determining the feasibility of percutaneous treatment toward defining the clinical scenarios, patient populations, and disease stages in which it should be prioritized. The dichotomous debate on the superiority of percutaneous vs surgical approaches fails to adequately address the real-world challenges in current clinical practice. Instead, constructing a dynamically adjustable clinical decision-making framework centered on cyst characteristics and based on risk stratification is emerging as the key direction for the evolution of management strategies for HCE. Although the World Health Organization (WHO) cyst classification system is widely adopted in clinical practice, reliance on classification alone is often insufficient for individualized treatment planning. Even within the same WHO stage, cysts may vary substantially in size, anatomical location, biliary communication, and procedure-related risk. Thus, real-world treatment decisions remain influenced by individual physician experience, institutional inertia, and complication-related concerns rather than by high-quality comparative evidence.

In this regard, large-scale real-world datasets are particularly valuable in overcoming the limitations of randomized controlled trials and clarifying the risk-benefit equilibrium in routine clinical practice. Against this background, the study by Tahtabasi et al[11], published in recent issue of World Journal of Gastroenterology, offers timely and clinically relevant insight. Using two decades of data from 989 patients, the authors systematically compared outcomes of percutaneous treatment and surgical management for CE1 and CE3a hepatic hydatid cysts, thereby strengthening the existing evidence base and prompting reconsideration of how emerging data should inform evolving clinical pathways. This commentary assesses the study within the broader context of the evolving management strategies and endeavors to redefine the roles of percutaneous and surgical treatments within contemporary HCE management frameworks from a review perspective.

DEFINITIONS, CLASSIFICATIONS, AND TECHNOLOGICAL EVOLUTIONS OF TREATMENT MODALITIES

The conceptual definition and technical categorization of echinococcosis treatment serve as the foundation for establishing clinical decision-making pathways. With the progress of minimally invasive concepts and techniques, its scope has evolved from the traditional binary division of surgical intervention and nonsurgical management to a continuous spectrum that includes multiple complementary approaches. The core perspective has also transitioned from radical eradication to risk-adapted disease control. As shown in Table 1, the WHO Informal Working Group on Echinococcosis classifies HCE into seven types, from CL to CE5, based on ultrasonographic features; each type exhibits characteristic imaging findings that provide the basis for subsequent treatment decisions[12,13].

Table 1 Classification of hepatic cystic echinococcosis.

WHO classification	Lesion characteristics
CL	Cystic lesion, nature to be determined
CE1	Unilocular cystic lesion, fluid-filled, often with characteristic “double-line sign” or “honeycomb sign”
CE2	Multivesicular, multiseptated cyst with internal daughter cysts
CE3a	Collapsed inner cyst membrane presenting as “water lily sign” or “floating membrane sign”
CE3b	Partially detached inner cyst wall floating freely within the cyst fluid, presenting as “tent sign”
CE4	Solidified lesion presenting as “brain-like sign”
CE5	Solid lesion with calcification

WHO: World Health Organization; CL: Cystic lesion; CE: Cystic echinococcosis.

From the perspective of radical surgery, its core definition pertains to accomplishing the complete resection of parasitic lesions via anatomic hepatectomy or complete capsular excision, with the objective of eradicating the lesion and minimizing the recurrence risk. In a 22-year retrospective analysis of 372 patients undergoing surgery for HCE, Priego et al[14] reported that radical surgical approaches were associated with a shorter hospital stay and lower rates of postoperative complications, mortality, and recurrence. These observations supported radical surgery as the preferred surgical option, while emphasizing that selection of the specific operative technique should be tailored to individual patient characteristics, cyst anatomy, and surgical expertise. In recent years, the introduction of laparoscopic techniques has further transformed surgical paradigms. Efanov et al[15] demonstrated through propensity-score matched analysis that both laparoscopic radical and conservative procedures result in favorable short- and long-term outcomes. However, radical surgery exhibits a lower recurrence rate, highlighting the potential of integrating minimally invasive techniques with radical principles. The single-incision laparoscopic transhepatic cystectomy reported by Soni et al[16] provides a novel minimally invasive radical option for cysts in specific anatomical locations, such as segment S7 of the liver. Collectively, the definition of radical surgery has evolved from a singular concept of liver resection to encompass a range of open and minimally invasive techniques aimed at achieving complete lesion removal.

From the perspective of conservative surgical approaches, its essence lies in maximizing the preservation of healthy hepatic tissue and minimizing surgical trauma via procedures such as capsular resection and subtotal cystectomy, while effectively managing cyst contents and inactivating parasites. Previously, such surgical procedures were accompanied by concern regarding higher risks of recurrence and complications. Nevertheless, large-scale clinical investigations have re-evaluated this viewpoint. A retrospective study conducted by Shi et al[17], which included 434 patients, demonstrated that after controlling for confounding variables through propensity score matching, conservative surgery exhibited no significant disparity from radical surgery in short-term outcomes such as overall complications, bile leakage, and length of hospital stay, while incurring significantly lower medical expenses. This finding offers robust practical evidence in support of the selection of conservative surgery in settings with limited resources or for patients unsuitable for complex procedures. A systematic review carried out by Al-Saeedi et al[18] further corroborated the efficacy of intracapsular resection within conservative surgical methods, with a single-arm meta-analysis indicating that the recurrence rate of this technique was as low as 4.8%.

From the perspective of percutaneous interventional therapy, its definition has undergone an evolution. Initially regarded as a palliative alternative for patients with surgical contraindications or those intolerant to surgery, it has now become the preferred treatment option for specific cyst types (predominantly CE1 and CE3a)[19-22]. The core technique entails image-guided cyst puncture, followed by physical or chemical manipulation of the cyst cavity[23]. Puncture-aspiration-injection-reaspiration (PAIR), represents a landmark technique in this domain. The systematic review and meta-analysis conducted by Mönnink et al[8] signified a milestone in the evolution of this perspective. By integrating evidence from prospective studies, it was clearly demonstrated that percutaneous therapy is noninferior to open surgery in terms of recurrence rates, while presenting advantages in terms of complication rates and hospital stay duration. Recently, large-scale real-world studies from high-prevalence regions have further consolidated this stance. A retrospective analysis by Tahtabasi et al[11] of 989 CE1 and CE3a liver cysts indicated that percutaneous therapy exhibited significant advantages over surgical intervention in terms of procedure duration (40.3 ± 15.7 minutes vs 85.6 ± 34.5 minutes) and mean hospitalization length (3.1 ± 2.3 days vs 7.3 ± 6.2 days). Moreover, the markedly lower incidence of intraoperative organ injury (0% vs 2.7%) provides additional real-world evidence supporting the safety advantages of minimally invasive approaches. The technique itself continues to develop, advancing from standard PAIR to modified approaches such as percutaneous evacuation of cyst contents, double-puncture aspiration injection, percutaneous drainage combined with praziquantel-albendazole, and the utilization of novel sclerosants like polyvinyl alcohol[24,25]. In recent years, the modified catheter technique has been extended to all subtypes, with its safety and efficacy confirmed in 183 patients[26]. These technical advancements collectively propel percutaneous therapy from an alternative option to a mature and standard component within the multidisciplinary treatment toolkit for HCE.

Overall, the extant conceptual framework for the treatment of HCE exhibits characteristics of precision, minimally invasive techniques, and individualized treatment. Determining a treatment modality can no longer rely solely on classifications such as “surgical” or “nonsurgical”. Instead, it requires the specification of technical particulars (e.g., laparoscopic hepatectomy, extracapsular resection, PAIR, microwave ablation), along with the corresponding attributes of the target cysts (WHO classification, size, location) and treatment aims (curative vs control). Despite the continuous enhancement of the complexity of this framework, the conceptual definitions and technical standards for optimal minimally invasive strategies remain undefined in the following scenarios: Megacysts (diameter > 15 cm), complex CE2/CE3b cysts, and cases with severe biliary fistula involvement. These deficiencies represent critical areas that demand future research.

INFLUENTIAL FACTORS IN TREATMENT SELECTION AND DECISION-MAKING CRITERIA

Academic investigations into the factors influencing the selection of treatment for HCE have transitioned from an initial dependence on single-type classification to a multidimensional decision-making paradigm that integrates cyst characteristics, patient-related factors, technical accessibility, and healthcare resources. The evidence predominantly originates from large-scale retrospective studies, systematic reviews, and the accumulating data from prospective cohorts.

The morphological features of the cyst serve as the most critical determinant

The WHO Informal Working Group on Echinococcosis classification system provides the internationally accepted framework for guiding treatment selection in HCE. Strong consensus and evidence support CE1 and CE3a cysts as the most appropriate indications for percutaneous intervention, notably PAIR[8,27,28]. This is further reinforced by high-level evidence from systematic reviews by Mönnink et al[8] and Nasseri-Moghaddam et al[29]. In contrast, for CE2, CE3b, and select CE4 cysts, surgical management - whether radical or conservative - is generally considered safer[30]. This preference stems from their frequent multilocular or solid components, which often preclude complete eradication by percutaneous means[8]. The cyst size and number represent another critical dimension in clinical decision-making. For CE1/CE3a cysts smaller than 5 cm in diameter, albendazole monotherapy results in complete disappearance of approximately 30% of cysts[31]. Tahtabasi et al[11] demonstrated that the initial cyst volume is an independent predictor of cystobiliary fistula formation, irrespective of the treatment modality. Patients who developed fistulas had significantly larger baseline cyst volumes than those who did not (approximately 726.8 mL vs 351.1 mL). Furthermore, fistula occurrence markedly prolonged the catheter drainage duration, particularly following percutaneous treatment (17.8 ± 8.7 days vs 3.5 ± 2.9 days). Consequently, management of large cysts warrants greater caution, necessitating thorough risk assessment and preemptive complication planning, regardless of the therapeutic approach chosen. Treatment strategies for multiple cysts are even more complex, requiring a comprehensive evaluation of the total hepatic volume involved, cyst distribution, and the aggregate risks and benefits of combined therapeutic approaches.

The existence or nonexistence of complications directly dictates the treatment approach

Cystobiliary fistula represents the most common complication associated with HCE[32,33]. When preoperatively identified by imaging or clinical signs, the therapeutic priority shifts from cyst eradication to biliary decompression and fistula management. In this setting, endoscopic retrograde cholangiopancreatography (ERCP), performed either before or after intervention, plays a crucial role. Gümüşoğlu et al[27] emphasized the definitive utility of ERCP in treating hydatid cysts that have ruptured into the biliary tract. Tahtabasi et al’s findings[11] further delineate differing management pathways: Surgical treatment allows direct intraoperative identification and repair of fistulous openings (successful in 83.2% of cases), thereby reducing the need for postoperative ERCP (8.8%). In contrast, percutaneous management depends primarily on postoperative drainage and expectant monitoring. Although most minor fistulas close spontaneously (73.4%), a considerable proportion of patients with persistent or high-output fistulas still require ERCP (21.8%).

Patient-related factors and local healthcare resources exert a profound influence on the ultimate selection

Treatment decisions for individual patients must integrate granular factors, including age, comorbidities, patient preferences, and surgical and institutional expertise. Equally critical are regional diagnostic and therapeutic traditions, as well as technical accessibility, which often decisively shape clinical practice. In centers with advanced interventional radiology capabilities, percutaneous interventions are more widely adopted; conversely, in regions with a strong surgical tradition, surgery often remains the preferred approach. Studies by Shi et al[17] in the Kashgar region and Huang et al[34] in the Nyingchi region of China reached different conclusions: Huang et al[34] reported lower complication rates with radical surgery, whereas Shi et al[17] found no significant difference; but both reflect clinical decisions and outcomes shaped by local experience and available resources within specific regional and patient contexts. Such variations do not represent contradictory evidence but rather highlight the diversity of real-world medical practice. A retrospective comparison by Tutuş et al[35] in endemic areas further supports this, identifying cyst size (particularly lesions > 75 mm) as a key predictor of biliary fistula in pediatric HCE. Notably, institutional preferences - including surgical repair, percutaneous drainage combined with ERCP, and laparoscopic exploration - varied based on cyst characteristics, complication management experience, and multidisciplinary collaboration availability, leading to center-specific optimal strategies. These findings underscore the necessity of individualized, multidisciplinary decision-making in complex cases.

In summary, the selection of treatment modalities has evolved into a multi-level decision-making framework. The first level is based on the objective WHO classification and cyst size (specifically volume). The second level requires assessment of complications, particularly biliary involvement. The third level necessitates comprehensive adjustment, incorporating patient-specific circumstances and the local healthcare environment. Current research controversies, such as comparisons of short-term outcomes between radical and conservative surgery, often stem from inconsistencies across studies in baseline patient characteristics (cyst complexity, size distribution), definitions of surgical techniques, and methods for controlling confounding factors[17,34]. Future studies should employ more meticulous subgroup analyses and standardized outcome reporting criteria to resolve these discrepancies. Building on this multilevel decision-making framework, we developed the clinical decision pathway for HCE presented in Figure 1. The pathway begins with WHO classification and incorporates cyst volume, complications, and the feasibility of intervention to establish a stratified, stepwise treatment strategy.

Figure 1 Clinical decision-making algorithm for hepatic cystic echinococcosis based on World Health Organization classification and cyst characteristics. This flowchart illustrates a stratified, stepwise approach to treatment selection for hepatic cystic echinococcosis. The algorithm begins with confirmation of diagnosis and World Health Organization cyst stage classification (CE1, CE3a, CE2, CE3b, CE4/CE5). Decision-making then proceeds through assessment of cyst volume, presence of complications (biliary fistula, infection), and technical accessibility of interventional procedures. For small uncomplicated cysts (< 5 cm) of CE1/CE3a types, albendazole monotherapy is recommended. For larger or complicated cysts, the choice between percutaneous techniques (puncture-aspiration-injection-reaspiration, catheterization, modified catheterization technique) and surgery is guided by cyst characteristics and local expertise. Inactive cysts (CE4/CE5) are managed with watchful waiting and long-term ultrasound follow-up. HCE: Hepatic cystic echinococcosis; WHO: World Health Organization; CE: Cystic echinococcosis; ABZ: Albendazole; PAIR: Puncture-aspiration-injection-reaspiration; MoCaT: Modified catheterization technique; ERCP: Endoscopic retrograde cholangiopancreatography.

COMPLICATION MANAGEMENT STRATEGIES AND PATIENT PROGNOSIS

The management of complications following treatment for HCE is essential, as it directly impacts both short-term patient safety and long-term prognosis, forming a critical component in the evaluation of any therapeutic approach. Research has primarily focused on biliary complications, residual cavity-related issues, and disease recurrence, with management strategies becoming increasingly systematic.

Biliary complications, particularly postoperative bile leakage (biliary fistula), represent a major management challenge. Their incidence varies according to the surgical technique. Evidence suggests a potentially higher risk of bile leakage after conservative surgery compared to radical resection[17,36]. For instance, Huang et al[34] reported a trend toward reduced bile leakage with radical surgery, whereas Shi et al[17] observed no statistically significant difference between the approaches. Regardless of the initial treatment, a management consensus exists: Adequate drainage is paramount. Most low-output leaks resolve spontaneously with continuous drainage via a surgical drain or percutaneous catheter[17]. For high-output or symptomatic leaks (e.g., causing jaundice or cholangitis), endoscopic intervention is essential. ERCP with nasobiliary drainage or stent placement can reduce biliary pressure and facilitate fistula closure. Prevention and prediction are key. Growing evidence, notably from Tahtabasi et al[11], identifies a large cyst volume as the most significant risk factor for biliary fistula. Consequently, precise preoperative imaging (including accurate volumetry) and meticulous intraoperative exploration with prophylactic management of suspicious biliary communications are increasingly crucial.

Residual cavity-related problems include infection, seroma, and hemorrhage. Cavities remaining after conservative surgery are the primary source. Preventive strategies involve proper intraoperative management (e.g., omentoplasty, capitonnage) and ensuring postoperative drain patency. Infected cavities require antibiotics and, if needed, redrainage. Ultrasound- or computed tomography-guided percutaneous drainage is an effective minimally invasive option for symptomatic effusions or infections. Distinguishing recurrence from re-accumulation is vital. Tahtabasi et al[11] provided important clarification: Recurrence indicates disease reappearance with viable parasite material, while re-accumulation refers to sterile fluid collection within the cavity. Their study found no significant difference in true recurrence rates (1.1% for surgery vs 1.6% for percutaneous therapy) but a significantly higher re-accumulation rate following percutaneous therapy (4.7% vs 1.2%). In contrast, CE4/CE5 cysts that undergo natural inactivation rarely recur, with a stability rate as high as 98.5%; whereas cysts inactivated following pharmacological treatment have a reactivation rate of up to 50%, necessitating closer follow-up[37,38]. This finding suggests that surgery may better prevent sterile fluid collection, while percutaneous therapy remains equally effective for parasite eradication. The higher re-accumulation rate likely reflects distinct pathological processes in cavity resolution after percutaneous treatment.

Disease recurrence is the key metric for long-term efficacy, though its definition and reported rates vary. Radical procedures (e.g., anatomical resection or total pericystectomy) are traditionally associated with the lowest recurrence rates. However, proficient conservative surgery and standardized percutaneous therapy can also achieve low recurrence rates. A meta-analysis by Mönnink et al[8] found no statistically significant difference in recurrence between percutaneous therapy and surgery. Meanwhile, a systematic review by Al-Saeedi et al[18] reported a 4.8% recurrence rate for pericystectomy. Recurrence risk correlates with cyst biology (initial WHO stage), treatment completeness, and standardized postoperative albendazole prophylaxis. Long-term follow-up (typically 5-10 years) is critical for accurate assessment but remains a limitation in many retrospective studies.

Patient prognosis is a composite endpoint encompassing complication and recurrence rates, hospital stay, cost, and long-term quality of life. Current evidence presents a complex picture: Percutaneous treatments generally offer advantages in terms of hospital stay length, invasiveness, and short-term cost. Radical surgery may provide benefits in long-term recurrence reduction but entails greater technical complexity and higher expense. Conservative surgery balances efficacy, invasiveness, and cost, proving particularly useful in resource-limited settings. Future prognostic research should move beyond biomedical outcomes alone to integrate patient-reported outcomes and health economic evaluations. A comprehensive assessment of how different treatments affect quality of life and socioeconomic burden will provide the most robust foundation for personalized, precision medicine recommendations. As summarized in Table 2, several high-quality studies published in recent years have provided critical evidence supporting this stratified framework, encompassing international guidelines, randomized controlled trials, systematic reviews, and large-scale real-world studies, and systematically consolidating the treatment options and clinical outcomes corresponding to each classification type.

Table 2 Summary of treatment strategies for hepatic cystic echinococcosis based on World Health Organization classification.

Ref.	Treatment modality	WHO classification	Recommended treatment	Remarks
[8,11,21,24,25,40,41]	PAIR	CE1/CE3a	PAIR + ABZ	PAIR vs catheterization: Major complications 2.94% vs 36.84% (aP = 0.002); hospital stay: 3.8 days; D-PAI: Cyst disappearance in 64.8%; PD + PZQ + ABZ avoids topical scolicidal toxicity
[20-22,28]	Percutaneous (giant cyst/biliary fistula)	CE1/CE3a	Catheterization + ABZ	Catheterization indicated for PAIR failure or visible fistula
[26,27,29,31]	Percutaneous (complex cysts)	CE2/CE3b	MoCaT + ABZ	Recurrence: 3.85% (all classifications), 4.5% (CE2/CE3b); hospital stay: 3.88 days
[17,18,32,33]	Conservative surgery	CE1/CE3/CE2/CE3b	Endocystectomy, subtotal pericystectomy	Endocystectomy recurrence: 4.8%; subadventitial cystectomy recurrence: 0.7%, spontaneous fistula closure: 100%
[14,15,17,37]	Radical surgery	CE2/CE3/complex	Hepatectomy, total pericystectomy	Recurrence: 1.85% vs 11.9% (conservative) (bP < 0.0001); hospital stay: 8.65 days vs 14.9 days; complications: 13.3% vs 31.4%
[7,15,16]	Laparoscopic surgery	All classifications	Laparoscopic surgery	Hospital stay: MD = -1.9 days; minor complications: RR = 0.13 (cP < 0.05)
[11,27,28,34,36]	Biliary fistula management	All classifications	ERCP + drainage	Risk factors for ERCP: Left lobe cysts (OR = 25.71), PAIR (OR = 29.79), conservative surgery (OR = 3.63); NBD vs BS: Hospital stay 8.3 days vs 16.13 days; BS: 69.5% required second ERCP
[32,38,39]	Watchful waiting	CE4/CE5	Long-term ultrasound follow-up	Naturally inactivated cysts: Stable in 98.5%; post-treatment CE4 reactivation: Up to 50%
[1,32]	Medical therapy	CE1/CE3a (< 5 cm)	ABZ monotherapy	Cyst disappearance: 30%; regression: 30%-50%
[11,34,36]	Cyst volume and biliary fistula risk	All classifications		Fistula group: Initial volume 726.8 mL vs 351.1 mL (dP < 0.001); diameter ≥ 9.5 cm: Sensitivity 70%, specificity 60%; children: > 75 mm associated with fistula (eP = 0.040); hospital stay: 32 days vs 7 days (fP < 0.0001)
[10,17,35]	Patient factors/medical resources	All classifications		Surgical decision predictors: Imaging, cyst stage, symptoms (Cox C-index: 0.94, AUC = 0.950)

^aP = 0.002 vs catheterization group;.

^bP < 0.0001 vs conservative surgery;.

^cP < 0.05 vs open surgery group;.

^dP < 0.001 vs patients without fistula;.

^eP = 0.040 vs children without fistula;.

^fP < 0.0001 vs patients without fistula.

WHO: World Health Organization; PAIR: Puncture, aspiration, injection, re-aspiration; ABZ: Albendazole; D-PAI: Double percutaneous aspiration and ethanol injection; PD: Percutaneous drainage; PZQ: Praziquantel; MoCaT: Modified catheterization technique; MD: Mean difference; RR: Risk ratio; ERCP: Endoscopic retrograde cholangiopancreatography; OR: Odds ratio; NBD: Nasobiliary drainage; BS: Biliary stenting; AUC: Area under the curve.

FUTURE RESEARCH DIRECTIONS

Building upon this foundation, future research should advance in three key domains. First, there is a need to promote prospective, multicenter collaborative studies. Where randomized controlled trials are not feasible, establishing a prospective registry with standardized data protocols - including precise cyst volumetry and unified definitions for complications and outcomes - can generate high-quality real-world evidence. Second, research should further elucidate the role of cyst volume in risk stratification. This involves defining volume thresholds to guide treatment selection and complication management, potentially integrating them into clinical decision-support tools. Third, comprehensive health economic and patient-reported outcome studies are essential. Particularly in high-prevalence, resource-limited regions, comparing the cost-effectiveness of different treatment pathways and assessing their impact on quality of life are critical for optimizing resource allocation and achieving patient-centered, precision care.

CONCLUSION

This editorial addresses the central question of evolving treatment strategies and clinical decision-making for HCE. Through a systematic examination of three critical themes - the definition of treatment modalities, factors influencing treatment selection, and the management of complications - it delineates the research evolution and clinical trends in this field, highlighting a shift from a focus on technical competition toward integrated therapeutic approaches. The core findings indicate that progress in HCE management is driven by disease morphological complexity, advancements in minimally invasive techniques, and global disparities in healthcare resources. International research has established a coherent evidence chain. Within the WHO classification framework, percutaneous interventions such as PAIR have become established, noninferior alternatives to surgery for CE1 and CE3a cysts. Concurrently, comparative studies of surgical approaches (radical vs conservative) are progressively clarifying their nuanced differences and optimal indications regarding short-term outcomes and cost-effectiveness through advanced statistical methods. An international consensus supports patient stratification based on WHO classification, the prioritization of biliary complication management, and the central role of multidisciplinary team decision-making. An emerging paradigm recognizes the initial cyst volume in eligible cases as a key predictor of procedural complexity - particularly the risk of biliary fistula - thereby guiding treatment selection toward more refined, individualized assessment.

However, this editorial also underscores persistent limitations and challenges in the field. First, there are structural limitations in the evidence base. Despite valuable systematic reviews and large-scale retrospective analyses (e.g., the study by Tahtabasi et al[11]), high-quality randomized controlled trials remain scarce. Inevitable selection biases, such as the preferential use of surgery for more complex CE3a cysts, continue to impose inherent constraints on the interpretation of available evidence. Second, key clinical concepts and outcome measures require standardization. While the distinction between disease recurrence and sterile re-accumulation, as illustrated by Tahtabasi et al[11], represents significant progress, broader international consensus on definitions for such core outcomes is needed to enable cross-study comparison and robust evidence synthesis. Finally, the research perspective requires expansion. Existing studies predominantly focus on biomedical endpoints, with insufficient attention to the long-term quality of life, mental health, and socioeconomic burden imposed on patients by different treatment pathways.

ACKNOWLEDGEMENTS

The authors thank all clinicians and staff involved in the diagnosis and management of patients with hepatic cystic echinococcosis.