Wagner T, Struck S, Persigehl T, Nierhoff D, Schmidt T, Hummels M, Bruns CJ, Stippel DL, Thomas MN. Long-term outcomes after open total pericystectomy for cystic echinococcosis. World J Gastrointest Surg 2025; 17(9): 106258 [DOI: 10.4240/wjgs.v17.i9.106258]
Corresponding Author of This Article
Tristan Wagner, Department of General, Visceral, Thoracic and Transplantsurgery, University of Cologne, Kerpener Street 62, Cologne 50923, North Rhine-Westphalia, Germany. tristan.wagner@uk-koeln.de
Research Domain of This Article
Surgery
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Tristan Wagner, Sebastian Struck, Thomas Schmidt, Marielle Hummels, Christiane J Bruns, Dirk L Stippel, Michael N Thomas, Department of General, Visceral, Thoracic and Transplantsurgery, University of Cologne, Cologne 50923, North Rhine-Westphalia, Germany
Thorsten Persigehl, Department of Diagnostic and Interventional Radiology, University of Cologne, Cologne 50923, North Rhine-Westphalia, Germany
Thorsten Persigehl, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne 50923, North Rhine-Westphalia, Germany
Dirk Nierhoff, Department of Gastroenterology and Hepatology, University of Cologne, Cologne 50923, North Rhine-Westphalia, Germany
Co-corresponding authors: Tristan Wagner and Michael N Thomas.
Author contributions: Wagner T and Thomas MN designed the study; Struck S, Thomas MN, Schmidt T, Stippel DL were responsible for developing the methodology; Persigehl T, Hummels M, Wagner T, Nierhoff D, Bruns CJ participated in the formal analysis and investigation; Wagner T and Struck S wrote the draft; Wagner T, Schmidt T, Thomas MN, Stippel DL participated in the review and editing.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of the University of Cologne (23-1371-retro).
Informed consent statement: Signed informed consent was obtained from all participants.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Tristan Wagner, Department of General, Visceral, Thoracic and Transplantsurgery, University of Cologne, Kerpener Street 62, Cologne 50923, North Rhine-Westphalia, Germany. tristan.wagner@uk-koeln.de
Received: February 24, 2025 Revised: April 13, 2025 Accepted: August 1, 2025 Published online: September 27, 2025 Processing time: 216 Days and 13.6 Hours
Abstract
BACKGROUND
Liver hydatid cysts (LHC) liver requires effective surgical treatment. Open closed total pericystectomy removes the entire echinococcus cyst while preserving healthy liver tissue.
AIM
To evaluate the outcomes of pericystectomy and its efficacy as a treatment modality for cystic echinococcosis (CE).
METHODS
Thirty-eight patients were analyzed after open total pericystectomy at the University Hospital of Cologne between January 2006 and January 2024. Demographic, clinical, and laboratory parameters were collected retrospectively. Intraoperative data and postoperative complications were documented and classified using the Clavien-Dindo classification. Throughout the follow-up period, patients underwent regular clinical, serological, and sonographic evaluations both at the outpatient department and by their general physicians.
RESULTS
Fifty-four cysts were treated with open total pericystectomy. Multiple cysts were found in 42.2% of cases. Singular cysts occurred in 57.8%. The right hepatic lobe was affected in 66.7%. Ectopic cysts occurred in 4 patients in the lung (n = 3) and spleen (n = 1). Median cyst size was 6.78 cm × 5.92 cm (range: 1.4-20.0 cm). The median surgical time of pericystectomy was 189 minutes (range: 78-455 minutes) with a median blood loss of 400 mL (range: 100-1400 mL). The complication rate (Clavien-Dindo > III) was 21.1%. The average hospital stay was 12.5 days. No recurrent disease could be detected after a median follow-up time of 97 months (range: 4-216 months). No recurrent cyst manifestation, postoperative liver failure or death was observed.
CONCLUSION
The presented surgical procedure known as open total pericystectomy is a safe surgical technique in treatment of cystic echinococcosis.
Core Tip: This study presents the largest cohort of standardized open total pericystectomies for cystic echinococcosis, demonstrating its effectiveness in achieving complete cyst removal while preserving liver tissue. Total pericystectomy has evolved as a superior surgical approach, showing significantly lower recurrence rates compared to conservative techniques. Despite concerns about bile leakage and cholestasis, our cohort experienced a low incidence of postoperative bile leakage. With a median 8-year follow-up, the recurrence rate was 0%, highlighting the procedure’s efficacy even in multiple cyst cases. These findings support total pericystectomy as a reliable and durable treatment option for hepatic cystic echinococcosis.
Citation: Wagner T, Struck S, Persigehl T, Nierhoff D, Schmidt T, Hummels M, Bruns CJ, Stippel DL, Thomas MN. Long-term outcomes after open total pericystectomy for cystic echinococcosis. World J Gastrointest Surg 2025; 17(9): 106258
Human cystic echinococcosis (CE) is a chronic infectious disease that can lead to the formation of hydatid cysts (HC), mainly in the liver[1]. HC caused by Echinococcus granulosus, is endemic in the Mediterranean, South America, the Far East, Central Asia and Eastern Europe[2]. It is increasingly occurring in non-endemic countries due to global travel and migration[3]. The formation of this benign cysts affects the right lobe of the liver in 55%-80% of cases[4].
Clinical manifestations vary depending on the location of the cysts and the clinical manifestations include dull pain in the right upper quadrant of the abdomen, allergic reactions in case of cyst rupture, cholestatic jaundice due to compression of the bile ducts or complications such as cholangitis, liver abscess, pancreatitis or septicemia, especially in cysto-biliary communication and secondary bacterial superinfection[5,6].
According to the guidelines of the World Health Organization (WHO) and the American College of Gastroenterology, surgery is recommended, especially for HC that involve multiple vesicles, daughter cysts, fistulas, rupture, hemorrhage, or secondary infection[4,7].
The surgical approach has evolved significantly ranging from conservative to radical procedures[4,8,9]. Long-term results following surgical resection suggest that total pericystectomy, is associated with significantly lower recurrence rates compared to more conservative methods[10,11]. Laparoscopic surgery is a major challenge due to the risk of cyst rupture, while interventional drainage is associated with a higher recurrence rate and a higher incidence of postoperative complications[4,12-16]. Open total pericystectomy, in which the cyst is completely removed along with its peri-cystic layer, appears to have better outcomes in terms of recurrence rate and overall patient recovery[4,17,18]. The preservation of healthy liver tissue is particularly beneficial in total pericystectomy as it minimizes the risk of postoperative liver dysfunction and allows for a faster recovery[15,19-21]. Despite the technical requirements, this method offers an approach that ensures comprehensive eradication of the disease while preserving liver function[22,23].
While several studies have highlighted the advantages of total pericystectomy, data on its long-term outcomes, recurrence and complication rates remain limited, particularly in non-endemic countries[19,24-26]. Therefore, the objective of this study is to evaluate the long-term outcomes, recurrence rates and postoperative complications associated with open total pericystectomy of liver HC (LHC) in a large patient cohort treated at our center in Germany.
MATERIALS AND METHODS
Study design and setting
Between August 2006 and August 2024, a total of 38 patients were referred to the Department of Surgery of the University Hospital of Cologne for surgical treatment of suspected LHC. This retrospective, single-center study evaluated the outcomes and efficacy of pericystectomy as a definitive treatment modality for LHC. All surgeries were performed by two senior hepatobiliary surgeons. All patients with LHC were included. Ethical approval was granted by the local ethics committee (protocol number 23-1371-retro), and written informed consent was obtained from all participants in compliance with institutional and international guidelines.
Patient selection and preoperative evaluation
Patients were included if they presented with LHC. Preoperative evaluation involved abdominal ultrasonography (US), computed tomography, or magnetic resonance imaging, which characterized multilocular cystic lesions with daughter cysts, frequently accompanied by calcified cyst walls (Figure 1)[17]. Serological confirmation of infection was obtained via indirect hemagglutination assay (IHA) or enzyme-linked immunosorbent assay[4,27]. Comprehensive imaging systematically assessed cyst size, number, anatomical location, and associated complications. Perioperative antibiotic prophylaxis was administered according to institutional protocols.
Figure 1 Imaging of hepatic cystic echinococcosis.
A and B: Ultrasound; C and D: Magnetic resonance imaging; E and F: Computed tomography.
Surgical procedure
In our institution, open total pericystectomy stands for the standard of care for treatment of LHC in accordance to the expert consensus of the diagnosis and treatment of cystic and alveolar echinococcosis in humans of the WHO-Informal Working Group on Echinococcosis[4]. Surgery was indicated for all patients with serological proven or radiological suspicion of LHC.
Patients were placed in a supine position, and aseptic preparation followed WHO and German Society for General and Visceral Surgery standards. A modified Makuuchi abdominal incision was performed to achieve optimal exposure. Intraoperative hepatic US was utilized to localize cysts and detect satellite lesions or biliary involvement. Parenchymal dissection was performed using a hydrojet dissector (ERBEJET 2, Erbe Elektromedizin, Tübingen, Germany), which enabled precise dissection along the adventitial layer of the cyst to minimize bile leakage and preserve critical vascular structures (Figure 2)[28]. Complete excision of the LHC was achieved without intraoperative spillage of infectious material in all cases (Figure 3)[29-32].
Figure 3 Intraoperative documentation of the cystic echinococcus and pericystectomy.
Postoperative management and follow-up
Postoperative complications were categorized using the Clavien-Dindo classification system, with significant complications defined as grade III or higher[33]. Biliary leakage was defined as a bilirubin concentration in the abdominal drain fluid at least 3 times the serum bilirubin concentration on or after postoperative day 3[34]. Recurrence was defined as the reappearance of hydatid disease near the surgical site or in new extrahepatic locations, confirmed by imaging or serology.
During the first year, follow-up included regular physical examinations, serological testing, and abdominal US. Thereafter, long-term follow-up data were collected in collaboration with primary care physicians, hepatology and infectious disease specialists, incorporating routine blood tests and imaging studies.
Data collection
Demographic and clinical data, including cyst characteristics (e.g., number, size, and location), surgical details, and outcomes, were retrospectively reviewed. Postoperative variables documented included morbidity, mortality, length of hospital stay, recurrence rates, and complications.
Statistical analysis
Statistical analyses were conducted using SPSS (version 28.0.1; IBM, Armonk, NY, United States) and GraphPad Prism (version 4; GraphPad Software, Inc., La Jolla, CA, United States). Descriptive statistics were used for continuous and categorical variables. The student’s t test was applied to compare continuous data, while Fisher’s exact test was used for categorical variables. Statistical significance was defined as P < 0.05.
RESULTS
The 38 patients with LHC received an open total pericystectomy at the University Clinic of Cologne, Germany. The median age of the patients was 39.5 years (range: 18-73 years; Table 1). Of the thirty-eight patients, 11 were male and 27 were female. The average body mass index was 26.8 kg/m2 (range: 18.8-39.3 kg/m2). Abdominal pain was the most common presenting symptom leading to discovery of hydatid disease. All patients received preoperative albendazole for two cycles consisting of 4 weeks treatment 2 × 400 mg/day with a treatment break of 2 weeks in between the cycle. In 42.1% of cases IHA serology was positive.
Table 1 Patients demographics and clinical presentation, n (%).
A total of 54 HC were removed by open total pericystectomy. Of 22 patients had singular cystic manifestation (57.8%) and multiple cysts could be detected in 16 patients (42.2%). The right liver lobe was affected in 66.7%, 25.9% of this manifestation was most frequently found in segment VII. Median cyst size was 6.78 cm × 5.9 cm (range: 1.4-20.0 cm). Secondary ectopic echinococcus cysts were detected in four patients within the lung (n = 3) and spleen (n = 1).
The median surgical time of pericystectomy was 189 minutes (range: 78-455 minutes) with a median blood loss of 400 mL (range: 100-1400 mL). Intermitted pringle maneuver was performed in 9 patients with a median cumulative ischemic time of 28.5 minutes (range: 0-58 minutes). All resections were finished as planed as pericystectomy without the need to extend the operative procedure. The median hospital stay was 12.5 days (range: 6-30 days). No local recurrent disease in the liver was detected after a median follow-up time of 97 months (range: 4 months to 18 years). In 2 cases (5.4%) recurrence was detected to distance. No postoperative liver failure or death was observed.
Following the Clavien-Dindo classification, complications of grade III and higher were considered relevant. Bile leakage was seen in five patients addressed with internal drainage (13.1%) and one revision laparotomy was necessary due to postoperative bleeding (2.7%). Following the definition of the International Study Group of Liver Surgery postoperative liver failure did not occur[35-37]. Pathological analyzes of the resected specimen revealed complete resection of the HC in all the observed cases.
The differentiation between multicystic and single cystic lesions showed that patients with multicystic lesions had a significantly longer clinical stay (14.8 days vs 10.8 days, P = 0.018; Table 2) and a significantly longer intermittent pringle maneuver duration (13.9 minutes vs 2.2 minutes, P = 0.006). While bile leakage was higher in the multicystic group (n = 3, 18.75% vs n = 2, 9.09%), this difference was not statistically significant (P = 0.632). Overall complication rates and postoperative wound infections did not show statistically significant differences between groups. Ectopic cysts were resected after primary liver surgery.
Table 2 Comparison of clinical and surgical outcomes between multicystic and single cystic lesions, n (%).
This study demonstrates that open total pericystectomy is a safe and effective strategy for LHC, with no in hospital mortality, a 0% recurrence rate and a low morbidity profile. These findings are particularly significant given the high proportion of patients with multiple cysts and the long-term follow-up. LHC is challenging due to the late onset of symptoms and often misleading characteristics[11,22].
Our study represents the largest reported cohort of standardized performed open total pericystectomies to date, achieving complete removal of all pathological cysts using this liver tissue-preserving surgical technique. The treatment of LHC is classified into three approaches: Puncture, aspiration, injection, and re-aspiration (PAIR), conservative surgery, and radical surgery[38]. PAIR is a minimally invasive approach involving the puncture and re-aspiration of cyst contents after the injection of scolicidal agents. Conservative surgical methods, such as cystotomy-drainage, deroofing-drainage, capitonage, omentoplasty, and marsupialization, aim to manage the HC but leave behind a residual cavity, which often requires further care[4,8,9,32]. In contrast, radical surgery involves the complete removal of the cyst and includes techniques such as open total pericystectomy, regular hepatectomy, or lobectomy.
According to the recommendations of the WHO[4], radical surgery is the primary strategy for treating LHC[30,32]. The advantages of radical surgery are the complete removal of parasitic tissue and the elimination of the residual cavity with potential decrease in recurrence and morbidity. In contrast, others favor conservative surgical treatment as they consider radical surgery as a high-risk treatment for a “benign” disease[9,18,36-38]. Comparing the effectiveness and morbidity rate of radical procedures for the treatment of LHC is challenging, since radical surgery in the literature encompasses a spectrum of techniques, ranging from minor resections to major hepatectomies, which vary significantly in complexity and associated risks. This emphasizes the critical need for studies focusing exclusively on singular radical surgical approaches to systematically stratify and identify the most effective surgical technique for the treatment of HC.
In our study the overall morbidity rate (Clavien-Dindo I-IV) was 21.6%, slightly higher than the mean morbidity rate reported in other studies analyzing open pericystectomy alone (18%)[18]. In contrast, if compared to series of major hepatectomy as an approach for radical treatment of HC the reported morbidity rate in these series ranges between 18%-61%[9,18,39,40]. Especially biliary leakage, as a common complication associated with LHC surgery, was observed in 13.1% of patients in this cohort. This rate is suggesting that pericystectomy provides a favorable level of safety in terms of bile duct integrity compared to major hepatectomy with a described biliary leak range of 22.4%[39,40]. Considering that the HC causes local cholestasis with a potentially higher rate of bile leakage due to compression of vital liver tissue, our patient cohort showed few bile leakages after pericystectomy[41-43]. A total of 38 patients underwent pericystectomy and all pathological cysts were removed completely. There were no cases of intraoperative or postoperative mortality and no local hepatic recurrence observed[27,29]. Comparing radical procedures with pericystectomy presents challenges, as radical surgery in literature encompasses a spectrum of techniques, ranging from minor resections to major hepatectomies, which vary significantly in complexity and associated risks[30,44]. The comparatively long follow-up allowed us to thoroughly evaluate the recurrence rate, which was 0% in our cohort. In contrast, other studies reported recurrence rates of 8.89% for open procedures, 3.15% for laparoscopic procedures and an overall recurrence rate of 8.7% for all surgical procedures[45]. The absence of local hepatic recurrence in our study highlights the efficacy of pericystectomy as a definitive treatment for LHC. Two patients (5.4%) presented with cystic hepatic lesions 4 and 7 years after surgery; however, these lesions were found in hepatic segments distinct from the original resection sites. The higher proportion of patients with multiple cysts in our study (42.1%) compared to other studies (17.9%), the recurrence-free results and manageable bile leakage rates emphasize the efficacy of pericystectomy even in more complex cases[39,40]. Despite being a retrospective, single-center study it represents the largest German cohort using this technique and lays a strong foundation for future multicenter or prospective research to confirm its broader applicability. Our results support open total pericystectomy as a reliable and safe first-line surgical option for LHC, particularly in complex cases involving multiple cysts or biliary involvement. This technique offers excellent long-term outcomes while minimizing the risk of recurrence and serious complications. Prospective comparisons between open total pericystectomy and other radical or conservative approaches are needed. Especially with standardized surgical protocols to define the optimal treatment strategy for LHC.
CONCLUSION
Open total pericystectomy is a safe and effective surgical approach for the treatment of CE in specialized centers. In our cohort, the procedure was associated with low postoperative morbidity and no observed local recurrence, even in complex cases. While these findings are encouraging, the absence of a control group limits comparisons with other surgical methods. Further prospective and comparative studies are needed to establish its efficacy and long-term benefits in these clinical settings.
ACKNOWLEDGEMENTS
The authors would like to thank the surgical team, nursing staff, and all healthcare professionals at Surgical Department of the University of Cologne for their support and dedication throughout the management and follow-up of patients included in this study.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Surgery
Country of origin: Germany
Peer-review report’s classification
Scientific Quality: Grade B
Novelty: Grade B
Creativity or Innovation: Grade C
Scientific Significance: Grade B
P-Reviewer: Lulic I, MD, Postdoctoral Fellow, Croatia S-Editor: Li L L-Editor: A P-Editor: Yu HG
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