Modified endocystectomy versus pericystectomy in echinococcus granulosus liver cysts: a randomized controlled study, and the role of specific anti-hydatid IgG4 in detection of early recurrence.

The evidence based data of hydatid liver disease indicate that the level of evidence was too low to help decide between radical or conservative surgeries (level IV evidence, grade C recommendation). So, there is a need for accurately designed randomized trials with precise goals to compare pericystectomy versus a specific modified endocystectomy technique for the treatment of hepatic hydatid cysts 8 cm or less in diameter in Egyptian patients, regarding the operative time, intra-operative blood loss, complications and long-term recurrence and to test the role of anti-hydatid IgG4 in diagnosis and detection of early recurrence. 60 patients with 131 liver cysts of E. granulosus fulfilling the study criteria were randomly divided to two groups. GI: 32 patients with 69 cysts treated by modified endocystectomy and GII: 28 patients with 62 cysts treated by closed total pericystectomy. GIa included 40 cysts >5 cm in diameter (mean 6.86, SD+/-0.809) & GIb 29 cysts < or = 5 cm in diameter (mean 4.17 SD+/-0.83). GIIa included 37 cysts >5 cm in diameter (mean 7.01 SD+/+0.79) & GIIb 25 cysts < or = 5 cm in diameter (mean 4.04 SD+/-0.93). Preoperative evaluation included history taking, clinical examination, blood tests, specific anti-hydatid IgG4, abdominal sonography and CT scan. The operative time for dealing with each cyst was in minutes. Operative blood loss and need for blood transfusion were estimated for each patient. Specific anti-hydatid IgG4 by ELISA was used to diagnose and to detect early recurrence. Patients were followed up clinically and by ultrasonography every 3 months and for anti-hydatid IgG4 every 6 months for 24-90 months. The mean maximum operative time was in GIIa followed by GIa, GIb, then GIIb. The operative time was significantly lower in GIIb than Ib and in GIa than IIa. Seven patients (GII) had blood transfusion. The intraoperative bleeding in GI was <500 ml/ patient, and 18 patients (GII) each bled >500 ml. No intraperitoneal seedling during the follow up. 5 of 55 patients (9%) were serologically suspected of relapse or incomplete cure. One (GII) showed early recurrence at 3 months. High IgG4 antibodies were detected in patients which decreased gradually after surgery and normal after 18 months post-operation.