Percutaneous vs surgical management of World Health Organization cystic echinococcosis 1 and 3a liver hydatid cysts

BACKGROUND Hydatid cyst disease of the liver remains a significant public health problem in endemic regions. While surgical treatment has traditionally been the mainstay of therapy, minimally invasive percutaneous approaches have emerged as safe and effective alternatives, especially for selected World Health Organization (WHO) cystic echinococcosis (CE) 1 and CE3a cysts. Comparative data on efficacy, complication rates, and clinical outcomes between the two methods are essential for guiding optimal treatment selection. AIM To compare and evaluate the efficacy, safety, complication rates, and clinical course of WHO CE1 and CE3a liver hydatid cysts treated with surgical and percutaneous methods. METHODS A total of 989 patients diagnosed with liver hydatid cyst and treated either surgically (n = 734) or percutaneously (n = 255) between 2005 and 2025 were included in the study. Demographic data, treatment process, complications, and recurrence rates of the retrospectively evaluated patients were recorded. Cyst volume, hospital stay duration, and catheter removal times were compared. Cases with and without fistula development were also analyzed separately. RESULTS There was no significant difference between the surgical (n = 734) and percutaneous (n = 255) groups in terms of gender (female: 76.0% vs 72.2%; P = 0.250) and age (38.4 ± 15.9 years vs 38.1 ± 16.1 years; P = 0.800), respectively. Operation time (85.6 ± 34.5 minutes vs 40.3 ± 15.7 minutes; P < 0.001), hospital stay duration (7.3 ± 6.2 days vs 3.1 ± 2.3 days; P < 0.001), catheter removal time (6.6 ± 5.3 days vs 5.5 ± 6.4 days; P = 0.014), and intraoperative organ injury rate (2.7% vs 0%; P = 0.002) were significantly longer/higher in the surgical group compared to the percutaneous group. Recollection was significantly more frequent in the percutaneous group (4.7% vs 1.2%; P = 0.001), as was anaphylaxis (1.6% vs 0.3%; P = 0.041). The rate of cysto-biliary fistula was similar in both groups surgical 14.6% (n = 113), percutaneous 14.9% (n = 43); P = 0.902. However, in patients with fistula, catheter removal time (surgical: 8.3 ± 4.9 days vs 5.9 ± 2.7 days and percutaneous: 17.8 ± 8.7 days vs 3.5 ± 2.9 days; P < 0.001) and initial cyst volumes (surgical: 774.8 ± 513.2 mL vs 356.7 ± 95.6 mL and percutaneous: 700.9 ± 288.2 mL vs 346.5 ± 279.2 mL; P < 0.001) were significantly higher compared to those without fistula. CONCLUSION For treatment of WHO CE1 and CE3a liver cysts, the percutaneous approach is a safe and effective method due to shorter hospital stays, minimal invasiveness, and negligible risk of intraoperative organ injury, whereas surgical methods appear marginally advantageous regarding recollection and anaphylaxis. In both groups, higher cyst volume increases the risk of fistula and may prolong the treatment process. Patient selection should consider these parameters.