Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Surgery for Hepatic Hidatidosis. Risk Factors and Variables Associated with Post...
Journal Information
Vol. 95. Issue 10.
Pages 566-576 (December 2017)
Visits
1208
Vol. 95. Issue 10.
Pages 566-576 (December 2017)
Review article
DOI: 10.1016/j.cireng.2017.11.008
Full text access
Surgery for Hepatic Hidatidosis. Risk Factors and Variables Associated with Postoperative Morbidity. Overview of the Existing Evidence
Cirugía de la hidatidosis hepática. Factores de riesgo y variables asociadas al desarrollo de morbilidad postoperatoria. Revisión global de la evidencia existente
Visits
...
Carlos Manterolaa,b,
Corresponding author
carlos.manterola@ufrontera.cl

Corresponding author.
, Tamara Otzenc,d, Gloria Muñozc,e, Martín Alanisa, Eileen Kruusea, Gustavo Figueroaa
a Departamento de Cirugía, Universidad de La Frontera, Temuco, Chile
b Centro de Excelencia en estudios Morfológicos y Quirúrgicos (CEMyQ), Universidad de La Frontera, Temuco, Chile
c Programa de Doctorado en Ciencias Médicas, Universidad de La Frontera, Temuco, Chile
d Facultad de Ciencias de la Salud, Universidad de Tarapacá, Arica, Chile
e Universidad Santo Tomás, Temuco, Chile
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (2)
Tables (3)
Table 1. Proposed Classification of the Levels of Evidence of the CEBM 2009.
Table 2. Search Strategies and Results Obtained for Each Source of Information Used.
Table 3. Summary of the Evidence Found.
Show moreShow less
Abstract

There are few publications related to postoperative morbidity in hepatic hydatidosis and these have mixed results. The aim of this study was to determine risk and protective factors of postoperative morbidity in patients operated on for hepatic hydatidosis.

A comprehensive review was made of the evidence, based on systematic reviews, clinical analyses and observational studies, obtained from the Trip Database, BVS, SciELO, Cochrane Central Register of Controlled Trials, WoS, MEDLINE, EMBASE, SCOPUS, EBSCOhost, IBECS, ePORTUGUESe, LILACS and WHOLIS.

1087 related articles were identified; 69 fulfilled the selection criteria (2 systematic reviews, 3 clinical trials and 64 observational studies). Age, history of previous surgery for hepatic hydatidosis, location in the hepatic center, existence of biliary communications and evolutionary complications of the cyst were identified as risk factors, and radical surgical techniques as protective factors.

Risk and protective factors were identified; however, the studies are few and the quality moderate to low.

Keywords:
Echinococcosis
Hepatic hydatid cyst
Echinococcosis, hepatic/surgery
Postoperative complications
Prognosis
Resumen

Las publicaciones relacionadas con morbilidad postoperatoria en hidatidosis hepática son escasas y de resultados disímiles. El objetivo de este estudio fue determinar factores de riesgo y protectores de morbilidad postoperatoria en pacientes intervenidos por hidatidosis hepática.

Se realizó una revisión global de la evidencia, basada en revisiones sistemáticas, ensayos clínicos y estudios observacionales, obtenidos de Trip Database, BVS, SciELO, Cochrane Central Register of Controlled Trials, WoS, MEDLINE, EMBASE, SCOPUS, EBSCOhost, IBECS, ePORTUGUESe, LILACS y WHOLIS.

Se identificaron 1.087 artículos relacionados y 69 cumplían criterios de selección (2 revisiones sistemáticas, 3 ensayos clínicos y 64 estudios observacionales). Se identificaron como factores de riesgo la edad, el antecedente de cirugía previa por hidatidosis hepática, la localización centro hepática, la existencia de comunicaciones biliares y complicaciones evolutivas del quiste y como protectores las técnicas quirúrgicas radicales.

Se identificaron factores de riesgo y protectores; sin embargo, los estudios son escasos y de calidad moderada a baja.

Palabras clave:
Hidatidosis
Quiste hidatídico hepático
Morbilidad
Complicaciones postoperatorias
Pronóstico
Full Text
Introduction

Hydatidosis is an endemic zoonosis in Chile, with an average incidence of 1.9/100000, hospital discharges of 6.3/100000 inhabitants and a mortality rate of 0.2/100000 inhabitants.1 The regions of Aysén and La Araucanía are the most widely affected, the latter with a discharge rate of 28.1/100000 inhabitants.2

This situation determines the need to treat a significant number of new cases of hydatid disease of the liver (HDL) per year in a timely and efficient manner, while investigating evolutionary complications3 and hydatidosis in other locations.4

Despite being an endemic disease in several countries, there have been few publications, with a low level of evidence. Their results are dissimilar, especially regarding the development of postoperative morbidity (POM) and potential variables associated with the development of POM, reason why it is complex to establish strategies to prevent POM in order to control risk factors (RF).

In articles from the 1990s, POM figures were reported between 23.7% and 62.5%.5–10 As of the year 2000, figures between 21.3% and 53.8% were reported,11–14 and from 2010 to date there have been reports of POM between 37.9% and 79.9%.15–17

A global review of the evidence is a qualitative method that is able to combine results from articles extracted from the published literature and later synthesize summaries and conclusions to answer questions related to clinical scenarios of treatment, causes, diagnosis and prognosis. Therefore, they can be used to assess the existing evidence regarding clinical situations in which there is uncertainty, thus allowing subsequent studies to be planned.18

The objective of this study was to summarize the available evidence about associated variables, risk and protective factors (PF) of POM in patients treated surgically for HDL.

MethodsType of Study

Overview of the evidence available.

Population

Included in the study were systematic reviews (SR), clinical trials (CT) and observational studies (OS [concurrent and historical cohorts; cases and controls and case series – CS]) published between January 1980 and May 2017, with no language restriction, that included adult human populations treated surgically for HDL and had evaluated the development of POM. We excluded from the study those articles that included patients treated with laparoscopic surgery, needle aspiration, or injection and re-aspiration, articles with topics unrelated to the objective, reviews of the literature, consensus documents and discussion articles.

Search Methodology

The search was completed with PICO components (study population [P], intervention in evaluation [I], comparator [C] and outcome [O]). Based on this strategy, we searched for studies with HDL patients (P), who underwent open surgery (I) and whose response variables were POM (O). To this end, the following metasearch engines, libraries and databases were reviewed: Trip Database, BVS, SciELO, Cochrane Central Register of Controlled Trials, WoS, MEDLINE, EMBASE, SCOPUS, EBSCOhost, IBECS, ePORTUGUESe, LILACS and WHOLIS. Sensitive searches were performed using MeSH terms, free words, truncated terms and Boolean connectors (AND and OR), with strategies adapted to each database.

Summary, Assessment and Classification of the Evidence

We began with an evaluation of the risk of bias (internal validity) of the studies, for which summary tables were generated and validity tables were constructed, using the design proposed by SIGN.19 Subsequently, a classification of levels of evidence was carried out, using the proposal of the Centre for Evidence-Based Medicine20 (Table 1). Finally, a global classification of the evidence was made by applying the GRADE system, which considers the study design, risk of bias, coherence, precision of the results, publication bias and whether the evaluation of the evidence is direct or indirect21 (Fig. 1a and b).

Table 1.

Proposed Classification of the Levels of Evidence of the CEBM 2009.

GR  LE  Treatment, Prevention, Etiology and Damage  Prognosis and Natural History  Diagnosis  Differential Diagnosis and Prevalence  Economic Studies and Analytical Decisions 
A1a  SR with homogeneity of CT with RA  SR of PC studies (including studies with comparable results in the same direction and validated in different populations)  SR of high-quality DT studies w/ homogeneity (including studies with comparable results, in the same direction and different clinical centers)  SR with homogeneity of PC studies  SR with homogeneity of high-quality economic studies 
1b  Individual CT with a narrow confidence interval  Studies of individual cohorts, with a follow-up greater than 80% of cohorts and validated in a single population  Studies of cohorts that validate the quality of a DT, with an adequate SR or based on algorithms to estimate the prognosis or to categorize the diagnoses or proven in a clinical center  PC studies with good follow-up  Analysis based on costs or clinically sensitive alternatives; SR of the evidence. Includes sensitivity analysis. 
1c  All or none  CS (all or none)  DT with specificity so high that a positive result confirms the diagnosis and sensitivity so high that a negative result rules out the diagnosis  CS (all or none)  Analysis in absolute terms of clinical risks and benefits: as good as or better but cheaper, as bad as or worse but more expensive 
B2a  SR of cohort studies with homogeneity  SR of HC studies or of control groups not treated in CT with homogeneity  SR of level 2 DT studies with homogeneity  SR with homogeneity of 2b studies and better  SR with homogeneity of economic studies with level greater than 2 
2b  PC studies with follow-up shorter than 80%
Of low-quality CT 
Individual HC study or follow-up of controls not treated in a CT or non-validated clinical practice guidelines  Exploratory studies with logistic regression determine significant and validated factors with adequate SR (regardless of the DT)  Individual HC study or insufficient follow-up  Analysis based on costs or clinically sensitive alternatives; limited to review of the evidence.
Includes analysis of sensitivity. 
2c  Ecological studies or about health results  Study about healthcare results    Ecological studies  Audits or studies about health results 
3a  SR of CC studies with homogeneity    SR of studies w/ homogeneity of 3b studies and better quality  SR of studies w/ homogeneity of 3b studies and better quality  SR of studies w/ homogeneity of 3b studies and better quality 
3b  Individual CC studies    Blinded and objective comparison of a spectrum of a cohort of patients that could normally be examined for a specific condition, but the SR is not applied in all the patients of the study. Non-consecutive studies or without application of an SR    Non-consecutive cohort study, or very limited analysis of the population based on few alternatives or costs, estimations of poor-quality data, but including the sensitivity analysis that incorporate clinically sensitive variations 
Low-quality CS, cohort and CC studies  CS and cohort studies with Low-quality prognosis  CC studies with limited or without independent SR  Obsolete CS or SR  Analysis without sensitivity analysis 
EO  EO  EO  EO  EO 

RA: random assignation; CC: cases and controls; HC: historic cohorts; PC: prospective cohorts, individual, with homogeneity; CT: clinical trial; SR: standard of reference; GR: grade of recommendation; LE: level of evidence; EO: expert opinion without explicit critical evaluation, not based on physiology, nor on judicial research work, nor on fundamental principles; DT: diagnostic tests; SR: systematic review; CS: case series.

Fig. 1.

Representation of the quality of the evidence (a) and the recommendation grade (b).

(0.1MB).
Exposure Variables

We evaluated preoperative clinical variables, parasite and surgical variables that could influence the development of POM.

Definitions

RF were defined as variables that determined the probability (estimated through measures of association and their respective 95% confidence intervals [95%CI]), for developing an event of interest (development of POM). PF were defined as variables capable of reducing the probability (estimated through measures of association and 95%CI) for developing POM. Finally, associated variables were defined as those associated with the outcome of interest (POM), but lacked a measure of association with the respective 95%CI, or whose result was meager (value close to 1 or 95%CI of 1).

Statistical Analysis

The selected data were compiled in an Excel spreadsheet. Clinical trials included in an SR were not considered in the analysis. No statistical analyses are used in this type of study design.

Ethical Considerations

Authors and study centers were not revealed so as to reduce selection and analytical bias.

Results

From the indicated search, 1087 studies were identified. After analyzing the titles, 532 were discarded because they were considered “unrelated” to the investigation. In this same stage, it was verified that 62 were duplicate articles among the databases consulted (Table 2). Afterwards, the abstracts were then analyzed, which eliminated 401 studies because they had little relevance for the review, or because they did not meet the selection criteria. Then we proceeded to the in-depth analysis of the 92 selected studies, and the detailed reading of these confirmed the definitive inclusion of 69 studies that fulfilled the selection criteria: 2 RS, one composed of 32 retrospective studies22 and the other by 5 studies without randomized assignment23; three low-quality CT24–26 and 64 OS (5 concurrent cohort studies27–31; 3 case and control, 2 nested in one cohort32,33 and another that was not34; 20 historical cohorts9,13,15,17,35–50 and 36 CS,3–8,10–12,14,16,29,51–74 representing a population of 11403 subjects that are the object of this analysis) (flowchart of identified studies [Fig. 2]).

Table 2.

Search Strategies and Results Obtained for Each Source of Information Used.

(N=1087, Duplicates Between Databases=62)
Metasearch Engines, Libraries and Databases  Search Strategy and Results 
Trip Database (n=37)  (Hepatic echinococcosis)(Surgery)(Morbidity) 
BIREME-BVS (n=35)  (tw:(“Hepatic echinococcosis”)) OR (tw:(“Liver hydatidosis”)) OR (tw:(“Liver hydatid cyst”)) AND (tw:(postoperative complications)) 
SciELO (n=21)  “Hepatic echinococcosis” OR “Liver hydatidosis” OR “Liver hydatid cyst” 
Cochrane Central Register of CT (n=6)  “Hepatic echinococcosis” AND “Postoperative Complications” 
Web of Science (n=139)  (TS=(hepatic echinococcosis OR Liver hydatid cyst OR Liver hydatidosis) AND TS=(Surgery) AND TS=(Postoperative complications) NOT TI=(Laparosc*) NOT TI=(Alveolar) NOT TI=(Lung or Pulmonary)) AND Type of document: (Article)
Indices=SCI-EXPANDED, SSCI, A&HCI, ESCI Período de tiePOM=1980–2017 
MEDLINE (n=271)  #1 “Echinococcosis, Hepatic/surgery”[Mesh]; #2 echinococ*[ti]
#3 1 OR 2; #4 liver[tiab] OR hepatic[ti] OR hepati*[tiab]
#5 3 AND 4; #6 “Postoperative Complications”[Mesh]
#7 5 AND 6. Filtros: Publicado entre 1980/01/01 y 2016/12/31, Humanos, Adults 19+ yrs 
EMBASE (n=191)  #1′liver hydatid cyst’ AND [1980–2016]/py
#2’echinococosis’ ti AND [1980–2016]/py; #3 1 OR 2
#4’liver surgery’ ab,ti AND [1980–2016]/py; #5 3 AND 4
#6’postoperative complication’:ab,ti AND [1980–2016]/py
#7 5 AND 6 
SCOPUS (n=218)  “hepatic echinococcosis” AND “surgery” AND “postoperative complications” OR “Liver echinococcosis” AND “surgery” AND “postoperative complications” OR “Liver hydatid cyst” AND “surgery” AND “postoperative complications” 
EBSCOhost (n=21)  (“hepatic echinococcosis” AND “surgery”) OR (“Liver echinococcosis” AND “surgery”) OR (“Liver hydatid cyst” AND “surgery”) OR (“liver hydatidosis” AND “surgery”) OR (“hepatic echinococcosis surgery” AND “Postoperative complications”) OR (“hepatic echinococcosis surgery” AND Morbidity) OR (Morbidity AND “hepatic echinococcosis surgery”) 
IBECS (n=100)  echinoco$ [Palabras] or hydat$ [Palabras] and surg$ [Palabras] 
ePORTUGUESe (n=0)  (tw:(“Hepatic echinococcosis”)) OR (tw:(“Liver hydatidosis”)) OR (tw:(“Liver hydatid cyst”)) AND (tw:(Morbidity)) 
LILACS (n=44)  (tw:(“Hepatic echinococcosis”)) AND (tw:(Morbidity)) 
WHOLIS (n=4)  “Hepatic echinococcosis” OR subject “Liver hydatidosis” OR subject “Liver hydatid cyst” 
Fig. 2.

Flowchart of the participating studies. CT: clinical trial; OS: observational study; RS: systematic review.

(0.24MB).
Perioperative Clinical VariablesGeneral

A low-quality SR with a historical cohort study stated that, in order to reduce POM, a surgical team with experience in hepatobiliary surgery is required, along with adequate infrastructure, perioperative support and a rigorous follow-up to be able to analyze complications23,50 (treatment studies 3a and 4 and prognostic studies 2a and 2b).

Age

There is a series of articles that suggest that this is a variable associated with the development of POM. An SR identified a tendency for higher POM in patients aged ≥61 years (POM: 25.4%, OR 1.38 [0.74–2.57], P=.310)23 (treatment study 3a and prognosis study 2a). Something similar was verified in a nested case-control study, in which age >45 years is indicated as a cut-off point for all types of cysts (P=.017; OR: 1.1 [1.0; 1.1]).32 In another study of equivalent design, age >60 years was estimated as the cut-off point in uncomplicated cysts (P=.002; OR: 1.1 [1.0–1.1]])33 (treatment study 3b and prognosis 2b). Finally, a CS mentioned the cut-off point of age >61 (POM of 64.3% vs 38.6% in the subgroup aged 41–60 years, and 23.5% of the subgroup aged <40 years of age; P=.0412) (treatment and prognosis studies 4).

History of Previous Surgery for Hydatid Disease of the Liver

There is evidence to indicate this as an RF compared to patients who are operated on for the first time, which is supported by a nested case–control study (P=.018; OR: 4.1 [1.3–13.2])32 (treatment study 3b and prognostic study 2b).

Laboratory Variables

A CS observed that, in patients with POM, average alkaline phosphatase levels were 616±576U/L vs 397±440U/L in those who did not develop POM62 (treatment and prognosis study 4).

Parasite VariablesLocation

Evidence was found in a nested case–control study that supported that the central location of the liver in uncomplicated cysts is associated with higher POM than lateral locations (P=.003; OR: 3.9 [1.6–9.8])33 and 2 CS mentioned the location in the “liver dome” as an RF63,65; P<.0001, OR: 2.84 (95%CI: 1.58–5.07)63 (treatment studies 3b and 4 and prognosis studies 2b and 4).

Diameter

A historical cohort concluded that cysts >10cm in diameter were associated with higher POM.42 In 4 CS, it was observed that cyst diameter was associated with the development of more complications. Two set a cut-off point of 10cm,61,65 with a POM of 30.0% and 26.6%, respectively; another one also set it at 10cm (POM 44.4% in cysts larger than 10cm vs 24.5% in those smaller than 10cm; P=.002; OR: 16.7 95%CI: 1.2–4.45)12 and another set the cut-off point at 9cm63 (treatment and prognosis study 4).

Number

There is evidence based on an RS that there is higher POM in patients with 3 or more cysts compared to those with 2 or fewer (POM 30.0% vs 14.5%; OR: 3.1 [1.85–5.17]; P=.001).23 Also, a historical cohort study concluded that having 3 or more cysts is an independent variable for greater POM (OR: 2.55; 95%CI: 1.42–4.59)41 (treatment studies 3b and 4 and prognosis studies 2a and 2b).

Wall Thickness

There is evidence that the thicker the cyst wall, the higher the risk for POM, based on an RS (POM 23.1% vs 6.2%; OR: 2.59 [1.27–5.29]; P=.009)23 (treatment study 3a and prognosis study 2a).

Cystobiliary Communications

The existence of cystobiliary communications (CBC) is an RF for the development of POM, based on an RS (POM 32.9% vs 135%; OR: 227 [1.38–372]; P=.001)23 (treatment study 3a and prognosis study 2a). This fact is also supported by a concurrent cohort (POM without CB 9.4% vs 21.8% with CB; P<.001; RR: 3.4 [2.6–4.2])30 and 2 CS that report POM in the presence of CBC of up to 25.0%60,63; P=.024; OR: 2.3 (95%CI: 1.11–4.85)63 (treatment studies 2b and 4 and prognosis studies 1b and 4).

Coexistence of Evolutive Complications

There is evidence based on an RS that found greater POM in patients with cyst complications compared to uncomplicated cysts (POM 35.5% vs 19.6%; OR: 2.55 [1.42–4.59]; P=.002)23 (treatment study 3a and prognosis study 2a). Furthermore, there is a historic cohort and 2 CS that provide evidence on this item: in this first, POM was verified at 27.8% vs 15.2% in patients with complicated HDL compared to those without complications (P=.02545); the series described that the coexistence of evolutive complications of HDL versus uncomplicated cysts were associated with 20.0% vs 9.0% POM,62 while verifying that the POM in complicated cysts was 52.0% vs 21.0% when uncomplicated; P<.00112 (treatment study 4 and prognosis studies 2b and 4).

By separating the different evolutive complication options of cysts, we found evidence to support the position that cyst infection, presence of cholangiohydatidosis, existence of hepatothoracic transit and hydatid seeding are associated with the development POM22,45 (treatment studies 3a and 4 and prognosis studies 2a and 4).

Cyst infection. There is evidence based on a prospective cohort showing that secondary hepatic abscess in patients with HDL behaves as an RF for the development of POM (28.9% vs 11.1%; P=.001; RR: 2.5 [1.4–5.0]).29 On the other hand, a CS reported a POM of 23.4% in this type of cases34 (treatment studies 2b and 4 and prognosis study 1b and 4).

Cholangiohydatidosis. Two CS were found about the role of cholangiohydatidosis as an entity associated with higher POM in patients with HDL. Both included few cases and reported POM with and without secondary acute cholangitis of 30.0% and 23.0%, respectively70,73 (treatment and prognosis study 4).

Hepatothoracic transit. Four small CS were found (37–42 cases) that reported POM from 24.3% to 58.1%52,54,59,71 (treatment and prognosis study 4).

Hydatid seeding. There is available evidence that in an RS showing that patients with HDL that present hydatid seeding, and therefore require procedures in addition to the treatment of HDL, have a greater probability to develop POM, which can reach 35.0%23 (treatment study 3a and prognosis study 2a). In addition, evidence was found from a retrospective cohort39 that verified statistically significant differences between patients with and without HDL rupture (26% vs 15%; P=.018) and in 3 small CS (17–43),4,64,74 in which POM reached 35.3% (treatment and prognosis study 4).

Surgical VariablesTreatment of Cystobiliary Communications

There is evidence from a low-quality RS that supports the use of the Kehr tube versus choledochoduodenostomy (POM: 18.1% Kehr tube vs 40.0%)22 (treatment study 3a and prognosis study 2a). Something similar has been seen in a historic cohort and 2 CS37,53,69 (treatment and prognosis study 4). Finally, a concurrent cohort advocates simple suture of the biliary comunications30 (treatment study 2b and prognosis study 1b).

Surgical Alternatives

Evidence was found in favor of radical surgery vs conservative techniques, demonstrating that radical techniques were associated with lower POM. One RS (POM: 17.7% vs 34.6%; OR=0.42, 95%CI: 0.32–0.56; P<.00001) indicated that radical surgery is a PF against the development of POM compared to conservative surgery).23 Further evidence: one CT (POM: 0.0% vs 35.3%; P=.011)25; 7 historic cohorts (POM: 13.3% vs 31.4%; P<.001),35 (POM: 16.6 vs 42.8%; P<.05),9 (POM: 3.2% vs 11.6%; P<.001),40 (POM: 26% vs 45%; P<.05)15; (POM: 19.0 vs 28.0; P<.05),44 (POM: 16.2% vs 79.9%; P<.001),17 (POM: 0.0% vs 31.0%; P=.004)49 (treatment studies 3a, 2b and 4, and prognosis studies 2a, 2b and 4). However, in a case–control study, no differences were verified (POM: 15.0% vs 19.0%; OR: 1.28; 95%CI: 0.57–2.86),34 which was likewise reported in a historic cohort (POM: 16.6% vs 24.2%; P>.05)43 (treatment and prognosis study 4).

There is also evidence comparing the results obtained from cystectomy, cystojejunostomy and Posadas procedure, showing evidence in favor of cystectomy over the Posadas in a historic cohort (POM: 0.0% vs 31.6%; P=.005)38 and partial cystectomy over other techniques in a historic cohort (POM: 7.3% vs 14.3%; P<.05).47 There is also evidence to support he use of Roux-en-Y cystojejunostomy versus cystectomy in a historic cohort (POM: 7.7% vs 40.0%; P<.05).48 Further evidence shows that cystectomy is superior to polar drainage and cystostomy with cavity wall suture, based on a historic cohort (POM: 8.3% vs 32.5%; POM: 8.3% vs 54.5%; POM: 8.3% vs P=.0037)13 (treatment and prognosis study 4).

Other evidence enables us to compare the results obtained by applying drainage vs other options in the treatment of the residual cavity. Evidence was confirmed that supports omentoplasty vs drainage based on a CT (POM: 22.7% vs 42.9%; P=.00163),26 2 concurrent cohorts (POM: 23.0% vs 6.0%; P=.03),27 (POM: 5.7% vs 16.6%; P<.05)28 and a historic cohort (POM: 9.7% vs 32.5%; P<.05)13 (treatment studies 2b and 4, and prognosis studies 1b, 2b and 4).

More evidence demonstrates that the use of drainage is associated with less development of POM than the use of cavity wall suture in a historic cohort (POM: 32.5% vs 54.4%; P<.05).13 However, in another historic cohort, the results show that it is the use of cavity wall suture which is associated with lower POM (POM: 5.6% vs 15.4%; P<.05)46 (treatment and prognosis study 4). Finally, there is evidence that the lack of use of drainage is associated with a lower POM than the use of drainage once the surgical procedure is done, based in a historic cohort (POM: 10.0% vs 44.7%; P<.05)36 (treatment and prognosis study 4).

Furthermore, there is evidence regarding the utilization of cavity wall suture vs omentoplasty, which indicates that the use of cavity wall suture associated with drainage is a PF against POM compared to the use of omentoplasty and cavity wall suture without drainage, based on an RS (POM 15.3% vs 23.8% vs 25.6%; OR: 2.23 [1.12–4.44]; P=.023)23 (treatment study 3a and prognosis study 2a). Evidence was also found in favor of using cavity wall suture over omentoplasty in a concurrent cohort (POM: 2.5% vs 18.8%; P=.04 and RR: 0.3 [0.03–0.70]), which determined that the use of cavity wall suture would be a PF against the development of local complications31 and in a historic cohort (POM: 28.6% vs 50.0%; P=.005)38 (treatment studies 2b and 4 and prognosis studies 1b and 4).

However, there is also evidence in favor of using omentoplasty versus not using it based on a multicenter CT (POM: 10.0% vs 34.0%; P<.03)24 and also in favor of using omentoplasty vs cavity wall suture in a historic cohort (POM: 9.7% vs 54.5%; P=.003713) (treatment and prognosis studies 2b and 4).

With regards to the need for additional surgery, there is evidence supporting that the treatment of concomitant localizations of HDL is associated with higher POM, based on a historic cohort13 and 2 CS12,14 (treatment and prognosis study 4).

The findings mentioned above are summarized in Table 3, which also indicates the corresponding quality of the evidence.

Table 3.

Summary of the Evidence Found.

Variables  N and Type of Studies  Quality of the Evidence  Summary of the Findings 
Perioperative clinical  1 RS
1 HC 
Moderate or low
Treatment studies 3a and 4 and prognosis 2a and 2b 
Experience of the surgical team, infrastructure, perioperative support and rigorous follow-up are PF against the development of POM 
Age  1 RS
2 nested CC
1 CS 
Moderate to very low
Treatment studies 3a, 3b and 4; and prognosis 2a, 2b and 4 
Age is RF for the development of POM 
History of previous surgery for HDL  1 nested CC  Moderate
Treatment studies 3b and prognosis 2b 
Previous surgery for HDL is a RF for the development of POM 
Laboratory variables  1 CS  Very low
Treatment and prognosis study 4 
Alkaline phosphatase would be a factor associated with POM 
Central hepatic location (hepatic dome)  1 nested CC
2 CS 
Moderate to very low
Treatment studies 3b and 4, and prognosis 2b and 4 
RF in uncomplicated cysts 
Cyst diameter  1 HC
4 CS 
Low to very low
Treatment and prognosis study 4 
Diameter >10cm would be RF for POM 
Number of cysts  1 RS
1 HC 
Moderate to low Treatment studies 3b and 4; and prognosis 2a and 2b  More than 3 lesions would be RF for POM 
Cyst wall thickness  1 RS  Moderate
Treatment study 3a and prognosis 2a 
Greater thickness of the cystic wall would be a RF for POM 
Existence of CBC  1 RS
1 PC
2 CS 
High, moderate and low
Treatment studies 3a, 2b and 4; and prognosis 1b, 2a and 4 
2 or more CBC is RF for POM 
Coexistence of cyst evolution complications  1 RS
1 HC
2 CS 
Moderate to very low
Treatment studies 3a and 4, and prognosis 2a, 2b and 4 
Evolutive complications are RF for POM 
Cyst infection  1 PC
1 CS 
High and very low
Treatment studies 2b and 4, and prognosis 1b and 4 
Cyst infection is an RF for POM 
Cholangiohydatidosis  2 CS  Very low
Treatment and prognosis study 4 
Could be associated with higher POM 
HTT  4 CS  Very low
Treatment and prognosis study 4 
Could be associated with higher POM 
Hydatid seeding  1 RS
1 HC
3 CS 
Moderate to low
Treatment studies 3a and 4, and prognosis 2a and 4 
Could be associated with higher POM 
Radical surgery vs conservative surgery  1 RS
1 CT
7 HC 
High, moderate and low
Treatment studies 3a, 2b and 4, and prognosis 2a, 2b and 4 
Radical surgery is associated with less development of POM 
  1 CC
1 HC 
Moderate to low
Treatment studies 3b and 4 and prognosis 4 
No differences were verified between the two options 
Treatment of CBC  1 RS
1 HC
2 CS
1 PC 
Moderate, low and very low
Treatment studies 3a, 2b and 4, and prognosis 1b, 2a and 4 
Kehr tube better than CDA
Simple suture of the CBC is associated with lower POM 
Need to perform additional surgeries  1 HC
2 CS 
Low to very low
Treatment and prognosis study 4 
Associated with greater POM 
Treatment of the residual cavity  1 CT
2 PC
1 HC 
High, moderate and low
Treatment studies 2b and 4, and prognosis 1b, 2b and 4 
Drainage is RF versus omentoplasty 
  2 HC  Low
Treatment and prognosis study 4 
Contradictory information between cavity suture and drainage 
  1 RS
1 PC
1 HC 
High, moderate and low
Treatment studies 2b, 3a and 4, and prognosis 1b, 2a and 4 
Cavity suture is PF for the development of POM versus the use of omentoplasty 
  1 CT
1 HC 
Moderate to low
Treatment and prognosis studies
2b and 4 
Omentoplasty is PF versus no omentoplasty and the use of cavity suture 

CC: cases and controls; CDA: choledochoduodenostomy; HC: historical or retrospective cohort; PC: concurrent or prospective cohort; CBC: cystobiliary communications; CT: clinical trial; PF: protective factor; RF: risk factor; POM: postoperative morbidity; CS: case series; HTT: hepatothoracic transit.

High quality: additional research is highly unlikely to modify our confidence in the estimations of the effect.21

Moderate quality: additional research is likely to have an important effect in our confidence in the estimation of the effect and may change it.21

Low quality: additional research is very unlikely to have an important impact on our confidence in the estimation of the effect, and it is likely to change the estimation.21

Very low quality: any estimation of the effect is highly uncertain.21

Discussion

For reasons of efficiency, this review was based on a critical evaluation of the best available evidence from the last 36 years, preferably in the form of SR. When these did not exist, CT and OS were identified. Consequently, we proceeded in a hierarchical manner, prioritizing levels of evidence and recommendation grades.

In this report, no recommendations have been made, since we believe that these should be formulated for each specific setting based on the overall quality of the evidence, initially assessing the balance between benefits and risks and finally taking into account factors such as local context, baseline risk of the population, values and preferences, as well as the associated costs.21

In our study, we decided to exclude patients treated with laparoscopy because these are usually subgroups with uncomplicated lesions that are smaller in size, with no preoperative evidence of cystobiliary communications, etc. In short, patients selected for laparoscopic surgery have a lower risk for POM.

The limitations of the study are mainly due to the low methodological quality of most of the studies that were included. However, some biases (selection, analysis and publication) were reduced with a thorough search of the literature, carried out in various sources of information and with the blinding of authors and centers.

It is difficult to find answers that explain why, in spite of technological advances, the POM of HDL surgery continues to have figures that have not changed substantially in the last 7 years, as there continue to be reports between 37.9% and 79.9%,15–17 especially when looked at from the perspective that it is a benign disease. The only way to comprehend the possible reasons for such variability would be to consider the heterogeneity of the studied populations, the different techniques applied and the diverse level of experience of the groups that report their results, which lead to an uncertainty that must be clarified.

We have identified some variables that can be considered RF for the development of POM in patients treated surgically for HDL (Table 3), including: age, history of previous surgery for HDL, location in the liver center in uncomplicated cysts, the existence of CBC (especially when there are 2 or more), and the coexistence of evolutive cyst complications (especially cyst infection). Additionally, radical surgical techniques appear as PF against the development of POM, as well as the treatment of CBC with simple suture or Kehr tube and the use of cavity wall suture versus omentoplasty. However, all of these are based on moderate to low quality evidence studies, which is why these results should be observed with caution.

Other variables that would be associated with higher POM in patients operated on for HDL were verified, such as cyst diameter (>10cm), the need to perform additional surgeries, and elevated lab workup variables, such as alkaline phosphatase. All of these are supported by quality studies of moderate, low or very low evidence, and could even be confounding or effect-modifying variables.

However, most of the studies analyzed reported results from heterogeneous populations (for example, mixing complicated and uncomplicated HDL), so that a variable that appears to be an RF might only be an effect of classification, measurement and even confounding bias.

What follows this manuscript is the development of a predictive model for POM in patients operated on for HDL, using a classification and regression tree analysis like CART (non-linear and non-parametric alternative to linear regression models), which is a robust tool that can be applied to numerical and categorical data, facilitating the identification and interpretation of complex interactions.75

As a conclusion, we can point out that the information regarding the development of POM in patients operated on for HDL is limited, heterogeneous and mostly from low-quality studies with low levels of evidence. In certain items, the results leave us with more questions than answers. It is therefore necessary to have a greater number of primary studies with a good level of evidence and quality in order to resolve the existing uncertainty regarding the existence of RF for the development of POM (for example, determining the effect that 2 or more RF could have when existing together in a population treated surgically for HDL).

Funding

This study has been partially funded by the DID-UFRO DI16-0119 project of the Research and Development Administration at the Universidad de La Frontera, Chile.

Conflict of Interests

None.

References
[1]
P. Martínez.
Human hydatidosis disease: general background and epidemiological situation in Chile, 2001–2009.
Rev Chilena Infectol, 28 (2011), pp. 585-591
[2]
S. Cortés, C. Valle.
Human hydatidosis: general aspects and epidemiological situation in Chile according to hospital discharge and mandatory reporting from 2001 to 2005.
Rev Chilena Infectol, 27 (2010), pp. 329-335
[3]
C. Manterola.
Post surgery morbidity in patients with complicated hepatic hydatidosis.
Rev Chilena Infectol, 32 (2015), pp. 43-49
[4]
C. Manterola, M. Vial, H. Losada, F. Fonseca, L. Bustos, S. Muñoz, et al.
Uncommon locations of abdominal hydatid disease.
Trop Doct, 33 (2003), pp. 179-180
[5]
P. Magistrelli.
Surgical treatment of hydatid disease of the liver. A 20-year experience.
Arch Surg, 126 (1991), pp. 518-522
[6]
P. Pinto.
Hidatidosis hepática: estudio de una serie de 534 casos.
Rev Chil Cir, 43 (1991), pp. 184-187
[7]
J. Camacho, J. Reyes, A. Pérez, E. Buckel, J. Giordano, L. Pérez, et al.
Cirugía del quiste hidatídico hepático.
Rev Chil Cir, 48 (1996), pp. 479-482
[8]
D. González, A. Vega, J. Monti, M. Torres.
Enfermedad hidática hepática: experiencia de los últimos 13 años en Florida.
Cir Urug, 69 (1999), pp. 200-203
[9]
L. Sarotto, M. Nallar, A. Ferraro, E. Danguise, J. Merello, P. Ferraina.
Tratamiento quirúrgico de la hidatidosis hepática: experiencia en el Hospital de Clínicas en los últimos 15 años.
Rev Argent Cir, 76 (1999), pp. 94-105
[10]
A.A. Balik.
Surgical treatment of hydatid disease of the liver: review of 304 cases.
Arch Surg, 134 (1999), pp. 166-169
[11]
G. Nari, O. Ponce, M. Cirami, J. Jozami, J. Toblli, M. Eduardo, et al.
Five years experience in surgical treatment of liver hydatidosis.
Int Surg, 88 (2003), pp. 194-198
[12]
S. Daradkeh, H. El-Muhtaseb, G. Farah, A.S. Sroujieh, M. Abu-Khalaf.
Predictors of morbidity and mortality in the surgical management of hydatid cyst of the liver.
Langenbecks Arch Surg, 392 (2007), pp. 35-39
[13]
S. Gourgiotis, C. Stratopoulos, P. Moustafellos, N. Dimopoulos, G. Papaxoinis, V. Vougas, et al.
Surgical techniques and treatment for hepatic hydatid cysts.
Surg Today, 37 (2007), pp. 389-395
[14]
R.M. Agayev, B.A. Agayev.
Hepatic hydatid disease: surgical experience over 15 years.
Hepatogastroenterology, 55 (2008), pp. 1373-1379
[15]
M.A. Secchi, R. Pettinari, C. Mercapide, R. Bracco, C. Castilla, E. Cassone, et al.
Surgical management of liver hydatidosis: a multicentre series of 1412 patients.
[16]
S. Sekulic, A.S. Sekulic-Frkovic, S. Secen, J. Vasic, M. Popovic.
Liver hydatidosis surgical treatment.
Hepatogastroenterology, 58 (2011), pp. 1343-1348
[17]
S. Tagliacozzo.
Surgical treatment of hydatid disease of the liver: 25 years of experience.
Am J Surg, 201 (2011), pp. 797-804
[18]
A.D. Oxman, D.J. Cook, G.H. Guyatt, Evidence-based medicine working group.
Users’ guides to the medical literature VI. How to use an overview.
JAMA, 272 (1994), pp. 1367-1371
[19]
Scottish Intercollegiate Guidelines Network SIGN 50.
A guidelines developers’ handbook.
SIGN, (2004),
[20]
Centre for Evidence-Based Medicine. OCEBM levels of evidence. Available from: http://www.cebm.net/ocebm-levels-of-evidence [accessed 21.03.17].
[21]
G. Guyatt, A.D. Oxman, R. Kunz, Y. Falck-Ytter, G.E. Vist, A. Liberati, for the GRADE Working Group, et al.
Going from evidence to recommendations.
[22]
C. Dziri, K. Haouet, A. Fingerhut, A. Zaouche.
Management of cystic echinococcosis complications and dissemination: where is the evidence?.
World J Surg, 33 (2009), pp. 1266-1273
[23]
Y.B. He, G. Yao, T. Tuxun, L. Bai, T. Li, J.M. Zhao, et al.
Efficacy of radical and conservative surgery for hepatic cystic echinococcosis: a meta-analysis.
Int J Clin Exp Med, 8 (2015), pp. 7039-7048
[24]
C. Dziri, J.C. Paquet, J.M. Hay, A. Fingerhut, S. Msika, G. Zeitoun, et al.
Omentoplasty in the prevention of deep abdominal complications after surgery for hydatid disease of the liver: a multicenter, prospective, randomized trial. French Associations for Surgical Research.
J Am Coll Surg, 188 (1999), pp. 281-289
[25]
O. Yüksel, N. Akyürek, T. Sahin, B. Salman, C. Azili, H. Bostanci.
Efficacy of radical surgery in preventing early local recurrence and cavity-related complications in hydatic liver disease.
J Gastrointest Surg, 12 (2008), pp. 483-489
[26]
A.A. Wani, A. Rashid, A.R. Laharwal, S.M. Kakroo, M. Abbas, M.A. Chalkoo.
External tube drainage or omentoplasty in the management of residual hepatic hydatid cyst cavity: a prospective randomized controlled study.
Ger Med Sci, 11 (2013),
Doc11
[27]
I.D. Ozacmak, F. Ekiz, V. Ozmen, A. Isik.
Management of residual cavity after partial cystectomy for hepatic hydatidosis: comparison of omentoplasty with external drainage.
Eur J Surg, 166 (2000), pp. 696-699
[28]
S. Reza Mousavi, J. Khoshnevis, P. Kharazm.
Surgical treatment of hydatid cyst of the liver: drainage versus omentoplasty.
Ann Hepatol, 4 (2005), pp. 272-274
[29]
C. Manterola, A. Sanhueza, M. Vial, J. Moraga.
MINCIR Group. Liver abscess of hydatid origin as a risk factor for postoperative complications in hidatidosis.
Rev Chil Cir, 61 (2009), pp. 333-338
[30]
C. Manterola, M. Vial, A. Sanhueza, J. Contreras.
Intrabiliary rupture of hepatic echinococcosis, a risk factor for developing postoperative morbidity: a cohort study.
World J Surg, 34 (2010), pp. 581-586
[31]
C. Manterola, J.C. Roa, S. Urrutia, MINCIR Group.
Treatment of the residual cavity during hepatic hydatidosis surgery: a cohort study of capitonnage vs omentoplasty.
Surg Today, 43 (2013), pp. 1412-1418
[32]
C. Manterola, M. Vial, V. Pineda, A. Sanhueza, M. Barroso.
Factors associated with morbidity in liver hydatid surgery.
ANZ J Surg, 75 (2005), pp. 889-892
[33]
C. Manterola, T. Otzen, S. Urrutia, MINCIR Group.
Risk factors of postoperative morbidity in patients with uncomplicated liver hydatid cyst.
Int J Surg, 12 (2014), pp. 695-699
[34]
H.O. El Malki, A. Souadka, A. Benkabbou, R. Mohsine, L. Ifrine, R. Abouqal, et al.
Radical versus conservative surgical treatment of liver hydatid cysts.
Br J Surg, 10 (2014), pp. 669-675
[35]
P. Priego, J. Nuño, P. López Hervás, A. López Buenadicha, R. Peromingo, J. Díe, et al.
Hepatic hydatidosis. Radical vs conservative surgery: 22 years of experience.
Rev Esp Enferm Dig, 100 (2008), pp. 82-85
[36]
N.A. Kama, M. Sahin, E. Göçmen, M. Bayrak, H. Kulaçoğlu, A.Z. Akat.
The results of surgical techniques in hepatic hydatidosis: treatment with drainage versus treatment without drainage – a 6-year experience.
J R Coll Surg Edinb, 43 (1998), pp. 254-256
[37]
O. Elbir, H. Gundogdu, M. Caglikulekci, C. Kayaalp, F. Atalay, M. Savkilioglu, et al.
Surgical treatment of intrabiliary rupture of hydatid cysts of liver: comparison of choledochoduodenostomy with T-tube drainage.
Dig Surg, 18 (2001), pp. 289-293
[38]
N. Agaoglu, S. Türkyilmaz, M.K. Arslan.
Surgical treatment of hydatid cysts of the liver.
Br J Surg, 90 (2003), pp. 1536-1541
[39]
A. Akcan, H. Akyildiz, T. Artis, A. Ozturk, M.A. Deneme, E. Ok, et al.
Peritoneal perforation of liver hydatid cysts: clinical presentation, predisposing factors, and surgical outcome.
World J Surg, 31 (2007), pp. 1284-1291
[40]
U. Aydin, P. Yazici, Z. Onen, M. Ozsoy, M. Zeytunlu, M. Kiliç, et al.
The optimal treatment of hydatid cyst of the liver: radical surgery with a significant reduced risk of recurrence.
Turk J Gastroenterol, 19 (2008), pp. 33-39
[41]
H.O. El Malki, Y. El Mejdoubi, A. Souadka, R. Mohsine, L. Ifrine, R. Abouqal, et al.
Predictive factors of deep abdominal complications after operation for hydatid cyst of the liver: 15 years of experience with 672 patients.
J Am Coll Surg, 206 (2008), pp. 629-637
[42]
H.O. El Malki, Y. El Mejdoubi, A. Souadka, B. Zakri, R. Mohsine, L. Ifrine, et al.
Does primary surgical management of liver hydatid cyst influence recurrence?.
J Gastrointest Surg, 14 (2010), pp. 1121-1127
[43]
S. Akbulut, A. Senol, A. Sezgin, B. Cakabay, M. Dursun, O. Satici.
Radical vs conservative surgery for hydatid liver cysts: experience from single center.
World J Gastroenterol, 16 (2010), pp. 953-959
[44]
M.R. Motie, M. Ghaemi, M. Aliakbarian, E. Saremi.
Study of the radical vs conservative surgical treatment of the hepatic hydatid cyst: a 10-year experience.
Indian J Surg, 72 (2010), pp. 448-452
[45]
N. Symeonidis, T. Pavlidis, M. Baltatzis, K. Ballas, K. Psarras, G. Marakis, et al.
Complicated liver echinococcosis: 30 years of experience from an endemic area.
Scand J Surg, 102 (2013), pp. 171-177
[46]
M. Mehrabi Bahar, A. Jabbari Nooghabi, A. Hamid, A. Amouzeshi, A. Jangjoo.
Study of treatment results and early complications of tube drainage versus capitonnage after the unroofing and aspiration of hydatid cysts.
Asian J Surg, 37 (2014), pp. 195-199
[47]
B. Özer, A. Kocakuşak, S. Benek, O. Güngörür, F. Erözgen, H. Aydın, et al.
Comparison of partial cystectomy and tube drainage technique with other surgical methods in hydatid cysts of the liver.
Med Bull Haseki, 52 (2014), pp. 287-290
[48]
F. Acar, M. Sahin, H. Alptekin, H. Yılmaz, M.E. Kafalı.
Surgical treatment of giant liver hydatid cysts: comparison of cystojejunostomy and partial cystectomy.
Surg Today, 44 (2014), pp. 2065-2071
[49]
G. Salamone, R. Tutino, J. Atzeni, L. Licari, N. Falco, G. Orlando, et al.
Liver hydatidosis: reasoned indications of surgical treatment. Comparison between conservative and radical techniques. Retrospective study.
Ann Ital Chir, 85 (2014), pp. 422-430
[50]
A. Benkabbou, A. Souadka, B. Serji, H. Hachim, R. Mohsine, L. Ifrine, et al.
Changing paradigms in the surgical management of cystic liver hydatidosis improve the postoperative outcomes.
Surgery, 159 (2016), pp. 1170-1180
[51]
J. Sapunar, J. Rappoport, J. Sapunar, F. Cumsille.
Quiste hidatídico hepático: características clínicas, factores pronósticos y resultados quirúrgicos.
Parasitol Día, 13 (1989), pp. 52-63
[52]
M. Castillo, R. Álvarez de Oro, C. Czicshke.
Lesiones anatomoquirúrgicas de los quistes hidatídicos en tránsito torácico.
Rev Chil Cir, 47 (1995), pp. 425-429
[53]
J. Prousalidis, E. Tzardinoglou, C. Kosmidis, K. Katsohis, O. Aletras.
Surgical management of calcified hydatid cysts of the liver.
HPB Surg, 11 (1999), pp. 253-259
[54]
T. Kilani, S. El Hammami, H. Horchani, K. Ben Miled-Mrad, S. Hantous, I. Mestiri, et al.
Hydatid disease of the liver with thoracic involvement.
World J Surg, 25 (2001), pp. 40-45
[55]
C. Kayaalp, K. Bzeizi, A.E. Demirbag, M. Akoglu.
Biliary complications after hydatid liver surgery: incidence and risk factors.
J Gastrointest Surg, 6 (2002), pp. 706-712
[56]
C. Manterola, M. Barroso, M. Vial, L. Bustos, S. Muñoz, H. Losada, et al.
Liver abscess of hydatid origin: clinical features and results of aggressive treatment.
ANZ J Surg, 73 (2003), pp. 220-224
[57]
S. Agarwal, S.S. Sikora, A. Kumar, R. Saxena, V.K. Kapoor.
Bile leaks following surgery for hepatic hydatid disease.
Indian J Gastroenterol, 24 (2005), pp. 55-58
[58]
R. Chautems, L.H. Bühler, B. Gold, E. Giostra, P. Poletti, M. Chilcott, et al.
Surgical management and long-term outcome of complicated liver hydatid cysts caused by echinococcus granulosus.
Surgery, 137 (2005), pp. 312-316
[59]
A. Tocchi, G. Mazzoni, M. Miccini, A. Drumo, D. Cassini, L. Colace, et al.
Treatment of hydatid bronchobiliary fistulas: 30 years of experience.
[60]
C. Tomuş, C. Iancu, F. Pop, N. Al Hajjar, C. Puia, D. Munteanu, et al.
Intrabiliary rupture of hepatic hydatid cysts: results of 17 years’ experience.
Chirurgia (Bucur), 104 (2009), pp. 409-413
[61]
I. Botrugno, S. Gruttadauria, S. Li Petri, D. Cintorino, M. Spada, F. Di Francesco, et al.
Complex hydatid cysts of the liver: a single center's evolving approach to surgical treatment.
Am Surg, 76 (2010), pp. 1011-1015
[62]
H. Losada Morales, L. Burgos San Juan, J. Silva Abarca, C. Muñoz Castro.
Experience with the surgical treatment of hepatic hydatidosis: case series with follow-up.
World J Gastroenterol, 16 (2010), pp. 3305-3309
[63]
H. Bedioui, K. Bouslama, H. Maghrebi, J. Farah, H. Ayari, H. Hsairi, et al.
Predictive factors of morbidity after surgical treatment of hepatic hydatid cyst.
Pan Afr Med J, 13 (2012), pp. 29
[64]
M.A. Majbar, A. Souadka, F. Sabbah, M. Raiss, A. Hrora, M. Ahallat.
Peritoneal echinococcosis: anatomoclinical features and surgical treatment.
World J Surg, 36 (2012), pp. 1030-1035
[65]
O. Baraket, M. Moussa, K. Ayed, B. Kort, S. Bouchoucha.
Predictive factors of morbidity after surgical treatment of hydatid cyst of the liver.
Arab J Gastroenterol, 15 (2014), pp. 119-122
[66]
G. Martel, S. Ismail, F. Vandenbroucke-Menu, R. Lapointe.
Can J Surg, 57 (2014), pp. 320-326
[67]
A. Montúfar-Valer, F.L. Huapaya-Jurado.
Clinical, radiological and laboratory features of liver hydatidosis of patients from a hospital of national reference, Lima 1997–2010.
Rev Gastroenterol Peru, 34 (2014), pp. 203-209
[68]
K.S. Mosaddeghi, H.K. Heris, A. Bayat, K.Z. Mosaddeghi.
Capsulorrhaphy in the management of liver hydatid cyst.
Ann Hepatol, 13 (2014), pp. 378-383
[69]
H. Lv, Y. Jiang, X. Peng, S. Zhang, X. Wu, H. Yang, et al.
Subadventitial cystectomy in the management of biliary fistula with liver hydatid disease.
[70]
C. Manterola, T. Otzen.
Cholangiohydatidosis: an infrequent cause of obstructive jaundice and acute cholangitis.
Ann Hepatol, 16 (2017), pp. 436-441
[71]
C. Manterola, T. Otzen.
Hepatic echinococcosis with thoracic involvement. Clinical characteristics of a prospective series of cases.
Ann Hepatol, 16 (2017), pp. 591-596
[72]
A. Surmelioglu, I. Ozer, E. Reyhan, T. Dalgic, Y. Ozdemir, M. Ulas, et al.
Risk factors for development of biliary complications after surgery for solitary liver hydatid cyst.
Am Surg, 83 (2017), pp. 30-35
[73]
C. Manterola, H. Losada, R. Carrasco, S. Muñoz, L. Bustos, M. Vial, et al.
Cholangiohydatidosis. An evolutive complication of hepatic hydatidosis.
Bol Chil Parasitol, 56 (2001), pp. 10-15
[74]
H. Derici, T. Tansug, E. Reyhan, A.D. Bozdag, O. Nazli.
Acute intraperitoneal rupture of hydatid cysts.
World J Surg, 30 (2006), pp. 1879-1883
[75]
H.O. El Malki, Y. El Mejdoubi, A. Souadka, R. Mohsine, L. Ifrine, R. Abouqal, et al.
Predictive model of biliocystic communication in liver hydatid cysts using classification and regression tree analysis.

Please cite this article as: Manterola C, Otzen T, Muñoz G, Alanis M, Kruuse E, Figueroa G. Cirugía de la hidatidosis hepática. Factores de riesgo y variables asociadas al desarrollo de morbilidad postoperatoria. Revisión global de la evidencia existente. Cir Esp. 2017;95:566–576.

Copyright © 2017. AEC
Article options
Tools
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos