Prognostic factors associated with recurrence in patients undergoing surgery for hepatic cystic echinococcosis. A systematic review.

Background:

Hepatic cystic echinococcosis (HCE) is a neglected zoonotic disease with a substantial burden in endemic regions. Surgery remains the most frequently employed therapeutic approach; however, recurrence rates range from 8% to 10% and are associated with increased morbidity and healthcare costs. Identifying prognostic factors (PFs) may enable risk stratification and optimization of clinical management.

Objective:

To identify prognostic factors associated with recurrence in patients undergoing surgery for HCE.

Methods:

A systematic review was conducted (PROSPERO: CRD42024538005). Observational and experimental studies were searched in MEDLINE, Scopus, Embase, Web of Science, BIREME-BVS, and SciELO up to January 2026. Studies evaluating preoperative or surgical characteristics associated with recurrence were included. Risk of bias was assessed using the QUIPS tool, and certainty of evidence was evaluated with a modified GRADE approach for prognostic factors. Random-effects meta-analyses (REML) were performed when appropriate.

Results:

Nineteen studies were included (3,849 patients; 334 recurrences, 8.7%). Twenty-eight PFs were identified. In unadjusted analyses, prior recurrence (OR: 2.4), extrahepatic cysts (OR: 2.5), cyst rupture (OR: 11.1), multiple cysts (OR: 2.9), and cyst diameter >9 cm (OR: 2.1) were associated with increased recurrence risk. In multivariable analyses, prior recurrence (aOR: 2.7), ≥2 cysts (aHR up to 3.8), and larger cyst size (aOR up to 4.0) showed consistent independent associations. Evidence regarding surgical factors was limited and highly imprecise. Overall certainty of evidence ranged from low to very low due to clinical heterogeneity, lack of standardized recurrence definitions, and risk of confounding.

Conclusions:

Parasitic burden and intraoperative dissemination appear to be the primary drivers of recurrence after HCE surgery. Well-designed prospective multicenter cohorts with standardized definitions and robust multivariable adjustment are needed to strengthen prognostic evidence.