Long-term experience on surgical treatment of alveolar echinococcosis.

INTRODUCTION: Alveolar echinococcosis (AE) is life-threatening and reports on surgical procedures and results are rare, but essential.
MATERIALS AND METHODS: Longitudinal surveillance and long-term follow-up of patients surgically treated for AE during the periods 1982-1999 (group A) and 2000-2006 (group B).
SETTING: University hospital within an endemic area.
RESULTS: The median (min-max) follow-up period was 141 (5-417) months. Forty-eight surgical procedures were performed in 36 patients with AE: 63% were partial resections of the liver (additional extrahepatic resection in ten of them), 17% just extrahepatic resections, 10% biliodigestive anastomosis, and 10% exploratory laparotomies. Seventy-five percent of the operations were first-time procedures, 25% done due to a relapse. Forty-two percent of the operations were estimated to be curative (R0), whereas 58% were palliative (R1, R2). All patients had additional medical treatment and periodical follow-up. Two out of 18 (11%) patients, estimated to have had curative surgery, developed a relapse 42 and 54 months later. R0-resection rates depended on the primary, neighboring, metastasis stage of AE (S1, 100%; S2, 100%; S3a, 33%; S3b, 27%; S4, 11%). During the period 2000-2006 elective radical surgery for AE was done only if a safe distance of at least 2 cm was attainable. This concept was associated with an increased R0-resection rate of 87% for group B compared to 24% for group A. Operative procedures done to control complicated courses of AE (jaundice, cholangitis, vascular compression, bacterial superinfection) have not been curative (R2) in 82% because the disease had spread into irresectable structures. Morbidity was 19%. All patients with curative resections are alive. Fifty-six percent of the patients with palliative treatment are alive as long as 14-237 months, 28% died from AE 164-338 months after diagnosis (late lethality), and 17% died due to others diseases 96-417 months after diagnosis of AE. One out of seven (14%) patients suffering from suppurative parasitic necrosis died because it was impossible to control systemic sepsis (3% hospital lethality).
CONCLUSION: Curative surgery for AE is feasible if the parasitic mass is removable entirely. The earlier the stage, the more frequent is R0 resectability. The observance of a minimal safe distance increases the rate of R0 resections. The benefit of palliative surgery is uncertain due to favorable long-term results of medical treatment alone. However, necrotic tissue is at risk of bacterial superinfection, which can cause life-threatening sepsis. Palliative surgery is an option to treat complications, which could not be managed otherwise.