Response to the Comment: Surgery of Liver Hydatid Cyst’s Recurrence is Always More Difficult

Abstract

Dear editor, We read with great interest the Letter to the Editor: Comments on the article about recurrence after surgical management of liver hydatid cyst by Enver Zerem et al. regarding our manuscript published in the Journal of Gastrointestinal Surgery. We first want to thank you for allowing us to answer this letter to the editor and to explain our point of view. Surgery remains the treatment of choice of liver hydatid cyst (LHC).Our rate of 8.5% of WTC recurrence is not high, it is an average rate of recurrence in all surgical studies ranging from to 4.5% to 30%. This rate may be explained by the fact that our center is a tertiary center which receives patients from all over the country with no selection of patients as reported in previous papers. Our series is a retrospective study of all LHCs surgically managed in our department. At the opposite, in the Zerem study performing ultrasound-guided puncture, aspiration, injection, and reaspiration (PAIR) method in the management of highly selected patients with types I and III Gharbi’s classification LHC, it is possible to assess this very low rate of recurrence, excluding initially complicated cysts. The diagnosis of LHC recurrence was assessed preoperatively during routine surveillance ultrasonography and then confirmed by a 6-month control ultrasonography associated with an abdominal CT scan showing either the same image or the worsening of the lesion. In doubtful cases, fine needle aspiration was performed to confirm the diagnosis. During surgery, after covering and isolating the area, the cyst was incised at its most accessible part and all its content was aspirated. We insured a total removal of germinative membrane with forceps which definitely proved the real nature of the recurrence and eliminated any other differential diagnosis (residual cavity or biliary collection) even for the 16% of Gharbi’s type I of LHC. Surgery for recurrences is always more difficult due to structural and anatomical modifications. Based on these general conclusions, we can easily imagine that the development of LHC recurrence may be perturbed and may escape the rule of 2 cm per year process. This may explain our 80% rate of cysts with a diameter greater than 10 cm. Moreover, new cysts can arise in free hepatic parenchyma but merge with old residual cavities, which can enhance the diameter of these new cysts. Finally, some small cysts may be unapparent at the first surgery and have fully the time to grow and to appear as a recurrence. Indeed, the use of Albendazole perioperatively can help to lower this rate of recurrence, but in Morocco, it was only recently introduced during these last 4 years. This factor was analyzed in univariate analysis, but we H. O. El Malki (*) :A. Souadka :B. Zakri :Y. El Mejdoubi : R. Mohsine : L. Ifrine :A. Belkouchi Surgery Departement “A”, Ibn Sina Hospital, BP 2151, Sale, Bab Chaâfa, Sale-Maroc, Rabat, Morocco e-mail: oelmalki@hotmail.fr