Hepatic Surgery in Alveolar Echinococcosis: Long-Term Outcomes and Practical Recommendations

Background: Alveolar echinococcosis (AE) is an infiltrative parasitic liver disease. Surgery remains preferred when feasible, but patient selection and the implications of resection margins remain uncertain. Methods: We retrospectively analysed 231 surgically treated AE patients first presenting at our centre between 1992 and 2021. A curative outcome required no recurrence on cross-sectional imaging and no ongoing benzimidazole therapy at last follow-up (≥2 years after R0; ≥4 years after R1). Kaplan–Meier analyses assessed recurrence-free survival (R0/R1) and progression-free survival (R2). Results: R0, R1, and R2 accounted for 42.4%, 19.9%, and 25.1%, respectively. Cure rates were 95.2% (R0) and 88.2% (R1) at ≥4 years post-surgery (p = 0.240). Estimated 10-year recurrence-free survival was 95.1% (R0) and 87.0% (R1; p = 0.183). After R2 resection, 84.0% had stable and 16.0% progressive residual disease. Extensive hepatic involvement (P4) was associated with lower cure rates (p < 0.001). Conclusions: An R1 margin does not preclude long-term cure and may represent an acceptable surgical endpoint in selected patients with postoperative benzimidazole therapy and imaging surveillance. Planned R2 resections should generally be avoided without specific clinical indications. In advanced disease or when macroscopic residual disease is anticipated, the benefits of surgery should be carefully weighed against medical treatment.