Objective To investigate the efficacy of standardized surgical training for hepatic cystic echinococcosis (HCE).

Methods The retrospective cohort study was conducted. The clinical data of 1 820 patients with HCE who were admitted to 12 medical centers of Xinjiang Production and Construction Corps, including The First Affiliated Hospital of Shihezi University, between January 2006 and January 2022 were collected. There were 921 males and 899 females, aged (42±14) years. All the 1 820 patients underwent surgical intervention, of which 645 cases were stratified into pre-training phase, 645 cases into early-training phase, 388 cases into mid-training phase, and 142 into late-training phase based on the training implementation timeline. There were 514 cases of 1 820 patients undergoing radical surgery, 1 306 cases undergoing non-radical surgery. There were 1 796 cases undergoing open surgery, 24 cases undergoing laparoscopic surgery. Observation indicators: (1) clinical characteristics of HCE patients in different training phases; (2) surgical and postoperative situations of HCE patients in different training phases; (3) Logistic regression analysis of postoperative biliary leakage from the residual cavity of HCE patients; (4) Cox regression analysis of postoperative recurrence of HCE patients. Comparison of measurement data with skewed distri-bution among multiple groups was conducted using the Kruskal-Wallis rank-sum test, and pairwise comparison was conducted using the Dunn-Bonferroni test. Comparison of count data among multiple groups was conducted using the chi-square test or Fisher's exact probability, with pairwise comparison adjusted by Bonferroni correction. Kaplan-Meier method was used to calculate survival rates and plot survival curves, and survival analysis was performed using the Log-rank test. The multivariate Logistic or Cox regression model was used to adjust the impact of imbalanced clinical factors across different training phases on postoperative biliary leakage from the residual cavity and recurrence.

Results (1) Clinical characteristics of HCE patients in different training phases: there were signifi-cant differences in age, presenting symptom of abdominal pain, lesion location, maximum cyst diameter, World Health Organization classification, and disease status among patients of the pre-training, early-training, mid-training, and late-training phases (P<0.05). (2) Surgical and postoperative situations of HCE patients in different training phases: ① Comparison of surgical procedure, there were significant differences in the utilization of closed total periadventitial cystectomy via laparotomy, open total periadventitial cystectomy via laparotomy, partical periadventitial cystectomy via laparotomy, endo-cystectomy combined with omentoplasty via laparotomy, endocystectomy combined with cavity drainage via laparotomy, endocystectomy via laparotomy, laparoscopic surgery among patients of the pre-training, early-training, mid-training, and late-training phases (P<0.05). Further analysis showed that the proportions of partial periadventitial cystectomy via laparotomy increased (P<0.05), endo-cystectomy combined with omentoplasty via laparotomy, and endocystectomy combined with residual cavity drainage via laparotomy decreased (P<0.05) significantly in the early-training, mid-training, and late-training phases compared with the pre-training phase. ② Comparison of application of scolicidal agents and postoperative complications, there were significant differences in the intra-operative use of 20% hypertonic saline, 3% hydrogen peroxide and others among patients of the pre-training, early-training, mid-training, and late-training phases (P<0.05). Further analysis showed that the intraoperative usage rate of 20% hypertonic saline increased significantly in the early-training, mid-training, and late-training phases compared with the pre-training phase (P<0.05). There were 109, 206, 141, 87 cases with cyst cavity management among patients of the pre-training, early-training, mid-training, and late-training phases, showing a significant difference (P<0.05). Further analysis showed that the proportions of intraoperative cyst cavity management increased significantly in the early-training, mid-training, and late-training phases compared with the pre-training phase (P<0.05). There were significant differences in the postoperative cyst cavity complications and biliary leakage among HCE patients of the pre-training, early-training, mid-training, and late-training phases (P<0.05). Further analysis showed that the incidence of postoperative cyst cavity complications and biliary leakage decreased in the early-training, mid-training, and late-training phases compared with the pre-training phase (P<0.05). ③ Comparison of preoperative albendazole use, there was a signifi-cant difference among HCE patients of the pre-training, early-training, mid-training, and late-training phases (P<0.05). Further analysis showed that the preoperative albendazole usage rate increased in the early-training, mid-training, and late-training phases compared with the pre-training phase (P<0.05). There were significant differences in the preoperative albendazole use after radical surgery and non-radical surgery among HCE patients of the pre-training, early-training, mid-training, and late-training phases (P<0.05). Further analysis showed that the preoperative albendazole usage rate after non-radical surgery increased (P<0.05), and the preoperative albendazole usage rate after radical surgery decreased (P<0.05) in the early-training, mid-training, and late-training phases compared with the pre-training phase. ④ Follow-up of HCE patients in different training phases, all the 1 820 pati-ents were followed up for 36(range, 36-120) months. Postoperative recurrence occurred in 48 cases in the pre-training phase, 9 cases in the early-training phase, 5 cases in the mid-training phase, and 2 cases in the late-training phase, showing a significant difference in recurrence rate among the four phases (P<0.05). Further analysis showed the proportions of patients with recurrence in the early-training, mid-training, and late-training phases decreased compared with the pre-training phase (P<0.05). (3) Logistic regression analysis of postoperative biliary leakage from the residual cavity of HCE patients: after adjusting for age, abdominal pain, lesion location, maximum cyst diameter, World Health Organization classification, and disease status factors, results of multivariable analysis showed that compared with the pre-training phage, the proportions of postoperative biliary leakage from the residual cavity decreased in the early-training, mid-training, and late-training phages (odds ratio=0.493, 0.330, 0.350, 95% confidence interval as 0.320-0.760, 0.195-0.558, 0.156-0.787, P<0.05). (4) Cox regression analysis of postoperative recurrence of HCE patients: after adjusting for age, abdominal pain, lesion location, maximum cyst diameter, World Health Organization classification, and disease status factors, results of multivariate analysis showed that compared with the pre-training phage, the proportions of postoperative recurrence decreased in the early-training, mid-training, and late-training phages (hazard ratio=0.193, 0.146, 0.203, with 95% confidence interval as 0.093-0.401, 0.057-0.374, 0.049-0.841, P<0.05).

Conclusion Standardized surgical training for HCE significantly improves surgical quality in grassroots hospitals, reduces residual cavity complications and post-operative recurrence rates.