**6. Outcomes**

The most frequent complications encountered in the treatment of the simple hepatic cysts are hemorrhage and infection of the residual cavity. Recurrence of the hepatic cystic mass in the same location must be differentially interpreted based on the previous treatment, elapsed time from the treatment, histological type and size of the cyst, and existing symptoms.

In case of early recurrence of the hepatic cystic mass after percutaneous treatment, absence of malignancy criteria and symptoms, the treatment may vary from simple observation by US scan to surgical treatment, based on the patient's consent.

In case of early recurrence of hepatic cystic mass of similar size after percutaneous sclerother‐ apy or laparoscopic fenestration and malignancy criteria absence, the treatment may vary from percutaneous treatment to open surgery. An intracystic hematoma should be suspected as a cause of hepatic mass persistence especially when it is associated with inflammatory and/or internal hemorrhage symptoms. Percutaneous drainage is the first choice in the treatment of hematoma. In case of active bleeding and/or hemodynamic instability, emergency surgical intervention is indicated.

If the patient develops symptoms of infection associated with the persistence of hepatic cystic mass, hepatic abscess should be suspected as a complication and antibiotic treatment should be initiated empirically followed by further adjustments depending on bacterial cultures. If the symptoms persist and localization of the abscess permits, the percutaneous drainage is advisable. If the symptoms do not remit under antibiotics or the percutaneous drainage is not feasible, the patient must be referred to surgery.

**Figure 24.** CT for central hepatic serous cyst (segments IV, V VII) (A) with recurrence after 3 months (B), having similar size and causing the same symptoms to the patient

In case of late recurrence after laparoscopic or classic fenestration for hepatic cyst, with documented US follow-up that initially attests the cyst remission, it should be reasonable to highly consider complete surgical removal of the recurrent cyst even if there are no serologic, imagistic, or histological criteria of malignancy (Figure 24).

The rate of symptomatic recurrence after percutaneous sclerotherapy is around 20%.

Laparoscopic unroofing or marsupialization can completely relieve symptoms from either simple lesions or PLD, with the procedure's morbidity, mortality, and recurrence rates being, respectively, 2%, 0%, and 2% for patients with simple cysts, and 25%, 0%, and 5% for patients with PLD. For infected cysts, the procedure of choice is percutaneous drainage, with morbidity, mortality, and recurrence rates for simple cysts being 0%, 0%, and 75%, respectively, and for PLD, 0%, 0%, and 20%, respectively [54]. The conversion rate from laparoscopy to laparotomy is less than 10% [66]. Postoperative morbidity in open deroofing of the hepatic cysts has been reported to be significantly higher than in laparoscopic procedure (33% versus 13%) but the difference may reflect the selection of more difficult cases for open surgery [66]. No mortality is acceptable for surgical therapy of hepatic cysts, unless liver transplantation is considered. Survival rate after OLT for PLD has been reported as high as 90% [67].
