REVIEW ARTICLE
Comparison of the Recurrence Rates of Nonparasitic
Hepatic Cysts Treated With Laparoscopy or With
Open Fenestration: A Meta-Analysis
Jian-Ying Zhang, MD,* Yan Liu, PhD,† Hong-Yan Liu, MD,‡
Long Chen, MD,§ Dai-Wen Su, MD,§ and Yun-Bing Wang, PhD§
Objective: This study aimed to compare the recurrence rates of
nonparasitic hepatic cysts that were treated with laparoscopy or
open fenestration.
Materials and Methods: PubMed, Embase, Cochrane Library, Web
of Science, Wan-fang data, CNKI, CqVip, and CBM were searched
for randomized controlled trials, cohort, and case-control studies
that reported on the treatment of nonparasitic hepatic cysts with
laparoscopy or with open fenestration. Studies that were published
from the establishment of the databases to October 1, 2016 were
retrieved. STATA software (version 13) was utilized for statistical
analysis.
Results: A total of 31 studies were included. Meta-analysis showed
that the recurrence rates of hepatic cysts between the laparoscopy-
deroofing and open-deroofing groups had no difference (odds ratio,
0.72; 95% confidence interval, 0.50-1.02; P = 0.061). This result was
in agreement with the result of subgroup analysis for solitary and
multiple hepatic cyst.
Conclusions: These findings underscore the distinct role of laparo-
scopy deroofing in the treatment of hepatic cysts because of the
certainty of its long-term curative effect.
Key Words: laparoscope, laparotomy, fenestration, hepatic cyst,
systematic review, meta-analysis
(Surg Laparosc Endosc Percutan Tech 2018;00:000–000)
N onparasitic and parasitic hepatic cysts are benign
lesions of the liver. The former, which is also known as
a simple liver cyst, accounts for 80% of all liver cysts. It is
due to the abnormal proliferation of intrahepatic bile ducts
and lymphatic epithelium during embryonic development.1
The number of clinically confirmed cases and the diagnostic
rate of hepatic cysts have increased by 18% in the past
30 years given the large-scale clinical application of Doppler
ultrasound and abdominal computed tomography.2
Most patients with hepatic cysts do not need to undergo
special treatments. Surgical treatment is mandatory only when
Received for publication November 10, 2017; accepted January 22,
2018.
From the *Department of Radiology, Chongqing People’s Hospital;
‡School of Public Health and Management, Chongqing Medical
University; §Department of Hepatobiliary Surgery, The Second
Affiliated Hospital of Chongqing Medical University, Chongqing;
and †Department of Gastroenterology, The Fifth People’s Hospital
of Chengdu, Chengdu, China.
The authors declare no conflicts of interest.
Reprints: Yun-Bing Wang, PhD, Department of Hepatobiliary Surgery,
The Second Affiliated Hospital of Chongqing Medical University,
No. 76, Linjiang Road, Yuzhong District, Chongqing 400010,
China (e-mail: wyb2016@stu.cqmu.edu.cn).
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Surg Laparosc Endosc Percutan Tech  Volume 00, Number 00, ’’ 2018
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the patients have a massive cyst or experience discomfort
caused by the enlargement of the liver volume. Although
various kinds of clinical therapies exist for hepatic cysts, these
different treatments have the common aim of reducing or
eliminating symptoms and improving the quality of life of
patients.3 Common treatment methods include ultrasound or
computed tomography–guided biopsy, fenestration, cys-
tectomy, hepatectomy, and liver transplantation.4,5 Ultra-
sound-guided puncture biopsy is widely used in clinical
practice because of its simple procedure and extensive indi-
cations. The high recurrence rate of hepatic cysts in this
treatment, however, remains an inevitable problem. Cys-
tectomy, hepatectomy, and liver transplantation are primarily
used when other procedures are inapplicable.
Fenestration is a common surgical procedure and is
classified as laparotomy or laparoscopy. Previous studies
have shown that laparoscopy fenestration is an effective
procedure for new or recurrent symptomatic liver cysts.6 Its
efficacy has been previously evaluated via the innovative
research and evaluation system, which revealed that mini-
mal trauma, short operation time, rapid postoperative
recovery, and short hospitalization time characterize this
treatment method. Compared with open fenestration, lap-
aroscopy fenestration exerts an excellent short-term curative
effect on hepatic cysts. However, few studies have explored
the long-term efficacy of laparoscopy fenestration based on
the recurrence rate. Moreover, previous studies have
included only a limited number of cases. Therefore, control
studies that reported on the treatment of hepatic cysts via
laparoscopy or open fenestration needs to be collected and
analyzed using meta-analysis. Such an analysis is important
to evaluate the long-term efficacy of laparoscopy fenestra-
tion in the treatment of hepatic cysts.
MATERIALS AND METHODS
Inclusion and Exclusion Criteria
Published studies were taken into account if they ful-
filled the following criteria: (1) Subjects: patients who were
diagnosed with hepatic cysts via imaging examination and
had indications for hepatic cyst fenestration surgery. (2)
Interventions: patients in the observation group were treated
with laparoscopy fenestration. Patients in the control group
were addressed in open fenestration. (3) Study design:
randomized controlled trial (RCT), case-control study, and
cohort study would be considered. (4) Outcomes: post-
operative recurrence rate of hepatic cysts.
Search Strategy
The following electronic databases were searched for
RCTs, case-control studies, or cohort studies that reported
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 Zhang et al Surg Laparosc Endosc Percutan Tech  Volume 00, Number 00, ’’ 2018

the recurrence rate of nonparasitic hepatic cysts after
treatment with laparoscopy or open fenestration: CqVip,
Wan-fang data, CNKI, CBM, Cochrane Library, PubMed,
Embase, and Web of Science. The final search was con-
ducted on October 1, 2016. Certain keywords (“hepatic
cyst,” “liver cyst,” “cyst of liver,” “open,” “laparotomy,”
“laparoscope,” “laparoscopic,” and “treatment”) were used.
Literature Screening, Data Extraction, and
Methodological Quality Assessment
Two independent reviewers (J.-Y.Z. and Y.L.) care-
fully reviewed all of the included papers and extracted
relevant information. Then, the filtered information was
cross-checked to ensure that the data were valid, objective,
and complete. Discrepancies were settled by panel dis-
cussion or expert consultation. Data with complete content
or different form were obtained through direct contact with
the author by e-mail or telephone. The study was excluded
when the required information is not achieved. The
methodological quality of the RCTs was assessed using the
Cochrane Collaboration tool based on 7 distinct aspects.7
The methodological quality of cohort studies and case-
control studies were assessed using the Newcastle-Ottawa
Scale with a star system.8
Statistical Analysis
Meta-analysis was performed using Stata software
version 13.0 (StataCorp, College Station, TX). The heter-
ogeneity of similar studies was evaluated using the Ι2 test
and data were merged using the random effects model. The
odds ratio (OR) and 95% confidence interval (CI) of the
merged outcomes were calculated. The recurrence rate of
hepatic cysts in the observation group and the control
group were calculated. Publication bias was evaluated
using the Begger test, the Egger test, and the corresponding
funnel plot.
RESULTS
Literature Search and Literature Characteristics
Results of the literature search are presented in
Figure 1. The literature search yielded 1373 studies. In the
end, we considered 31 qualified clinical trials,9–39 including
971 cases in the observation group and 907 cases in the
control group. The studies were retrieved with the following
steps: exclusion of duplicates and reading of the title,
abstract, and full text.
As we found, these studies were published between the
years 1995 and 2015, and comprised 5 RCTs,20,22,28,33,38
5 cohort studies,10,12,19,24,32 and 21 case-control
studies.9,11,13–18,21,23,25–27,29–31,34–37,39 Regardless of solitary or
multiple hepatic cysts, all of these studies reported the total
recurrence rate of hepatic cysts. Among these studies, 4
studies9–12 described the recurrence rate of solitary and mul-
tiple hepatic cysts. In addition, 26 studies14–39 came from
China, whereas 5 studies9–13 originated from other countries.
The quality evaluation of included studies disclosed that 5
RCTs20,22,28,33,38 have consistent results. All studies did not
comprehensively report blinding in the study design, indicating
potential performance and detection bias. Moreover, all studies
did not provide enough information for the identification of
other biases. Therefore, the methodological quality of these 5

FIGURE 1. Flow diagram of literature selection. CqVip, Wan-fang data, CNKI, CBM, Cochrane Library, PubMed, Embase, and Web of
Science databases were searched for randomized controlled trials, cohort studies, and case-control studies. After screening titles,
abstracts, and then the full text for relevance step by step, 31 studies were included in our final meta-analysis.

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 Surg Laparosc Endosc Percutan Tech  Volume 00, Number 00, ’’ 2018 Laparoscopy for Hepatic Cysts

FIGURE 2. Meta-analysis of the overall recurrence rates. The meta-analysis revealed that the recurrence rates between the laparoscopy
fenestration group (7.62%) and the open fenestration group (10.36%) were not statistically different (OR, 0.72; 95% CI, 0.50-1.02;
P = 0.061), with no statistical heterogeneity (I2 = 0%, P = 0.962). Study ID was presented with the first author and the corresponding
publication year for each study. CI indicates confidence interval; OR, odds ratio.

studies was general. Among the cohort studies, 3 studies10,19,32
received full stars. One cohort24 received 8 stars because no
accurate follow-up time was offered. Another cohort12 received
8 stars because no other factor was controlled. As for the case-
control studies, 10 case-control studies14,17,18,21,23,26,29–31,35
received full marks; 4 studies25,34,36,37 received 8 stars because
no follow-up time was reported; 2 studies11,13 received 8 stars
because not enough mix factors were controlled; 3 studies9,15,39
received 7 stars because most mix factors did not provide
controls; 2 studies16,27 received 6 stars because both mix factors
control and accurate follow-up time were not provided. Over-
all, these studies get a reliable methodological quality.
Data Analysis
The long-term therapeutic results of laparoscopy or
open fenestration on hepatic cysts were reported for 907
cases in the control group and 971 cases in the observation
group, including 31 clinical trials.9–39 The meta-analysis
showed that the recurrence rates between the laparoscopy
fenestration group (7.62%) and the open fenestration group
(10.36%) were not statistically different (OR, 0.72; 95% CI,
0.50-1.02; P = 0.061; Fig. 2), with no statistical hetero-
geneity (I2 = 0%, P = 0.962).
Subgroup Analysis
Four studies9–12 reported the recurrence rates of solitary
and multiple hepatic cysts that were treated with laparoscopy
versus open fenestration. Meta-analysis in the solitary hepatic
cyst subgroup revealed no statistical difference in recurrence
rates between the laparoscopy fenestration group (16.22%)
and the open fenestration group (9.26%) (OR, 1.17; 95% CI,
0.20-6.95; P = 0.862; Fig. 3A), with low statistical hetero-
geneity (I2 = 47.5%, P = 0.126). Meta-analysis in the multiple
hepatic cysts subgroup showed no statistical difference in
recurrence rates between the laparoscopy fenestration group
(19.51%) and the open fenestration group (16.67%) (OR, 1.46;
95% CI, 0.32-6.72; P = 0.625; Fig. 3B), with low statistical
heterogeneity (I2 = 5.2%; P = 0.367).
Sensitivity Analysis
Sensitivity analysis was used to validate the efficiency
of laparoscopy fenestration in controlling the recurrence of
hepatic cysts. First, the merged effect of clinical trials did
not obviously change after 1 article was excluded (Fig. 4).
Then, when the data were analyzed by the fixed-effects
model, the meta-analysis results were not reversed, which
showed that the results of our study are reliable.

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 Zhang et al Surg Laparosc Endosc Percutan Tech  Volume 00, Number 00, ’’ 2018

FIGURE 3. Meta-analysis of the recurrence rates for solitary and multiple hepatic cysts. A, Meta-analysis for the solitary hepatic cyst
subgroup revealed no statistical difference in recurrence rates between the laparoscopy fenestration group (16.22%) and the open
fenestration group (9.26%) (OR, 1.17; 95% CI, 0.20-6.95; P = 0.862), with low statistical heterogeneity (I2 = 47.5%, P = 0.126). B, Meta-
analysis for the multiple hepatic cysts subgroup showed no statistically significant difference in recurrence rates between the laparoscopy
fenestration group (19.51%) and the open fenestration group (16.67%) (OR, 1.46; 95% CI, 0.32-6.72; P = 0.625), with low statistical
heterogeneity (I2 = 5.2%, P = 0.367). Study ID was presented with the first author and the corresponding publication year for each study.
CI indicates confidence interval; OR, odds ratio.

Publication Bias Analysis already compared in 3 systematic reviews.40–42 Although

The results of the Begger test (P = 0.58) and the Egger
test (P = 0.29) strongly suggested no publication bias. The
funnel plot showed that the points on both sides of the fitted
curve had a good symmetry, also suggesting no significant
publication bias (Fig. 5).
DISCUSSION
Laparoscopic fenestration is a very common, mini-
mally invasive surgical treatment method for hepatic cysts.40
As we found, treatment methods for hepatic cysts have been
these systematic reviews attempted to comprehensively
evaluate the effect of laparoscopy fenestration, the long-
term efficacy of treatment on hepatic cysts remains worthy
of exploration. Therefore, we collected controlled study data
on the treatment of hepatic cysts with laparoscopy versus
open fenestration.
The present meta-analysis included 31 clinical con-
trolled studies. We found no difference in recurrence rates
between laparoscopy group and open fenestration group,
regardless of single or multiple hepatic cyst. As we know,
the recurrence of hepatic cysts was a main consideration

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 Surg Laparosc Endosc Percutan Tech  Volume 00, Number 00, ’’ 2018
FIGURE 4. Sensitivity analysis. By removing 1 study every time, the merged effect of clinical trials did exhibit no evident changes, which
showed that the results of our study are reliable. Study ID was presented with the first author and the corresponding publication year for
each study. CI indicates confidence interval.
when patients choose therapies. Many patients would be
doubtful about the efficiency of laparoscopy method,
because it was conducted through only several ports and the
operation would not be so easy like the open surgery. In
reality, laparoscope has the function of magnification and
could provide a better field of vision for surgeons. Hence, it was
understandable that we concluded a comparable long-term
efficiency of laparoscopy fenestration versus open surgery.
Statistical heterogeneity of each pooled analysis was low or
none, so the conclusion resulted from our study was relatively
believable. Besides, the robustness of the conclusion was also
backed by the sensitivity analysis, because no changes in the
effect value were observed after excluding 1 study every time.
As showed in many studies, the short-term curative effect of
laparoscopy fenestration is greater than that of open fenestra-
tion on the treatment of hepatic cysts. After combining with the
conclusions obtained in our study, it was indicated that
FIGURE 5. Publication bias analysis. From this funnel plot, we
thought that the spots did exhibit good symmetry, and there was
no obvious publication bias detected in our study.
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Laparoscopy for Hepatic Cysts
laparoscopy fenestration might be the first choice for clinicians
in the treatment of liver cysts.
Nevertheless, our meta-analysis possesses some limi-
tations. First, the characteristics of the included studies
indicated that some patients were lost to follow-up, which
have potential effects on the pooled results. Second, the
follow-up duration of the included studies is different, which
might lead to heterogeneity in outcome measures. Third, the
biggest limitation of this study is the quality of the included
studies, including informal reporting forms and incomplete
content, which might result in a biased conclusion. There-
fore, if possible, more prospective studies were expected to
properly evaluate the efficacy of laparoscopy fenestration in
the treatment of hepatic cysts.
In summary, laparoscopy fenestration has certain
short-term and long-term clinical effects in the treatment of
hepatic cysts. Laparoscopic fenestration is the most prom-
ising substitute for traditional open surgery, thus justifying
its extensive application in clinical settings.
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