Japanese clinical practice guidelines for congenital biliary dilatation

Novel 3D morphological characteristics for congenital biliary dilatation diagnosis: a case-control study

BACKGROUND

Congenital biliary dilatation (CBD) necessitates the timely removal of dilated bile ducts. Accurate differentiation between CBD and secondary biliary dilatation (SBD) is crucial for treatment decisions, and identification of CBD with intrahepatic involvement is vital for surgical planning and supportive care. This study aimed to develop quantitative models based on bile duct morphology to distinguish CBD from SBD and further identify CBD with intrahepatic involvement.

MATERIALS AND METHODS

The retrospective study included 131 CBD and 209 SBD patients between December 2014 and December 2021 for model development, internal validation, and testing. A separate cohort of 15 CBD and 34 SBD patients between January 2022 and December 2022 was recruited for temporally-independent validation. Quantitative shape-based (Shape) and diameter-based (Diam) morphological characteristics of bile ducts were extracted to build a CBD diagnosis model to distinguish CBD from SBD and an intrahepatic involvement identification model to classify CBD with/without intrahepatic involvement. The diagnostic performance of the models was compared with that of experienced hepatobiliary surgeons.

RESULTS

The CBD diagnosis model using clinical, Shape, and Diam characteristics showed good performance with an AUROC of 0.942 (95% CI: 0.890-0.994), AUPRC of 0.917 (0.855-0.979), accuracy of 0.891, sensitivity of 0.950, and F1-score of 0.864. The model outperformed two experienced surgeons in accuracy, sensitivity, and F1-score. The intrahepatic involvement identification model using clinical, Shape, and Diam characteristics yielded outstanding performance with an AUROC of 0.944 (0.879-1.000), AUPRC of 0.982 (0.947-1.000), accuracy of 0.932, sensitivity of 0.971, and F1-score of 0.957. The models demonstrated generalizable performance on the temporally-independent validation cohort.

CONCLUSIONS

This study developed two robust quantitative models for distinguishing CBD from SBD and identifying CBD with intrahepatic involvement, respectively, based on morphological characteristics of the bile ducts, showing great potential in risk stratification and surgical planning of CBD.

Whole-Course Intraperitoneal Robot-Assisted Choledochal Cyst Excision with a Hidden Incision in Children Under 1 Year Old

Background: Whole-course intraperitoneal robot-assisted choledochal cyst resection in children under 1 year of age is controversial due to its technical challenges. Current Pfannenstiel incision is widely used in adults for its cosmetic effects but is rarely used in children. Materials and Methods: We conducted a prospective, single-center study to assess the feasibility, safety, and cosmesis of whole-course intraperitoneal robot-assisted choledochal cyst resection with Pfannenstiel incision in children under 1 year of age. Results: Ten patients were treated with our surgical protocol, and there was no conversion to laparotomy. The average total operation time was 223 minutes. The average duration of anesthesia was 260.2 minutes. The average docking time between the robot arm and Trocar was 17.5 minutes. The average intraoperative blood loss was 16 mL. No postoperative complications occurred in the 10 patients. The mean time to start drinking water after surgery was 2.4 days. The mean postoperative drainage tube removal time was 2.6 days. The average length of stay was 8.5 days. The scar assessment scale total scores of the 2 observers were (6.8 ± 1.23) and (7.4 ± 1.84), respectively. For every patient, there are only four abdominal surgery scars of which 75% of scars were hidden by underpants and 25% of scars were not covered. Conclusion: It is feasible and safe to perform whole-courses intraperitoneal robot-assisted choledochal cyst resection with Pfannenstiel incision in children under 1 year old. It also has a hidden incision effect and is worthy of promotion.

The timing of minimally invasive surgery for prenatally diagnosed choledochal cysts

OBJECTIVE

There are no clear evidence-based recommendations concerning when patients with prenatally diagnosed choledochal cysts (CCs) should undergo surgery. This study was primarily designed to explore the proper timing of minimally invasive surgery for prenatally diagnosed CC patients.

METHODS

Seventy-three patients with prenatally diagnosed CC were enrolled in this study and divided into 4 subgroups according to age at surgery (15 patients in the < 1 month group, 27 in the 1-2 months group, 14 in the 2-3 months group and 17 in the > 3 months group). Eighty-five healthy infants were recruited and divided into 4 age groups (29 in the < 1 month group, 20 in the 1-2 month group, 19 in the 2-3 month group and 17 in the > 3 month group). Preoperative data were collected and compared between CC patients and healthy controls in 4 age groups. Additionally, 73 patients were divided into laparoscopic and open groups to compare postoperative recovery indices and the occurrence of complications to determine the safety and feasibility of laparoscopic CC application in neonates and young infants.

RESULTS

Twenty-one of 73 (28.8%) patients who were prenatally diagnosed with CCs experienced various clinical symptoms, and 15 of 21 (71.4%) patients experienced clinical symptoms less than 2 months after birth. No differences were found in alanine transaminase (ALT), aspartate transaminase (AST) or aspartate transaminase (APRI) levels between CC patients and controls at ≤ 1 month or 1-2 months of age (all p > 0.05), while higher levels were found in CC patients at 2-3 months or > 3 months of age (all p < 0.05). ALT, AST and DBIL levels 1 week after surgery were significantly lower than those before surgery in CC patients who underwent laparoscopic CC excision at > 2 months of age, while DBIL levels 1 week after surgery were also significantly lower than those before surgery in patients who underwent CC excision at ≤ 2 months of age. The initial oral feeding time in the laparoscopic surgery group was significantly earlier than that in the open surgery group for both CC patients who underwent CC excision at ≤ 2 months of age and those > 2 months of age (all p < 0.05). No differences were found in the rates of anastomotic leakage or stricture formation between the laparoscopic and open surgery groups at ≤ 2 months or > 2 months of age.

CONCLUSION

Most clinical symptoms attributed to CC occur less than 2 months after birth, while liver function and liver fibrosis may deteriorate after 2 months of age in patients with prenatally diagnosed CC. Laparoscopic surgery for CC in newborns and young infants (either less than or more than 2 months old) is safe and feasible and can shorten the initial oral feeding time without increasing complications such as postoperative anastomotic leakage or stricture. Thus, performing laparoscopic CC excisions within 2 months after birth in patients with prenatally diagnosed CC may be appropriate.

Cholangiocarcinoma identified in perforated choledochal cyst in a 3-year-old boy

Cholangiocarcinoma in patients with Choledochal cysts is rare in childhood; however, it seriously affects the prognosis of the disease. The key to addressing this situation lies in completely removing the extrahepatic cyst. We herein present a case report of a 3-year-old boy with cholangiocarcinoma associated with a choledochal cyst (CDC). Preoperative 3D simulation, based on CT data, played an important role in the treatment of this patient.

Safety and benefit of modified mesohepatectomy in the treatment of bilobar involvement congenital biliary dilatation

BACKGROUND

The diseased bile duct in bilobar congenital biliary dilatation is extensive and often requires major hepatectomy or liver transplantation associated with a higher risk. We aimed to evaluate the safety and benefit of modified mesohepatectomy, in comparison with trisectionectomy, to treat bilobar congenital biliary dilatation.

METHODS

This study included 28 patients with type IV and V bilobar congenital biliary dilatation. An innovative mesohepatectomy comprising the hepatectomy technique beyond the P/U point and bile duct shaping was applied to 14 patients to address the extensively diseased bile duct and difficulty in hepaticojejunostomy. Another 14 patients received trisectionectomy. The perioperative and long-term outcomes of these patients were compared.

RESULTS

The ratio of residual liver volume to standard liver volume in the mesohepatectomy group was higher (78.68% vs. 40.90%, p = 0.005), while the resection rate of the liver parenchyma was lower (28.25% vs. 63.97%, p = 0.000), than that in trisectionectomy group. The mesohepatectomy group had a lower severe complication (>Clavein III, 0% vs. 57.70%, p = 0.019) and incidence of posthepatectomy liver failure (7.14% vs. 42.86%, p = 0.038). No significant difference was observed in blood loss and bile leakage (p > 0.05). All the patients in the mesohepatectomy group achieved optimal results in the long-term follow-up.

CONCLUSIONS

mesohepatectomy provides an efficient treatment option for bilobar congenital biliary dilatation and can achieve radical resection, retain more liver parenchyma, and reduce the difficulty of hepaticojejunostomy, especially for patients that are not eligible for major hepatectomy and liver transplantation.

A case of congenital biliary dilatation without pancreaticobiliary maljunction, so-called Type Ib according to Todani's classification

Congenital biliary dilatation (CBD) is a congenital malformation of focal dilatation of the extrahepatic bile ducts, including the common bile duct, and is often associated with pancreaticobiliary maljunction (PBM). In this article, we report a CBD case that presented with focal dilation of the common bile duct without PBM (Todani's classification type Ib). The patient was a 32-year-old man who visited a doctor with a chief complaint of abdominal distension. Computed tomography revealed cystic dilatation of the common bile duct, and the patient was referred to our institution. Magnetic resonance cholangiopancreatography showed cystic dilatation of the common bile duct with a maximum diameter of 7 cm; however, evaluating the presence of PBM was challenging. Endoscopic ultrasonography showed small gallstones and debris in the dilated common bile duct and no thickening of the gallbladder wall. Endoscopic retrograde cholangiopancreatography revealed no PBM or markedly elevated bile amylase levels. Based on these findings, the patient was diagnosed with Todani Type Ib CBD. Since this patient did not have pancreatobiliary reflux, it was unclear whether the risk of developing biliary tract cancer was high, and since the treatment was highly invasive, the decision was to follow up without surgical treatment.

Choledochocele with hyperplastic epithelium in a patient who developed severe acute pancreatitis and underwent subtotal stomach-preserving pancreatoduodenectomy: a case report

Choledochocele is defined as a congenital dilatation of the distal intramural part of the common bile duct protruding into the wall of the descending duodenum, typically without pancreaticobiliary maljunction. However, some cases present with a similar pathophysiology to pancreaticobiliary maljunction, including reciprocal reflux of pancreatic juices and bile, leading to protein plugs, pancreatitis, and biliary tract carcinogenesis. Choledochocele is relatively rare and its anatomy, physiology, pathology, and clinical features are thus not well known. We describe a patient with choledochocele who suffered from repeated severe acute pancreatitis and underwent subtotal stomach-preserving pancreatoduodenectomy, in whom the pathological findings of choledochocele showed hyperplasia.

Does Congenital Biliary Dilatation Todani Type II (Diverticular Type) Really Exist?

AIM OF THE STUDY

The aim of the study is to clarify the clinicopathological and biliary morphological characteristics in reported cases of diverticular congenital biliary dilatation (CBD).

METHOD

Using PubMed and the Japan Medical Abstracts Society, articles on possible diverticular CBD were extracted and the clinical pictures examined. We also sought evidence for definitions of diverticular CBD and the associated condition of pancreaticobiliary maljunction (PBM) using the original articles by Alonso-Lej and Todani. The characteristic biliary morphologies of cases with images were also investigated.

RESULTS

Analyses of 211 possible cases superficially demonstrated multiple diverticula in 12 (12%) and single diverticulum in 89 (88%), with diverticula located in the upper (n = 38, 38%), middle (n = 32, 32%), or lower (n = 26, 26%) biliary tract in and presence of intra-diverticular stones, PBM, and biliary carcinoma in 23% (n = 18), 39% (n = 25), and 11% (n = 14), respectively. However, evidence defining diverticular CBD or justifying the lack of associated PBM was not demonstrated even in the original articles. Scrutiny of the biliary anatomy in 59 cases with images showed incorrect inclusions of types I or IV-A with an irregular biliary duct wall or dilated cystic duct, periampullary choledochal diverticula, or even solitary biliary cysts. Authentic diverticular CBD, representing the diverticulum connected to the middle of the common bile duct via a thin, patent stalk was seen in only 6 cases.

CONCLUSION

Real diverticular CBD appears extremely rare. The lack of an objective definition allows wide interpretations of clinical pictures, creating inconsistencies in the diagnosis and treatment of CBD and raising questions regarding the utility of conventional classifications.

LEVEL OF EVIDENCE

Level III.

Treatment of pancreaticobiliary maljunction by minimally invasive endoscopic common channel sphinctertomy: Analysis of 35 cases

BACKGROUND

Patients with pancreaticobiliary maljunction (PBM) have a common channel (CC) that is too long, causing the Oddi sphincter not to directly affect the pancreaticobiliary junction. As a result, reflux between pancreatic juice and bile occurs, causing various pathological changes in the bile duct or pancreas. Exploring the application and mechanism of minimally invasive endoscopic shortening of the pancreatic bile duct CC channel in PBM has become particularly important, providing patients with another treatment option.

AIM

To investigate the clinical efficacy and safety of minimally invasive endoscopic common channel sphinctertomy (CCEST) in the treatment of patients with PBM.

METHODS

The clinical data of 35 PBM patients treated by minimally invasive CCEST were analyzed, and there were BP type (n = 19) and PB type (n = 16) PBM. All 35 patients underwent CCEST with the help of endoscopic retrograde cholangiopancreatography, and the therapeutic effects and complications of minimally invasive CCEST in PBM patients were analyzed.

RESULTS

A total of 35 patients were diagnosed with PBM, of whom 12 were male and 23 were female. The patients ranged in age from 3 to 89 years, with a mean age of (46 ± 26.38) years. CCEST was performed in all patients to reduce the length of the CC. Among the 35 patients with PBM, 18 (51.43%) had combined biliary and pancreatic duct stones and underwent intraoperative lithotripsy. First-time ERCP stone extraction was successful in 14 patients, with a success rate of 78% (14/18). One week after minimally invasive intervention therapy, the serum biochemistry and C-reactive protein (CRP) and bile amylase in the 35 patients showed a significant decrease compared to the preoperative levels (P < 0.05). Post-ERCP pancreatitis was observed in five patients, but no serious complications such as postoperative bleeding, gastrointestinal perforation, and severe pancreatitis occurred after symptomatic treatment. After a mean follow-up period of (22.05 ± 10.67) mo in the 35 patients, one patient was diagnosed with carcinoma of the bile duct and treated by surgery, and four were treated by ERCP again because of stone recurrence and achieved satisfactory efficacy. The total effective rate of the treatment was 88.6% (31/35).

CONCLUSION

PBM patients often present with an insidious onset. ERCP is a valuable procedure for the diagnosis of PBM. CCEST effectively improves biliopancreatic drainage in early-stage PBM patients by reducing the length of the common biliopancreatic confluence channel. CCEST is a safe and effective minimally invasive intervention for the treatment of PBM patients.

Long-term outcome for children undergoing open hepatico-jejunostomy for choledochal malformations: a 43-year single-center experience

PURPOSE

To report on our 43-year single-center experience with children operated on for Choledochal Malformations (CMs), focusing on long-term results and Quality of life (QoL).

MATERIALS AND METHODS

All consecutive pediatric patients with CMs who underwent surgical treatment at our center between October 1980 and December 2022 were enrolled in this retrospective study. We focused on long-term postoperative complications (POCs), considered to be complications arising at least 5 years after surgery. We analyzed QoL status once patients reached adulthood, comparing the results with a control group of the same age and sex.

RESULTS

One hundred and thirteen patients underwent open excision of CMs with a Roux-en-Y hepaticojejunostomy (HJ). The median follow-up was 8.95 years (IQR: 3.74-24.41). Major long-term POCs occurred in six patients (8.9%), with a median presentation of 11 years after surgery. The oldest patient is currently 51. No cases of biliary malignancy were detected. The QoL of our patients was comparable with the control group.

CONCLUSION

Our experience suggests that open complete excision of CMs with HJ achieves excellent results in terms of long-term postoperative outcomes. However, since the most severe complications can occur many years after surgery, international cooperation is advisable to define a precise transitional care follow-up protocol.

Characteristics and malignancy rates of adult patients diagnosed with choledochal cyst in the West: a systematic review

BACKGROUND

The approach to patients with choledochal cysts (CCs) remains varied and subject to institutional practices. Owing to the rarity of the disease, the optimal treatment remains poorly defined, particularly in the adult population. This study aimed to review the literature on adult patients with CCs to evaluate trends of diagnosis and management in Western countries.

METHODS

A literature search of 3 electronic databases was performed on adult patients diagnosed with CCs in Western institutions. A review of published literature was completed with comprehensive screening by 2 independent reviewers. Studies were analyzed, and data on surgical approach, malignancies, and follow-up were collected. Findings are presented in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

RESULTS

Of the 3488 articles retrieved, 21 studies evaluated Western adults with CCs for a combined population of 1337 patients. The most common Todani subtypes included types I (64%) and IV (22%). Symptoms at presentation included abdominal pain and jaundice, although many were asymptomatic. Ultrasound was used most frequently for diagnosis, followed by computed tomography and endoscopic cholangiopancreatography. The combined malignancy rate was 10.9%, with cholangiocarcinoma being the most prevalent. Complete extrahepatic cyst resection was standard for type I and IV CCs. Among malignancies, 18.5% and 16.4% were observed in patients with prior resection and internal drainage, respectively.

CONCLUSIONS

A significant proportion of patients who undergo resection of CC disease harbor malignancy. Cancer risk seems reduced but not eliminated with complete resection, which remains the standard treatment. Additional studies are needed to standardize guidelines for the diagnosis and postoperative care of patients in Western countries.

Early and late outcomes of congenital biliary dilatation in pediatric patients

BACKGROUND

This study aimed to reveal the early and late postoperative complications and outcomes after surgery for congenital biliary dilatation (CBD) by reviewing cases over the past 40 years.

METHODS

We retrospectively evaluated 59 patients with CBD who underwent radical surgery for complications and outcomes, based on medical records. Early complications were defined as those requiring treatment within 5 years of the initial operation. Late complications were defined as those treated more than 5 years later.

RESULTS

The median age at the first surgery was 37 months. Regarding biliary reconstruction, 54 of the 59 patients (91.5%) underwent hepaticojejunostomy. Although three patients underwent cholecystoduodenostomy and one patient underwent hepaticoduodenostomy, all were converted to hepaticojejunostomy after a median of 12.5 years. One patient developed synchronous biliary carcinoma and underwent pancreaticoduodenectomy. Early complications occurred in seven patients with 10 events (surgical site infection, n = 3 bile leakage, n = 3; ileus, n = 3; bile duct obstruction, n = 1 and intussusception, n = 1). Late complications occurred in nine patients with 12 events (ileus, n = 3; anastomotic stricture, n = 3; hepatolithiasis, n = 3; asynchronous biliary carcinoma, n = 2; pancreatolithiasis, n = 1). Two of the three patients with hepatolithiasis underwent hepatectomy refractory to the endoscopic approach. Two patients developed asynchronous biliary carcinoma at 34 and 13 years after last operation; both ultimately died of the carcinoma. Only 35 patients (61.4%) underwent a follow-up examination. A total of 11 female patients (45.8%) eventually married, and all successfully gave birth.

CONCLUSION

Although the long-term prognosis is excellent with complete cyst excision and hepaticojejunostomy, we emphasize the importance of long-term follow-up.

[Choledochal cysts: surgical treatment in newborns and infants]

OBJECTIVE

To improve postoperative outcomes in newborns and infants with choledochal cysts and to determine the indications for surgery.

MATERIAL AND METHODS

There were 13 children aged 0-3 months with choledochal cyst who underwent reconstructive surgery between 2019 and 2023. In all children, choledochal cyst was associated with cholestasis. Acholic stool was observed in almost half of the group (n=7). All children underwent cyst resection and Roux-en-Y hepaticoenterostomy.

RESULTS

Symptoms of cholestasis regressed in all patients. Mean surgery time was 128±27 min. There were no complications. Enteral feeding was started after 1-2 postoperative days, abdominal drainage was removed after 6.2±1.6 days. Mean length of hospital-stay was 16±3.7 days. Adequate bile outflow is one of the main principles. For this purpose, anastomosis with intact tissues of hepatic duct should be as wide as possible. Roux-en-Y loop should be at least 40-60 cm to prevent postoperative cholangitis.

CONCLUSION

Drug-resistant cholestasis syndrome and complicated choledochal cysts (cyst rupture, bile peritonitis) are indications for surgical treatment in newborns and infants. When forming Roux-en-Y hepaticoenterostomy, surgeon should totally excise abnormal tissues of the biliary tract to prevent delayed malignant transformation.

Non-stapled, total laparoscopic Roux-en-Y anastomosis: A safe and effective procedure for radical pediatric choledochal cyst excision

Background

Laparoscopic or robot-assisted surgery has become the main pediatric minimal invasive surgery for a choledochal cyst (CDC). However, the Roux-en-Y jejunal limb was created extracorporeally in most reports and intracorporeally in a few reports using an endoscopic stapler.

Objectives/methods

To investigate the safety and feasibility of non-stapled laparoscopic Roux-en-Y reconstruction in the radical treatment of congenital choledochal cysts (CDC). Between January 2019 and February 2023, 40 patients diagnosed with CDC underwent non-stapled laparoscopic Roux-en-Y reconstruction (non-stapled totally laparoscopic radical treatment, NTLR), 40 patients underwent conventional reconstruction (conventional laparoscopic radical treatment, CLR) included as control. Their clinical data such as intraoperative blood loss, proportion of transit laparotomy, length of operation, postoperative fasting times, postoperative drainage time, postoperative hospital stay, hospitalization cost, and postoperative complications were retrospectively analyzed.

Conclusion

non-stapled laparoscopic Roux-en-Y reconstruction is feasible and safe in total laparoscopic radical treatment of CDC. It may have the following advantages: rapid recovery of postoperative gastrointestinal function, short hospitalization, no age limit on the patient and no additional hospitalization costs, which is worthy of promotion and application.

Using machine learning models to predict the surgical risk of children with pancreaticobiliary maljunction and biliary dilatation

PURPOSE

To develop machine learning (ML) models to predict the surgical risk of children with pancreaticobiliary maljunction (PBM) and biliary dilatation.

METHODS

The subjects of this study were 157 pediatric patients who underwent surgery for PBM with biliary dilatation between January, 2015 and August, 2022. Using preoperative data, four ML models were developed, including logistic regression (LR), random forest (RF), support vector machine classifier (SVC), and extreme gradient boosting (XGBoost). The performance of each model was assessed via the area under the receiver operator characteristic curve (AUC). Model interpretations were generated by Shapley Additive Explanations. A nomogram was used to validate the best-performing model.

RESULTS

Sixty-eight patients (43.3%) were classified as the high-risk surgery group. The XGBoost model (AUC = 0.822) outperformed the LR (AUC = 0.798), RF (AUC = 0.802) and SVC (AUC = 0.804) models. In all four models, enhancement of the choledochal cystic wall and an abnormal position of the right hepatic artery were the two most important features. Moreover, the diameter of the choledochal cyst, bile duct variation, and serum amylase were selected as key predictive factors by all four models.

CONCLUSIONS

Using preoperative data, the ML models, especially XGBoost, have the potential to predict the surgical risk of children with PBM and biliary dilatation. The nomogram may provide surgeons early warning to avoid intraoperative iatrogenic injury.

Analysing Factors Prolonging Hospital Stay After Excision of Choledochal Cyst-A Pathway Towards Enhanced Recovery After Surgery

BACKGROUND

To evaluate factors affecting length of stay (LOS) after choledochal cyst resection in paediatric patients.

METHODS

This was a retrospective study on patients operated between 2004 and 2021. Associations between clinical factors and LOS were evaluated by bivariate analysis, multiple regression, and equivalence test.

RESULTS

Sixty-two patients were included. Twenty-four underwent hepaticoduodenostomy as biliary reconstruction. Five suffered from major complications. The median (25th-75th percentile) operation time was 279 (182-378) min. Median LOS, time to enteral feeding, and time to abdominal drain removal were 8(6-10), 2(1-3), and 5(4-7) days, respectively. Seven factors were found significantly associated with a shorter LOS in bivariate analysis and were included in multiple regression. It revealed that early abdominal drain removal (p < 0.001), early enteral feeding (p = 0.042), and the absence of major complications (p < 0.001) were significantly associated with shorter LOS. Equivalence test suggested that age and preoperative cholangitis had no practical effect on LOS.

CONCLUSIONS

Early enteral feeding, early drain removal, and avoidance of major complications are associated with a shorter LOS.

Clinical characteristics of solitary intrahepatic biliary cyst

Solitary intrahepatic biliary cyst (SIBC) is a rare disease, and due to the lack of adequate understanding of it, SIBC is often misdiagnosed as simple liver cyst (SLC), which in turn affects the therapeutic effect. In order to arouse more attention to SIBC, combined with clinical experience in our center, this study specifically screened 3 representative cases of SIBC, and conducted a comprehensive retrospective analysis of their clinical characteristics, diagnosis and treatment process. Combined with the relevant literature, the diagnosis and treatment process of SIBC is widely discussed.

Preliminary Experience with Continuous Submucosal Anastomosis in Small-Diameter Hepaticojejunostomy during Single-Port Laparoscopic Choledochal Cyst Surgery in Children

PURPOSE

 Hepaticojejunostomy anastomosis (HJA) is the most challenging aspect in single-port laparoscopic choledochal cystectomy and Roux-en-Y hepaticojejunostomy (SPCH) in children, especially in small-diameter anastomoses (diameters less than 5 mm), which are more susceptible to anastomotic stricture. We developed the continuous submucosal technique for HJA (CS-HJA) to lessen postoperative complications. The purpose of this study is to introduce our preliminary experiences with CS-HJA.

METHODS

 We retrospectively analyzed all available clinical data of children who underwent SPCH surgery between March 2020 and October 2022. We operated with CS-HJA on 10 children who were diagnosed with small-diameter hepaticojejunostomy (diameter less than 5 mm). Data collection mainly included demographic information, imaging data, perioperative details, and postoperative outcomes. Ten patients were included in this study. The average patient age was 55.2 months; the age range was 3 to 120 months, and the average weight was 11.6 kg; male-female ratio was 1:9. The choledocho had fusiform dilatation in five cases and cystic dilatation in five cases. There was no dilatation of the left and right hepatic ducts or intrahepatic bile ducts in all patients. All patients had no dilatation of the left and right hepatic ducts or intrahepatic bile ducts. All patients underwent a single-port laparoscopic bile-intestinal anastomosis using a submucosal jejunal anastomosis technique. Analysis of the duration of the bile-intestinal anastomosis, the length of the child's stay in the hospital after surgery, the intraoperative complications, and the postoperative complications was performed.

RESULTS

 All the 10 patients underwent successful SPCH by CS-HJA technique. The average length of time for hepaticojejunostomy ranged from 22 to 40 minutes, and the postoperative hospital stay was 5.2 to 9.2 days. There were no instances of bile leakage following the operation. At 17 to 30 months of follow-up, there was no abdominal pain or jaundice, and the reexamination of transaminases, bilirubin, and amylase were normal. Ultrasonography showed no bile duct stricture or dilated bile ducts, and the incision is elegant, and the families of the patients were satisfied.

CONCLUSION

 In SPCH surgery in children, the CS-HJA technique is safe and feasible for small-diameter hepaticojejunostomy.

LncRNA-mRNA coexpression analysis reveals distinct pathogenic mechanisms for subtypes of congenital biliary dilatation

BACKGROUND/PURPOSE

Congenital biliary dilatation (CBD) is a bile duct malformation often associated with pancreaticobiliary maljunction. Different subtypes of CBD have been noted for clinical differences, but their pathogenic mechanisms are unclear.

METHODS

To elucidate the genetic basis of CBD, we performed lncRNA and mRNA sequencing and bioinformatic analysis on 18 cystic and 18 fusiform CBD samples.

RESULTS

We identified differentially expressed mRNAs and lncRNAs between the two types of CBD, and constructed coexpression modules that correlated with clinical characteristics of CBD using weighted gene coexpression network analysis. We found that the brown module was the highest positive correlation with fusiform CBD (R = 0.67, p = 7.9e-6) and contained the most genes. We then built a lncRNA-mRNA coexpression network to identify potential target genes of lncRNAs in CBD, and a protein-protein interaction network to investigate the hub genes from the target genes and the brown module. Finally, we performed enrichment analyses and found differences between cystic and fusiform CBD in hepatobiliary system development, liver and pancreas development involving hub genes ONECUT1 and HNF1B that could be regulated by corresponding lncRNAs.

CONCLUSION

Our study suggests that lncRNAs may modulate pancreaticobiliary duct development differently in cystic and fusiform CBD, providing new insights for etiology studies and clinical treatment.

Risk factors analysis for clinical symptoms of prenatally diagnosed choledochal cysts: a retrospective study

BACKGROUND

This study aimed to screen the impact factors for clinical symptoms of prenatally diagnosed choledochal cysts (CDCs), to warn about the occurrence of clinical symptoms and the timing of surgery.

METHODS

Medical records of patients with prenatally diagnosed CDCs admitted to our hospital from April 2013 to April 2018 were retrospectively reviewed. Fetal hilar or abdominal cysts were found by prenatal ultrasonogram. All patients underwent laparoscopic cyst excision and hepaticojejunostomy in our center. Univariate analysis and multivariate logistic regression analysis were performed to screen the factors related to clinical symptoms intimately.

RESULTS

Two hundred eighteen cases were included. One hundred thirty-four patients (134/218, 61.5%) presented clinical symptoms before surgery. The results of univariate analysis showed that patients with clinical symptoms had earlier time of prenatal diagnosis (P = 0.002), higher values of GGT, TBIL, DBIL (P < 0.001, P < 0.001, P < 0.001, respectively) and larger maximum diameter of cyst before surgery (P = 0.012). Multivariate logistic regression analysis suggested that the time of prenatal diagnosis (P = 0.001, OR = 0.898, 95% CI: 0.845 ~ 0.955) and the GGT value within one week of life (P = 0.028, OR = 1.002, 95% CI: 1.000 ~ 1.003) were independent influencing factors for symptoms.

CONCLUSIONS

For children with prenatally diagnosed CDCs, approximately 2/3 patients presented noticeable clinical symptoms before surgery. The time of prenatal diagnosis and the GGT value within 1 week of life were independent impact factors for the occurrence of clinical symptoms.

Characteristics, management and outcomes of choledochal malformations in Finnish adult patients

CONCLUSIONS

Nearly half of operated patients developed long-term postoperative complications. A novel association between CMs and IBD was observed. Although no hepatobiliary malignancies regardless of treatment modality were encountered, the number of patients and length of follow-up remained limited.

Efficacy analysis of enhanced recovery after surgery in laparoscopic-assisted radical resection of type I choledochal cyst

Objective

The objective of this study was to investigate the feasibility and effectiveness of laparoscopic-assisted radical resection of type I choledochal cyst (CC) guided by the principles of enhanced recovery after surgery (ERAS).

Methods

A retrospective cohort study of type I CC admitted to our hospital between May 2020 and December 2021 were analyzed, a total of 41 patients with choledochal cyst underwent surgery during this period and 30 cases were selected based on inclusion and exclusion criteria. Patients (n = 15) who received the traditional treatment from May 2020 to March 2021 were included in the traditional group. Patients (n = 15) who received ERAS from April 2021 to December 2021 were included in the ERAS group. Both groups underwent surgery performed by the same surgical team. Preoperative data of the two groups were recorded, and relevant data were statistically analyzed and compared.

Results

There was a statistically significant difference in the dose of opioids. Significant differences were observed between the ERAS and traditional groups in the results of the FLACC pain assessment scale on the 1st and 2nd day after surgery, time of gastric tube, urinary catheter and abdominal drainage tube removal, time of first defecation after operation, time of first eating after operation, time to reach full food intake, results of CRP, ALB, and ALT on the 3rd and 7th postoperative day, postoperative hospital stay, and total treatment cost. No significant differences were observed between the two groups in terms of gender, age, body weight, cyst size, preoperative CRP, ALB, ALT, intraoperative blood loss, operation time, and the number of cases converted to laparotomy. Neither the FLACC pain assessment scale on the 3rd day after surgery, the incidence of postoperative complications, nor the rate of readmission within 30 days showed significant differences.

Conclusions

Laparoscopic-assisted radical resection of type I CC guided by the principles of ERAS is safe and effective for children. The ERAS concept demonstrated advantages over traditional laparoscopic surgery, including reduced opioid use, shorter time to first postoperative defecation, earlier resumption of postoperative feeding, shorter time to reach full feeding, shorter postoperative hospital stay, and lower total treatment cost.

The Curious Case of the Choledochal Cyst—Revisiting the Todani Classification: Case Report and Review of the Literature

Choledochal cysts (CCs) are rare occurrences presenting as dilatations of biliary structures, which can present as single or multiple dilatations and can appear as both intra- and extrahepatic anomalies. The most widespread classification of CCs is the Todani classification, but there have been numerous reports of cysts that do not fall into any of the types described. We present such a case—a male patient 36 years of age who underwent preoperative CT, MRCP, and ERCP, which mistakenly indicated a type II Todani CC, and intraoperatively was found to be located at the confluence of the hepatic ducts and encompassed the origin of the common bile duct. Complete resection of the cyst and the proximal segment of the common bile duct was performed, and reconstruction was carried out by Roux-en-Y double-tutorized hepaticojejunostomy. Considering the risk of malignant transformation, the frequent preoperative misdiagnosis, as well as the technically challenging surgery required in such cases, we advocate for a revision of the classification and raise awareness of the need for guidelines regarding the proper short-term and long-term management of this disease to ensure adequate quality of life and disease-free survival for patients.

[Robot-assisted choledochal cyst resection in a child]

The generally accepted method for choledochal cysts is total resection of cystic extrahepatic bile ducts and gallbladder followed by biliodigestive anastomosis. Minimally invasive interventions have recently become the «gold» standard in pediatric hepatobiliary surgery. However, laparoscopic resection of choledochal cysts has certain disadvantages related to difficult positioning of instruments in narrow surgical field. The disadvantages of laparoscopy can be compensated by surgical robots. A 13-year-old girl underwent robot-assisted resection of hepaticocholedochal cyst, cholecystectomy and Roux-en-Y hepaticojejunostomy. Total anesthesia time was 6 hours. Laparoscopic stage took 55 min, docking of robotic complex - 35 min. Robotic stage of surgery required 230 min, removal of cyst and suturing the wounds - 35 min. Postoperative period was uneventful. Enteral nutrition was started after 3 days, and drainage tube was removed after 5 day. The patient was discharged after 10 postoperative days. The follow-up period was 6 months. Thus, robot-assisted resection of choledochal cysts in children is possible and safe.

Choledochal Cyst Excision in Infants-A Retrospective Study

A choledochal cyst is a rare malformation primarily diagnosed in children. The only effective therapy remains surgical cyst resection followed by Roux-en-Y hepaticojejunostomy. Treating asymptomatic neonates remains a point of discussion. Between 1984 and 2021, we performed choledochal cyst (CC) excision in 256 children at our center. Out of this group, we retrospectively reviewed the medical records of 59 patients who were operated on under one year of age. Follow-up ranged from 0.3 to 18 years (median 3.9 years). The preoperative course was asymptomatic in 22 (38%), while 37 patients (62%) had symptoms before surgery. The late postoperative course was uneventful in 45 patients (76%). In symptomatic patients, 16% had late complications, while in asymptomatic patients, only 4%. Late complications were observed in the laparotomy group in seven patients (17%). We did not observe late complications in the laparoscopy group. Early surgical intervention is not followed by a high risk of complications and may prevent the onset of preoperative complications, giving excellent early and long-term results, especially after minimally invasive laparoscopic surgery.

Risk Assessment and Cholangiocarcinoma: Diagnostic Management and Artificial Intelligence

Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver tumor, with a median survival of only 13 months. Surgical resection remains the only curative therapy; however, at first detection, only one-third of patients are at an early enough stage for this approach to be effective, thus rendering early diagnosis as an efficient approach to improving survival. Therefore, the identification of higher-risk patients, whose risk is correlated with genetic and pre-cancerous conditions, and the employment of non-invasive-screening modalities would be appropriate. For several at-risk patients, such as those suffering from primary sclerosing cholangitis or fibropolycystic liver disease, the use of periodic (6-12 months) imaging of the liver by ultrasound (US), magnetic Resonance Imaging (MRI)/cholangiopancreatography (MRCP), or computed tomography (CT) in association with serum CA19-9 measurement has been proposed. For liver cirrhosis patients, it has been proposed that at-risk iCCA patients are monitored in a similar fashion to at-risk HCC patients. The possibility of using Artificial Intelligence models to evaluate higher-risk patients could favor the diagnosis of these entities, although more data are needed to support the practical utility of these applications in the field of screening. For these reasons, it would be appropriate to develop screening programs in the research protocols setting. In fact, the success of these programs reauires patient compliance and multidisciplinary cooperation.

Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy for biliary reconstruction after resection of congenital biliary dilatation: a systematic review and meta-analysis

The ideal surgical management for reconstruction after excision of congenital biliary dilatation remains controversial. This updated meta-analysis compared the clinical outcomes of hepaticoduodenostomy (HD) and hepaticojejunostomy (HJ) after resection of congenital biliary dilatation. PubMed, Web of Science, Embase, Ovid, and the Cochrane Library were searched for studies published from November 1981 through July 2020. The primary outcomes were the operative time, enteral feeding time, hospital stay, and postoperative complications. The quality and risk of bias were assessed with the Newcastle-Ottawa Quality Assessment Scale. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using random-effects models. Thirteen total studies included 518 (55.76%) HD cases and 411 (44.24%) HJ cases. Five studies were published post-2013; one was a randomized clinical trial. Patients undergoing HD had a shorter hospital stay (MD, 0.40; p = 0.02) and operative time (MD, 59.54; p < 0.00001) and a lower incidence of adhesive intestinal obstruction (OR, 0.20; p = 0.02) than HJ. HD was comparable to conventional HJ with regard to most postoperative outcomes; however, it was associated with a higher incidence of postoperative bilious gastritis (OR, 6.24; p = 0.002). HD is as safe and feasible as HJ with better outcomes in the short run, although reports with long-term follow-up are relatively few. Long-term follow-up will be necessary to monitor possible associated malignancies in the future.

Lilly's Technique for Delayed Hemorrhage After Choledochal Cyst Radical Surgery

Background: Choledochal cysts (CCs) are characterized by dilations of the extra- and/or intrahepatic bile ducts. Surgery (cyst excision and Roux-en-Y hepaticojejunostomy) remains the gold standard for treatment. However, delayed hemorrhage can occur postoperatively, and although rare, it can be life-threatening. This study aimed to determine the risk factors and corresponding prevention of delayed hemorrhage after radical CC surgery, and to apply a technique to lower its incidence. Materials and Methods: This retrospective study enrolled 267 patients who received CC surgery between June 2016 and December 2020 at Shenzhen Children's Hospital. Univariate and multivariate logistic regression analyses were performed to identify risk factors for delayed hemorrhage. Results: Eleven (4.1%) patients had delayed hemorrhage after laparoscopic radical surgery. The most common hemorrhage site was the dissected surface between the cyst and adjacent structures with chronic severe adhesions, postoperatively. The occurrence of recurrent CC-associated complication and excessive total blood loss during surgery were risk factors for delayed hemorrhage after CC radical surgery. Length of disease course, operation when cholangitis/pancreatitis still existed, cyst diameter, and application of trypsin inhibitor after the surgery were not significantly different between the two groups. Conclusion: For patients without adhesions, complete cyst resection is the gold standard. However, for those with intensive adhesions, in cases of delayed hemorrhage on the dissection surface and malignancy transformation risk, the Lilly's technique with Roux-en-Y hepaticojejunostomy could be an alternative.

Development of gallbladder cancer during follow-up of pancreaticobiliary maljunction: a report of two cases

Pancreaticobiliary maljunction (PBM) is a congenital malformation. The reflux of pancreatic juice into the biliary tract caused by PBM plays a significant role in the development of biliary tract cancers (BTCs), such as gallbladder cancer and cholangiocarcinoma. Previous studies have demonstrated a high incidence of BTC in patients with PBM. However, there are only a few reports of patients who developed BTC after a diagnosis of PBM. We report the cases of two patients who developed gallbladder cancer after being diagnosed with PBM. They had refused treatment and were being managed with follow-up observation alone after the diagnosis of PBM and developed gallbladder cancer after several years of observation. Thus, surgical treatment should be recommended for all patients with PBM in order to prevent the development of BTC. Moreover, long-term, close, regular follow-up is necessary to facilitate the early diagnosis of subsequent BTC in patients with untreated PBM.

Efficacy of robot-assisted hepaticojejunostomy and laparoscopic-assisted hepaticojejunostomy in pediatric congenital choledochal dilatation: a system review and meta-analysis

PURPOSE

The efficacy of robot-assisted hepaticojejunostomy (RAHJ) and laparoscopic-assisted hepaticojejunostomy (LAHJ) in children with congenital choledochal dilatation has been a topic of much debate and controversy. The purpose of this study was to evaluate the role of RAHJ and LAHJ in pediatric congenital choledochal dilatation.

METHOD

The review program has been prospectively registered (PROSPEROID: CRD42022306868). We searched the PubMed, Embase, Cochrane, CBM, VIP, Web of Science, CNKI databases, and Wanfang databases from March 2021. The Mantel-Haenszel method and a random-effects model were used to figure out the hazard ratio (95% CI).

RESULTS

Ten studies evaluated eight hundred and sixty-nine subjects (three hundred and thirty-two in the robotic group and five hundred and thirty-seven in the laparoscopic group), meeting all inclusion criteria. Compared with the laparoscopic group, robotic group demonstrated fewer postoperative complications [p = 0.0009; OR = 0.34 (95% CI, 0.18-0.64); I² = 3%], shorter postoperative hospital stay [p < 00,001; MD = - 2.05 (95% CI, - 2.40-1.70); I² = 0%], and less intraoperative bleeding [p = 0.008; MD = - 10.80 (95% CI, - 18.80-2.81); I² = 99%]. There was no significant difference in operative time between the two groups [p = 0.10; MD = 24.53 (95% CI, - 5.11-54.17); I² = 99%]. The same situation happened in short-term complication outcomes [p = 0.06; RR = 0.45 (95% CI, 0.19-1.04); I² = 0%]. However, children in the RAHJ group had significantly lower levels of long-term complications [p = 0.04; OR = 0.41 (95% CI, 0.17-0.96); I² = 0%]. Hospitalization costs were significantly higher in the RAHJ group [p < 0.00001; OR = 27,113.86 (95% CI, 26,307.24-27,920.48); I² = 0%]. For overall complications, subgroup analysis of literature published after 2020 and of literature with high quality scores showed a significant decrease in the RAHJ group.

CONCLUSION

In children with congenital choledochal dilatation, RAHJ is associated with reduced intraoperative bleeding, postoperative complications, and length of stay. Robotic surgery has a bright future in the treatment of pediatric common hepatic duct cysts and deserves to be promoted and popularized.

Baseline assessment of enhanced recovery after pediatric surgery in mainland China

BACKGROUND

Enhanced recovery after surgery (ERAS) is a clinical pathway that optimizes perioperative management based on evidence-based medicine. ERAS has been gradually introduced to pediatric surgery in recent years. However, there are limited reports on its overall implementation. We aimed to determine the implementation of ERAS in patients who received pediatric surgery in mainland China.

METHODS

We designed a questionnaire involving 17 key ERAS elements and sent the questionnaire to 66 chiefs of pediatric surgery distributed throughout 31 provinces in mainland China to obtain a baseline assessment of the assimilation of ERAS protocols in the care of congenital biliary dilatation (CBD).

RESULTS

A total of 66 questionnaires were collected. The range of elements implemented at participating centers was 4-16, with a mean of 10.23. The least commonly practiced elements were administration of non-opioid preoperative analgesia (6 centers, 9.09%), prevention of postoperative nausea and vomiting [PONV] (9 centers, 13.64%), and postoperative pain management (26 centers, 39.39%).

CONCLUSIONS

The implementation of elements differed from center to center. Measures relying primarily on anesthesiologists had lower execution. The adherence to ERAS elements was often inhibited by a lack of institutional support, poor knowledge of ERAS protocols, and difficulties in coordinating multidisciplinary care, as well intransigence in changing surgical practices out of fear of liability for poor outcomes.

Postoperative anastomotic stricture following excision of choledochal cyst: a systematic review and meta-analysis

PURPOSE

Postoperative anastomotic stricture (PAS) is a well-known complication after correcting choledochal cyst (CC). Although the exact cause of PAS is unknown, various risk factors, such as Todani classification type IV-A, hepaticoduodenostomy, and narrow anastomosis have been reported to be associated with PAS. As far as we know, there is no report with a cumulative analysis of such risk factors of PAS. This systematic review and meta-analysis aimed to investigate the risk factors of PAS following surgical correction of CC in children.

METHODS

A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms "Congenital biliary dilatation", "Congenital choledochal cyst", "Choledochal cyst", "Stenosis", "Stricture", and "Complication" for studies published between 1973 and 2022. The relevant cohorts of PAS were systematically searched for clinical presentation and outcomes.

RESULTS

The search strategy identified 795 reports. Seventy studies met the defined inclusion criteria, reporting a total of 206 patients with PAS. There is no prospective study in this search. The incidence of PAS was 2.1%. The proportion of Todani classification of the patient with PAS was higher in type IV-A with significant difference (2.0% in type I and 10.1% in type IV-A (p = 0.001)). Fourteen studies reported a comparison between hepaticojejunostomy and hepaticoduodenostomy. There was no significant difference between the two groups (p = 0.36). Four studies reported the diameter of the anastomosis at the primary surgery. The mean diameter was 12.5 mm. Nine studies reported a comparison between laparoscopic surgery and open surgery. Pooled odds ratio of PAS did not show a statistical difference (p = 0.29).

CONCLUSIONS

This study suggests that close careful follow-up is important in the patients with type IV-A of CC who underwent excision surgery, considering the possibility of PAS.

Usefulness of hepatobiliary scintigraphy for predicting late complications in patients with choledochal cysts

PURPOSE

Hepatobiliary scintigraphy is a minimally invasive imaging method that evaluates bile flow dynamics. At our hospital, it has been performed for postoperative evaluation of patients with choledochal cysts (CC). This study evaluated the usefulness of biliary scintigraphy for predicting late complications in patients with CCs.

METHODS

The study included pediatric patients with CC who underwent surgery at Chiba University Hospital from 1978 to 2020, followed by postoperative biliary scintigraphy and subsequent radiologic evaluation. The patients were divided into two groups according to the presence or absence of "biliary cholestasis" on biliary scintigraphy.

RESULTS

The study included 108 patients, with a median age at surgery of 2 years and 11 months. The median follow-up period was 5203 days, with 11 hepatolithiasis cases and 8 cholangitis cases. No patients had cholangiocarcinoma. Twelve patients were considered to have "cholestasis" following biliary scintigraphy evaluation. There was no significant difference in the occurrence of hepatolithiasis between the cholestasis and non-cholestasis groups (p = 0.47), but cholangitis was significantly more common in the cholestasis group (p = 0.016).

CONCLUSION

Biliary cholestasis on postoperative hepatobiliary scintigraphy was a risk factor for cholangitis in patients with CCs. These particular patients should be monitored carefully.

Changes in operative trends and short‐term outcomes of surgery for congenital biliary dilatation in adults using real‐world data: A multilevel analysis based on a nationwide administrative database in Japan

Aim

We aimed to evaluate the operative trends and compare the short-term outcomes between open and laparoscopic surgery for congenital biliary dilatation (CBD) in adults using real-world data from Japan.

Methods

Data from the Japanese Diagnosis Procedure Combination database on 941 patients undergoing surgery for CBD at 357 hospitals from April 1, 2016, to March 31, 2021, were analyzed. The patients were divided into two groups: open surgery (n = 764) and laparoscopic surgery (n = 177). We performed a retrospective analysis via a multilevel analysis of the short-term surgical outcomes and costs between open and laparoscopic surgery.

Results

The rate of laparoscopic surgery has been increasing annually and had almost doubled to 25% by 2021. There were no significant differences in the in-hospital mortality rate or postoperative morbidity between the two groups. The length of anesthesia was significantly longer in the laparoscopic than open surgery group (8.80 vs 6.16 hours, p < .001). The time to removal of the abdominal drain and length of hospital stay were significantly shorter in the laparoscopic than open surgery group (6.12 vs 8.35 days, p = .001 and 13.57 vs 15.79 days, p < .001, respectively). The coefficient for cost was 463 235 yen (95% confidence interval, 289 679-636 792) higher in laparoscopic than open surgery (p < .001).

Conclusion

The short-term results were comparable between laparoscopic and open surgery for CBD. Further investigation is needed to validate our findings and long-term outcomes.

Outcomes and comparations of pediatric surgery about choledochal cyst with robot-assisted procedures, laparoscopic procedures, and open procedures: A meta-analysis

Background

Choledochal cysts (CC) are rare disorders characterized by congenital biliary dilatation of the intrahepatic or extrahepatic bile ducts and always relate to pancreaticobiliary maljunction. Robot-assisted surgery has been able to complete almost all pediatric endoscopic surgery nowadays. But evidence of the post-operative outcomes of robotic-assisted operation is limited, comparing with the laparoscopic operation and traditional open operation. The aim of this meta-analysis was to identify the advantages and deficiencies about robotic-assisted operation for CC.

Methods

A meta-analysis of retrospective studies published in PUBMED, MEDLINE, Web of Science and China National Knowledge Infrastructure (CNKI). No date limit was used, with the last search on April 30, 2022. No publication restrictions or study design filters were applied.

Results

Nine retrospective cohort studies with 1,395 patients [366 in the robotic-assisted operation group (RG), 532 in the laparoscopic operation group (LG) and 497 in the open operation group (OG)] were enrolled in our study. Subgroup analysis demonstrated the RG had significant longer operative time [standardized mean difference (SMD) = 1.59, 95% CI = (0.02, 3.16), P < 0.05], less blood loss [SMD = -1.52, 95% CI = (-2.71, -0.32), P < 0.05], shorter enteral feeding time [SMD = -0.83, 95% CI = (-1.22, -0.44), P < 0.001], shorter time to stay in the hospital [SMD = -0.81, 95% CI = (-1.23, -0.38), P < 0.001], fewer post-operative complications [Relative risk (RR) =1.09, 95% CI = (1.04, 1.13), P < 0.001] but higher expenses [SMD = 8.58, 95% CI = (5.27, 11.89), P < 0.001] than LG. While a significant older age [SMD = 0.46, 95% CI = (0.26, 0.66), P < 0.001], longer operative time [SMD = 3.96, 95% CI = (2.38, 5.55), P < 0.001] and shorter time to stay in the hospital [SMD = -0.93, 95% CI = (-1.62, -0.25), P < 0.05] than OG.

Conclusions

Laparoscopic and robotic-assisted procedure are both safe and minimal invasive operational strategies. Robotic-assisted procedure may slowly surpass and has a trend to replace laparoscopy for its advantages. More experiences in robotic-assisted operation should be accumulated for the unexpected complexities, so as to be more stable in the younger age of children.

Clinical efficacy and safety of robot assisted surgery for choledochal cysts excisions: a systematic review and meta-analysis

BACKGROUND

This study aimed to evaluate the safety and therapeutic effect of Robot-assisted surgery (RAS) for choledochal cysts (CCs) excisions.

RESEARCH DESIGN AND METHODS

PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, WanFang, VIP, and CBM were searched from database inception to 1 May 2022. The Newcastle-Ottawa scale (NOS) was used to conduct quality assessments, and RevMan (Version 5.4) was used to perform the meta-analysis.

RESULTS

In all, 9 studies, involving 623 patients, were analyzed. RAS compared with LAS was associated with less intraoperative blood loss, shorter time to start solid diets, shorter postoperative hospital stay, and lower complications. There was no significant difference in operative time between the two groups, but the total costs were higher in RAS. Our subgroup analysis showed that RAS had significant advantages over LAS in the child group: minor bleeding, shorter length of hospital stay, and fewer postoperative complications.

CONCLUSIONS

The available evidence indicates that the RAS system has the advantages of less intraoperative blood loss, minor tissue damage, quick recovery, and sound healing in treating choledochal cyst, which proves that the RAS is safely feasible. Especially in children, RAS tends to be a better choice.

Laparoscopic definitive surgery for choledochal cyst is performed safely and effectively in infants

Background:

Laparoscopic definitive surgery for choledochal cyst (CC) in infants requires advanced skills because of their small size. If patients with a prenatal diagnosis of CC have any biliary symptoms, they need semi-emergency definitive surgery. This study aimed to estimate whether laparoscopic definitive surgery for CC can be performed safely and effectively in infants, especially when emergency surgery is required.

Patients and Methods:

From January 2006 to December 2019, 21 patients under 1 year of age underwent laparoscopically or open definitive surgery, and 16 patients aged 3–5 years underwent laparoscopic surgery for CC at our institution. In cases of prenatal diagnosis, elective surgery (EL) was performed at about 6 months of age for patients with no biliary symptoms; the semi-emergency surgery (EM) was performed when patients had any biliary symptoms. Surgical outcomes were retrospectively compared between the Lap <1 y and Op <1 y groups and between the Lap <1 y and Lap 3–5 y groups. In addition, the surgical outcomes of those who underwent EM were also evaluated.

Results:

Operative time was significantly longer, and blood loss was significantly lower in the Lap <1 y group than in the Op <1 y group. All surgical outcomes were similar between the Lap <1 y and Lap 3–5 y groups and between the EM and EL groups.

Conclusion:

Laparoscopic definitive surgery for CC in infants under 1 year of age is safe and feasible. Even semi-emergency laparoscopic surgery can be performed safely and effectively in small infants.

Transabdominal Ultrasound Evaluation of Pancreaticobiliary Maljunction in Children

ABSTRACT

The development of high-frequency ultrasound made the diagnosis of pancreaticobiliary maljunction (PBM) possible. However, no study has been performed to clarify the sensitivity and specificity of transabdominal ultrasound (TAUS) in the diagnosis of PBM. The purpose of this study was to evaluate the accuracy of TAUS in the diagnosis of pediatric PBM and to assess factors that may influence the accuracy of ultrasound. This was a prospective study and 43 patients with suspected PBM were enrolled. All of these patients underwent TAUS examination to detect the pancreaticobiliary ductal union. Final diagnoses were determined by endoscopic retrograde cholangiopancreatography or intraoperative cholangiography. Sensitivity and specificity were calculated. Fisher exact test was used to analyze the difference of sonographic features between false-negative group and true-positive group. Transabdominal ultrasound demonstrated 77.4% (95% confidence interval, 58.5%-89.7%) sensitivity and 100% (95% confidence interval, 69.9%-100%) specificity for PMB diagnosis. In the false-negative group, infant patients (71.4% vs 16.7%, P = 0.012), cystic dilatation of the common bile duct (CBD) (71.4% vs 16.7%, P = 0.012), and stenosis of the distal CBD (71.4% vs 16.7%, P = 0.012) were more frequently observed than in the true-positive group. On the other hand, the true-positive group showed a higher incidence of protein plugs than the false-negative group (62.5% vs 0%, P = 0.007). Transabdominal ultrasound may serve as a potential alternative detection modality for pediatric patients with suspected PBM. Nondetection of the anomaly may be attributed to factors, such as younger age, cystic dilatation of the CBD, and stenosis of the distal CBD.

Todani type III: like biliary dilatation with duodenal prolapse-a case report

BACKGROUND

Biliary dilatation is a rare disease involving intrahepatic and extrahepatic biliary tract abnormalities. With the development of imaging technology, an increasing number of special cases have been diagnosed, which poses a challenge to the traditional classification method.

CASE PRESENTATION

A 50-year-old woman was admitted to the hospital due to right upper quadrant pain for more than 10 days. The patient had previous episodes of similar symptoms, which were relieved after symptomatic treatment at a local community hospital. After the symptoms developed, she underwent a computed tomography scan at the local hospital, which showed biliary dilatation; thus, she was referred to our hospital for further treatment. After admission, her magnetic resonance imaging examination also suggested biliary dilatation, but abnormal signals were found in her duodenum. First, a duodenal diverticulum was considered. Later, endoscopic ultrasonography was conducted, and the results suggested that the dilated biliary tract had herniated into the duodenum. This type of lesion is most closely classified as a Todani type III lesion. The patient finally underwent choledochectomy and Roux‑en‑Y hepaticojejunostomy, and the postoperative pathology was consistent with our preoperative diagnosis. The patient was followed up for approximately 2 years, and no obvious postoperative complications were found.

CONCLUSIONS

The manifestations of this case are relatively rare and involve one of the undiscussed categories of the Todani classification system; therefore, this case has certain clinical value. Moreover, there is no report similar to this experience in the previous literature.

Laparoscopic definitive surgery for congenital biliary dilatation with aggressive hilar bile ductoplasty and complete resection of the intrapancreatic bile duct in pediatric patients is safe and effective, comparable to open surgery

BACKGROUND

After surgery for congenital biliary dilatation (CBD), hilar and hepatic bile duct stenosis and intrapancreatic bile duct remnants can cause many postoperative complications. We investigated the efficacy of laparoscopic surgery with aggressive bile ductoplasty and complete excision of the intrapancreatic bile duct in CBD patients compared to open surgery.

METHODS

Pediatric patients who underwent surgery for CBD at our institution between 2006 and 2020 were divided into two groups: laparoscopic surgery (Lap group) and open surgery (Op group). Surgical outcomes were compared between the two groups.

RESULTS

We enrolled 160 patients (85 in the Lap group and 75 in the Op group). Hilar bile ductoplasty was performed in 52 (61%) patients from the Lap group and 40 (53%) patients from the Op group. The operative time was significantly longer, the amount of blood loss was significantly lower, and the length of hospital stay was significantly shorter in the Lap group than in the Op group. Postoperative early and late complications occurred at a similarly low rate in both groups. When the surgical outcomes were compared between the group who underwent laparoscopic bile ductoplasty and the group that did not, postoperative early and late complications occurred similarly in both groups.

CONCLUSIONS

Laparoscopic surgery for CBD with aggressive hilar bile ductoplasty and complete excision of the intrapancreatic bile duct is safe and effective, comparable to open surgery. However, it is necessary to verify whether long-term occurrence of hepatolithiasis similar to open definitive surgery can be obtained in the future.

Controversies in Choledochal Malformation in Children: An International Survey among Pediatric Hepatobiliary Surgeons and Gastroenterologists

BACKGROUND

While congenital choledochal malformation (CCM) is relatively well known within the pediatric surgical and pediatric gastroenterological communities, many controversies and questions remain.

METHODS

In this paper, we will discuss the results of an international Delphi survey among members of the European Reference Network RARE-LIVER and of the faculty of the Biliary Atresia and Related Diseases (BARD) network to identify the most common practices as well as controversies regarding diagnosis, treatment and follow-up of this still enigmatic disease.

RESULTS

Twenty-two individual respondents completed the survey. While there seems to be agreement on the definitions of CCM, preoperative workup, surgical approach and follow-up still vary considerably. The mainstay of treatment remains the removal of the entire extrahepatic biliary tract, clearance of debris both proximally and distally, followed by reconstruction with (according to 86% of respondents) a Roux-en-Y hepaticojejunostomy. Nonetheless, both laparoscopic and robotic-assisted resections are gaining ground with the suggestion that this might be facilitated by concentration of care and resources in specialized centers. However, long-term outcomes are still lacking.

CONCLUSIONS

As even post-surgical CCM has to be considered as having premalignant potential, follow-up should be well-organized and continued into adulthood. This seems to be lacking in many centers. International cooperation for both benchmarking and research is paramount to improving care for this rare disease.

Development of the human pancreas and its exocrine function

The pancreas has both endocrine and exocrine function and plays an important role in digestion and glucose control. Understanding the development of the pancreas, grossly and microscopically, and the genetic factors regulating it provides further insight into clinical problems that arise when these processes fail. Animal models of development are known to have inherent issues when understanding human development. Therefore, in this review, we focus on human studies that have reported gross and microscopic development including acinar-, ductal-, and endocrine cells and the neural network. We review the genes and transcription factors involved in organ formation using data from animal models to bridge current understanding where necessary. We describe the development of exocrine function in the fetus and postnatally. A deeper review of the genes involved in pancreatic formation allows us to describe the development of the different groups (proteases, lipids, and amylase) of enzymes during fetal life and postnatally and describe the genetic defects. We discuss the constellation of gross anatomical, as well as microscopic defects that with genetic mutations lead to pancreatic insufficiency and disease states.

Laparoscopic surgery versus robot-assisted surgery for choledochal cyst excision: A systematic review and meta-analysis

The aim of this following study is to systematically review and analyze the published data comparing laparoscopic surgery and robotic assisted surgery for choledochal cyst excisions through the metrics of operative time, length of hospital stay and postoperative outcome. PubMed, Web of Science, Embase, Ovid, and the Cochrane Library databases were combed through and data was retrieved from the timespan between January 1995 and October 2021. The primary measures included operative time, intraoperative bleeding, hospital stay, and postoperative complications. Quality and risk of bias were assessed using the Newcastle-Ottawa Quality Assessment Scale. Making use of random-effects models, we pooled the odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (95% CIs). Six studies comprising a total 484 patients who had undergone either laparoscopic surgery [307 (63.43%) patients] or robot-assisted surgery [177 (36.57%) patients] were included in this analysis. Three of the articles involved adults while the other three involved children. All of the studies were published after 2018 and were retrospective case-control studies. Patients undergoing robotic surgery had a shorter hospital stay (MD, 0.95; 95% CI, 0.56 to 1.35; p < 0.00001) and a longer operative time (MD, -57.52; 95% CI, -67.17 to -47.87; p < 0.00001). And there was no significant discrepancy in complications between the two groups. Compared to laparoscopic surgery, robot-assisted surgery is associated with a shorter hospital stay, scores highly in terms of both safety and feasibility, however it also results in a longer operative time. And the two procedures have the same short- and long-term results.

Novel analysis using magnetic resonance cholangiography for patients with pancreaticobiliary maljunction

PURPOSE

We used a novel diagnostic Fourier transform (FT) algorithm of the entire extrahepatic bile duct (EHBD) measured by magnetic resonance cholangiography (MRC) to evaluate subtle deformation of bile duct lumen, indicating the malignant potential of EHBD, in patients with pancreaticobiliary maljunction (PBMJ) and in a comparative group of controls without PBMJ.

METHODS

From the workstation, the EHBD lumen was traced automatically and a 2D diagram cross section was measured at 0.5 mm-longitudinal intervals. The FT-based integrated power spectral density function value (FTPSDI) of the diameter or area (mm² or mm⁴/Hz) and the phase value distribution entropy (PVDE) were also measured.

RESULTS

There were 16 patients with undilated PBMJ and 7 with dilated PBMJ. The control group comprised 10 patients with a normal bile duct, 20 with bile duct carcinoma (BDC), and 1 with primary sclerosing cholangitis. Both the diameter and area of the dilated bile ducts and the ducts with early- or advanced-stage BDC were significantly greater than those of the normal duct (p < 0.05). The undilated type of PBMJ tended to have a larger FTPSDI diameter than a normal bile duct, which had a smaller diameter than the dilated type of PBMJ or BDC. BDC had a significantly larger FTPSDI diameter (p < 0.05) and the cutoff value for accuracy was 168 mm² Hz^-1.

CONCLUSION

The novel mathematical FTPSDI is a promising indicator of whether preventive EHBD resection is necessary for patients with PBMJ, which can be widely applied in the early diagnosis of other biliary diseases.

Pancreaticobiliary maljunction without biliary dilatation in pediatric patients

PURPOSE

Pancreaticobiliary maljunction (PBM) without biliary dilatation is a condition in which dilatation of the bile duct is not seen in patients with PBM. Recently, the Japanese Study Group on Pancreaticobiliary Maljunction (JSGPM) published new diagnostic criteria for PBM. In these criteria, biliary dilatation is defined according to the standard diameter at each age. We reviewed cases of pediatric patients with PBM without biliary dilatation.

METHODS

From 1992 to 2019, 134 patients with PBM were treated in our institution. Among these, 7 patients were retrospectively diagnosed with PBM without biliary dilatation. The clinical information was retrospectively assessed in these patients.

RESULTS

Of the seven patients, six were female. All patients had symptoms similar to those of patients with congenital biliary dilatation. In all seven patients, the diagnosis of PBM was made before definitive surgery. Six patients had type B PBM, and one had type D PBM. All patients underwent extrahepatic bile duct resection and hepaticojejunostomy, and their symptoms resolved. One patient experienced postoperative complications of anastomotic leakage followed by anastomotic stricture.

CONCLUSION

The present report revealed important clinical features of this entity. However, there are still some issues that need to be discussed, and further research is needed.

Pancreaticobiliary maljunction in Turkish patients: a multicenter case series

BACKGROUND AND AIMS

Pancreaticobiliary maljunction (PBM) is a malformation in which the pancreatic and bile ducts join outside the duodenal wall. It is associated with various biliary and pancreatic diseases. In addition, patients with PBM carry a substantial lifetime risk of developing biliary or gallbladder carcinoma. We aimed to present a multicenter case series of PBM from Turkey.

METHODS

This study was conducted in adult and pediatric PBM patients who were referred to three tertiary reference centers of Turkey for endoscopic retrograde cholangiopancreatography (ERCP) between July 2007 and May 2020. The clinical presentations, types of PBM, ERCP findings, surgical histories, and the postoperative courses, including the development of biliary malignancies, were retrospectively reviewed.

RESULTS

The study group included 47 (31 adult and 16 children) patients. Type D PBM was more frequent (13/41: 27.7%) than that reported in Eastern studies. Type A PBM was more common in the adults (51.6% vs. 12.5%, p < 0.05), whereas type C was more common in pediatric patients (31.3% vs. 13.2%, p < 0.05). Although fusiform anatomy was predominant in both of the groups, cystic dilatation was more common (25.8% vs. 12.5%) in adults and the common bile duct diameter was greater [22 mm (range 11-58) vs. 12 mm (range 5-33)] in adult patients compared to pediatric patients. Resective surgeries were more frequently done in pediatric patients (73.3% vs. 53.6%), whereas cholecystectomy was more frequently performed in adult patients (21.4% vs. 6.7%).

CONCLUSION

Although our findings were compatible with Eastern studies, type D PBM (associated with pancreas divisum) was more frequent in our study population.

Total robot-assisted choledochal cyst excision using da Vinci surgical system in pediatrics: Report of 10 cases

BACKGROUND

The robotic surgery has been proposed as another adjunct for pediatric minimal surgery for choledochal cyst. However, the Roux-en-Y jejunal limb in most reports on robot-assist choledochal cyst resection is usually created extracorporeally in children. The pediatric surgery team of West China Hospital of Sichuan University had completed 10 cases of total robot-assisted choledochal cyst resection. The aim of this current study was to present our initial experience in total robot-assisted surgery and discuss the technical points.

METHODS

Between January 2015 and February 2020, patients with choledochal cysts treated with total robot-assisted procedures were retrospectively analyzed. The data collected included demographic information of all patients, type and size of cyst, operative details and postoperative outcomes.

RESULTS

A total of 10 episodes of patients were enrolled in the study. The median age of the patient was 69.50 months with a mean weight of 20.50 kg. The most common symptoms were abdominal pain, vomiting, and jaundice (60%, 30%, and 30%, respectively). The types of cyst included 2 Ia, 7 Ic and 1 IV. The mean operation time was 218.70 min and there were no red blood cell transfusion and conversion in the 10 patients. The mean time to taking water was 3.37 days and mean time to starting liquid diet was 3.77 days. And the average length of postoperative hospital stay was 7.92 days. All 10 patients were eventually discharged and made uneventful recoveries after the operation.

CONCLUSIONS

Total robot-assisted choledochal cyst excision comprising Roux-en-Y limb formation, excision of the cyst and hepaticojejunostomy appears to be safe and feasible in pediatrics. Our initial experience shows that it is recommended to perform total robot-assisted choledochal cyst excision for patients over 4 years while a Roux-en-Y jejunojejunal anastomosis is recommended to be performed extracorporeally by prolapsing the jejunum out of abdominal cavity for patients under 4 years old.

LEVEL OF EVIDENCE

Treatment Study.

TYPE OF STUDY

Retrospective Study.