Duodenogastric reflux following biliary reconstruction after excision of choledochal cyst

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.

Outcome of Biliary-enteric Reconstruction with Hepaticoduodenostomy Following Choledochal Cyst Resection: A Prospective Study

BACKGROUND

The two most commonly performed methods of biliary-enteric reconstruction following choledochal cyst resection are Roux-en-Y hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD). There is a lack of consensus regarding the better technique between them. This study aimed to evaluate the outcomes, efficacy and early complications of HD as a mode of biliary reconstruction after surgical resection of a choledochal cyst.

MATERIALS AND METHODS

This was a multi-institutional prospective study carried out in high-volume tertiary care teaching institutes from January 2010 to December 2022. All children managed with HD following choledochal cyst resection were analysed for their early complications and outcomes.

RESULTS

A total of 74 patients were included in this study. There were 59 (79.73%) females and 15 (20.27%) males. Thirty-nine (52.70%) patients had jaundice at the time of presentation. Magnetic resonance cholangiopancreatography was performed in 57 (77.03%) patients following ultrasonography. Intraoperatively, malrotation was present in 2 (2.70%) patients. In our study, operating time ranged from 60 to 195 min (mean: 118 min). Hospital stays ranged from 8 to 17 days (mean: 11.5 days). The post-operative biliary leak was seen in 7 (9.50%) patients, out of which 6 (8.11%) minor leaks were managed conservatively. Roux-en-Y HJ was performed on 1 (1.35%) patient with a major leak. In our series, 4 (5.40%) patients developed cholangitis; post-operative haemorrhagic nasogastric aspirate 5 (6.76%), post-operative pancreatitis 3 (4.05%) and wound infection 4 (5.40%) were observed and managed conservatively. None of the patients in our study developed an anastomotic stricture, bile gastritis and adhesive small bowel obstruction.

CONCLUSION

Resection of choledochal cyst with HD reconstruction is safe and feasible with short operative time. HD is a viable option for operative management of choledochal cyst with low complication rates and faster recovery.

Choledochal cyst

Choledochal cyst (CC) or congenital biliary dilatation, has a skewed distribution with hereditary features that is far more common in East Asian females. CC is usually associated with pancreaticobiliary malunion (PBMU) forming a common channel. CC requires early definitive diagnosis, since there is a risk for malignancy occurring in the CC and/or intrahepatic bile ducts (IHBD). Complete CC excision and Roux-en-Y hepaticoenterostomy is required and can be performed by open or minimally invasive surgery with hepatojejunostomy the recommended procedure of choice. Principles of open surgical intervention form the basis of minimally invasive management with laparoscopy and robotic assistance. Current surgical management is associated with fewer early and late complications, such as hepaticoenterostomy anastomotic leakage, cholangitis, anastomosis stricture, and cholangiocarcinoma. Specific features of CC management at Juntendo include: intraoperative endoscopy of the common channel and IHBD for inspecting and clearing debris to significantly reduce post-operative pancreatitis or stone formation; near infra-red fluorescence with indocyanine green for visualizing tissue planes especially during minimally invasive surgery for CC; and a classification system for CC based on PBMU that overcomes inconsistencies between existing classification systems and clinical presentation.

Outcomes of laparoscopic versus open resection of pediatric choledochal cyst

BACKGROUND

Untreated pediatric choledochal cyst (CC) is associated with complications including cholangitis, pancreatitis, and risk of malignancy. Therefore, CC is typically treated by surgical excision with biliary reconstruction. Both open and laparoscopic (lap) surgical approaches are regularly used, but outcomes have not been compared on a national level.

METHODS

The Nationwide Readmissions Database was used to identify pediatric patients (age 0-21 years, excluding newborns) with choledochal cyst from 2016 to 2018 based on ICD-10 codes. Patients were stratified by operative approach (open vs. lap). Demographics, operative management, and complications were compared using standard statistical tests. Results were weighted for national estimates.

RESULTS

Choledochal cyst excision was performed in 577 children (75% female) via lap (28%) and open (72%) surgical approaches. Patients undergoing an open resection experienced longer index hospital length of stay (LOS), higher total cost, and more complications. Anastomotic technique differed by approach, with Roux-en-Y hepaticojejunostomy (RYHJ) more often utilized with open cases (86% vs. 29%) and hepaticoduodenostomy (HD) more common with laparoscopic procedures (71% vs. 15%), both p < 0.001. There was no significant difference in post-operative cholangitis or mortality.

CONCLUSIONS

Although utilized less frequently than an open approach, laparoscopic choledochal cyst resection is safe in pediatric patients and is associated with shorter LOS, lower costs, and fewer complications. HD anastomosis is more commonly performed during laparoscopic procedures, whereas RYHJ more commonly used with the open approach. While HD is associated with more short-term gastrointestinal dysfunction than RYHJ, the latter is more commonly associated with sepsis, wound infection, and respiratory dysfunction.

LEVEL OF EVIDENCE

Level III: Retrospective Comparative Study.

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.

Biliary reconstruction after choledochal cyst resection: a systematic review and meta-analysis on hepaticojejunostomy vs hepaticoduodenostomy

Choledochal cysts are a rare pediatric biliary pathology. Excision of the extrahepatic cyst and restoration of biliary-enteric continuity through either hepaticoduodenostomy (HD) or Roux-en-Y hepaticojejunostomy (HJ) is the mainstay treatment. This study aims to determine if either method provides an advantage. Following PRISMA guidelines, a systematic review was conducted, identifying studies comparing hepaticojejunostomy to hepaticoduodenostomy in patients with choledochal cysts. Data were analyzed using Review Manager 5.3. Nine studies were included, operative time was shorter - 97.50 [- 172.31, - 22.69] p = 0.01 and bleeding reduced - 48.98 [- 88.25, - 9.71] p = 0.01 in HD. HD was associated with shorter length of stay 2.18 [- 3.87, - 0.50] p = 0.01 and similar cholangitis and reintervention rates. Time to a normal diet was similar between groups. Biliary reflux was seen more frequently in HD 19.14 [2.60, 140.63] p = 0.004. Complications such as leak and cholangitis were similar between groups. HD represents a viable alternative to HJ with various advantages such as shorter operative time, decreased bleeding and shorter length of hospital stay. Bile reflux remains a major limitation.Level of evidence IV.

Differences in post-operative complications after reconstruction for congenital biliary dilatation in a single institution-Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy

BACKGROUND

The standard surgical procedure for congenital biliary dilatation (CBD) consists of excision of extrahepatic bile duct and Roux-en-Y hepaticojejunostomy (HJ). However, alternative reconstructive operations for CBD includes hepaticoduodenostomy (HD). We compared postoperative complications and therapeutic outcomes of these two operations at our institution.

METHODS

From 1981 to 2009, there were 23 traceable patients who underwent operation for CBD, They were divided into an HJ Group (n = 15) and an HD Group (n = 8). Demographic and outcome data were compared.

RESULTS

There were no significant differences in postoperative complications (cholangitis, pancreatitis, and anastomotic stenosis) and current blood test data (AST, ALT, Total Bilirubin, Direct Bilirubin, Amylase) between the two groups. Current abdominal pain and carcinogenesis were not observed in either group. Intrahepatic stones occurred in one patient in each group, both > 25 years post-operation.

CONCLUSION

HD is considered to be an acceptable reconstruction method compared to HJ, based on our results. There has been a suggestion that inadequate diversion in HD might increase the risk of cholangiocarcinoma. To date, in this series, that has not happened.

What is the better surgical treatment option for recurrent common bile duct stones?

Purpose

Repeating endoscopic retrograde cholangiopancreatography (ERCP) in patients with recurrent common bile duct (CBD) stones is problematic in many ways. Choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) are 2 surgical treatment options for recurrent CBD stones, and each has different advantages and disadvantages. The aim of this study was to compare the 2 surgical options in terms of the recurrence rate of CBD stones after surgical treatment.

Methods

This retrospective multicenter study included all patients who underwent surgical treatment due to recurrent CBD stones that were not effectively controlled by medical treatment and repeated ERCP between January 2006 and March 2015. We collected data from chart reviews and medical records. A recurrent CBD stone was defined as a stone found 6 months after the complete removal of a CBD stone by ERCP. Patients who underwent surgery for other reasons were excluded.

Results

A total of 27 patients were enrolled in this study. Six patients underwent CDS, and 21 patients underwent CJS for the rescue treatment of recurrent CBD stones. The median follow-up duration was 290 (180–1,975) days in the CDS group and 1,474 (180–6,560) days in the CJS group (P = 0.065). The postoperative complications were similar and tolerable in both groups (intestinal obstruction; 2 of 27, 7.4%; 1 in each group). CBD stones recurred in 4 patients after CDS (4 of 6, 66.7%), and 3 patients after CJS (3 of 21, 14.3%) (P = 0.010).

Conclusion

CJS may be a better surgical option than CDS for preventing further stone recurrence in patients with recurrent CBD stones.

Treatment of complex complications after choledochal cyst resection by multiple minimal invasive therapies: A case report

•

Complications after choledochal cyst resection are common, mainly anastomotic stricture, bowel obstruction, biliary fistula and pancreatic cyst remnant.

•

Reoperation is the optimal method for patients with pancreatic cyst remnant and hepaticojeju-nal anastomotic stricture.

•

ERCP, balloon dilation should be considered as a supporting tools to reduce the risk and mor-bidity of surgery.

Introduction

Choledochal cyst is a rare benign congenital dilation of the bile duct, which causes recurring disturbing symptoms without totally resection. Nonetheless, postoperative complications are still a common issue. A step up management for patients with complex complications is required to address the problem.

Case presentation

We report a 10-year-old child who suffered complex postoperative complications after choledochal cyst resection at the age of 5, including cholangitis, bilioenteric stenosis and cystolithiasis in remnant intrapancreatic duct cyst. She occasionally endured episodes of epigastric pain, fever and jaundice afterwards. As the symptoms and recurrent rate were worsen over time, the patient was admitted multiple times and various approaches (balloon dilation, percutaneous transhepatic biliary drainage, endoscopic retrograde cholangiopancreatography and laparoscopic surgery) were applied. Afterwards, patient recovered and discharged without any complications.

Conclusion

Our case presented sophisticated complications relating to choledochal cyst that were successfully treated by a combination of modern minimal invasive techniques. Despite operated by experienced surgeons, the post-op complications are still a concerned problem due to difficult laparoscopic techniques, injuries of hepatic artery, infection and risk of malignancy. We suggested that minimal-invasive procedures should be considered first with the aim of relieving symptoms, biliary drainage and preparing for the reoperation.

Biliary Reconstruction by Isolated Jejunal Interposition Loop: Our Experience after Excision of Choledochal Cyst

BACKGROUND

Choledochal cyst is a fairly common hepatobiliary condition in pediatric surgical practice. For the most common type (type I), it is well established that the total excision of the cyst with an wide biliary-enteric anastomosis is key for long-term good result. Multiple options remain for biliary-enteric reconstruction after excision. Jejunal interposition loop reconstruction is thought to be the most physiologic.

MATERIALS AND METHODS

We have retrospectively reviewed the data of patients of type I choledochal cysts which were operated between January 2010 and September 2018 and undergone jejunal interposition loop reconstruction. Clinical presentation, investigations, operative procedure morbidity and complications were reviewed.

RESULTS

There were 33 patients, with a male-to-female ratio of 1:3 and a mean age of 4.63 years (mean ± standard deviation [SD] = 4.63 ± 2.98 years). The follow-up period ranged from 3 to 81 months (mean ± SD = 36.30 ± 19.24 months). There was no stricture or cholangitis. Reoperation required in one due to leak at biliary-enteric anastomosis leading to biliary peritonitis. One each had pancreatitis and prolonged ileus. Two bile leaks stopped spontaneously. Operative time and postoperative hospital stay were 228.78 ± 40.43 min (mean ± SD) and 8.96 ± 3.63 days (mean ± SD), respectively.

CONCLUSION

Jejunal interposition loop reconstruction is safe and reproducible with acceptable morbidity. However, if this procedure is abandoned, the long-term benefits may remain ever elusive.

Choledochal cyst mimicker-When small bowel length matters

•

The diagnosis and treatment of choledochal cysts (and conditions mimicking choledochal cysts) may prove difficult in patients with short bowel syndrome.

•

Laparoscopic bile duct excision and reconstruction is a feasible and safe approach to bile duct excision in experienced hands.

•

Hepatico-duodenostomy should be considered a safe alternative for biliary reconstruction in individuals with limited material for conduit.

Objective

Due to the risk of malignancy, the established management of choledochal cysts mandates bile duct excision and biliary reconstruction. While the reconstructive procedure of choice for most surgeons has traditionally been hepatico-jejunostomy, this may not be feasible in selected cases due to immobility or inadequacy of the jejunum. The following case will outline the management of a 32-year-old woman with short bowel syndrome, who was diagnosed with choledocholithiasis and a type 1 choledochal cyst.

Method and materials

As a child, our patient suffered midgut volvulus secondary to malrotation which resulted in extensive bowel resection and developed short bowel syndrome. She presented with recurrent bouts of cholangitis. Imaging of her biliary tree confirmed common duct stones extending into the branched hepatic ducts, as well as a fusiform dilatation of the common bile duct, that appeared consistent with a type 1 choledochal cyst. Laparoscopic excision of the cyst with reconstruction using a hepatico-duodenostomy was planned.

Results

The patient underwent successful laparoscopic cholecystectomy, CBD clearance with excision of the bile duct and reconstruction with hepatico-duodenostomy. Recovery was uneventful and she is asymptomatic on subsequent follow-up. Histology is consistent with a markedly dilated bile duct rather than a choledochal cyst.

Conclusions

This case illustrates the dilemma of diagnosis and treatment of a dilated bile duct mimicking a choledochal cyst in the setting of short bowel syndrome and the feasibility of a laparoscopic approach in such cases. Also, it demonstrates that hepatico-duodenostomy may be a safe alternative in cases with limited material for conduit.

Imaging of Pancreaticobiliary Maljunction

Pancreaticobiliary maljunction (PBM) is a congenital malformation in which the pancreatic and bile ducts join outside the duodenal wall, usually forming a long common channel. A major issue in patients with PBM is the risk of biliary cancer. Because the sphincter of Oddi does not regulate the pancreaticobiliary junction in PBM, pancreatic juice frequently refluxes into the biliary tract and can cause various complications, including biliary cancer. Most cancers arise in the gallbladder or dilated common bile duct, suggesting that bile stasis is related to carcinogenesis. Early diagnosis and prophylactic surgery to reduce the risk of cancer are beneficial. The diagnosis of PBM is made mainly on the basis of imaging findings. The development of diagnostic imaging modalities such as multidetector CT and MR cholangiopancreatography has provided radiologists with an important role in diagnosis of PBM and its complications. Radiologists should be aware of PBM despite the fact that it is rare in non-Asian populations. In this review, the authors present an overview of PBM with emphasis on diagnosis and management of PBM and its complications. For early diagnosis, the presence of extrahepatic bile duct dilatation or gallbladder wall thickening may provide a clue to PBM with or without biliary dilatation, respectively. The pancreaticobiliary anatomy should be closely examined if imaging reveals these findings. Radiologists should also carefully evaluate follow-up images in PBM patients even years after prophylactic surgery because residual bile ducts remain at risk for cancer.^©RSNA, 2020.

Correctable biliary atresia and cholangiocarcinoma: a case report of a 63-year-old patient

Background

Although cancer occurrence following surgery for biliary atresia has gradually increased, the development of cholangiocarcinoma in a native liver survivor of biliary atresia is extremely rare.

Case presentation

A 3-month-old female patient with the correctable type of biliary atresia underwent a cystoduodenostomy. At 16 years of age, she underwent multiple surgeries including lysis of intestinal adhesions, ileostomy, and gastrojejunostomy at another hospital. At 54 years of age, she underwent lithotomy at the porta hepatis, resection of the residual cystic bile duct with gallbladder, and hepaticojejunostomy in Roux-en-Y fashion. As she approached the age of 63, her computed tomography scan showed no liver tumors. In the following year, she developed cholangiocarcinoma at the porta hepatis and underwent chemotherapy. However, the cancer progressed, and she died before she reached the age of 64 years.

Conclusions

Cholangiocarcinoma is extremely rare in patients with biliary atresia. However, physicians should follow up patients with biliary atresia as closely as possible, as malignant tumors secondary to biliary atresia may increase in number in the near future because of the growing number of long-term survivors with biliary atresia.

Comparison between hepaticojejunostomy and hepaticoduodenostomy after excision of choledochal cyst in children: a cohort study

Objective

Hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD) are commonly used biliary reconstruction techniques after choledochal cyst excision. HD has been suggested to be a more physiologic alternative during reconstruction. The objective of this study is to compare operative time, hospital stay, morbidity (leak, cholangitis, ileus, and obstruction), and mortality between HJ and HD after cyst excision.

Methods

This is a 14-year retrospective cohort study of pediatric patients (≤18 years old) who underwent choledochal cyst excision and subsequent biliary reconstruction at the Philippine Children’s Medical Center. Data were taken from inpatient charts, operative technique, OPD logbook, readmission, and OPD charts.

Results

There were 122 patients: 56% HD and 44% HJ. Majority were female (72%), with 1:2.6 male to female ratio. The average age was 36.1 months, with a mean follow-up of 32.8 months (range 6 months–14 years). The most common cyst was type I (87%). Operative time was longer for HJ compared with HD (321.3 vs 203.6 min; p=0.000). Hospital stay was longer with HJ compared with HD (7.7 vs 6.8 days; p=0.002). Mortality rate was low at 1.6% while morbidity was at 13.9% in both groups. Although morbidity was higher among those who underwent HD, there was no significant difference between the two procedures. Anastomotic leak (4%) and cholangitis (7.4%) were observed in HD, and ileus (7.4%) was observed in the HJ group.

Conclusions

In our series, HD provided less operative time and hospital stay than with HJ. We did not observe bile gastritis after HD as compared with others. It is suggested that longer follow-up is needed to confirm such findings.

Choledochal malformations: global research, scientific advances and key controversies

Choledochal malformations (CMs) represent a spectrum of relatively rare and complex congenital anomalies, characterized by abnormal dilatation of the biliary tract in the absence of any acute obstruction. Today, almost 20% of CMs can be detected in-utero using maternal ultrasonography. Formal scientometric analysis was used to identify where modern CM research is taking place and perhaps where our attention should be directed in the future. Thus, this article offers a comprehensive review of recent scientific advances relating to CMs including the current understanding of etiology and classification, whilst also discussing key controversies such as risk of malignant transformation and the role of newer modalities of surgical treatment. Although laparoscopic excision of CMs and biliary reconstruction is nowadays feasible and safe, care should be taken before dispensing with standard open techniques, which have minimal complication rates and proven long-term benefit.

Duodenogastric regurgitation in hepaticoduodenostomy after excision of congenital biliary dilatation (choledochal cyst)

PURPOSE

We examined the clinical significance of duodenogastric regurgitation (DGR) as a late complication in the long-term follow-up after hepaticoduodenostomy (HD) as a reconstruction surgery for congenital biliary dilatation (CBD).

METHODS

Seventeen patients with CBD were retrospectively analyzed for late complications (mean follow-up, 16.8 years). All patients had undergone total resection of the extrahepatic bile duct followed by HD. DGR was identified using endoscopic examination, intraluminal bile monitoring, and liver scanning.

RESULTS

DGR was found in all 17 patients by endoscopic examination and intraluminal bile monitoring. Fourteen of the 17 (82.4%) patients with DGR had experienced abdominal symptoms since a mean of 6.9 years postoperatively. Liver scanning also revealed apparent DGR in all 14 symptomatic patients. We converted 7 of the 14 patients to hepaticojejunostomy reconstruction at a mean of 13.0 years after the initial excisional surgery. Their symptoms were completely relieved postoperatively.

CONCLUSIONS

DGR is an important complication after HD. Examination of patients for the development of DGR is an essential part of long-term follow-up in patients with CBD who have undergone HD as a reconstruction surgery. Conversion surgery is recommended in patients with DGR accompanied by long-term abdominal symptoms.

LEVELS OF EVIDENCE

Level IV.

Laparoscopic management of choledochal cysts: is a keyhole view missing the big picture?

In recent years, numerous articles have promoted laparoscopic surgical treatment of choledochal cysts in children. Most of these reports assert that laparoscopic excision and biliary reconstruction are as safe as open surgery and achieve equivalent or better results. However, these conclusions are based on retrospective analyses with median follow-up periods that rarely exceed 5 years. Closer scrutiny of the laparoscopic literature indicates that the optimum procedure for treating type I and most type IVa choledochal cysts, namely radical excision of the extrahepatic bile ducts and reconstruction by wide hilar hepaticoenterostomy, preferably hepaticojejunostomy, is not being carried out in most cases. Performing a less radical excision exposes patients to a greater long-term risk of a bilioenteric stricture and its complications and malignant change in residual extrahepatic bile ducts. Currently, the long-term outcomes of surgery for choledochal cysts are being eclipsed by the short-term gains of laparoscopic techniques. The prime objective in the surgical management of choledochal cysts is the long-term health of the patient; laparoscopic techniques are simply another method of performing the surgery and they should not become the standard of care unless long-term outcomes are similar to best practice open surgery.

Japanese clinical practice guidelines for congenital biliary dilatation

Until now, there have been no practical clinical guidelines for congenital biliary dilatation (CBD). In this review article, the Japanese Study Group on Congenital Biliary Dilatation (JSCBD) propose to establish clinical practice guidelines for CBD. Because the evidence-based literature is relatively small, we decided to create guidelines based on the consensus of experts, using the medical literature for reference. A total of 20 clinical questions (CQs) were considered by the members of the editorial committee responsible for the guidelines. The CQs included the distinct aspects of CBD: (1) Concepts and Pathology (three CQs); (2) Diagnosis (six CQs); (3) Pancreaticobiliary Complications (three CQs); Treatments and Prognosis (eight CQs). Each statements and comments for CQs were made by the guidelines committee members. CQs were finally approved after review by members of the editorial committee and the guidelines evaluation board of CBD. These guidelines were created to provide assistance in the clinical practice of CBD management; their contents focus on clinical utility, and they include general information on CBD to make this disease more widely recognized.

Biliary-enteric reconstruction with hepaticoduodenostomy following laparoscopic excision of choledochal cyst is associated with better postoperative outcomes: a single-centre experience

BACKGROUND

With the advent of laparoscopic surgery, more choledochal cysts are excised laparoscopically. In this study, we compared the outcomes from laparoscopic hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD) for biliary-enteric reconstruction.

METHODS

A retrospective analysis of patients who had undergone laparoscopic choledochal cyst excision between February 2005 and January 2014 in a tertiary referral centre was performed. Demographics data, operative techniques and surgical outcomes were analysed according to the way of biliary-enteric reconstruction.

RESULTS

A total of 31 patients were identified, 20 of whom underwent HJ and 11 underwent HD. There were no significant differences in terms of demographics. Median operative time was significantly shorter in HD group (211.0 ± 96.4 vs. 386.0 ± 90.4 min, p = 0.001). Although postoperative enteral feeding was initiated later in HD group (5.0 ± 0.8 vs. 4.0 ± 3.6 days, p = 0.036), postoperative stay in intensive care unit (ICU) (0.7 ± 1.0 vs. 2.4 ± 1.7 days, p = 0.007) and overall hospital stay (9.1 ± 1.0 vs. 14.4 ± 12.2 days, p = 0.157) favoured HD group. There was no perioperative mortality. Median follow-up duration was 24.0 (±11.0) months in HD group and 67.5 (±23.7) months in HJ group. One patient in HJ group had postoperative cholangitis related to anastomotic stricture whereas no cholangitis noted in HD group. In total, five patients in HJ group required second operation for complications and residual diseases whereas none in HD group required reoperation.

CONCLUSIONS

Laparoscopic excision of choledochal cyst with hepaticoduodenostomy reconstruction is safe and feasible with shorter operative time, ICU stay and overall hospital stay. It is not inferior to HJ in terms of short-term postoperative outcomes.

Mid-term Outcomes of Laparoscopic Versus Open Choledochal Cyst Excision in a Tertiary Paediatric Hospital

Introduction: Paediatric laparoscopic choledochal cyst excision has increasingly gained acceptance as an alternative to open excision. Laparoscopic excision is feasible and safe in the short term, but long-term outcomes are not as well established. KK Women’s and Children’s Hospital started performing laparoscopic choledochal cyst excision in children since 2007. In this paper, we report our experience with the laparoscopic approach, and the early and mid-term outcomes in comparison with the conventional open approach. Materials and Methods: Thirty-five consecutive cases by a single surgeon between May 2006 and April 2012 were retrospectively reviewed. Patient characteristics and surgical outcomes were analysed. Results: There were 13 laparoscopic and 22 open cases. Baseline patient characteristics were similar. Operative time was longer in the laparoscopic group. Three cases in the laparoscopic group were converted to open in our early experience. There were no differences in time to feeds or length of hospitalisation. One laparoscopic case developed minor bile leak that resolved on conservative management. There were no complications in the laparoscopic group on median follow-up of 35 months. In the open group, there was 1 case of pancreatitis, cholangitis, and hypertrophic scarring respectively. There were 3 cases of suspected adhesive colic that resolved without surgery. Conclusion: Laparoscopic choledochal cyst excision enjoys excellent early and mid-term outcomes compared to open excision, even in centres with smaller patient volume. It should be the approach of choice where technical expertise is available. Key words: Hepaticojejunostomy, Minimally invasive, Postoperative outcomes

Hepaticoduodenostomy versus hepaticojejunostomy after resection of choledochal cyst: a systematic review and meta-analysis

BACKGROUND

Excision has been established as a standard management practice for choledochal cysts in the last few decades. The two most commonly performed methods of reconstruction after excision are hepaticoduodenostomy (HD) and Roux-en-Y hepaticojejunostomy (HJ), of which the HJ is favored by most surgeons. Evidence concerning the optimal method of reconstruction is, however, sparse.

MATERIALS AND METHODS

Studies comparing outcomes from HD and HJ after choledochal cyst excision were identified by searching Medline, Ovid, Search Medica, Elsevier Clinicalkey, Google Scholar and Cochrane library. Suitable studies were chosen and data extracted for meta-analysis. Outcomes evaluated included operative time, hospital stay and incidence of postoperative bile leak, cholangitis, reflux/gastritis, anastomotic stricture, bleeding, intestinal obstruction and re-operative rate. Pooled odds ratios (OR) were calculated for dichotomous variables; pooled mean differences (MD) were measured for continuous variables.

RESULTS

Six retrospective studies were included in this meta-analysis, comprising a total of 679 patients, 412 of whom (60.7%) underwent HD, and the remainder, 267 (39.3%) underwent HJ. Although, HD group had slightly shorter hospital stay (MD: 0.30; 95% CI: -0.22-0.39; P < 0.00001) it showed a higher incidence of postoperative reflux/gastritis (OR: 0.08; 95% CI: -0.02-0.39; P = 0.002). However, the other outcomes such as bile leak, cholangitis, anastomotic stricture, bleeding, operative time, reoperation rate and adhesive intestinal obstruction did not differ between HD and HJ groups.

CONCLUSIONS

HD shows higher postoperative reflux/gastritis than HJ but a shorter hospital stay. There are few good-quality studies that compare the outcomes from HD and HJ, meaning that caution should be exercised in the generalization of the results of this meta-analysis, which suggests HD to be comparable with HJ in terms of other complications, operative benefits and outcomes.

Role of laparoscopy in treatment of choledochal cysts in children

Laparoscopy enables surgeons to approach the surgical conditions from a new perspective. Laparoscopic surgery has revolutionized the treatment of choledochal cysts (CDC). Yet, this new technique requires objective evaluations. We have examined the controversies about the CDC dissection, distal common bile duct ligation, ductoplasty for hepatic duct stenosis, intrahepatic duct and common channel protein plug clearance, timing of surgery for antenatally diagnosed CDC, and the Roux loop length in CDC children. In the hands of experts, laparoscopic excision of the cyst and Roux-en-Y hepaticojejunostomy is a safe and effective approach. We provide our opinions on these issues based on our experience and publications. We conclude that the main outcomes comparable to those of the open surgery. The better wound cosmesis and reduction of surgical trauma are the advantages.

Japanese clinical practice guidelines for pancreaticobiliary maljunction

There have been no clinical guidelines for the management of pancreaticobiliary maljunction (PBM). The Japanese Study Group on Pancreaticobiliary Maljunction (JSPBM) has proposed to establish clinical practice guidelines on how to deal with PBM, with the support of the Japan Biliary Association (JBA). Because the body of evidence-based literature is relatively small, we decided to create guidelines based on the consensus of experts, using the medical literature for reference. A total of 46 clinical questions (CQs) were considered by the members of the editorial committee responsible for the guidelines. The CQs covered distinct aspects of PBM: (1) Concepts and Pathophysiology (10 CQs); (2) Diagnosis (10 CQs); (3) Pancreatobiliary complications (9 CQs); and (4) Treatments and prognosis (17 CQs). Statements and comments for each CQ were prepared by the guidelines committee members and collaborating partners. The CQs were completed after review by members of the editorial committee, meetings of this committee, public comments on the homepages of the JSPBM and the JBA, public hearings, and assessment and approval by the guidelines evaluation board. PBM includes cases where the bile duct is dilated (PBM with biliary dilatation) and those in which it is not (PBM without biliary dilatation). In these guidelines, PBM with biliary dilatation is defined as being identical to congenital biliary dilatation of Todani type I (except for type Ib) and type IV-A, both of which are accompanied by PBM in almost all cases. These guidelines are created to provide assistance in the clinical practice of PBM management; their contents focus on clinical utility, and they include general information on PBM to make this disease more widely recognized.

[Hepatobiliary anastomosis techniques]

The success of hepatobiliary anastomoses is influenced by the diameter of the bile duct, the location within the biliary tract, the situation of primary or revision surgery and accompanying infections. The exact preoperative diagnostics of the anatomy of the biliary tract are indispensable for low complication rates. Within reconstructive surgery, hepaticojejunostomy has been established as the standard technique and a biliodigestive anastomosis is performed proximal to the cystic duct and 2-3 cm below the fork in the hepatic duct. In general, end-to-end anastomoses of the common bile duct are not recommended due to the high risk for stenosis. Within the liver hilus an exact preparation of all tubular structures is mandatory. With regard to possible perioperative complications operations on the hepatic duct or segmental bile ducts should be performed in specialized centers. Methods of drainage in hepatobiliary surgery are percutaneous transhepatic cholangiodrainage (PTCD), internal-external drainage, internal drainage with endoscopic or surgically placed stents, external-internal-external drainage and the T-drain.

Hepaticoduodenostomy vs hepaticojejunostomy for reconstruction after resection of choledochal cyst

PURPOSE

Roux-en-Y hepaticojejunostomy (HJ) is currently the favored reconstructive procedure after resection of choledochal cysts. Hepaticoduodenostomy (HD) has been argued to be more physiologically and technically easier but is feared to have associated complications. Here we compare outcomes of the 2 procedures.

METHODS

A retrospective chart review identified 59 patients who underwent choledochal cyst resection within our institution from 1999 to 2009. Demographic and outcome data were compared using t tests, Mann-Whitney U tests, and Pearson χ(2) tests.

RESULTS

Fifty-nine patients underwent repair of choledochal cyst. Biliary continuity was restored by HD in 39 (66%) and by HJ in 20 (34%). Open HD patients required less total operative time than HJ patients (3.9 vs 5.1 hours, P = .013), tolerated a diet faster (4.8 days compared with 6.1 days, P = .08), and had a shorter hospital stay (7.05 days for HD vs 9.05 days for HJ, P = .12). Complications were more common in HJ (HD = 7.6%, HJ = 20%, P = .21). Three patients required reoperation after HJ, but only one patient required reoperation after HD for a stricture (HD = 2.5%, HJ = 20%, P = .037).

CONCLUSIONS

In this series, HD required less operative time, allowed faster recovery of bowel function, and produced fewer complications requiring reoperation.

Laparoscopic repair for choledochal cyst: lessons learned from 190 cases

OBJECTIVE

The aim of this study is to report the technical details, early outcomes, and lessons learned from laparoscopic repair of 190 cases of choledochal cyst.

METHOD

The operation was performed using 4 ports. The cystic duct was identified and divided. The liver was elevated by 2 stay-sutures: one on the round ligament and the other on the distal cystic duct. The choledochal cyst was isolated and removed completely, and then biliary-digestive continuity was reestablished.

RESULTS

From January 2007 to April 2009, 190 patients were operated on. There were 144 girls and 46 boys. Ages ranged from 2 months to 16 years (mean, 46.9 +/- 29.3 months). Cyst diameter ranged from 10 to 184 mm. A total of 106 patients were classified as Todani type I cysts, and 84 were type IV. Cystic excision and hepaticoduodenostomy were performed in 133 patients and hepaticojejunostomy in 57 patients. The operating time varied from 70 to 505 minutes (mean, 186 minutes). Conversion to open surgery was required in 2 patients. Intraoperative blood transfusion was required in 4 patients. There were no perioperative deaths. Postoperative anastomotic leakage occurred in 7 patients, resolving spontaneously in 6 and requiring a second operation in 1. Postoperative hospital stay ranged from 5 to 27 days (mean, 7.2 +/- 3.3 days). Follow-up occurred between 1 and 24 months postdischarge (mean, 9 +/- 2.2 months) and was obtained in 161 patients (84.7%). Of these patients, cholangitis occurred in 4 patients (2.4%).

CONCLUSION

Laparoscopic repair is a safe and effective procedure for choledochal cyst.

Laparoscopic complete cyst excision and hepaticoduodenostomy for choledochal cyst: early results in 74 cases

OBJECTIVE

To report the technical details and early outcomes of complete laparoscopic cyst excision and hepaticoduodenostomy for choledochal cyst.

METHODS

The operation was performed using four ports. The cystic duct was identified and divided. The liver was elevated by two stay sutures: one on the round ligament, and the other on the distal cystic duct. The choledochalcyst was isolated and removed completely and the duodenum was mobilized. Hepaticoduodenostomy was constructed 2 cm distal to the pylorus using two running sutures with 5-0 polydioxane sutures.

RESULTS

From January to December 2007, 74 patients were operated. There were 59 girls and 15 boys. Ages ranged from 2.5 months to 16 years old. The diameter of the cyst ranged from 10 mm to 184 mm. The operating time ranged from 90 minutes to 340 minutes (mean: 186 minutes). Conversion to open surgery was required in one patient. Blood transfusion was required in four patients. Postoperative anastomotic leakage occurred in three patients, resolving spontaneously in two patients and requiring a second operation in the third.Postoperative hospital stay ranged from 4 days to 21 days (average: 6.6 days). Follow-up from 3 months to 12 months was obtained in 56 patients (75.5%). Of these patients, cholangitis occurred in three patients (5.3%) and gastritis due to bilious reflux in eight patients (14.3%).

CONCLUSION

Laparoscopic complete cyst excision and hepaticoduodenostomy is a safe and physiologic procedure for choledochal cyst.

Choledochal cysts in infancy and childhood

OBJECTIVE

To study the clinical presentation, management and results of treatment of 41 consecutive cases of choledochal cyst (CC) managed from 1999 to 2006.

METHODS

The age of the patients ranged from 20 days to 11 years. Eleven cases were 1 year or less in age (infantile group) and 30 patients were more than 1 year old (classical pediatric group). Children less than 1 year old presented with jaundice (72%), hepatomegaly (54%) and clay-colored stools (63%); whereas those above one year in age presented with pain (83.3%) and jaundice (47.6%). Three cases had biliary perforation with localized or generalized biliary peritonitis. Ultrasonography (US) diagnosed/suggested CC in all 41 patients, however, contrast-enhanced computed tomographic (CECT) scan (n=12), radionuclide DISIDA scan (n=5) and magnetic resonance cholangiopancreatogram (MRCP) (n=3) also contributed to the diagnosis. 19 patients, including 4 from the 'infantile' group, had significant dilatation of intrahepatic biliary ducts.

RESULTS

Nine patients from the 'infantile' group had cystic type I CC (type Ic), while 2 patients had fusiform dilatation of the common bile duct (type If disease). In contrast, 21 of the older patients had type If disease while 9 had type Ic disease. Operative management included primary complete excision of the cyst with a Roux-en-Y hepaticodochojejunostomy (HDJ) (n=32), Lilly's modification of submucosal resection with a HDJ (n=8) and cyst excision with a hepaticodochoduodenostomy (HDD) (n=1). All 3 patients with biliary perforation had primary excision of the CC with a HDJ. Unusual operative findings included accessory hepatic ducts (n=2), anteriorly placed common or right hepatic arteries (n=3) and partially or completely blocked proximal extrahepatic bile ducts (n=3). There were 2 postoperative deaths, one had cirrhotic liver disease with portal hypertension, the other had deep icterus with poor general condition. Both patients succumbed to overwhelming sepsis. One patient required reexploration and refashioning of the HDJ for biliary leak. Short-term follow-up was satisfactory in all 39 patients.

CONCLUSION

Infants with CC constitute a distinct group with regard to clinical presentation and the pathological should be kept in mind while evaluating neonates and infants with cholestatic jaundice and older children with recurrent abdominal pain. Primary excision of the cyst with a HDJ provides satisfactory results in the management of the vast majority of cases of CC including those in infants, massive CC and in the presence of biliary perforation and peritonitis.

Wide hilar hepaticojejunostomy: the optimum method of reconstruction after choledochal cyst excision

Standard reconstruction after choledochal cyst excision is by Roux-en-Y hepaticojejunostomy to the common hepatic duct. Long-term follow up studies have shown a 10% incidence of late complications, including anastomotic stricture. By extending the bilio-enteric anastomosis along the left hepatic duct, a wide hilar bilio-enteric anastomosis is created which may help to minimize late anastomotic complications. Forty-one consecutive patients (24 girls, 18 infants) with a median age of 2.3 years (range 44 days to 15.6 years) and median weight 11.5 kg (range 2.1-59 kg) underwent radical choledochal cyst excision with a wide hilar hepaticojejunostomy. Thirty-eight were followed-up both clinically and by ultrasound scan and biochemical liver function tests for a median of 2.7 years (range 0.1-12.5 years). The median width of the hilar hepaticojejunostomy was 8 mm (range 6-25 mm) in 18 infants, and 15 mm (range 10-25 mm) in 22 older children. In one patient it was not measured. Only one surgical complication occurred--a self-limiting bile leak which settled spontaneously. Median postoperative stay was 6 days (range 5-21 days). No patient has had an episode of cholangitis or adhesive small bowel obstruction to date. Postoperative biochemical liver function tests have remained normal in all but one child (with pre-existing biliary cirrhosis). After radical resection of a choledochal cyst, a wide hilar hepaticojejunostomy is a, safe, effective and durable reconstructive technique that can be performed at any age and may help to minimize the long-term risk of complications.

A hepaticojejunostomy: technical errors with 'twists and turns'

Excision of a choledochal cyst followed by biliary reconstruction with a Roux-en-Y hepaticojejunostomy is the treatment of choice for type I and IV choledochal cysts. We present a rare complication which was identified 8 years after the original reconstructive surgery. Conventional imaging modalities failed to identify the pathology. Only a contrast enhanced CT scan supported by image rendering software allowed for the visualization of the underlying chronic obstruction of part of the mesentery.