Risk factors and outcomes of bile leak after laparoscopic surgery for congenital biliary dilatation

Laparoscopic Hepatic Ductoplasty in Pediatric Choledochal Cyst: What Is the Role, Feasibility, and Outcome?-Systematic Review and Meta-Analysis

Introduction: The pediatric choledochal cyst with hepatic duct stenosis occurs postoperative hepatolithiasis, recurrent cholangitis, or pancreatitis. The laparoscopic hepatic ductoplasty can prevent these incidences. Objectives: To determine the characteristic of hepatic duct stenosis, laparoscopic treatment, and outcomes in systematic review and meta-analysis. Methodology: We searched the published studies on PubMed, Scopus, and Cochrane Library databases from January 1985 to April 2022 in English language. This protocol was registered to PROSPERO (CRD42022332145). Results: Nine published studies and 412 patients were included. The meta-analysis revealed that the locations were the confluence of the left and right hepatic ducts 43.1%, the left or/and the right hepatic duct 8.3%, and the unclassified location 60.4%. These characteristics included a membranous/septum appearance (44.7%) and a circumferential/relative stenosis (22.7%). The laparoscopic techniques were the wide hilar Roux-en-Y hepaticojejunostomy (28.5%), the excision of membranes/septum (26.5%), and the mixed hepatic ductoplasty (45.0%). The outcomes revealed a minor bile leakage of 3.8% and minimal bleeding. The meta-analysis showed no statistical difference between laparoscopic and open techniques in hepatolithiasis (0% versus 2.00%), anastomosis stricture (4.83% versus 10.00%), and no recurrent cholangitis. There was no conversion rate but showed a trend the prolonged operating time in laparoscopy. Conclusion: Laparoscopic hepatic ductoplasty is safe and effective. The characteristics and location can be feasible laparoscopic procedures. So, hepatic ductoplasty decreases hepatolithiasis, anastomosis stricture, or recurrent cholangitis and may increase minor bile leakage. The systematic review registration was PROSPERO system with CRD42022332145.

Variations of the hepatic artery and bile duct in patients with pancreaticobiliary maljunction: Impact on postoperative outcomes

PURPOSE

Preoperative comprehension of the anatomical variations of the hepatic artery and bile duct is essential for safe laparoscopic surgery for pancreaticobiliary maljunction (PBM). This study aimed to investigate the impact of anatomical variations of the hepatic artery and bile duct on surgical technique and postoperative complications.

METHODS

We conducted a retrospective review of patients with PBM who underwent laparoscopic surgery at our institution between January 2014 and December 2022 to investigate anatomical variations in the hepatic artery and bile duct, surgical technique, and postoperative complications.

RESULTS

We included 112 patients with PBM, with a median age of 4 years (interquartile range, 0-55). Overall, 29 of 112 patients had an aberrant right hepatic artery (ARHA) running ventral to the common hepatic duct (CHD), and they underwent hepaticojejunostomy on the ventral side of the ARHA. Additionally, eight of 112 patients had an aberrant posterior hepatic duct (APHD), which was joined to the CHD in all but one case. The presence of APHD was associated with postoperative bile leak occurrence.

CONCLUSION

Performing hepaticojejunostomy ventral to the ARHA is important to prevent complications. Furthermore, APHD may be a risk factor for postoperative bile leak and requires careful bile duct plasty.

Risk factors for the development of biliary tract infection after choledochal-malformation surgery

OBJECTIVE

To explore the risk factors of biliary tract infection after bile duct dilatation surgery.

METHODS

The study included 135 patients with choledochal malformation after bile duct dilatation surgery at our hospital from January 2019 to June 2021. We analyzed general data of infected and uninfected groups after bile duct dilatation surgery. Single/multiple factor logistic regression was used to analyse the factors influencing postoperative biliary tract infection in bile duct dilatation.

RESULTS

There were statistically significant differences in preoperative history of biliary tract infection, partial hepatectomy, hilar anastomosis, and Todani staging between the two groups. Single factor Logistic regression analysis showed that preoperative history of biliary tract infection, partial hepatectomy, hepatic portal anastomosis and Todani staging IV and V were positively correlated with postoperative biliary tract infection following biliary duct dilatation (P＜0.05). In addition, logistic regression analysis of these general data with differential indicators as independent variables and postoperative biliary tract infection in biliary duct dilatation as a dependent variable showed that history of preoperative biliary tract infection and hepatic portal anastomosis were risk factors of postoperative biliary tract infection following biliary duct dilatation.

CONCLUSION

Risk factors of biliary tract infection after bile duct dilatation include a history of preoperative biliary tract infection and hepatoportal anastomosis, which should be noted during clinical procedures to prevent or reduce the development of biliary tract infection after bile duct dilatation.

The Role of Laparoscopic Treatment of Choledochal Malformation in Europe: A Single-Center Experience and Review of the Literature

BACKGROUND

 Numerous studies from Asian countries, including large collectives, have reported excellent results after laparoscopic resection of choledochal malformation (CM). However, the role of laparoscopic CM resection is still controversial outside Asia. We aimed to analyze the outcome of laparoscopic CM resection in our institution and to compare our outcome with the data reported in the literature.

METHODS

 All patients who underwent laparoscopic CM resection in our pediatric surgical department from 2002 to 2019 were retrospectively analyzed for surgical details and postoperative complications, which were graded according to the Clavien-Dindo classification. A systematic literature search identified all reports on over 10 cases of laparoscopic pediatric CM resection and surgical details, follow-up, and complication rates were extracted.

RESULTS

 Fifty-seven patients (72% female) with a mean age of 3.6 + 4.1 years underwent laparoscopic CM resection in our department. Conversion rate was 30%. Total complication rate was 28%. The rate of major complications (Clavien-Dindo grade III or more) was 16% and included stricture of the biliodigestive or enteric anastomosis (n = 4), adhesive ileus (n = 3), portal vein thrombosis (n = 1), and recurrent cholangitis with consecutive liver transplantation (n = 1). With increasing experience, complication rates decreased. The majority of publications on laparoscopic CM resections originated from Asia (n = 36) and reported on low complication rates. In contrast, publications originating from non-Asian countries (n = 5) reported on higher complications following laparoscopic CM resection.

CONCLUSION

 Our data indicate that laparoscopic CM resection can be safely performed. The learning curve in combination with the low incidence calls for a centralization of patients who undergo laparoscopic CM resection. There seems to be a discrepancy on complications rates reported from Asian and non-Asian countries following laparoscopic CM resection.

How we acquire suturing skills for laparoscopic hepaticojejunostomy

Laparoscopic choledochal cyst excision and hepaticojejunostomy is a representative surgical procedure requiring laparoscopic suturing including needle driving and knot tying. Laparoscopic needle driving and knot tying is a highly technically demanding skill, especially in small infants and children. We developed a laparoscopic hepaticojejunostomy simulator for training. This simulator was developed for a 1-year-old infant body size based on computed tomography data and reproduced a pneumoperitoneum condition based on 3D scanner data of the clinical situation. Surgeon in training (SITs) of our institution have to acquire practice of laparoscopic hepaticojejunostomy using a simulator before performing clinical cases. Thirteen cases of choledochal cyst have been managed at our institution since the introduction of practice using this simulator in 2016. Six SITs performed 13 cases of laparoscopic choledochal cyst excision and hepaticojejunostomy. There were no cases of anastomotic bile leakage. Laparoscopic disease-specific simulator practice is effective for the acquisition of secure hepaticojejunostomy skills for the treatment of choledochal cysts in children as off-the-job training.