Laparoscopic management for aberrant hepatic duct in children with choledochal cysts

Laparoscopic choledochal cyst excision and biliary reconstruction in patients with previous surgery/ intervention: Feasibility and outcome

INTRODUCTION

The aim of the study was to evaluate the feasibility and outcome of laparoscopic surgery in complicated choledochal cyst (CDC) with previous interventions (laparotomy or biliary drainage).

PATIENTS AND METHODS

Patients with CDC who underwent surgery from July 2014 to July 2019 were evaluated. CDC without previous interventions (Group A) was compared with CDC that had previous interventions (Group B) to assess the feasibility and outcome of laparoscopic surgery.

RESULTS

In 5 years' period, 38 patients were operated for CDC. The mean age was similar in both groups (3.78 ± 2.27 in Group A and 4.08 ± 2.73 in Group B). Out of six CDC with previous intervention (Group B), five patients were previously managed at other institutions as follows: (1) Laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) stenting. (2) Laparotomy for biliary peritonitis and ERCP. (3) Percutaneous drainage of the large cyst. (4) Laparoscopic cholecystectomy. (5) ERCP stenting. (6) Percutaneous drainage for biliary ascites. All patients underwent laparoscopic CDC excision and hepatico-duodenostomy. The mean duration of surgery was 160.3 ± 17.22 in Group A and 169.2 ± 17.5 in Group B ( P = 0.258). None required intraoperative blood transfusion. None had a bile leak. Drain was removed at 4.47 ± 0.98 in Group A, while at 4.17 ± 0.75 days in Group B ( P = 0.481). There was statistically no significant difference in feed starting time or length of stay. In follow-up of 6 months-3 years, all patients are asymptomatic.

CONCLUSIONS

Laparoscopy in complicated CDC with previous intervention is technically tedious but is feasible. The procedure is safe and delivers a good outcome.

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.

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.

Robotic versus laparoscopic surgery for choledochal cyst in children with aberrant hepatic ducts: A retrospective study

BACKGROUND

The aim of this current study was to compare the safety and effectiveness between robotic and laparoscopic surgery in pediatric patients suffered from choledochal cysts associated with aberrant hepatic duct.

METHODS

Patients suffered from choledochal cysts associated with aberrant hepatic duct who were treated with laparoscopic or robotic procedures between January 2009 and June 2022 were retrospectively analyzed. The patients were divided into laparoscopic and robotic group according to different surgical methods. The data collected included the demographic information, imaging information, operative details and postoperative complications.

RESULTS

Twenty-two patients were included in the analysis consisting of 14 cases in laparoscopic group and 8 cases in robotic group. The male to female ratio was 1:6.33. The median age of the patients was 40.00 months with a mean weight of 16.99 kg. There were no significant differences in patient characteristics between the two groups. The operation and anesthesia time were significantly longer in the laparoscopic procedures group (238.14 ± 17.24 min, 265.93 ± 19.51 min, respectively) than robotic procedures group (208.00 ± 9.24 min, 230.13 ± 12.87 min, respectively) (p < 0.001). The time to take water and hospital stay were longer in laparoscopic group (3.33 ± 0.44 days, 8.92 ± 0.52 days, respectively) than robotic group (3.01 ± 0.22 days, 7.88 ± 1.13 days, respectively) (p < 0.05). There was no statistical difference in total complications between the two groups (p = 0.912).

CONCLUSIONS

Robotic surgery can achieve the same results as laparoscopic surgery in the management of patients suffered from choledochal cysts associated with aberrant hepatic duct, at the same time reducing the difficulty of operation and recovering faster.

Laparoscopic Kasai Procedure of Treating Biliary Atresia with an Aberrant Right Hepatic Artery

Background: An aberrant vascular anatomy might present a technical pitfall for biliary atresia (BA) surgery. The purpose of this study was to report the rare cases and discuss the significance and management strategy for BA with an aberrant right hepatic artery (ARHA) by laparoscopic Kasai procedure in children. Methods: The subjects for this study were 10 consecutive type III BA patients with an ARHA who had laparoscopic Kasai procedure at our institute between January 2012 and August 2021. The common bile duct was mobilized between the right hepatic artery and the right branch of portal vein, and then lifted to the liver hilum. The fibrous cord was transected and then the laparoscopic Kasai was carried out. Results: All patients survived the laparoscopic Kasai without any intraoperative complications. The mean operative time was 235 minutes for each laparoscopic Kasai. The mean follow-up time was 32.6 months. The total and direct bilirubin dropped to normal within 4 months of surgery in 7 patients. One patient died of repeated cholangitis and liver failure 1 year after surgery. In the additional 2 patients the bilirubin levels dropped significantly after the surgery but elevated again because of repeated cholangitis and requiring ongoing observation and intermittent treatment. Conclusions: With the perfect laparoscopic skills, the common bile duct could be safely mobilized between the right hepatic artery and right branch of portal vein for the infants with type III BA associated with an ARHA, and laparoscopic Kasai could be carried out safely and successfully.

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.

An essential technique for modern hepato-pancreato-biliary surgery: minimally invasive biliary reconstruction

Introduction: Minimally invasive reconstruction of the biliary tract is complex and involves multiple steps. The procedure is challenging and has been an essential technique in modern hepato-pancreato-biliary surgery in recent years. Additionally, the quality of the reconstruction directly affects long-and short-term complications and affects the prognosis and quality of life. Various minimally invasive reconstruction methods have been developed to improve the reconstruction effect; however, the optimal method remains controversial. Areas covered: In this study, were viewed published studies of minimally invasive biliary reconstruction within the last 5 years and discussed the current status and main complications of minimally invasive biliary reconstruction. More importantly, we introduced the current reconstruction strategies and technical details of minimally invasive biliary reconstruction, which may be potentially helpful for surgeons to choose reconstruction methods and improve reconstruction quality. Expert opinion: Although several improved and modified methods for biliary reconstruction have been developed recently, no single approach is optimal or adaptable to all situations. Patient-specific selection of appropriate technical strategies according to different situations combined with sophisticated and skilled minimally invasive techniques effectively improves the quality of anastomosis and reduces complications.