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Onishi S, Murakami M, Ishimaru T, Miyano G, Scholz S, Perger L, Yamada K, Pandya S, Ieiri S. Current Practice of Laparoscopic Surgery for Choledochal Cyst in Children -a Survey on Opinion and Experience Among IPEG Members. J Pediatr Surg 2024:161683. [PMID: 39218729 DOI: 10.1016/j.jpedsurg.2024.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 08/04/2024] [Accepted: 08/05/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Laparoscopic resection of choledochal cyst (CC) has become a popular approach. As the discussion about optimal treatment and technical strategies continues, we aimed to investigate perspectives of IPEG members. METHODS An online survey was conducted in 2023 on behalf of the IPEG Research Committee. IPEG members were asked to complete an anonymous questionnaire that included 36 items on the management of CC. RESULT 148 members responded to the survey (North America:49/Asia:44/Europe:23/South America:21/Others:11) and 116 completed all questions. Most surgeons (92.5%) operate on less than 5 cases annually. Diagnostic tools of choice were Magnetic Resonance Imaging (MRI, 95.9%) and ultrasonography (US, 74.5%). Regarding fusiform-type CC, operative indications were cyst size greater than 10 mm (68.9%), typical symptoms (78.5%), or anomalous pancreatico-biliary junction (63.8%). In unilateral intrahepatic biliary cysts (type IVa) cases, 81.3% of respondents do not perform a simultaneous liver resection with the initial cyst resection. While 22.0% resect the CC at diagnosis, even if asymptomatic, a larger group of surgeons (41%; 49/118) wait until the infant reaches six months. Intraoperative cholangiography and choledochoscopy are performed routinely by 38.9% and 13.7%, respectively. The majority (52.5%) ligates the common bile duct stump just below the CC. Laparoscopic reconstructions are performed by retrocolic hepatico-jejunostomy (48.3%) or hepatico-duodenostomy (45.8%) at similar rates, but when done open, 71.2% of respondents prefer retrocolic hepatico-jejunostomy. For the laparoscopic anastomosis, interrupted sutures with intracorporeal knot tying were most often utilized (48.3%). CONCLUSION Inidividual pediatric surgeons treat a small number of patients with CC each year. Laparosopic and open reconstruction techniques vary, likely due to technical challenges. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Shun Onishi
- Department of Pediatric Surgery, Kagoshima University, Kagoshima, Japan.
| | - Masakazu Murakami
- Department of Pediatric Surgery, Kagoshima University, Kagoshima, Japan
| | - Tetsuya Ishimaru
- Department of Pediatric Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Go Miyano
- Department of Pediatric Surgery, Juntendo Urayasu Hospital, Urayasu, Japan
| | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lena Perger
- Division of Pediatric Surgery, Department of General Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Koji Yamada
- Department of Pediatric Surgery, Kagoshima University, Kagoshima, Japan
| | - Samir Pandya
- Department of Surgery, UT Southwestern Medical Center Dallas, TX, USA
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Kagoshima University, Kagoshima, Japan.
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Ran T, Gong C, Rui D, Shan Z. Rhabdomyosarcoma of the biliary tract in a child: a case report. Front Pediatr 2024; 12:1436446. [PMID: 39170603 PMCID: PMC11335511 DOI: 10.3389/fped.2024.1436446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 07/24/2024] [Indexed: 08/23/2024] Open
Abstract
Pediatric rhabdomyosarcoma of the biliary tract (BRMS) is extremely rare. Here, we present a case of a 2-year-old child who was initially misdiagnosed with choledocholithiasis upon admission. The diagnosis was later confirmed as BRMS through endoscopic retrograde cholangiopancreatography (ERCP). The patient was cured through surgery followed by chemotherapy. Due to the lack of specific early symptoms and the challenges in imaging differentiation, particularly in pediatric patients, clinical awareness of this condition needs to be heightened. Our findings indicate that ERCP is currently the optimal diagnostic tool for this disease, and a combination of surgery and chemotherapy can yield better therapeutic outcomes.
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Affiliation(s)
- Tang Ran
- Department of Pediatric Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Chen Gong
- Shanghai Key Laboratory of Birth Defect, Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Dong Rui
- Shanghai Key Laboratory of Birth Defect, Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Zheng Shan
- Shanghai Key Laboratory of Birth Defect, Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
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3
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Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, Pakarinen MP, Losty PD. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open 2024; 8:zrae028. [PMID: 38776252 PMCID: PMC11110943 DOI: 10.1093/bjsopen/zrae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/30/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood. METHODS A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership. RESULTS This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer. CONCLUSION The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.
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Affiliation(s)
- Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Children Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Dina Fouad
- Department of Paediatric Surgery, Leicester Children’s Hospital, Leicester, UK
| | - Allan M Goldstein
- Department of Paediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Y Wong
- Department of Paediatric Surgery, Queen Mary’s Hospital, University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Ampaipan Boonthai
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pablo Lobos
- Department of Paediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mikko P Pakarinen
- The New Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, University of Southern Denmark, Odense, Denmark
| | - Paul D Losty
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Stern MV, Boroni G, Parolini F, Torri F, Calza S, Alberti D. Long-term outcome for children undergoing open hepatico-jejunostomy for choledochal malformations: a 43-year single-center experience. Pediatr Surg Int 2024; 40:36. [PMID: 38240939 DOI: 10.1007/s00383-023-05622-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/23/2024]
Abstract
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.
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Affiliation(s)
- M V Stern
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy.
| | - G Boroni
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Brescia, Italy
| | - F Parolini
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Brescia, Italy
| | - F Torri
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
| | - S Calza
- Department of Molecular and Translational Medicine, Unit of Biostatistics and Bioinformatics, University of Brescia, Brescia, Italy
| | - D Alberti
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Ma MKI, Chung PHY, Yeung F, Wong KKY. Analysing Factors Prolonging Hospital Stay After Excision of Choledochal Cyst-A Pathway Towards Enhanced Recovery After Surgery. World J Surg 2023; 47:3012-3019. [PMID: 37816975 DOI: 10.1007/s00268-023-07206-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/12/2023]
Abstract
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.
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Affiliation(s)
- Marco King In Ma
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Room 1540, Floor 15, Block K, Queen Mary Hospital, Pokfulam, Hong Kong, China
| | - Patrick Ho Yu Chung
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Room 1540, Floor 15, Block K, Queen Mary Hospital, Pokfulam, Hong Kong, China.
| | - Fanny Yeung
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Room 1540, Floor 15, Block K, Queen Mary Hospital, Pokfulam, Hong Kong, China
| | - Kenneth Kak Yuen Wong
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Room 1540, Floor 15, Block K, Queen Mary Hospital, Pokfulam, Hong Kong, China
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Nguyen SH, Abella M, Gutierrez JV, Tabak B, Puapong D, Johnson S, Woo RK. Robotic Surgery for Pediatric Choledochal Cysts: An American Case Series and Literature Review. J Surg Res 2023; 291:473-479. [PMID: 37531675 DOI: 10.1016/j.jss.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 06/01/2023] [Accepted: 06/25/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Choledochal cysts are rare congenital biliary cystic dilations. The US incidence rate varies between 5 and 15 cases per 1,000,000 people. In contrast, Asians, which are a large subset of the population of Hawaii, have an incidence of approximately one in every 1000 births. We report our experience with robot-assisted laparoscopic surgical management with biliary reconstruction of choledochal cysts which to date is the largest American case series to be reported. MATERIALS AND METHODS From 2006 to 2021, patients diagnosed with a choledochal cyst(s) at a tertiary children's hospital were retrospectively reviewed. Perioperative analysis was performed. Complications were defined as immediate, early, or late. The data underwent simple descriptive statistics. RESULTS Nineteen patients underwent choledochal cystectomy and hepaticoduodenostomy. Thirteen underwent a robotic approach while the rest were planned laparoscopic. Eighteen of 19 were female with 15/19 of Asian descent. The ages ranged from 5 mo to 21 y. Presenting diagnoses included jaundice, primary abdominal pain, pancreatitis, and cholangitis. Sixty eight percent had type 1 fusiform cysts while the rest were type 4a. Operative time and length of stay for robotic versus laparoscopic were 321 versus 267 min and 8.2 versus 17.3 d, respectively. For the robotic group, there was one immediate complication due to peritonitis. One-year follow-up revealed two patients requiring endoscopic retrograde cholangiopancreatography with dilation/stenting for an anastomotic stricture. There were no anastomotic leaks. CONCLUSIONS Robot-assisted laparoscopic choledochal cystectomy with hepaticoduodenostomy is associated with overall good outcomes with the most common long-term complication being anastomotic stenosis.
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Affiliation(s)
- Scott H Nguyen
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii.
| | | | | | - Benjamin Tabak
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii
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Kalayarasan R, Sai Krishna P. Minimally invasive surgery for post cholecystectomy biliary stricture: current evidence and future perspectives. World J Gastrointest Surg 2023; 15:2098-2107. [PMID: 37969703 PMCID: PMC10642471 DOI: 10.4240/wjgs.v15.i10.2098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 10/27/2023] Open
Abstract
Postcholecystectomy bile duct injury (BDI) remains a devastating iatrogenic complication that adversely impacts the quality of life with high healthcare costs. Despite a decrease in the incidence of laparoscopic cholecystectomy-related BDI, the absolute number remains high as cholecystectomy is a commonly performed surgical procedure. Open Roux-en-Y hepaticojejunostomy with meticulous surgical technique remains the gold standard surgical procedure with excellent long-term results in most patients. As with many hepatobiliary disorders, a minimally invasive approach has been recently explored to minimize access-related complications and improve postoperative recovery. Since patients with gallstone disease are often admitted for a minimally invasive cholecystectomy, laparoscopic and robotic approaches for repairing postcholecystectomy biliary stricture are attractive. While recent series have shown the feasibility and safety of minimally invasive post-cholecystectomy biliary stricture management, most are retrospective analyses with small sample sizes. Also, long-term follow-up is available only in a limited number of studies. The principles and technique of minimally invasive repair resemble open repair except for the extent of adhesiolysis and the suturing technique with continuous sutures commonly used in minimally invasive approaches. The robotic approach overcomes key limitations of laparoscopic surgery and has the potential to become the preferred minimally invasive approach for the repair of postcholecystectomy biliary stricture. Despite increasing use, lack of prospective studies and selection bias with available evidence precludes definitive conclusions regarding minimally invasive surgery for managing postcholecystectomy biliary stricture. High-volume prospective studies are required to confirm the initial promising outcomes with minimally invasive surgery.
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Affiliation(s)
- Raja Kalayarasan
- Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry 605006, India
| | - Pothugunta Sai Krishna
- Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry 605006, India
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Liao W, Zhao X, Huang H, Peng Q. Transumbilical single incision combined with robot-assisted surgery in pediatric congenital choledochal cyst excision: A case report. Asian J Surg 2023; 46:3820-3821. [PMID: 37045624 DOI: 10.1016/j.asjsur.2023.03.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Affiliation(s)
- Wenge Liao
- Department of Surgery, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
| | - Xing Zhao
- Department of Surgery, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hong Huang
- Department of Surgery, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qiang Peng
- Department of Surgery, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Cazares J, Koga H, Yamataka A. Choledochal cyst. Pediatr Surg Int 2023; 39:209. [PMID: 37261604 DOI: 10.1007/s00383-023-05483-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/02/2023]
Abstract
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.
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Affiliation(s)
- Joel Cazares
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
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Ramsey WA, Huerta CT, Ingle SM, Gilna GP, Saberi RA, O'Neil CF, Ribieras AJ, Parreco JP, Perez EA, Sola JE, Thorson CM. Outcomes of laparoscopic versus open resection of pediatric choledochal cyst. J Pediatr Surg 2023; 58:633-638. [PMID: 36670004 DOI: 10.1016/j.jpedsurg.2022.12.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Carlos T Huerta
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Shreya M Ingle
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Antoine J Ribieras
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua P Parreco
- Memorial Regional Hospital, Division of Trauma and Surgical Critical Care, Hollywood, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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Miron A, Popa LG, Toma EA, Calu V, Parvuletu RF, Enciu O. The Curious Case of the Choledochal Cyst—Revisiting the Todani Classification: Case Report and Review of the Literature. Diagnostics (Basel) 2023; 13:diagnostics13061059. [PMID: 36980367 PMCID: PMC10047054 DOI: 10.3390/diagnostics13061059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
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.
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Affiliation(s)
- Adrian Miron
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania (O.E.)
- Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Liliana Gabriela Popa
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania (O.E.)
- Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Elena Adelina Toma
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania (O.E.)
- Elias Emergency University Hospital, 011461 Bucharest, Romania
- Correspondence: ; Tel.: +40-213161600
| | - Valentin Calu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania (O.E.)
- Elias Emergency University Hospital, 011461 Bucharest, Romania
| | | | - Octavian Enciu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania (O.E.)
- Elias Emergency University Hospital, 011461 Bucharest, Romania
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12
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Zhang MX, Chi SQ, Cao GQ, Tang JF, Tang ST. Comparison of efficacy and safety of robotic surgery and laparoscopic surgery for choledochal cyst in children: a systematic review and proportional meta-analysis. Surg Endosc 2023; 37:31-47. [PMID: 35913517 DOI: 10.1007/s00464-022-09442-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 07/04/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Most commonly, cyst excision and Roux-en-Y hepaticojejunostomy reconstruction are the optimal treatment for choledochal cysts (CC). Robotic surgery (RS) is being conducted with increasing frequency to treat CC. It is unclear whether RS can overcome the limitations of laparoscopic surgery (LS) and improve the prognosis of patients. In terms of efficacy, evidence concerning which minimally invasive surgery is preferred is, however, sparse. Our objective is to further compare the efficacy of RS and LS in children with CC and draw a useful clinical conclusion. METHODS Studies meeting inclusion criteria were identified from a series of databases, consisting of PubMed, Embase, Scopus, Web of Science, the Cochrane Library and their reference list of articles up to May 2022. Eligible articles comprised at least five objects that were younger than 18 years of age and the language was limited to English. Two authors independently evaluated selected studies and extracted data for analysis. RESULTS Forty studies were selected for analysis, with thirty-six reporting data on LS and eight containing data on RS. The pooled conversion rate and pooled postoperative complication rate of RS were lower than those of LS, but none of them was statistically significant. Moreover, comparisons of the following detailed postoperative complication rates were not statistically significant, such as intestinal obstruction or ileus, anastomotic bleeding, anastomotic or bile leakage, and anastomotic stenosis. However, the intraoperative blood loss and the postoperative hospital stay in RS group were significantly lower than those in LS group. CONCLUSIONS RS is a safe and feasible option for children with CC. Further studies with more cases, long-term efficacy and health economics analysis are needed to confirm whether RS is more advantageous.
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Affiliation(s)
- Meng-Xin Zhang
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, 430022, Hubei Province, China
| | - Shui-Qing Chi
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, 430022, Hubei Province, China
| | - Guo-Qing Cao
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, 430022, Hubei Province, China
| | - Jing-Feng Tang
- Department of Hepatobiliary Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, 430022, Hubei Province, China
| | - Shao-Tao Tang
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, 430022, Hubei Province, China.
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13
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Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy for biliary reconstruction after resection of congenital biliary dilatation: a systematic review and meta-analysis. Surg Today 2023; 53:1-11. [PMID: 35059844 DOI: 10.1007/s00595-021-02425-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/15/2021] [Indexed: 01/11/2023]
Abstract
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.
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14
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Tanaka R, Nakamura H, Yoshimoto S, Okunobo T, Satake R, Doi T. Postoperative anastomotic stricture following excision of choledochal cyst: a systematic review and meta-analysis. Pediatr Surg Int 2022; 39:30. [PMID: 36454303 DOI: 10.1007/s00383-022-05293-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/04/2022]
Abstract
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.
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Affiliation(s)
- Rina Tanaka
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Hiroki Nakamura
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Sakiko Yoshimoto
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Tokiko Okunobo
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Ryosuke Satake
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Takashi Doi
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Osaka, Japan.
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15
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Schukfeh N, Abo-Namous R, Madadi-Sanjani O, Uecker M, Petersen C, Ure BM, Kuebler JF. The Role of Laparoscopic Treatment of Choledochal Malformation in Europe: A Single-Center Experience and Review of the Literature. Eur J Pediatr Surg 2022; 32:521-528. [PMID: 35764302 DOI: 10.1055/s-0042-1749435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Reem Abo-Namous
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | | | - Marie Uecker
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Abstract
This article discusses current standard of care in neonatal biliary disease, particularly management of biliary atresia and choledochal cysts. It highlights surgical considerations, guidelines for adjuvant therapies, and promising therapeutic options that are under investigation.
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Affiliation(s)
- Sarah Mohamedaly
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1652, Campus Box 0570, San Francisco, CA 94143-0570, USA
| | - Amar Nijagal
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1652, Campus Box 0570, San Francisco, CA 94143-0570, USA; The Liver Center, University of California, San Francisco, CA, USA; The Pediatric Liver Center at UCSF Benioff Childrens' Hospitals, San Francisco, CA, USA.
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17
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Yaghi M, Jaafar R, Kanso M, Khalife M, Faraj W. Choledochal anomalies in adults: A 20-year single-center retrospective cohort experience in the Middle East. Arab J Gastroenterol 2022; 23:235-240. [PMID: 36371373 DOI: 10.1016/j.ajg.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 03/31/2022] [Accepted: 10/14/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Choledochal cysts are rare congenital cystic dilatations of the bile ducts that occur in fewer than 1% of individuals. The disease is common in East Asia, and most of the literature concerns those populations, but some data about Western populations have been published recently. Long-term reports about the disease in Middle Eastern populations, however, are currently lacking. We report a single-center 20-year experience in diagnosing and managing choledochal anomalies. PATIENTS AND METHODS Participants were adult patients in whom choledochal cysts were diagnosed over a 20-year (2000-2019) period at a single tertiary academic care center. Clinical data, including radiologic imaging findings, were retrieved from the patients' medical records. To describe the baseline characteristics of the population, we calculated descriptive statistics. RESULTS Choledochal anomalies were diagnosed in 19 adult patients, whose median age was 30 years (interquartile range [IQR], 23-67 years). Of the choledochal cysts 13 (68.4%) were classified as Todani type I, 4 (21.1%) as Todani type IV, and 3 (15.8%) as Todani type V (Caroli's disease). No patient had underlying chronic liver disease, and liver synthetic function was preserved in all. Eighteen patients (94.7%) underwent surgery: cyst excision with Roux-en-Y hepaticojejunostomy in 17 and liver transplantation in 1. All 18 survived surgery, and the median postoperative hospital stay was 11 days (IQR, 5-34 days). All 18 were alive 90 days after surgery, and the median follow-up period was 40 months (IQR, 12-140 months). Seven patients (36.8%) developed postoperative surgical complications; 2 patients required rehospitalization, and 1 required reoperation. CONCLUSION This description of adults with choledochal cysts is the latest long-term report about this disease in the Middle East. In our 20-year experience, the disease characteristics in our patients were moderately consistent with those described previously.
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Affiliation(s)
- Marita Yaghi
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Rola Jaafar
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Mariam Kanso
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Mohamed Khalife
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Walid Faraj
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon.
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18
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Meng Y, Guo K, Jiang Y, Wei S. Todani type III: like biliary dilatation with duodenal prolapse-a case report. BMC Gastroenterol 2022; 22:220. [PMID: 35508976 PMCID: PMC9066763 DOI: 10.1186/s12876-022-02278-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/13/2022] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Yunpeng Meng
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Kangli Guo
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yu Jiang
- Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Shaohua Wei
- The Second Affiliated Hospital of Soochow University, Suzhou, China.
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19
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An NSQIP survey of outcomes after resection of choledochal cysts in adults. Hepatobiliary Pancreat Dis Int 2021; 20:585-587. [PMID: 33077368 DOI: 10.1016/j.hbpd.2020.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/29/2020] [Indexed: 02/05/2023]
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20
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Hinojosa-Gonzalez DE, Roblesgil-Medrano A, Leon SUVD, Espadas-Conde MA, Flores-Villalba E. Biliary reconstruction after choledochal cyst resection: a systematic review and meta-analysis on hepaticojejunostomy vs hepaticoduodenostomy. Pediatr Surg Int 2021; 37:1313-1322. [PMID: 34115175 DOI: 10.1007/s00383-021-04940-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- David Eugenio Hinojosa-Gonzalez
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico.
| | - Andres Roblesgil-Medrano
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico
| | - Sergio Uriel Villegas-De Leon
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico
| | - Maria Alejandra Espadas-Conde
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico
| | - Eduardo Flores-Villalba
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico
- Tecnológico de Monterrey, Escuela de Ingeniería y Ciencias, Monterrey, Nuevo León, Mexico
- Laboratorio Nacional de Manufactura Aditiva y Digital (MADIT), Apodaca, Nuevo León, Mexico
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21
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Fuchs J, Murtha-Lemekhova A, Kessler M, Günther P, Fichtner A, Pfeiffenberger J, Probst P, Hoffmann K. Biliary Rhabdomyosarcoma in Pediatric Patients: A Systematic Review and Meta-Analysis of Individual Patient Data. Front Oncol 2021; 11:701400. [PMID: 34660271 PMCID: PMC8515851 DOI: 10.3389/fonc.2021.701400] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/14/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The biliary tree is a rare location of pediatric rhabdomyosarcoma. Due to the low incidence, there is a lack of evidence concerning therapeutic guidelines for this tumor location. In particular, the impact of surgery is discussed controversially. PURPOSE Objective is to generate evidence-based treatment guidelines for pediatric biliary rhabdomyosarcoma (BRMS). All available published data on therapeutic regimens and important prognostic factors are investigated with a focus on the role of surgery. METHODS A systematic literature search of MEDLINE, Web of Science, and CENTRAL was performed. Patient data were entered individually. Data was pooled and qualitative and quantitative analyses of demographic data, therapy, postoperative/interventional outcomes, relapse, and survival were conducted. In an individual patient data analysis, cox regression was applied to identify key factors predicting the outcome of patients with BRMS. RESULTS 65 studies met the inclusion criteria, providing data on 176 patients with BRMS. Individual patient data analysis showed a 5-year overall survival and progression-free survival of 51% and 50% for the total study population. For patients treated after 2000, 5-year OS and PFS was 65% and 59%, respectively. Absence of surgical tumor resection was an independent risk factor for death (Hazard ratio 8.9, 95%-CI 1.8-43.6, p = 0.007) and significantly associated with recurrent disease and disease-related death. CONCLUSION This analysis provides comprehensive information on the largest number of patients hitherto reported in the literature. BRMS is still associated with high morbidity and mortality. Surgical tumor resection is essential for appropriate oncological treatment of BRMS. International cooperation studies are needed to enhance evidence and improve the outcome of this orphan disease. PROTOCOL REGISTRATION PROSPERO (CRD42021228911) https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021228911.
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anastasia Murtha-Lemekhova
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Kessler
- Department of General, Visceral and Transplantation Surgery, Division of Pediatric Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrick Günther
- Department of General, Visceral and Transplantation Surgery, Division of Pediatric Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Fichtner
- Department of Pediatrics I, Division of Pediatric Gastroenterology, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Jan Pfeiffenberger
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
- Study Center of the German Surgical Society (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
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22
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Jones RE, Zagory JA, Clark RA, Pandya SR. A narrative review of the modern surgical management of pediatric choledochal cysts. Transl Gastroenterol Hepatol 2021; 6:37. [PMID: 34423158 DOI: 10.21037/tgh-20-235] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/23/2020] [Indexed: 12/31/2022] Open
Abstract
Choledochal cysts (CC) ae rare congenital dilations of the biliary tract that harbor lifelong malignancy risk. CC are treated with surgical excision and bilioenteric reconstruction. In the modern era, the surgical approach to pediatric patients has enjoyed significant innovation with regards to minimally invasive techniques. In this review, we discuss these advances, including laparoscopic, single-incision laparoscopic, and robotic strategies, with a focus on the clinical outcomes of patients undergoing these procedures. By presenting an overview of the technical pearls emphasized by pioneers of these procedures, we examine the benefits and limitations of various minimally invasive techniques and analyze the utility and effectiveness of laparoscopy and robotics in comparison to each other and open techniques. Additionally, we highlight the importance of surgeon experience and skill in the management of this rare pediatric disease and explore the significance of the surgical learning curve in minimally invasive approaches in the excision of CC. We discuss the challenge of achieving surgical competency along this learning curve, and present proposed strategies to improve skill sets in the face of low case volumes. Finally, the relative dearth of data discussing long-term follow-up in these patients is discussed, and additional research regarding outcomes, malignancy risk and surveillance, and quality of life is necessary to better understand this disease and the implications of its surgical management.
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Affiliation(s)
- R Ellen Jones
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jessica A Zagory
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Division of Pediatric Surgery, Children's Medical Center, Dallas, TX, USA
| | - Rachael A Clark
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Samir R Pandya
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Division of Pediatric Surgery, Children's Medical Center, Dallas, TX, USA
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23
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Razumovskiy AY, Mitupov ZB, Kulikova NV, Stepanenko NS, Zadvernyuk AS, Adler AV, Shubin NV. [Comparative analysis of the bile duct reconstruction methods in children with choledochal malformation]. Khirurgiia (Mosk) 2021:49-57. [PMID: 34363445 DOI: 10.17116/hirurgia202108149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare various methods of bile duct reconstruction in children with choledochal malformation (CM). MATERIAL AND METHODS There were 99 children with CM over 10-year period. Mini-laparotomy (ML), laparoscopy (LS) and laparotomy (LT) were used. We performed radical CM resection and bile duct reconstruction using Roux-en-Y hepaticojejunostomy (RYHJ) and hepaticoduodenostomy (HD). Surgery time, short-term and long-term postoperative outcomes were evaluated. RESULTS ML was performed in 39 patients, LS - 51 patients, LT - 9 patients. In case of LS, hospital-stay was significantly lower after intracorporeal RYHJ formation compared to extracorporeal technique (p=0.02, Mann-Whitney U-test). Intracorporeal RYHJ requires more time (p=0.0003). Intestinal passage recovered 3 times faster in the ML RYHJ group compared to the LS RYHJ group (p=0.016, Mann-Whitney U-test). ML RYHJ was followed by significantly less duration of postoperative narcotic anesthesia compared to LS HD (3 vs. 4 days, p=0.02, Mann-Whitney U-test). In our study, ML RYHJ has an advantage over LS RYHJ regarding long-term outcomes. HD resulted higher incidence of severe postoperative pancreatitis (p=0.033) that required surgical correction (LT, p=0.043). CONCLUSION ML RYHJ has some advantages over other methods of bile duct reconstruction. Therefore, we can currently recommend this method as a preferable one.
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Affiliation(s)
- A Yu Razumovskiy
- Pirogov Russian National Research Medical University, Moscow, Russia.,Filatov Children`s Hospital, Moscow, Russia
| | - Z B Mitupov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Filatov Children`s Hospital, Moscow, Russia
| | - N V Kulikova
- Pirogov Russian National Research Medical University, Moscow, Russia.,Filatov Children`s Hospital, Moscow, Russia
| | - N S Stepanenko
- Pirogov Russian National Research Medical University, Moscow, Russia.,Filatov Children`s Hospital, Moscow, Russia
| | - A S Zadvernyuk
- Pirogov Russian National Research Medical University, Moscow, Russia.,Filatov Children`s Hospital, Moscow, Russia
| | - A V Adler
- Filatov Children`s Hospital, Moscow, Russia
| | - N V Shubin
- Pirogov Russian National Research Medical University, Moscow, Russia.,Filatov Children`s Hospital, Moscow, Russia
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24
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Wu J, Xiang Y, You G, Liu Z, Lin R, Yao X, Yang Y. An essential technique for modern hepato-pancreato-biliary surgery: minimally invasive biliary reconstruction. Expert Rev Gastroenterol Hepatol 2021; 15:243-254. [PMID: 33356656 DOI: 10.1080/17474124.2021.1847081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Jiacheng Wu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , Changchun, China
| | - Yien Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , Changchun, China
| | - Guangqiang You
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Zefeng Liu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Ruixin Lin
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Xiaoxiao Yao
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Yongsheng Yang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
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Ohyama K, Furuta S, Shima H, Tuji S, Nagae H, Tanaka K, Obayashi J, Kawaguchi K, Kawaguchi T, Nishiya Y, Kudou K, Kawase K, Wakisaka M, Kitagawa H. Differences in post-operative complications after reconstruction for congenital biliary dilatation in a single institution-Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy. Pediatr Surg Int 2021; 37:241-245. [PMID: 33483835 DOI: 10.1007/s00383-020-04790-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Kei Ohyama
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shigeyuki Furuta
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hideki Shima
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shiho Tuji
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hideki Nagae
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kunihide Tanaka
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Juma Obayashi
- Department of Pediatric Surgery, St. Marianna University School of Medicine Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi, Yokohama, Kanagawa, 241-0811, Japan
| | - Kouhei Kawaguchi
- Department of Pediatric Surgery, St. Marianna University School of Medicine Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi, Yokohama, Kanagawa, 241-0811, Japan
| | - Takuya Kawaguchi
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yuri Nishiya
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kousuke Kudou
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kouichi Kawase
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Munechika Wakisaka
- Department of Pediatric Surgery, St. Marianna University School of Medicine Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi, Yokohama, Kanagawa, 241-0811, Japan
| | - Hiroaki Kitagawa
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan.
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Liem NT, Agrawal V, Aison DS. Laparoscopic management of choledochal cyst in children: Lessons learnt from low-middle income countries. J Minim Access Surg 2021; 17:279-286. [PMID: 32964871 PMCID: PMC8270031 DOI: 10.4103/jmas.jmas_114_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Choledochal cyst (CC) is a disease with a strong Asian preponderance. As laparoscopic surgery has become mainstay in its treatment, the experience in these countries has been phenomenal. However, there are many contentious issues related with the laparoscopic management of CC. In this review article, we will try to answer the contentious questions related to the laparoscopic management of CC. The issues related to aetiology, classification, surgical technique, type of biliary anastomosis, intrahepatic stones and malignancy are discussed. We also discuss the current and future considerations of laparoscopic management with reference to it becoming a gold standard. This article describes the standard surgical approach and will discuss its technical nuances. This article will also discuss the outcome of treatment in different settings of low- and middle-income countries based on lessons learnt by the authors from their experience and research.
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Affiliation(s)
- Nguyen Thanh Liem
- Department of Pediatric Surgery, National Children Hospital, Hanoi; Department of Pediatric Surgery, Vinmec Research Institute of Stemcell and Gene Technology, Hà Nôi, Vietnam
| | - Vikesh Agrawal
- Department of Surgery, Division of Pediatric Surgery, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | - Dexter S Aison
- Department of Pediatric Surgery, Philippine Children's Medical Center, Quezon City, Philippines
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de Kleine RH, Ten Hove A, Hulscher JBF. Long-term morbidity and follow-up after choledochal malformation surgery; A plea for a quality of life study. Semin Pediatr Surg 2020; 29:150942. [PMID: 32861446 DOI: 10.1016/j.sempedsurg.2020.150942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Much about the aetiology, pathophysiology, natural course and optimal treatment of choledochal malformation remains under debate. Surgeons continuously strive to optimize their roles in the management of choledochal malformation. Nowadays the standard treatment is complete cyst excision followed by Roux-en-Y hepaticojejunostomy, be it via a laparotomy, laparoscopy or robot-assisted procedure. Whatever surgical endeavor is undertaken, it will be a major operation, with significant morbidity. It is important to realize that especially in asymptomatic cases, this is considered prophylactic surgery, aimed at preventing symptoms but even more important the development of malignancy later in life. A clear overview of long-term outcomes is therefore necessary. This paper aims to review the long-term outcomes after surgery for choledochal malformation. We will focus on biliary complications such as cholangitis, the development of malignancy and quality of life. We will try and identify factors related to a worse outcome. Finally, we make a plea for a large scale study into quality and course of life after resection of a choledochal malformation, to help patients, parents and their treating physicians to come to a well-balanced decision regarding the treatment of a choledochal malformation.
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Affiliation(s)
- R H de Kleine
- Department of Surgery, Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, the Netherlands.
| | - A Ten Hove
- Department of Surgery, Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, the Netherlands; Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, the Netherlands
| | - J B F Hulscher
- Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, the Netherlands
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Chan KWE, Lee KH, Wong HYV, Tsui SYB, Mou JWC, Tam YHP. Comparison of Characteristics and Outcomes in Antenatally and Postnatally Detected Choledochal Cyst in Infants and Young Children in a Laparoscopic Surgery Center. J Laparoendosc Adv Surg Tech A 2020; 30:1237-1241. [PMID: 32716684 DOI: 10.1089/lap.2020.0433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: The aim of this study was to compare the characteristics and the outcome between infants and young children with antenatally (AN) and postnatally (PN) detected choledochal cyst (CC) in a laparoscopic surgery center. Methods: A retrospective review was conducted for all children who underwent excision of CC and hepaticojejunostomy (HJ) before 36 months of age between October 2004 and October 2019. Results: Thirty-nine children (28 girls and 11 boys) were included in this study. Twenty-one children had AN detected CC and 18 had PN detected CC. The median age at operation (AN vs. PN; 3 months vs. 15.5 months, P < .001) and body weight (AN vs. PN; 5.6 kg vs. 10.5 kg, P < .001) were significantly different between the two groups. Children in PN group has an increased risk of being symptomatic (AN vs. PN; 6 vs. 18, P < .001) and having intervention before operation (AN vs. PN; 0 vs. 4, P = .037). Laparoscopic excision was performed in all children in AN group and in 12 children (66.7%) in PN group (P = .006). Conversion to open HJ was performed in 4 children in AN group but none in PN group (P = .146). There was no statistical differences in success in laparoscopic operation (P = .257), median operative time (P = .094), postoperative complication (P = .576), and median length of hospital stay (P = .749). Conclusions: Despite younger age at operation, the outcome of laparoscopic excision of AN detected CC was comparable with PN detected CC. Earlier detection and operation decreased the risk of preoperative intervention.
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Affiliation(s)
- Kin Wai Edwin Chan
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Kim Hung Lee
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hei Yi Vicky Wong
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Siu Yan Bess Tsui
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Jennifer Wai Cheung Mou
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Yuk Him Peter Tam
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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