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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

Background

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

Objectives/methods

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

Conclusion

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

Robotic Surgery for Pediatric Choledochal Cysts: An American Case Series and Literature Review

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.

Management of complicated choledochal cyst in children: ultrasound-guided percutaneous external drainage and subsequent definitive operation

OBJECTIVE

The purpose of this study was to analyze the outcomes of the combination of ultrasound (US)-guided percutaneous external drainage and subsequent definitive operation to manage complicated choledochal cyst in children.

METHODS

This retrospective study included 6 children with choledochal cyst who underwent initial US-guided percutaneous external drainage and subsequent cyst excision with Roux-en-Y hepaticojejunostomy between January 2021 and September 2022. Patient characteristics, laboratory findings, imaging data, treatment details, and postoperative outcomes were evaluated.

RESULTS

Mean age at presentation was 2.7 ± 2.2 (0.5-6.2) years, and 2 patients (2/6) were boys. Four patients (4/6) had a giant choledochal cyst with the widest diameter of ≥ 10 cm and underwent US-guided percutaneous biliary drainage on admission or after conservative treatments. The other 2 patients (2/6) underwent US-guided percutaneous transhepatic cholangio-drainage and percutaneous transhepatic gallbladder drainage due to coagulopathy, respectively. Five patients (5/6) recovered well after US-guided percutaneous external drainage and underwent the definitive operation, whereas 1 patient (1/6) had liver fibrosis confirmed by Fibroscan and ultimately underwent liver transplantation 2 months after external drainage. The mean time from US-guided percutaneous external drainage to the definitive operation was 12 ± 9 (3-21) days. The average length of hospital stay was 24 ± 9 (16-31) days. No related complications of US-guided percutaneous external drainage occurred during hospitalization. At 10.2 ± 6.8 (1.0-18.0) months follow-up, all patients had a normal liver function and US examination.

CONCLUSIONS

Our detailed analysis of this small cohort suggests that US-guided percutaneous external drainage is technically feasible for choledochal cyst with giant cysts or coagulopathy in children, which may provide suitable conditions for subsequent definitive operation with a good prognosis.

TRIAL REGISTRATION

Retrospectively registered.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Smart Health

In recent decades, healthcare organizations around the world have increasingly appreciated the value of information technologies for a variety of applications. Three of the new technological advancements that are impacting smart health are metaverse, artificial intelligence (AI), and data science. The metaverse is the intersection of three major technologies — AI, augmented reality (AR), and virtual reality (VR). Metaverse provides new possibilities and potential that are still emerging. The increased work efficiency enabled by artificial intelligence and data science in hospitals not only improves patient care but also cuts costs and workload for healthcare providers. Artificial intelligence, coupled with machine learning, is transforming the healthcare industry. The availability of big data enables data scientists to use the data for descriptive, predictive, and prescriptive analytics. This article reviews multiple case studies and the literature on AI and data science applications in hospital administration. The article also presents unresolved research questions and challenges in the applications of the metaverse, AI, and data science in the smart health context. For researchers, in addition to providing a good synopsis of the development and applications of the metaverse, AI, and data science in the healthcare area, this article identifies possible future research directions and discusses the possibilities of the metaverse, artificial intelligence, and data science in smart health. For practitioners, this article provides both hospital decision-makers and healthcare workers with practical guidelines and a smart health management model.

Clinical characteristics of patients with malignancy and long-term outcomes of surgical treatment of patients with choledochal cyst

Purpose

There are few reports of postoperative long-term malignant risk or postoperative sequelae after surgery for choledochal cysts (CCs). This study aimed to analyze the clinical characteristics of patients with malignancy and the long-term results of operated CC.

Methods

The patients who underwent surgical treatments for CC between 2003 and 2020 at Seoul National University Hospital were enrolled. Clinicopathologic factors and pre-/postoperative computed tomography or magnetic resonance imaging were reviewed.

Results

Of the 153 patients, Todani classification Ic (36.6%), C-P type (43.8%) anomalous pancreaticobiliary duct union were the most common type respectively. Fourteen patients (9.2%) had biliary tract cancer and a comparison of patients with and without malignancy showed that the diameter of cyst was significantly lower in malignant patients and malignancy was observed to be significantly higher in P-C type. The incidence of long-term complications was 9.8%, and the median time interval was 30 months. The 2 most common complications were cholangitis and stricture (60.0%). There was one case of new cancer near the intrapancreatic remnant bile duct.

Conclusion

Of the resected CCs, 9.2% had a combined malignancy on the biliary tracts. Long-term complications such as cholangitis, anastomotic stricture, and new cancers may occur. Therefore, continuous surveillance is required.

Changes in outcomes and operative trends with pediatric robot-assisted resection of choledochal cyst

BACKGROUND

This study aimed to report our experience with a robot-assisted resection of choledochal cysts (CCs) in pediatric patients, especially focusing on changes in outcomes and operative trends.

METHODS

We retrospectively reviewed medical records of all 158 patients under 18 years of age who underwent robot-assisted resection of CC in a single tertiary center between July 2008 and January 2021. Patients were divided into the first period (P1, July 2008-March 2016; N = 79) and second period (P2, April 2016-January 2021; N = 79) with equal number of participants. The patients of P2 were compared with those of P1 to assess clinical outcomes with operative details. Operative characteristics and postoperative prognosis were compared for each group.

RESULTS

The mean operative time was 383.6 min for the P2 group and 462.6 min for the P1 group (p < 0.001). The mean estimated blood loss was 28 mL in the P2 group and 63 mL in the P1 group (p = 0.025). The rate of emergency department visit after the operation was lower in the P2 group (3.8% vs. 13.9%, respectively, p = 0.047). The two groups showed no significant differences in the rate of late postoperative complications and reoperations.

CONCLUSION

With the increase in the center's experience, robot-assisted resection of CC can be safely adopted and feasible, especially for pediatric patients.

LEVELS OF EVIDENCE

Treatment Study, Level III.

Preliminary Experiences With Robot-Assisted Choledochal Cyst Excision Using the Da Vinci Surgical System in Children Below the Age of One

The purpose of this study is to introduce our preliminary experiences with using the da Vinci surgical system to treat choledochal cysts in children under 1 year old and discuss the application of this robot-assisted surgery. We retrospectively analyzed all available clinical data of children below the age of 1 who underwent surgery for choledochal cysts using the da Vinci robotic surgical system between January 2015 and December 2020. Data collection mainly included demographic information, imaging data, perioperative details, and postoperative outcomes. Ten patients were included in this study. The average patient age was 8.5 months, and the average weight was 9.11 kg. Half of these patients suffered from abdominal pain, while 30% exhibited vomiting and 10% jaundice. Eight of them were type Ia, and two were Ic. The average operation time among the patients was 219.5 min. None of the 10 patients had to receive a blood transfusion or conversion. The average time of the patients' subsequent fluid diet was 3.28 days, and the solid diet was 3.76 days. Meanwhile, the average length of hospital stay was 7.6 days. All 10 patients recovered and were eventually discharged. We believe that the da Vinci surgical system is a safe and feasible form of treatment for choledochal cysts in children <1 year old.