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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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Alkhasov AB, Gurskaya AS, Bayazitov RR, Nakovkin ON, Sulavko MA, Karnuta IV, Ekimovskaya EV, Kyarimov IA, Akhmedova DM, Klepikova AA, Ratnikov SA, Fisenko AP. [Choledochal cysts: surgical treatment in newborns and infants]. Khirurgiia (Mosk) 2024:5-13. [PMID: 38477238 DOI: 10.17116/hirurgia20240315] [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: 03/14/2024]
Abstract
OBJECTIVE To improve postoperative outcomes in newborns and infants with choledochal cysts and to determine the indications for surgery. MATERIAL AND METHODS There were 13 children aged 0-3 months with choledochal cyst who underwent reconstructive surgery between 2019 and 2023. In all children, choledochal cyst was associated with cholestasis. Acholic stool was observed in almost half of the group (n=7). All children underwent cyst resection and Roux-en-Y hepaticoenterostomy. RESULTS Symptoms of cholestasis regressed in all patients. Mean surgery time was 128±27 min. There were no complications. Enteral feeding was started after 1-2 postoperative days, abdominal drainage was removed after 6.2±1.6 days. Mean length of hospital-stay was 16±3.7 days. Adequate bile outflow is one of the main principles. For this purpose, anastomosis with intact tissues of hepatic duct should be as wide as possible. Roux-en-Y loop should be at least 40-60 cm to prevent postoperative cholangitis. CONCLUSION Drug-resistant cholestasis syndrome and complicated choledochal cysts (cyst rupture, bile peritonitis) are indications for surgical treatment in newborns and infants. When forming Roux-en-Y hepaticoenterostomy, surgeon should totally excise abnormal tissues of the biliary tract to prevent delayed malignant transformation.
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Affiliation(s)
- A B Alkhasov
- National Medical Research Center for Children's Health, Moscow, Russia
| | - A S Gurskaya
- National Medical Research Center for Children's Health, Moscow, Russia
| | - R R Bayazitov
- National Medical Research Center for Children's Health, Moscow, Russia
| | - O N Nakovkin
- National Medical Research Center for Children's Health, Moscow, Russia
| | - M A Sulavko
- National Medical Research Center for Children's Health, Moscow, Russia
| | - I V Karnuta
- National Medical Research Center for Children's Health, Moscow, Russia
| | - E V Ekimovskaya
- National Medical Research Center for Children's Health, Moscow, Russia
| | - I A Kyarimov
- National Medical Research Center for Children's Health, Moscow, Russia
| | - D M Akhmedova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - A A Klepikova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - S A Ratnikov
- National Medical Research Center for Children's Health, Moscow, Russia
| | - A P Fisenko
- National Medical Research Center for Children's Health, Moscow, Russia
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Zhang X, Jin J, Qiu T, Zhou J, Che G, Ji Y, Xu Z. The strategy of laparoscopic surgery for asymptomatic antenatally diagnosed choledochal cyst. BMC Surg 2023; 23:204. [PMID: 37464354 DOI: 10.1186/s12893-023-02095-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The aim was to investigate the characteristics, surgical management, and outcomes of asymptomatic patients with antenatally diagnosed choledochal cysts (ADCCs) and to justify the strategy of laparoscopic surgery (LS) for them in our hospital. METHODS We developed our LS strategy for asymptomatic ADCCs. Patients with asymptomatic ADCCs who underwent LS or open surgery (OS) during January 2010 and January 2020 were included. Patients with recorded symptomatic ADCCs were exclude. All data of group LS and group OS were statistically compared and analyzed. RESULTS Twenty-five patients received LS and 18 patients received OS were included. There was no significant difference in baseline characteristics between the groups. A total of 65.1% of biliary sludge formation was detected preoperatively by ultrasonography (US) (72.0% in group LS, 55.6% in group OS, P = 0.26). Compared to the OS group, the LS group had a longer operative time (313.4 ± 27.2 vs. 154.0 ± 11.9 min, P = 0.02), shorter postoperative fasting period (3.1 ± 1.2 vs. 6.2 ± 2.3 days, P = 0.03), and shorter postoperative hospital stay (5.1 ± 1.9 vs. 9.2 ± 1.1 days, P = 0.03). The incidence of late complications, such as reflux cholangitis, adhesive intestinal obstruction, and biliary enteric anastomotic stricture with stone formation, was not significantly different between the two groups. The liver function and liver stiffness of all patients in the two groups were normal. CONCLUSIONS Based on the strategy for asymptomatic ADCCs in our hospital, the perioperative safety and midterm follow-up results after LS were satisfactory and comparable to those after OS.
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Affiliation(s)
- Xuepeng Zhang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jianli Jin
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Tong Qiu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China
| | - Jiangyuan Zhou
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yi Ji
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China.
| | - Zhicheng Xu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China.
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Quelhas P, Cerski C, Dos Santos JL. Update on Etiology and Pathogenesis of Biliary Atresia. Curr Pediatr Rev 2022; 19:48-67. [PMID: 35538816 DOI: 10.2174/1573396318666220510130259] [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: 12/08/2021] [Revised: 01/16/2022] [Accepted: 02/15/2022] [Indexed: 01/31/2023]
Abstract
Biliary atresia is a rare inflammatory sclerosing obstructive cholangiopathy that initiates in infancy as complete choledochal blockage and progresses to the involvement of intrahepatic biliary epithelium. Growing evidence shows that biliary atresia is not a single entity with a single etiology but a phenotype resulting from multifactorial events whose common path is obliterative cholangiopathy. The etiology of biliary atresia has been explained as resulting from genetic variants, toxins, viral infection, chronic inflammation or bile duct lesions mediated by autoimmunity, abnormalities in the development of the bile ducts, and defects in embryogenesis, abnormal fetal or prenatal circulation and susceptibility factors. It is increasingly evident that the genetic and epigenetic predisposition combined with the environmental factors to which the mother is exposed are potential triggers for biliary atresia. There is also an indication that a progressive thickening of the arterial middle layer occurs in this disease, suggestive of vascular remodeling and disappearance of the interlobular bile ducts. It is suggested that the hypoxia/ischemia process can affect portal structures in biliary atresia and is associated with both the extent of biliary proliferation and the thickening of the medial layer.
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Affiliation(s)
- Patrícia Quelhas
- CICS-UBI - Centro de Investigação em Ciências da Saúde, University of Beira Interior, 6200-506 Covilhã, Portugal
| | - Carlos Cerski
- Department of Pathology, University Federal Rio Grande do Sul, 90040-060, Porto Alegre, Brasil
| | - Jorge Luiz Dos Santos
- CICS-UBI - Centro de Investigação em Ciências da Saúde, University of Beira Interior, 6200-506 Covilhã, Portugal
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Chou CM, Huang SY, Yeh CM, Chen HC. Clinical presentation and outcome of pediatric congenital biliary dilatation: A study based on pancreaticobiliary maljunction. FORMOSAN JOURNAL OF SURGERY 2021. [DOI: 10.4103/fjs.fjs_186_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ryu HS, Lee JY, Kim DY, Kim SC, Namgoong JM. Minimally-invasive neonatal surgery: laparoscopic excision of choledochal cysts in neonates. Ann Surg Treat Res 2019; 97:21-26. [PMID: 31297349 PMCID: PMC6609415 DOI: 10.4174/astr.2019.97.1.21] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/13/2019] [Accepted: 05/02/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Improvements in surgical techniques and a better understanding of the unique anesthetic requirements in neonates undergoing laparoscopy have suggested that laparoscopic surgery may be effective in newborns. This study therefore evaluated the safety and feasibility of laparoscopic excision of the cyst (LEC) in neonates. Methods This retrospective study included 43 neonates who underwent excision of choledochal cysts between November, 2001, and January, 2018, including 21 who underwent open excision and 22 who underwent LEC. Their perioperative and surgical outcomes were reviewed. The patients were followed up for a median 37 months (range, 3–141 months). Results Baseline characteristics did not differ significantly in the open and LEC groups. Mean intraoperative peak partial pressure of arterial CO2 (PaCO2) (45.5 mmHg vs. 48.0 mmHg) and total operation time (208.3 ± 71.0 minutes vs. 235.0 ± 47.2 minutes) were similar in both groups. Parents of the patients in the LEC group provided a more positive evaluation of scar scale and greater satisfaction with wound. No patient in either group experienced any critical complications. Three patients in the open excision group required readmission for cholangitis and 2 patients had ileus. No patient in the laparoscopic excision group experienced any postoperative complications during follow-up. Conclusion Despite difficulties performing laparoscopic surgery in neonates, LEC was safe and feasible when intraperitoneal peak pressure was maintained under 10 mmHg and PaCO2 was closely monitored by a pediatric anesthesiologist. Compared with open excision, LEC provided improved cosmetic outcomes without severe complications. Prospective randomized studies with large numbers of patients are warranted.
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Affiliation(s)
- Hyo Seon Ryu
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Yeon Lee
- Department of Pediatric Surgery, Chonnam National University Children's Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Chul Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Urushihara N, Fukumoto K, Yamoto M, Miyake H, Takahashi T, Nomura A, Sekioka A, Yamada Y, Nakaya K. Characteristics, management, and outcomes of congenital biliary dilatation in neonates and early infants: a 20-year, single-institution study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:544-549. [PMID: 30328288 DOI: 10.1002/jhbp.590] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The aim of the present study was to investigate the characteristics, management, and outcomes of congenital biliary dilatation (CBD) in neonates and infants (<1 year old) in a single institution over the past 20 years. METHODS From 1997 to 2016, 21 patients <1 year old underwent definitive surgery for CBD. Open surgery (OS) was performed between 1997 and 2008, and laparoscopic surgery (LS) has been performed since 2009. RESULTS The bile duct showed cystic dilatation in all patients. Sixteen (76.2%) of the 21 patients were diagnosed prenatally, and the incidence increased with time (OS 63.6%, LS 90%). Fourteen patients (66.7%) were symptomatic before surgery, with jaundice in 11 (52.4%), acholic stool in seven (33.3%), and vomiting in three (14.3%). There were no significant differences in operation time and blood loss, but the postoperative fasting period and hospital stay were significantly shorter in the LS group (P < 0.05). There were no intraoperative complications, but there was one postoperative early complication in one LS group patient, who had bile leakage and was treated with redo hepaticojejunostomy. CONCLUSION The incidences of prenatally diagnosed and asymptomatic patients increased with time. Although longer follow-up is needed, LS for CBD could be safely performed even in neonates and early infants.
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Affiliation(s)
- Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Toshiaki Takahashi
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Akiyoshi Nomura
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Akinori Sekioka
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Yutaka Yamada
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Kengo Nakaya
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
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Tang J, Zhang D, Liu W, Zeng JX, Yu JK, Gao Y. Differentiation between cystic biliary atresia and choledochal cyst: A retrospective analysis. J Paediatr Child Health 2018; 54:383-389. [PMID: 29105184 DOI: 10.1111/jpc.13779] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 09/16/2017] [Indexed: 12/20/2022]
Abstract
AIM Cystic biliary atresia (CBA) can be easily misdiagnosed as choledochal cyst (CC). Some patients have already progressed to severe liver fibrosis and missed the optimal surgical time, when the differential diagnosis is made. We aim to determine the differentiation between CBA and CC, and to validate the value of aspartate aminotransferase-to-platelet ratio index (APRI) in the assessment of liver fibrosis and prediction of post-operative outcome for infants with biliary cystic malformations (BCMs). METHODS Clinical data of children (categorised into CBA and CC groups) with BCMs were analysed retrospectively. Biochemical indicators together with B-ultrasound examinations and the degree of liver fibrosis were analysed, and those with statistical difference between the two groups were selected for diagnostic receiver operating characteristic curve analysis. RESULTS The parameter that showed the highest accuracy with a significant diagnostic performance for differentiating CBA from CC was cyst size. Liver assessment at operation was categorised into mild fibrosis and moderate-to-severe fibrosis. The APRI values were much lower in the mild fibrosis groups than in the moderate-to-severe fibrosis group (0.4 ± 0.2 vs. 1.4 ± 0.8, P < 0.001). A cut-off value of 0.96 (area under the curve 0.92, P < 0.001) showed a sensitivity of 81.3% and a specificity of 100% for moderate-to-severe fibrosis. Lower APRI value was correlated with short-term post-operative bilirubin clearance. CONCLUSION There is still certain difficulty in the early identification of CBA and CC clinically. Liver fibrosis could occur as early as infantile period in both CBA and CC. In infants with BCMs, APRI can be used as a non-invasive method to detect liver fibrosis in early stages.
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Affiliation(s)
- Jue Tang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China.,Department of Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong Province, China
| | - Dan Zhang
- Reproductive Medicine Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Wei Liu
- Department of Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong Province, China
| | - Ji-Xiao Zeng
- Department of Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong Province, China
| | - Jia-Kang Yu
- Department of Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong Province, China
| | - Yi Gao
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
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Upadhyaya VD, Kumar B, Raut SK, Sthapak E. External Drainage of Giant Infantile Choledochal Cyst before Definitive Repair: Is it Worth? J Clin Diagn Res 2017; 11:PR01-PR04. [PMID: 28892977 DOI: 10.7860/jcdr/2017/22210.10125] [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: 06/22/2016] [Accepted: 02/11/2017] [Indexed: 11/24/2022]
Abstract
Infantile Choledochal Cysts (IFCC) usually present with jaundice, acholic stool and abdominal lump or abdominal distension. If the surgical intervention is delayed, they rapidly progress to liver fibrosis which is considered to be irreversible if progressed to cirrhosis. We present the data of four cases (aged one month to seven months) of IFCC presented with cholangitis managed in one surgical unit in last two years. In one case, cholangitis was treated with prolonged antibiotic course before definitive repair whereas in rest, external drainage of cyst was done in addition to intravenous antibiotic to treat cholangitis. All the infants had features of cholangitis at time of presentation. Total leucocyte count ranged from 18x1000/UL to 30.6x1000/UL. Total bilirubin level at presentation ranged from 8.2 mg/dl to 18 mg/dl and Prothrombin time (INR) ranged from 1.33 to 1.9. Hepatic fibrosis was observed in all cases but cirrhosis was observed in only one case. There was no mortality but one patient had postoperative complication with prolonged hospital stay. External drainage helps in early recovery from cholangitis and better optimization of liver function. It also delays further progression to liver fibrosis by relieving the biliary outflow obstruction while waiting for definitive repair.
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Affiliation(s)
- Vijai Datta Upadhyaya
- Assistant Professor, Department of Paediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, Uttar Pradesh, India
| | - Basant Kumar
- Assistant Professor, Department of Paediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, Uttar Pradesh, India
| | - Sandeep Kumar Raut
- Postdoctoral Fellowship, Department of Paediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, Uttar Pradesh, India
| | - Eti Sthapak
- Assistant Professor, Department of Anatomy, Era's Medical College, Lucknow, Uttar Pradesh, India
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Tanaka H, Sasaki H, Wada M, Sato T, Kazama T, Nishi K, Kudo H, Nakamura M, Nio M. Postnatal management of prenatally diagnosed biliary cystic malformation. J Pediatr Surg 2015; 50:507-10. [PMID: 25840051 DOI: 10.1016/j.jpedsurg.2014.08.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/03/2014] [Accepted: 08/06/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE Recent advances in ultrasonography have increased prenatal diagnosis of biliary atresia (BA) and choledochal cyst (CC). These conditions are not easy to distinguish before or just after birth. This study investigated diagnostic and therapeutic problems in prenatal diagnosis of BA and CC. METHODS We retrospectively studied clinical characteristics and progression of hepatobiliary cysts in 10 patients (4 cases of BA, 6 cases of CC) from the time of diagnosis. Chronological changes in cyst size and gallbladder morphology were assessed and measured sequentially by ultrasonography. RESULTS Three cases of BA were type I cyst and 1 case was type III-d. All cases of CC were type Ia. Cyst size decreased between birth and surgery in BA but increased in CC. The gallbladder appeared atrophic in BA. There was no significant difference in gestational age or cyst size at prenatal diagnosis, changes in cyst size between birth and surgery, and degree of liver fibrosis. CONCLUSIONS BA should be suspected if cyst size decreases before and after birth and the gallbladder atrophies after birth. Cholangiography is the only reliable method to differentiate BA from CC. Neonatal surgery is indicated for CC with icterus and liver dysfunction.
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Affiliation(s)
- Hiromu Tanaka
- Department of Pediatric Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Hideyuki Sasaki
- Department of Pediatric Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Motoshi Wada
- Department of Pediatric Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Tomoyuki Sato
- Department of Pediatric Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Takuro Kazama
- Department of Pediatric Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Kotaro Nishi
- Department of Pediatric Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Hironori Kudo
- Department of Pediatric Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Megumi Nakamura
- Department of Pediatric Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Masaki Nio
- Department of Pediatric Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan.
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Jung SM, Seo JM, Lee SK. The relationship between biliary amylase and the clinical features of choledochal cysts in pediatric patients. World J Surg 2012; 36:2098-101. [PMID: 22552497 DOI: 10.1007/s00268-012-1619-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although the clinical features of choledochal cysts (CC) in different age groups have been widely studied, the causes of differences in clinical features are unknown. To determine the relationship between biliary amylase and the clinical features of CC in pediatric patients, clinical outcomes were compared in two groups with different amylase levels. METHODS From May 1995 to August 2010, 80 patients under 18 years old who underwent choledochal cyst excision and hepaticojejunostomy and measurements of biliary amylase levels were allocated to a low-amylase-level group (amylase level < 200 U/L, n = 26) and a high-amylase-level group (amylase level > 200 U/L, n = 54). Their medical records were retrospectively reviewed. RESULTS The median age was 4 months (range = 17 days-169 months) in the low group and 48 months (range = 22 days-147 months) in the high group (p = 0.008). In the low group, jaundice was the most common symptom, while abdominal pain was the main symptom in the high group. In histological findings, bile duct proliferation and cholestasis predominated in the low group and portal inflammation predominated in the high group. Radiological findings and preoperative laboratory data were also significantly different between the groups. Postoperative complications occurred in the high group only. There was no mortality in either group. CONCLUSION This study shows a relationship between biliary amylase level and clinical manifestations in pediatric patients with CC, implying that there are different underlying pathophysiologies with anomalous pancreaticobiliary ductal union (APBDU).
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Affiliation(s)
- Soo-Min Jung
- Department of Surgery, Samsung Medical Center, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, South Korea.
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Abstract
The classification of choledochoceles as a type of choledochal cyst stems from the 1959 article by Alonso-Lej and colleagues describing 94 choledochal cysts, only 4 of which were choledochoceles. Even then, Alonso-Lej questioned the propriety of including the choledochocele, stating it was unclear "as to whether or not it originates from the same etiologic factors [as other choledochal cysts]". In 1971, Trout and Longmire also questioned the validity of classifying choledochoceles as choledochal cysts, noting the anatomic position article and variant mucosa of the choledochocele. Wearn and Wiot, in an article titled "Choledochocele: not a form of choledochal cyst", cite the differences in clinical presentation, demographics, and histology as reasons why choledochoceles represent separate entities from choledochal cysts. Over the ensuing decades, numerous investigators have questioned the legitimacy of classifying choledochoceles as choledochal cysts. In our recent series (the only one to our knowledge directly comparing patients with choledochocele and other [type I, II, IV, and V] choledochal cysts), patients with choledochoceles differed from patients with choledochal cysts in their age, gender, presenting symptoms, history of previous cholecystectomy, pancreatobiliary ductal anatomy, management, and most importantly, propensity to developing biliary malignancy. Based on the available cases of choledochoceles found in the literature, combined with the recent series from our institution, we conclude that choledochoceles seem to be distinct entities from choledochal cysts.
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Affiliation(s)
- Kathryn M Ziegler
- Department of Surgery, Indiana University, 545 Barnhill Drive, EH 202, Indianapolis, IN 46202, USA
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Hung MH, Lin LH, Chen DF, Huang CS. Choledochal cysts in infants and children: experiences over a 20-year period at a single institution. Eur J Pediatr 2011; 170:1179-85. [PMID: 21350805 DOI: 10.1007/s00431-011-1429-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 02/10/2011] [Indexed: 02/07/2023]
Abstract
This analysis was undertaken to compare the clinicopathological features of infants with choledochal cysts to those of older children with these entities and to evaluate the surgical outcomes for both subject groups. The medical records of all children admitted to the Cathay General Hospital with choledochal cysts over a 20-year period were retrospectively reviewed. Twenty-five subjects were included and divided into the infant (<1 year at presentation; 8 subjects) and classical pediatric (1-18 years at presentation; 17 subjects) groups. Anatomical subtypes were: IA (16), IC (6), and IVA (3). The median biliary amylase value was markedly elevated for the pediatric group but not for the infant group. Most (82.4%) patients in the pediatric group, but none in the infant group, presented with abdominal pain. Jaundice and clay-colored stool were present in all patients in the infant group but only 35% of those in the pediatric group. All patients underwent choledochocystectomy and Roux-en-Y hepaticojejunostomy with good outcomes. Neonates/infants with choledochal cysts present differently from older children with these entities. Amylase measurements may serve to distinguish biliary atresia with cystic dilatation from choledochal cyst in neonates/infants. Prognosis following radical cyst excision and reconstruction with Roux-en-Y hepaticojejunostomy is excellent.
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Affiliation(s)
- Min-Hsuan Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
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Ishimaru T, Kitano Y, Uchida H, Kawashima H, Gotoh C, Satoh K, Yoshida M, Kishimoto H, Iwanaka T. Histopathologic improvement in biliary cirrhosis after definitive surgery for choledochal cyst. J Pediatr Surg 2010; 45:e11-4. [PMID: 20438907 DOI: 10.1016/j.jpedsurg.2010.01.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2009] [Revised: 01/06/2010] [Accepted: 01/22/2010] [Indexed: 11/29/2022]
Abstract
Choledochal cyst causes liver fibrosis, the extent of which varies with each case. Liver damage seldom progresses to cirrhosis, but when it does, it is generally irreversible. We report an infantile case of liver cirrhosis associated with choledochal cyst in which complete clinical resolution was achieved by surgery. Pancytopenia caused by splenomegaly, massive ascites, hypoalbuminemia, and coagulation abnormality that were observed during the early postoperative period had disappeared within 4 months after surgery. Needle liver biopsy performed at 1 year after surgery revealed marked improvement in liver fibrosis.
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Affiliation(s)
- Tetsuya Ishimaru
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan.
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Liu SL, Li L, Hou WY, Zhang J, Huang LM, Li X, Xie HW, Cheng W. Laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in symptomatic neonates. J Pediatr Surg 2009; 44:508-11. [PMID: 19302849 DOI: 10.1016/j.jpedsurg.2008.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 07/30/2008] [Accepted: 08/02/2008] [Indexed: 01/30/2023]
Abstract
PURPOSE Choledochal cysts require surgical excision, preferably before the onset of cholangitis. Recently, it has become feasible to accomplish the excision laparoscopically in adults and older children. Yet, whether laparoscopic excision of choledochal cyst can be performed safely in symptomatic neonates with choledochal cyst is unclear. We herewith reviewed our experience of laparoscopic excision of choledochal cysts in neonates. METHODS We managed 9 neonates with choledochal cysts between April 2003 and February 2007. The choledochal cysts were excised laparoscopically. The Roux-en-Y hepaticojejunostomy was fashioned extracorporeally by exteriorizing the jejunum through the extended umbilical port site. End-to-side anastomosis between the common hepatic duct stump and Roux loop was carried out intracorporeally. The patients were followed up for an average of 26 months. RESULTS The patients presented with jaundice, pale stool, and deranged liver function tests. The diagnosis was confirmed with ultrasonography postnatally. The median operation time was 3.6 hours. There was no operative complication and no conversion. The blood loss was minimal. The recovery was uneventful, and the median hospital stay was 6 days. The liver function tests normalized 3 to 16 weeks postoperatively. No complication was detected at the follow-up visits. CONCLUSIONS Our preliminary results show that laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in neonates is both feasible and safe. It curtails further complication of the cysts and reverses the derangement of liver function. In addition, the laparoscopic approach minimizes surgical trauma.
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Affiliation(s)
- Shu-Li Liu
- Department of Pediatric Surgery, Peking University First Hospital, Beijing 100034, China
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Abstract
PURPOSE Although the incidence of choledochal cyst (CC) diagnosed in the prenatal or neonatal period is increasing, excision of CC in early infancy is not universally recommended. To validate the rationale of excision of CC in the neonatal period, operative complications and the histologic grade of liver fibrosis at the time of excision of CC were compared in three age groups. METHODS 198 patients who underwent excision of CC, were divided into three age groups, i.e., within 30 days old (group 1, n = 11), 1 to 12 month-old (group 2, n = 40) and over 12 month-old (group 2, n = 147). Retrospective review of their medical records was performed. RESULTS The overall operative complications were 12 (7 cholangitis, 4 bleeding, 1 ileus). No complication occurred in the group 1. The grade of liver fibrosis had statistically significant positive correlation among groups. CONCLUSION Excision of CC in the neonatal period is a safe procedure. The grade of liver fibrosis increased with age. These results support the rationale of early excision of CC.
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Affiliation(s)
- Seong-Cheol Lee
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Chongno-ku, Seoul, 110-744, Korea
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Vijayaraghavan P, Lal R, Sikora SS, Poddar U, Yachha SK. Experience with choledochal cysts in infants. Pediatr Surg Int 2006; 22:803-7. [PMID: 16947025 DOI: 10.1007/s00383-006-1771-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2006] [Indexed: 10/24/2022]
Abstract
The purpose of this analysis is to study the clinical features, liver histology and the outcome after surgery in infants with choledochal cysts (CDCs), and to draw conclusions on the management strategy accordingly. The clinical features, liver histology and the outcome after surgery in 14 cases of CDCs treated before 1 year of age (the "infantile group") were compared with 52 cases that were diagnosed and treated between 1 and 12 years of age (the "classical pediatric group"). The differentiation of the "infantile choledochal cysts" from "biliary atresia with cystic dilatation" was based on the configuration of intrahepatic bile ducts on cholangiogram. Jaundice was the universal presenting feature in 14 patients in the "infantile group", the clinical presentation in 6 infants was indistinguishable from biliary atresia. On the other hand, pancreatitis as a presenting complication was seen exclusively in those presenting later, i.e. the "classical pediatric group". Fibrosis, as early as 4 weeks of age, was seen in all nine (100%) infants in whom a liver histology was available. Seven of these nine infants had bridging fibrosis (n = 4) or cirrhosis (n = 3) on liver histology. The outcome was satisfactory in 9 of the 14 (64.3%) infants despite bridging fibrosis (n = 4) or cirrhosis (n = 1) in 5 of these 9 babies. The CDCs presenting in infancy differ from the classical variety of later presenting pediatric CDCs in terms of their presentation, liver histology and outcome. They merit an emergent surgical treatment following which the outcome is satisfactory. Delay results in progression to end stage liver disease.
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Affiliation(s)
- Paari Vijayaraghavan
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014 UP, India
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