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van den Eijnden MHA, de Kleine RH, de Blaauw I, Peeters PMJG, Koot BGP, Oomen MWN, Sloots CEJ, van Gemert WG, van der Zee DC, van Heurn LWE, Verkade HJ, Wilde JCH, Hulscher JBF. The timing of surgery of antenatally diagnosed choledochal malformations: A descriptive analysis of a 26-year nationwide cohort. J Pediatr Surg 2017; 52:1156-1160. [PMID: 28318597 DOI: 10.1016/j.jpedsurg.2017.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 01/23/2017] [Accepted: 03/06/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Choledochal malformations (CMs) are increasingly diagnosed antenatally. There is a dilemma between early surgery to prevent CM-related symptoms and postponing surgery to reduce complications. We aimed to identify the optimal timing of surgery in asymptomatic neonates with antenatally diagnosed CM and to identify predictors for development of symptoms. METHODS Using the Netherlands Study group on CHoledochal Cyst/malformation (NeSCHoc) we retrospectively collected demographic, biochemical and surgical data from all Dutch patients with an antenatally detected CM. RESULTS Between 1989 and 2014, antenatally suspected CM was confirmed in 17 patients at a median age of 10days (1day-2months). Four patients developed symptoms directly after birth (24%). Thirteen patients (76%) remained asymptomatic. Two of these progressed to symptoms before surgical intervention at 0.7 and 2.1months resp. Postoperatively, four patients developed short-term complications and three developed long-term complications. Patients <5.6kg (the series median) showed more short-term complications (66%) when compared to patients >5.6kg (0%, p=0.02). CONCLUSION When not symptomatic within the first days of life, the majority of children with antenatally detected CM remains asymptomatic. Surgery might safely be delayed to the age of 6months or a weight of 6kg. Postponing surgery in the clinically and biochemical asymptomatic patient might decrease the complication rate. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
| | - Maria H A van den Eijnden
- Department of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ruben H de Kleine
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ivo de Blaauw
- Department of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Paul M J G Peeters
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart G P Koot
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Matthijs W N Oomen
- Department of Pediatric Surgery, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Wim G van Gemert
- Department of Pediatric Surgery, University Medical Center Maastricht, Maastricht, The Netherlands
| | - David C van der Zee
- Department of Pediatric Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L W Ernest van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Henkjan J Verkade
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Jim C H Wilde
- University Center of Pediatric Surgery of Western Switzerland, Division of Pediatric Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Jan B F Hulscher
- Department of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Sarin YK, Raj P, Kumar P, Garg A. Giant Choledochal Cyst in A Neonate. J Neonatal Surg 2017; 6:22. [PMID: 28083508 PMCID: PMC5224756 DOI: 10.21699/jns.v6i1.408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 10/09/2016] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yogesh Kumar Sarin
- Department of Pediaric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Prince Raj
- Department of Pediaric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Parveen Kumar
- Department of Pediaric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Anju Garg
- Department of Pediaric Surgery, Maulana Azad Medical College, New Delhi, 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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Cherqaoui A, Haddad M, Roman C, Gorincour G, Marti JY, Bonnard A, Guys JM, de Lagausie P. Management of choledochal cyst: Evolution with antenatal diagnosis and laparoscopic approach. J Minim Access Surg 2012; 8:129-33. [PMID: 23248439 PMCID: PMC3523449 DOI: 10.4103/0972-9941.103113] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 07/11/2011] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIM: Laparoscopic excision of a choledochal cyst (CC) with hepaticojejunostomy gained a wide acceptance in the treatment of children even in neonatal period. Although, the use of prenatal diagnostic techniques causes a significant increase in antenatal diagnosis of CC, the time of surgical intervention during infancy is still controversial. A retrospective study was performed to evaluate the results of laparoscopic management of CC with special emphasis on antenatal diagnosis and treatment, and to compare the results with open procedure. MATERIALS AND METHODS: The patients who were diagnosed with choledochal cyst and underwent either open or laparoscopic hepaticojejunostomy in two centres, hopital d’enfant de La Timone from Marseille and hopital Robert Debre from Paris between November 2000 and December 2009 were included in the study. The data obtained from medical reports were evaluated for sex, time of antenatal diagnosis, age at time of operation, operative time, time of postoperation. RESULTS: A total of 19 hepaticojejunostomy were performed, including 10 open procedures (group A), and 9 laparoscopic procedures (group B, 4 were diagnosed prenatally, without conversion to open procedure). There were 3 boys and 16 girls, ranging in age from 2 weeks to 16 years. Patients in the group A were older than patients in the group B. The mean hospital stay and time to return of bowel fuction was longer in the group B. there were 60% of pre-operative complications in group A versus 22% in group B. There was one postoperative complications in group B (biliary leakage nedeed redo surgery). No significant differences were found between different parameters except for operative time (288.56 min in the group B versus 206 min in the group A. (p = 0.041)). CONCLUSIONS: Our initial experience indicates that the laparoscopic approach in infancy is technically feasible, safe, and effective, with a low morbidity and a comparable outcome to the open approach. Therefore, we propose a laparoscopic approach for antenatally diagnosed CC as early as possible, before the onset of complications.
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Affiliation(s)
- Abdelmounim Cherqaoui
- Department of Pediatric Surgery, Hopital d'enfants de la Timone, Marseille 13385, France
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Yasufuku M, Hisamatsu C, Nozaki N, Nishijima E. A very low-birth-weight infant with spontaneous perforation of a choledochal cyst and adjacent pseudocyst formation. J Pediatr Surg 2012; 47:E17-9. [PMID: 22813825 DOI: 10.1016/j.jpedsurg.2012.03.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 03/06/2012] [Accepted: 03/14/2012] [Indexed: 11/16/2022]
Abstract
Spontaneous perforation of a choledochal cyst with ensuing pseudocyst formation is a very rare complication. We report the development of a pseudocyst adjacent to a choledochal cyst in a very low-birth-weight infant at 2 months of age. Elective excision of the choledochal cyst and biliary tract reconstruction were successfully performed 2 months later when the infant weighed 3 kg. Delayed primary repair may be a viable alternative treatment for low-birth-weight infants with choledochal cysts.
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Affiliation(s)
- Masao Yasufuku
- Department of Pediatric Surgery, Kakogawa West City Hospital, 384-1 Hiratsu, Yoneda-cho, Kakogawa-shi, Hyogo, 675-8611, Japan.
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Tanaka N, Ueno T, Takama Y, Fukuzawa M. Diagnosis and management of biliary cystic malformations in neonates. J Pediatr Surg 2010; 45:2119-23. [PMID: 21034931 DOI: 10.1016/j.jpedsurg.2010.06.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 05/06/2010] [Accepted: 06/28/2010] [Indexed: 12/29/2022]
Abstract
PURPOSE Recent advances in ultrasonography have made it possible to identify biliary atresia (BA) and choledochal cyst (CC) with biliary cystic malformations (BCM) both prenatally and neonatally. The early differential diagnosis between BA and CC is extremely important because operations must be performed as soon as possible before the livers of BA patients advance to an irreversible cirrhotic stage. The aim of this study was to differentiate patients with BCM and to determine the best course of management in the neonatal period. METHODS The medical records of patients that were diagnosed with BCM by a prenatal or neonatal ultrasound between 1997 and 2008 were reviewed. We retrospectively divided the BCM patients into the BA and CC groups and then compared the results of ultrasound, computed tomography, and laboratory tests between the 2 groups. RESULTS Ten patients were enrolled in the study. The median age at the time of corrective surgery was 74 days (range, 24-206 days). All of the BA cases received an operation by the time they were 60 days old. In the BA group (5 patients), the mean cyst size was 15 mm, the mean direct bilirubin (D-Bil) was 3.3 mg/dL, and the mean total bile acid (TBA) was 138.1 µmol/L at 30 days of age, whereas in the CC group (5 patients), cyst size, D-Bil, and TBA were 40 mm, 0.9 mg/dL, and 46.9 µmol/L, respectively. These differences between the 2 groups were statistically significant. All of the patients with CC successfully cleared their jaundice, whereas 4 patients with BA subsequently required liver transplantation for liver failure. In our study, all patients with BCM less than 21 mm, D-Bil greater than 2.5 mg/dL, and TBA greater than 111 µmol/L in the neonatal period were diagnosed with BA. CONCLUSIONS Our data suggested that patients with BCM smaller than 21 mm, D-Bil higher than 2.5 mg/dL, and TBA higher than 111 µmol/L in the neonatal period were more likely to have BA than CC. This potential diagnosis should be surgically examined and corrected as soon as possible.
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Affiliation(s)
- Natsumi Tanaka
- Division of Pediatric Surgery, Department of Surgery, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
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Ruiz-Elizalde AR, Cowles RA. A practical algorithm for accurate diagnosis and treatment of perinatally identified biliary ductal dilation: three cases that underscore the importance of an individualised approach. J Matern Fetal Neonatal Med 2009; 22:622-8. [DOI: 10.1080/14767050902755486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Okada T, Sasaki F, Ueki S, Hirokata G, Okuyama K, Cho K, Todo S. Postnatal management for prenatally diagnosed choledochal cysts. J Pediatr Surg 2004; 39:1055-8. [PMID: 15213898 DOI: 10.1016/j.jpedsurg.2004.03.054] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE The aim of this study was to determine an appropriate postnatal management plan for prenatally diagnosed congenital biliary dilatation (CBD). METHODS Between 1962 and 2002, 5 (5.9 %) of 85 patients had CBD diagnosed prenatally and were examined clinically. Of these 5 patients, 2 (group A) underwent delayed primary definitive surgery after percutaneous transhepatic cholangiodrainage (PTCD), 1 (group B) underwent early definitive surgery in the neonatal period, and 2 (group C) underwent delayed primary definitive surgery without PTCD in early infancy (within 6 months after birth). The clinical data, operative findings, intra- and postoperative complications, and follow-up were evaluated in these 3 groups. RESULTS There were no postoperative complications, such as catheter-related complications, in group A. However, there was adhesion around the choledochal cyst, and the operation was therefore difficult in group A. The diameter of the anastomosis in the hepaticojejunostomy was small, and the cyst wall was thin in group B. Consequently, anastomotic leakage of the hepaticojejunostomy occurred in group B. Neither operative nor postoperative complications such as anastomotic leakage or stenosis occurred in group C. Slight fibrosis of Glisson's sheath was seen in 2 patients of groups A and C. No liver cirrhosis was seen in any group. CONCLUSIONS The authors propose that asymptomatic patients should undergo elective definitive surgery by 6 months of age. For symptomatic patients, especially when a differential diagnosis of type I cystic biliary atresia is doubtful, early definitive surgery is needed before 2 months of age. PTCD appears to be indicated only under certain circumstances, and delayed primary definitive surgery should be performed as early as possible thereafter.
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Affiliation(s)
- Tadao Okada
- Department of Pediatric Surgery, Hokkaido University School of Medicine, Sapporo, Japan
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