Laparoscopic Management of Choledochal Cysts Associated with Aberrant Hepatic Ducts

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.

Clinical implications of aberrant anatomy of the common hepatic duct in liver surgery: a systematic review and meta-analysis

INTRODUCTION

Knowledge of anatomical variants that affect the hepatic duct (HD) are of particular clinical relevance during hepatobiliary surgical procedures. More specifically, the aberrant anatomy of the common HD is the most common anatomical variation affecting the biliary tree. Below, we describe different classifications of anatomical variants that affect this canal. According to Huang's classification, variations are determined depending on the insertion of the right posterior hepatic duct (RPHD).

MATERIALS AND METHODS

Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases were investigated until January 2024. The methodological quality was assessed with an anatomical studies assurance tool (AQUA). Pooled prevalence was estimated using a random effects model. For the subgroup analysis, Student's T-test was used.

RESULTS

The prevalence rate of aberrant hepatic duct (AHD) was 15% (confidence interval [CI] of 7-22%). The first subgroup had cadavers and images. For the cadavers, the prevalence was 15.83% (CI: 11.22-18.3%), while the images had a prevalence of 22.06% (CI: 18.12-25.33%). This subgroup analysis showed no statistically significant difference between these groups (p = 0.127). The second subgroup comprised the continents where the included studies were from. In this subgroup, no statistically significant differences were found (p = 0.613). Finally, regarding the right or left laterality of the HD variant, there were no statistically significant differences (p = 0.089).

CONCLUSION

A AHD corresponds to a finding that can occur in a significant percentage of our society, which could be an accidental discovery during surgeries or present asymptomatically throughout life and be a cadaveric discovery later. We believe it is important for surgeons to have prior knowledge of the possible variants of HD to prevent possible complications during and after surgery.

Type I choledochal cyst. Total laparoscopic resection and Roux-en-Y reconstruction to two separated ducts

A choledochal cyst is a rare condition that requires surgical treatment to prevent complications, such as obstructive jaundice, cyst rupture, cholangitis, and the risk of malignancy. Complete cyst excision is considered the best option, as it reduces the risk of inflammation and the development of cholangiocarcinoma. Therefore, cholecystectomy and complete cyst resection followed by reconstruction with a Roux-en-Y hepaticojejunostomy is the treatment of choice. We present a case (with video) that shows the complete resection of a type I choledochal cyst with Roux-en-Y reconstruction of two separate ducts since the right posterior duct reached the cyst independently. The laparoscopic approach offers all the advantages of mini-invasive surgery and better visualization of the structures; however, biliary reconstruction to fine ducts implies a surgical challenge that requires high training in mini-invasive surgery.

The Initial Experience of Laparoscopic Management for Type VI Choledochal Cyst in Children

Purposes: Dilatation of cystic duct is very rare and had been classified as Todani type VI choledochal cyst. Choledochal cyst combined with dilatation of cystic duct is difficult to diagnose preoperatively. The purpose of this study is to report the rare variants and discuss the significance and laparoscopic management strategy in children. Methods: The subjects for this study were 10 consecutive patients with type VI choledochal cyst who had laparoscopic procedures at our institute between January 2009 and January 2023. Laparoscopic cholecystectomy, excision of the dilated cystic duct, and choledochal cyst were carried out, and the continuity of the biliary duct was re-established through a Roux-en-Y hepaticojejunostomy. Results: Cystic duct combined with the common bile duct dilatation was revealed in all the patients intraoperatively. Laparoscopic procedures were completed with no conversions. The postoperative recovery was uneventful. The mean follow-up duration was 27 ± 12.7 months (range 5-36 months) with no postoperative complications encountered. Conclusions: The rare entity of type VI choledochal cyst should be recognized as a distinct type of choledochal cyst and need to be given enough attention clinically. The laparoscopic procedure is a feasible option for experienced surgeons.

Using machine learning models to predict the surgical risk of children with pancreaticobiliary maljunction and biliary dilatation

PURPOSE

To develop machine learning (ML) models to predict the surgical risk of children with pancreaticobiliary maljunction (PBM) and biliary dilatation.

METHODS

The subjects of this study were 157 pediatric patients who underwent surgery for PBM with biliary dilatation between January, 2015 and August, 2022. Using preoperative data, four ML models were developed, including logistic regression (LR), random forest (RF), support vector machine classifier (SVC), and extreme gradient boosting (XGBoost). The performance of each model was assessed via the area under the receiver operator characteristic curve (AUC). Model interpretations were generated by Shapley Additive Explanations. A nomogram was used to validate the best-performing model.

RESULTS

Sixty-eight patients (43.3%) were classified as the high-risk surgery group. The XGBoost model (AUC = 0.822) outperformed the LR (AUC = 0.798), RF (AUC = 0.802) and SVC (AUC = 0.804) models. In all four models, enhancement of the choledochal cystic wall and an abnormal position of the right hepatic artery were the two most important features. Moreover, the diameter of the choledochal cyst, bile duct variation, and serum amylase were selected as key predictive factors by all four models.

CONCLUSIONS

Using preoperative data, the ML models, especially XGBoost, have the potential to predict the surgical risk of children with PBM and biliary dilatation. The nomogram may provide surgeons early warning to avoid intraoperative iatrogenic injury.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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