Proper bile duct flow, rather than radical excision, is the most critical factor determining treatment outcomes of bile duct cysts

Surgical Management of Recurrence of Primary Intrahepatic Bile Duct Stones

BACKGROUND

The surgical treatment of primary intrahepatic bile duct stones is associated with high rates of postoperative complications, stone recurrence, and reoperation. This study aimed to report an 11-year experience in the management of postoperative recurrence of intrahepatic bile duct stones, analyze the causes of the reoperation, and establish appropriate surgical procedures.

MATERIALS AND METHODS

The records of 148 patients with postoperative recurrence of primary intrahepatic bile duct stones treated from January 2005 to December 2015 were retrospectively reviewed. Prior surgical treatment and postoperative data were analyzed to investigate possible causes of recurrence and reoperation.

RESULTS

All patients with a prior cholangiojejunostomy (n = 61) developed biliary stenosis (100%). Of the 86 patients without cholangiojejunostomy, 71 (82.56%) had abnormalities in the structure and function of the lower end of the common bile duct, and 86 had hilar and intrahepatic bile duct stenosis. Of all 148 patients, 136 (91.89%) had positive intraoperative bile cultures. Patients were treated with a modified surgical procedure, and the combined excellent and good rate of long-term outcomes reached 85.48% (106/124). The stone recurrence rate of the 124 patients decreased from 100% (124/124) of the prior operation to 5.65% (7/124) during the reoperation.

CONCLUSIONS

The pathogenesis of primary intrahepatic bile duct stones is associated with biliary infection and intrahepatic bile duct cholestasis. According to the etiology and pathogenic mechanism, surgical procedures that improve long-term outcomes and reduce postoperative recurrence include bile duct exploration with stone extraction, partial hepatectomy, hilar ductoplasty, and Roux-en-Y hepaticojejunostomy.

Diagnosis and management of choledochal cysts

BACKGROUND

Choledochal cysts (CCs) are rare cystic dilatations of the intrahepatic and/or extrahepatic bile ducts. We review the pathophysiology, diagnosis, and management of CCs.

METHODS

MEDLINE/PubMed and Web of Science databases were queried for "choledochal cyst", "bile duct cyst", "choledochocele", and "Caroli disease". Data were synthesized and systematically reviewed.

RESULTS

Classified according to the Todani Classification, CCs are generally believed to arise secondary to reflux of pancreatic enzymes into the biliary tree due to anomalous pancreaticobiliary duct union. Complications of CCs include abdominal pain, jaundice, cystolithiasis, cholecystitis, pancreatitis, liver abscess, liver cirrhosis and malignant transformation (3-7.5%). Radiological and endoscopic imaging is the cornerstone of CC diagnosis and full delineation of cyst anatomy is imperative for proper management. Management is generally guided by cyst classification with complete cyst excision necessary for CCs with high potential of malignant transformation such as types I and IV. 5-year overall survival after choledochal cyst excision is 95.5%.

CONCLUSION

Most CCs should undergo surgical intervention to mitigate the risk of cyst related complications such as cholangitis and malignant transformation.

Surgical Management and Prognosis of Congenital Choledochal Cysts in Adults: A Single Asian Center Cohort of 69 Cases

Background

The choledochal cyst (CC) is a rare cystic dilatory condition with malignant tendency, which is more frequently reported in children. Surgical resection of cysts can significantly decrease the risk of malignancy and reduce associated complications. However, CC has been paid lesser attention in adults, and its surgical parameters have been frequently reported to be in dispute. This study aimed to report experience associated with the treatment of an adult with CC and to suggest the appropriate parameters for the surgery, including the extent of excision (complete or not), the length of the Y limb, the diameter of the cholangio-intestinal anastomosis (CIA), and different operative approaches (open, laparoscopic, and laparoscopic converted to open) by comparing the various indicators, including postoperative bile leakage, cholangitis, choledocholithiasis, carcinogenesis, and surgical re-excision.

Methods

We conducted a single-center noninterventional retrospective study of 69 different congenital choledochal cyst patients who were admitted to our hospital between July 2010 and July 2020. We collected and analyzed their demographic data, clinical presentations, underlying complications, imaging tests, endoscopic interventions, and parameters for the surgery, histological data, and prognostic indicators over a mean 77-month follow-up period.

Results

We found that out of the 69 cases, the median age at diagnosis was 32 (IQR = 22–45) years. Seven (10.1%) patients were asymptomatic before the diagnosis, with abdominal pain as the primary complaint in 62 (89.9%) patients, whereas nausea/vomiting was observed in 29 (42.0%) patients. CCs were mainly evaluated by using magnetic resonance cholangiopancreatography (MRCP) (n = 47, 68.1%). It was observed that surgery, cholecystectomy, choledochal cysts excision, and Roux-en-Y hepaticojejunostomy (n = 65, 94.2%), and laparotomy (n = 58, 84.1%) were the dominant therapeutic modalities employed. However, seventeen (24.6%) patients were treated with incomplete cyst resection, while 52 (75.4%) patients received complete cyst resection. We also conducted regular follow-ups after the surgery for a mean duration of 77 months. Postoperative complications were found to be experienced by 35 (50.7%) patients, and a further two patients (2.9%) developed malignancy during the follow-up. Moreover, increasing the diameter of cholangio-intestinal anastomosis served as a potential protective factor for postoperative choledocholithiasis (p = 0.040) and a risk factor for cholangitis (p = 0.002).

Conclusions

Among the 69 CC participants, abdominal pain was their major symptom. Those with an abnormal pancreaticobiliary junction were more likely to have choledocholithiasis and pancreatitis. The diagnosis was found to be highly dependent on the Todani classification scheme and MRCP. Surgical resection remains the key to CC treatment. The results suggested that the complete resection, the length of the Y limb of 40 cm–60 cm, and the diameter of the CIA of 1.0 cm–1.5 cm were appropriate values for predicting the lower risk of postoperative complications.

Resection of extrahepatic bile ducts with partial hepatectomy for treating intra- and extrahepatic hepatolithiasis

Background

To evaluate the efficacy and safety of our new surgical procedures for primary intra- and extrahepatic hepatolithiasis. Hepatolithiasis is an intractable disease with frequent recurrences.

Methods

From 1996 to 2005, 142 patients with intrahepatic and/or extrahepatic hepatolithiasis treated with the conventional surgical methods were included as the control group, while 128 consecutive patients treated with new surgical methods from 2006 to 2015 were included as the observation group. The new surgical procedures included a comprehensive intraoperative exploration of the bile ducts, focusing on the structure and function of the hilar bile duct and duodenal papilla, exploration of the affected liver, and bile culture.

Results

The observation group had a significantly higher complete stone clearance rate than the control group (100% vs. 65.96%). The observation group had significantly lower incidences of cholangitis and bile duct stones, as well as a higher excellent and good long-term surgical efficacy rate (86.24% vs. 52.73%). Multivariate Cox analysis showed that the control group had a higher risk for fair + poor efficacy than the observation group (HR: 8.47).

Conclusions

Our new surgical procedures are safe and can provide a good long-term efficacy for treating primary hepatolithiasis intra- and extrahepatic hepatolithiasis.

Risk factors for preoperative carcinogenesis of bile duct cysts in adults

BACKGROUND

Bile duct cyst (BDC) is a rare congenital bile duct malformation. The incidence of bile duct malignancy in BDC patients is markedly higher than that in the general population. However, few studies have been conducted on the risk factors for preoperative carcinogenesis in BDC patients.

AIM

To analyze the risk factors associated with preoperative carcinogenesis in BDC patients.

METHODS

The medical records of BDC patients treated at our hospital between January 2012 and December 2018 were retrospectively reviewed. We constructed a database and compared the characteristics of BDC patients with dysplasia and carcinoma against those with benign cysts. The risk factors for preoperative carcinogenesis were identified using univariate and multivariate analyses.

RESULTS

The cohort comprised 109 BDC patients. Ten patients had preoperative dysplasia or adenocarcinoma. Univariate and multivariate analyses showed that gallbladder wall thickness > 0.3 cm [odds ratio (OR), 6.551; 95% confidence interval (CI), 1.351 to 31.763; P = 0.020] and Todani type IV (OR, 7.675; 95%CI, 1.584 to 37.192; P = 0.011) were independent factors associated with preoperative carcinogenesis.

CONCLUSION

BDC is a premalignant condition. Our findings show that gallbladder wall thickness > 0.3 cm and Todani type IV are independent risk factors for preoperative carcinogenesis of BDC. They are therefore useful for deciding on the appropriate treatment strategy, especially in asymptomatic patients.

Surgical strategy for recurrent common bile duct stones: a 10-year experience of a single center

Recurrence of common bile duct stones (CBDS) is common after surgical stone extraction, but the causes of recurrence are not fully understood. This study aimed to report the experience of treating recurrent CBDS. A total of 106 consecutive cases of recurrent CBDS treated from January 2006 to December 2015 were included. During surgery, the choledochoscopic pass-through test was performed to assess the structure and function of the duodenal papilla. The choledochoscopic pass-through test revealed 62 patients (58.49%) with incomplete closure of the lower end of the common bile duct, and 28 (26.42%) with stenosis at the lower common bile duct. Intra-operative bile bacterial culture was positive in 98 (92.45%) patients. The rate of complete stone clearance was 99.1%. The total recurrence rate of CBDS was 3.13%. The long-term success rate of surgical treatment (excellent and good) reached 92.7% .Duodenal papilla (Oddi sphincter) dysfunction is the main cause of recurrent CBDS. Common bile duct exploration with stone extraction, hilar ductoplasty, and Roux-en-Y hepaticojejunostomy can effectively eliminate the recurrence of CBDS and reduce the incidence of post-hepaticojejunostomy complications. Thus, it is an optimal surgical procedure for recurrent CBDS.

Standardized Surgical Management for Cystic Dilation of the Bile Ducts Based on Clinical and Pathological Studies: A Narrative Review

The surgical method of complete/radical cyst excision plus Roux-en-Y hepaticojejunostomy remains the primary therapy and the only effective treatment for cystic dilation of the bile ducts (CDBDs). However, the incidence of long-term postoperative complications is still high, as is the reoperation rate, and the potential for postoperative malignant transformation still exists. In recent years, significant progress has been made in understanding the pathogenic mechanism and pathological changes of adult CDBDs. Based on which, the surgical procedures for CDBDs have been revised to further improve their effectiveness. The purpose of this review is to systematically summarize the latest concepts of the etiology and pathogenic mechanism and the pathological changes of adult CDBDs. Based on the findings of these clinical and pathological studies, a comprehensive theoretical system in the surgical treatment of CDBDs has been established, which corrects many previous theoretical misunderstandings. The specific surgical method for each type of CDBDs and the key technical notes are also described in detail. Using these principles, treatment outcomes for CDBDs can be significantly improved, and the current high complication rate, reoperation rate, and rate of postoperative malignant transformation can be reduced.

Survey of the attitudes of hepatopancreatobiliary surgeons in northern Europe to resection of choledochal cysts in asymptomatic Western adults

Background

Todani type 1 and 4 choledochal cysts are associated with a risk of developing cholangiocarcinoma. Resection is usually recommended, but data for asymptomatic Western adults are sparse. The aim of this study was to investigate diagnostic interpretation and attitudes towards resection of bile ducts for choledochal cysts in this subgroup of patients across northern European centres.

Methods

Thirty hepatopancreatobiliary centres were provided with magnetic resonance cholangiopancreatograms and asked to discuss the management of six cases: asymptomatic non‐Asian women, aged 30 or 60 years, with variable common bile duct (CBD) dilatations and different risk factors in the setting of a multidisciplinary team (MDT). The Fleiss κ value was calculated to estimate overall inter‐rater agreement.

Results

For all case scenarios combined, 83·3 and 86·7 per cent recommended resection for a CBD of 20 and 26 mm respectively, compared with 19·4 per cent for a CBD of 13 mm (P < 0·001). For patients aged 30 and 60 years, resection was recommended in 68·5 and 57·8 per cent respectively (P = 0·010). There was a trend towards recommending resection in the presence of a common channel, most pronounced in the 60‐year‐old patient. High amylase levels in the CBD aspirate led to recommendations to resect, but only for the 13‐mm CBD dilatation. There were no differences related to centre size or region. MDT discussion was associated with recommendations to resect. Inter‐rater agreement was 73·3 per cent (κ = 0·43, 95 per cent c.i. 0·38 to 0·48).

Conclusion

The inter‐rater agreement to resect was intermediate, and the recommendation was dependent mainly on the diameter of the CBD dilatation.

Clinical Features and Surgical Management of Bile Duct Cyst in Adults

Objectives

Bile duct cyst (BDC) is a rare congenital biliary malformation with 20% of cases initially diagnosed during adulthood. Although the incidence of BDC in adults is increasing worldwide, the clinical features of adult BDC remain unclear. The present study was aimed at characterizing the demographic and clinical features of this rare disease.

Methods

We constructed a retrospective database and analyzed records of 106 patients (mean age, 41.0 ± 14.8 years; 18 men (17.0%)) with BDC treated at our institution from May 2012 to October 2018. Data collected included demographic characteristics, clinical manifestations, surgical patterns, and prognoses. We compared the characteristics of patients undergoing their primary BDC resection against those of patients undergoing reoperation. Risk factors for bile duct infection (BDI), a common complication of BDC, were identified using univariate and multivariate analyses.

Results

Abdominal pain was the most common preoperative symptom, but 12 patients (11.3%) were asymptomatic. Ninety-nine patients underwent their primary BDC resection, and 7 patients received reoperation at our hospital. There was no significant difference in the postoperative complication rate between the two groups. Ninety-four patients were followed up for 37.8 ± 23.8 months, and BDI occurred in 33 patients (35.1%). Hilar anastomosis was an independent risk factor for BDI (odds ratio = 3.561; 95%confidence interval = 1.101, 11.517; and p = 0.034).

Conclusion

BDC was more frequent in women and abdominal pain was the most common preoperative symptom. The primary reason for reoperation was anastomotic stenosis. Reoperation had similar outcomes to primary resection and may be considered safe and acceptable if performed by a skillful surgeon. BDI was the most frequent postoperative complication with hilar anastomosis being the only independent risk factor. This highlights the importance of proper bile duct flow for surgical outcomes of BDC.