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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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2
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Takahashi Y, Kobayashi T, Kinoshita Y, Arai Y, Ohyama T, Yokota N, Sugai Y, Takano S. Early and late outcomes of congenital biliary dilatation in pediatric patients. Pediatr Int 2024; 66:e15712. [PMID: 38563281 DOI: 10.1111/ped.15712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 10/15/2023] [Accepted: 10/25/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND This study aimed to reveal the early and late postoperative complications and outcomes after surgery for congenital biliary dilatation (CBD) by reviewing cases over the past 40 years. METHODS We retrospectively evaluated 59 patients with CBD who underwent radical surgery for complications and outcomes, based on medical records. Early complications were defined as those requiring treatment within 5 years of the initial operation. Late complications were defined as those treated more than 5 years later. RESULTS The median age at the first surgery was 37 months. Regarding biliary reconstruction, 54 of the 59 patients (91.5%) underwent hepaticojejunostomy. Although three patients underwent cholecystoduodenostomy and one patient underwent hepaticoduodenostomy, all were converted to hepaticojejunostomy after a median of 12.5 years. One patient developed synchronous biliary carcinoma and underwent pancreaticoduodenectomy. Early complications occurred in seven patients with 10 events (surgical site infection, n = 3 bile leakage, n = 3; ileus, n = 3; bile duct obstruction, n = 1 and intussusception, n = 1). Late complications occurred in nine patients with 12 events (ileus, n = 3; anastomotic stricture, n = 3; hepatolithiasis, n = 3; asynchronous biliary carcinoma, n = 2; pancreatolithiasis, n = 1). Two of the three patients with hepatolithiasis underwent hepatectomy refractory to the endoscopic approach. Two patients developed asynchronous biliary carcinoma at 34 and 13 years after last operation; both ultimately died of the carcinoma. Only 35 patients (61.4%) underwent a follow-up examination. A total of 11 female patients (45.8%) eventually married, and all successfully gave birth. CONCLUSION Although the long-term prognosis is excellent with complete cyst excision and hepaticojejunostomy, we emphasize the importance of long-term follow-up.
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Affiliation(s)
- Yoshiaki Takahashi
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-Ku, Niigata City, Japan
| | - Takashi Kobayashi
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-Ku, Niigata City, Japan
| | - Yoshiaki Kinoshita
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-Ku, Niigata City, Japan
| | - Yuhki Arai
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-Ku, Niigata City, Japan
| | - Toshiyuki Ohyama
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-Ku, Niigata City, Japan
| | - Naoki Yokota
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-Ku, Niigata City, Japan
| | - Yu Sugai
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-Ku, Niigata City, Japan
| | - Shoichi Takano
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-Ku, Niigata City, Japan
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3
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Goyal AK, Gupta R, Meena N. Outcome of Biliary-enteric Reconstruction with Hepaticoduodenostomy Following Choledochal Cyst Resection: A Prospective Study. Afr J Paediatr Surg 2024; 21:39-47. [PMID: 38259018 PMCID: PMC10903726 DOI: 10.4103/ajps.ajps_43_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/07/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The two most commonly performed methods of biliary-enteric reconstruction following choledochal cyst resection are Roux-en-Y hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD). There is a lack of consensus regarding the better technique between them. This study aimed to evaluate the outcomes, efficacy and early complications of HD as a mode of biliary reconstruction after surgical resection of a choledochal cyst. MATERIALS AND METHODS This was a multi-institutional prospective study carried out in high-volume tertiary care teaching institutes from January 2010 to December 2022. All children managed with HD following choledochal cyst resection were analysed for their early complications and outcomes. RESULTS A total of 74 patients were included in this study. There were 59 (79.73%) females and 15 (20.27%) males. Thirty-nine (52.70%) patients had jaundice at the time of presentation. Magnetic resonance cholangiopancreatography was performed in 57 (77.03%) patients following ultrasonography. Intraoperatively, malrotation was present in 2 (2.70%) patients. In our study, operating time ranged from 60 to 195 min (mean: 118 min). Hospital stays ranged from 8 to 17 days (mean: 11.5 days). The post-operative biliary leak was seen in 7 (9.50%) patients, out of which 6 (8.11%) minor leaks were managed conservatively. Roux-en-Y HJ was performed on 1 (1.35%) patient with a major leak. In our series, 4 (5.40%) patients developed cholangitis; post-operative haemorrhagic nasogastric aspirate 5 (6.76%), post-operative pancreatitis 3 (4.05%) and wound infection 4 (5.40%) were observed and managed conservatively. None of the patients in our study developed an anastomotic stricture, bile gastritis and adhesive small bowel obstruction. CONCLUSION Resection of choledochal cyst with HD reconstruction is safe and feasible with short operative time. HD is a viable option for operative management of choledochal cyst with low complication rates and faster recovery.
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Affiliation(s)
- Ashok Kumar Goyal
- Department of Paediatric Surgery, Government Medical College, Kota, Rajasthan, India
| | - Rahul Gupta
- Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
| | - Neelam Meena
- Department of Paediatrics, Government Medical College, Kota, Rajasthan, India
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Farrukh AM, Bhagat HR, Ismail MB, Sandesara MP, Assal MW, Makonyonga RD. Choledochal cyst mimicking as choledocholithiasis: A case report and review of literature. SAGE Open Med Case Rep 2023; 12:2050313X231223317. [PMID: 38162421 PMCID: PMC10757428 DOI: 10.1177/2050313x231223317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024] Open
Abstract
Choledochal cysts are rare congenital anomalies of the biliary system, mostly diagnosed during childhood. In adults, a lower incidence and symptom overlap with more common biliary conditions may hinder the diagnosis. This case study presents a 50-year-old female patient who presented with abdominal pain and multiple gallstones on ultrasonography which also showed a dilation of the common bile duct, presumably left by a stone that had already passed. However, the dilation still existed 3 days later, which raised suspicion of a choledochal cyst. Magnetic resonance cholangiopancreatography was performed, and following surgical consultation, the patient underwent a successful cyst excision by Roux-en-Y hepaticojejunostomy with a smooth recovery leading to hospital discharge. This case highlights the importance of considering choledochal cysts as one possible diagnosis in adults with biliary symptoms and the significance of the more specific imaging modalities such as magnetic resonance cholangiopancreatography.
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Affiliation(s)
| | | | | | | | - Mazen W Assal
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
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5
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Durgun AV, Ergün S, Turgut BC, Şimşek O, Velidedeoglu M, Sarıbeyoğlu K, Pekmezci S. Biliary cysts in adults: Cerrahpaşa experience. Turk J Surg 2023; 39:315-320. [PMID: 38694518 PMCID: PMC11057935 DOI: 10.47717/turkjsurg.2023.6285] [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: 11/30/2023] [Accepted: 12/16/2023] [Indexed: 05/04/2024]
Abstract
Objectives Biliary cysts are biliary duct dilatations, with 20% of the cysts being diagnosed in adulthood. Abdominal pain, jaundice and palpable abdominal mass are defined as the classical triad. However, nausea, vomiting, fever, itching and weight loss are frequent complaints. There are several treatment options depending on the type of the cyst. This study aimed to share our experience with biliary cysts and contribute to the literature on this subject. Material and Methods Thirty patients, who received treatment for biliary cyst from January 1981 to December 2018 at our clinic, were studied retrospectively. The patients were analyzed based on age, sex, type of the cyst, diagnosis and treatment methods, post-op follow up and complications. Results Twenty-seven of the patients were females, and three were males. The patients were aged between 16 and 76 years, and the median age was 41.9 years. All patients presented with abdominal pain, which was accompanied by cholangitis in nine patients, nausea and vomiting in four patients, dyspepsia in three patients and palpable mass in one patient. According to the Todani classification, biliary cyst findings were consistent with Type I in 23 patients, Type V in three patients, Type IV in two patients, Type II in one patient and Type III in one patient. Conclusion Diagnosis and treatment are complex in biliary cysts due to anatomical proximity and variations. Therefore, it would be beneficial to refer them to referral centers. Choice of treatment should be based on the type of the cyst.
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Affiliation(s)
- Ali Vedat Durgun
- Department of General Surgery, İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye
| | - Sefa Ergün
- Department of General Surgery, İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye
| | - Başar Can Turgut
- Department of General Surgery, İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye
| | - Osman Şimşek
- Department of General Surgery, İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye
| | - Mehmet Velidedeoglu
- Department of General Surgery, İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye
| | - Kaya Sarıbeyoğlu
- Department of General Surgery, Charite University, Berlin, Germany
| | - Salih Pekmezci
- Department of General Surgery, İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye
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6
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Cazares J, Koga H, Yamataka A. Choledochal cyst. Pediatr Surg Int 2023; 39:209. [PMID: 37261604 DOI: 10.1007/s00383-023-05483-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/02/2023]
Abstract
Choledochal cyst (CC) or congenital biliary dilatation, has a skewed distribution with hereditary features that is far more common in East Asian females. CC is usually associated with pancreaticobiliary malunion (PBMU) forming a common channel. CC requires early definitive diagnosis, since there is a risk for malignancy occurring in the CC and/or intrahepatic bile ducts (IHBD). Complete CC excision and Roux-en-Y hepaticoenterostomy is required and can be performed by open or minimally invasive surgery with hepatojejunostomy the recommended procedure of choice. Principles of open surgical intervention form the basis of minimally invasive management with laparoscopy and robotic assistance. Current surgical management is associated with fewer early and late complications, such as hepaticoenterostomy anastomotic leakage, cholangitis, anastomosis stricture, and cholangiocarcinoma. Specific features of CC management at Juntendo include: intraoperative endoscopy of the common channel and IHBD for inspecting and clearing debris to significantly reduce post-operative pancreatitis or stone formation; near infra-red fluorescence with indocyanine green for visualizing tissue planes especially during minimally invasive surgery for CC; and a classification system for CC based on PBMU that overcomes inconsistencies between existing classification systems and clinical presentation.
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Affiliation(s)
- Joel Cazares
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
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7
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Ramsey WA, Huerta CT, Ingle SM, Gilna GP, Saberi RA, O'Neil CF, Ribieras AJ, Parreco JP, Perez EA, Sola JE, Thorson CM. Outcomes of laparoscopic versus open resection of pediatric choledochal cyst. J Pediatr Surg 2023; 58:633-638. [PMID: 36670004 DOI: 10.1016/j.jpedsurg.2022.12.024] [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: 12/01/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Untreated pediatric choledochal cyst (CC) is associated with complications including cholangitis, pancreatitis, and risk of malignancy. Therefore, CC is typically treated by surgical excision with biliary reconstruction. Both open and laparoscopic (lap) surgical approaches are regularly used, but outcomes have not been compared on a national level. METHODS The Nationwide Readmissions Database was used to identify pediatric patients (age 0-21 years, excluding newborns) with choledochal cyst from 2016 to 2018 based on ICD-10 codes. Patients were stratified by operative approach (open vs. lap). Demographics, operative management, and complications were compared using standard statistical tests. Results were weighted for national estimates. RESULTS Choledochal cyst excision was performed in 577 children (75% female) via lap (28%) and open (72%) surgical approaches. Patients undergoing an open resection experienced longer index hospital length of stay (LOS), higher total cost, and more complications. Anastomotic technique differed by approach, with Roux-en-Y hepaticojejunostomy (RYHJ) more often utilized with open cases (86% vs. 29%) and hepaticoduodenostomy (HD) more common with laparoscopic procedures (71% vs. 15%), both p < 0.001. There was no significant difference in post-operative cholangitis or mortality. CONCLUSIONS Although utilized less frequently than an open approach, laparoscopic choledochal cyst resection is safe in pediatric patients and is associated with shorter LOS, lower costs, and fewer complications. HD anastomosis is more commonly performed during laparoscopic procedures, whereas RYHJ more commonly used with the open approach. While HD is associated with more short-term gastrointestinal dysfunction than RYHJ, the latter is more commonly associated with sepsis, wound infection, and respiratory dysfunction. LEVEL OF EVIDENCE Level III: Retrospective Comparative Study.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Carlos T Huerta
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Shreya M Ingle
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Antoine J Ribieras
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua P Parreco
- Memorial Regional Hospital, Division of Trauma and Surgical Critical Care, Hollywood, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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8
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Cai TN, Huang SG, Yang Y, Mao HM, Guo WL. Prediction of post-operative acute pancreatitis in children with pancreaticobiliary maljunction using machine learning model. Pediatr Surg Int 2023; 39:158. [PMID: 36959375 DOI: 10.1007/s00383-023-05441-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE This study aimed to develop a prediction model to identify risk factors for post-operative acute pancreatitis (POAP) in children with pancreaticobiliary maljunction (PBM) by pre-operative analysis of patient variables. METHODS Logistic regression (LR), support vector machine (SVM), and extreme gradient boosting (XGBoost) models were established using the prospectively collected databases of patients with PBM undergoing surgery which was reviewed in the period comprised between August 2015 and August 2022, at the Children's Hospital of Soochow University. Primarily, the area beneath the receiver-operating curves (AUC), accuracy, sensitivity, and specificity were used to evaluate the model performance. The model was finally validated using the nomogram and clinical impact curve. RESULTS In total, 111 children with PBM met the inclusion criteria, and 21 children suffered POAP. In the validation dataset, LR models showed the highest performance. The risk nomogram and clinical effect curve demonstrated that the LR model was highly predictive. CONCLUSION The prediction model based on the LR with a nomogram could be used to predict the risk of POAP in patients with PBM. Protein plugs, age, white blood cell count, and common bile duct diameter were the most relevant contributing factors to the models.
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Affiliation(s)
- Tian-Na Cai
- Department of Radiology, Children's Hospital of Soochow University, Suzhou, 215025, China
| | - Shun-Gen Huang
- Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, 215025, China
| | - Yang Yang
- Department of Radiology, Children's Hospital of Soochow University, Suzhou, 215025, China
| | - Hui-Min Mao
- Department of Radiology, Children's Hospital of Soochow University, Suzhou, 215025, China
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Wan-Liang Guo
- Department of Radiology, Children's Hospital of Soochow University, Suzhou, 215025, China.
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Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy for biliary reconstruction after resection of congenital biliary dilatation: a systematic review and meta-analysis. Surg Today 2023; 53:1-11. [PMID: 35059844 DOI: 10.1007/s00595-021-02425-z] [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: 07/15/2021] [Accepted: 09/15/2021] [Indexed: 01/11/2023]
Abstract
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.
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Our Experience with Cyst Excision and Hepaticoenterostomy for Choledocal Cyst: A Single Center Case Review of 16 Patients. Medicina (B Aires) 2022; 58:medicina58030416. [PMID: 35334592 PMCID: PMC8948927 DOI: 10.3390/medicina58030416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives: Choledocal cyst is a rare congenital disease of the biliary tree defined by dilatation of the extrahepatic and/or intrahepatic biliary ducts. Untreated, it leads to complications such as cholangitis, stone formation and malignant degeneration. The standard treatment for choledocal cyst is complete excision and subsequent biliary reconstruction via hepaticojejunostomy or hepatiocoduodenostomy. Materials and Methods: We report our experience with 16 pediatric cases of choledocal cyst over a 10-year period. Results: The predominant symptoms were nausea and jaundice, both at 62.5% (n = 10), followed by abdominal pain at 56.3% (n = 9). Ultrasonography was the diagnostic method used in all patients. Computed tomography was used in 75% (n = 12) and magnetic resonance imaging in 25% (n = 4) of cases. Age at the time of intervention ranged from 2 months to 17 years with a mean of 4 years and 5 months. The open approach was used in nine patients and the laparoscopic approach was used in seven patients, with one conversion to open surgery. Complete excision of the choledocal cyst was performed in 15 cases (93.7%), and partial excision with mucosectomy was performed in one case (6.2%). Eight patients (50%) underwent hepaticoduodenostomy and eight (50%) underwent hepaticojejunostomy, out of which one was attempted laparoscopically but was converted. We had a postoperative complication rate of 12.5% (n = 2) represented by anastomotic leak and pancreatitis. Conclusions: From our experience with these cases, we concluded that a wide hepaticoduodenostomy constitutes a favorable choice over the traditional hepaticojejunostomy, being more physiological and less time consuming.
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11
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Harilal S, Mangray H, Madziba S, Ghimenton F. Isolated vascularized gastric tube biliary enteric drainage: a paediatric case series experience. ANNALS OF PEDIATRIC SURGERY 2021. [DOI: 10.1186/s43159-021-00122-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Despite the enormous surgical advancements in the last century, access to the biliary system is lost when a Roux-en-Y (RY) biliary drainage procedure is performed. Attempts have been made to overcome this inconvenient sequel using variations in the RY anastomosis, small bowel grafts and vascular grafts. These have been predominantly unsuccessful. An isolated vascularized gastric tube (IVGT) graft has been reported in the literature, which was successfully used for adult patients with common bile duct injuries. We have adopted the technique of using an IVGT graft for bile duct reconstruction in the paediatric patients at our institution. We reviewed our experience at our institution between January 2015 and October 2019. This was a retrospective review of all paediatric patients undergoing an IVGT graft procedure for biliary tract anatomical obstruction in the past 5 years. We looked at the indications for surgery, the demographic profile of the patients and outcomes following surgery and outlined the surgical technique used.
Results
IVGT bile duct reconstruction was performed on eight patients. Patients ranged from 2 months to 7 years, and there was an equal number of males and females. The diagnosis was made on clinical suspicion and confirmed with ultrasound (U/S) and magnetic resonance cholangiopancreatography (MRCP). There was an 87.5% resolution of biliary obstruction, and two patients who had bile leaks postoperatively were managed conservatively. Unfortunately, one patient died in the early postoperative period from sepsis due to pneumonia. Follow-up was for a minimum of 6 months and up to 5 years.
Conclusion
IVGT biliary enteric drainage is a safe, reproducible procedure that allows access to the biliary tree if required in the future. Thus, this procedure serves as an alternative, especially in limited-resource areas where interventional radiology is not available for future interventions.
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Hinojosa-Gonzalez DE, Roblesgil-Medrano A, Leon SUVD, Espadas-Conde MA, Flores-Villalba E. Biliary reconstruction after choledochal cyst resection: a systematic review and meta-analysis on hepaticojejunostomy vs hepaticoduodenostomy. Pediatr Surg Int 2021; 37:1313-1322. [PMID: 34115175 DOI: 10.1007/s00383-021-04940-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 12/13/2022]
Abstract
Choledochal cysts are a rare pediatric biliary pathology. Excision of the extrahepatic cyst and restoration of biliary-enteric continuity through either hepaticoduodenostomy (HD) or Roux-en-Y hepaticojejunostomy (HJ) is the mainstay treatment. This study aims to determine if either method provides an advantage. Following PRISMA guidelines, a systematic review was conducted, identifying studies comparing hepaticojejunostomy to hepaticoduodenostomy in patients with choledochal cysts. Data were analyzed using Review Manager 5.3. Nine studies were included, operative time was shorter - 97.50 [- 172.31, - 22.69] p = 0.01 and bleeding reduced - 48.98 [- 88.25, - 9.71] p = 0.01 in HD. HD was associated with shorter length of stay 2.18 [- 3.87, - 0.50] p = 0.01 and similar cholangitis and reintervention rates. Time to a normal diet was similar between groups. Biliary reflux was seen more frequently in HD 19.14 [2.60, 140.63] p = 0.004. Complications such as leak and cholangitis were similar between groups. HD represents a viable alternative to HJ with various advantages such as shorter operative time, decreased bleeding and shorter length of hospital stay. Bile reflux remains a major limitation.Level of evidence IV.
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Affiliation(s)
- David Eugenio Hinojosa-Gonzalez
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico.
| | - Andres Roblesgil-Medrano
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico
| | - Sergio Uriel Villegas-De Leon
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico
| | - Maria Alejandra Espadas-Conde
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico
| | - Eduardo Flores-Villalba
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave. Batallón San Patricio #112, San Pedro Garza García, Monterrey, Nuevo León, Mexico
- Tecnológico de Monterrey, Escuela de Ingeniería y Ciencias, Monterrey, Nuevo León, Mexico
- Laboratorio Nacional de Manufactura Aditiva y Digital (MADIT), Apodaca, Nuevo León, Mexico
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13
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Schreuder AM, Franken LC, van Dieren S, Besselink MG, Busch OR, van Gulik TM. Choledochoduodenostomy versus hepaticojejunostomy - a matched case-control analysis. HPB (Oxford) 2021; 23:560-565. [PMID: 32938564 DOI: 10.1016/j.hpb.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Choledochoduodenostomy (CD) is believed to cause certain long-term complications, such as sump syndrome and reflux gastritis. Therefore, CD is considered inferior to a Roux-and-Y hepaticojejunostomy (HJ). The aim of this study was to compare short- and long-term outcomes following CD and HJ for benign biliary diseases. METHODS This was a retrospective, matched case-control study of patients undergoing biliary-digestive anastomosis for benign diseases between 2000 and 2016 in a tertiary centre. Patients undergoing CD and HJ were matched 1:1 based on age, sex, ASA-classification, indication, history of abdominal surgery or acute cholecystitis/pancreatitis. Short- and long-term outcomes were compared. RESULTS Of 336 patients undergoing biliary-digestive anastomoses, 27 patients underwent CD. Matching resulted in two comparable groups of 26 patients each. Overall morbidity after HJ and CD was comparable: 30.8% versus 26.9% (p>0.999). Long-term complications occurred in 23.1% after HJ, and in 50% after CD (p=0.118). After CD, 2 patients (7.7%) developed sump syndrome. Both patients with an anastomotic stricture after HJ could be managed by endoscopic/radiological re-intervention, whilst all six patients with a stricture after CD required surgical re-intervention (p=0.016). CONCLUSION Although short-term complications were comparable, the number of anastomotic strictures was higher in patients undergoing CD. We therefore conclude that HJ is the biliary bypass of choice while CD should be performed in selected patients only.
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Affiliation(s)
- A Marthe Schreuder
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | - Lotte C Franken
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Susan van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
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Wu J, Xiang Y, You G, Liu Z, Lin R, Yao X, Yang Y. An essential technique for modern hepato-pancreato-biliary surgery: minimally invasive biliary reconstruction. Expert Rev Gastroenterol Hepatol 2021; 15:243-254. [PMID: 33356656 DOI: 10.1080/17474124.2021.1847081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Jiacheng Wu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , Changchun, China
| | - Yien Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , Changchun, China
| | - Guangqiang You
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Zefeng Liu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Ruixin Lin
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Xiaoxiao Yao
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Yongsheng Yang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
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15
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Ohyama K, Furuta S, Shima H, Tuji S, Nagae H, Tanaka K, Obayashi J, Kawaguchi K, Kawaguchi T, Nishiya Y, Kudou K, Kawase K, Wakisaka M, Kitagawa H. Differences in post-operative complications after reconstruction for congenital biliary dilatation in a single institution-Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy. Pediatr Surg Int 2021; 37:241-245. [PMID: 33483835 DOI: 10.1007/s00383-020-04790-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The standard surgical procedure for congenital biliary dilatation (CBD) consists of excision of extrahepatic bile duct and Roux-en-Y hepaticojejunostomy (HJ). However, alternative reconstructive operations for CBD includes hepaticoduodenostomy (HD). We compared postoperative complications and therapeutic outcomes of these two operations at our institution. METHODS From 1981 to 2009, there were 23 traceable patients who underwent operation for CBD, They were divided into an HJ Group (n = 15) and an HD Group (n = 8). Demographic and outcome data were compared. RESULTS There were no significant differences in postoperative complications (cholangitis, pancreatitis, and anastomotic stenosis) and current blood test data (AST, ALT, Total Bilirubin, Direct Bilirubin, Amylase) between the two groups. Current abdominal pain and carcinogenesis were not observed in either group. Intrahepatic stones occurred in one patient in each group, both > 25 years post-operation. CONCLUSION HD is considered to be an acceptable reconstruction method compared to HJ, based on our results. There has been a suggestion that inadequate diversion in HD might increase the risk of cholangiocarcinoma. To date, in this series, that has not happened.
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Affiliation(s)
- Kei Ohyama
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shigeyuki Furuta
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hideki Shima
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shiho Tuji
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hideki Nagae
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kunihide Tanaka
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Juma Obayashi
- Department of Pediatric Surgery, St. Marianna University School of Medicine Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi, Yokohama, Kanagawa, 241-0811, Japan
| | - Kouhei Kawaguchi
- Department of Pediatric Surgery, St. Marianna University School of Medicine Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi, Yokohama, Kanagawa, 241-0811, Japan
| | - Takuya Kawaguchi
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yuri Nishiya
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kousuke Kudou
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kouichi Kawase
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Munechika Wakisaka
- Department of Pediatric Surgery, St. Marianna University School of Medicine Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi, Yokohama, Kanagawa, 241-0811, Japan
| | - Hiroaki Kitagawa
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan.
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16
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Park CY, Choi SH, Kwon CI, Cho JH, Jang SI, Lee TH, Han JH, Jeong S, Ko KH. What is the better surgical treatment option for recurrent common bile duct stones? Ann Surg Treat Res 2020; 99:329-336. [PMID: 33304860 PMCID: PMC7704274 DOI: 10.4174/astr.2020.99.6.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/05/2020] [Accepted: 08/25/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose Repeating endoscopic retrograde cholangiopancreatography (ERCP) in patients with recurrent common bile duct (CBD) stones is problematic in many ways. Choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) are 2 surgical treatment options for recurrent CBD stones, and each has different advantages and disadvantages. The aim of this study was to compare the 2 surgical options in terms of the recurrence rate of CBD stones after surgical treatment. Methods This retrospective multicenter study included all patients who underwent surgical treatment due to recurrent CBD stones that were not effectively controlled by medical treatment and repeated ERCP between January 2006 and March 2015. We collected data from chart reviews and medical records. A recurrent CBD stone was defined as a stone found 6 months after the complete removal of a CBD stone by ERCP. Patients who underwent surgery for other reasons were excluded. Results A total of 27 patients were enrolled in this study. Six patients underwent CDS, and 21 patients underwent CJS for the rescue treatment of recurrent CBD stones. The median follow-up duration was 290 (180–1,975) days in the CDS group and 1,474 (180–6,560) days in the CJS group (P = 0.065). The postoperative complications were similar and tolerable in both groups (intestinal obstruction; 2 of 27, 7.4%; 1 in each group). CBD stones recurred in 4 patients after CDS (4 of 6, 66.7%), and 3 patients after CJS (3 of 21, 14.3%) (P = 0.010). Conclusion CJS may be a better surgical option than CDS for preventing further stone recurrence in patients with recurrent CBD stones.
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Affiliation(s)
- Chi Young Park
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Sung Hoon Choi
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Gachon Gil Hospital, Gachon University College of Medicine, Incheon, Korea
| | - Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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Hepatic vascular variations and visual three-dimensional reconstruction technique in pediatric patients with choledochal cyst. Surg Radiol Anat 2020; 42:1489-1499. [PMID: 33040160 DOI: 10.1007/s00276-020-02590-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/29/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of the present study was to identify the hepatic vascular variations with visual three-dimensional (3D) reconstruction of vessels in pediatric patients with choledochal cyst (CDC). METHODS We retrospectively analyzed the data of 84 children with pathologically confirmed CDCs treated in the Children's Hospital of Soochow University. 180 patients without CDCs as a control to analysis the hepatic artery and portal vein anatomy. All patients were examined by multi-slice spiral CT (MSCT) and the images of children with CDC were reconstructed by Hisense computer-assisted surgery system (Hisense CAS) to obtain visual 3D images. RESULTS There were 71 females and 13 males diagnosed with CDC. According to Todani classification of CDC, there were 42 cases of type Ia, 10 cases of type Ic and 32 cases of type IVa. There were 10 (11.9%) patients with hepatic artery variations, 14 (16.7%) patients with right hepatic artery located on the ventral side of the CDC, and 16 (19.0%) patients with portal vein variations. Sex, age and types of the cyst were not associated with the presence of vascular variations. There was no significant difference in hepatic vascular variation between CDCs and control groups. Visual 3D images clearly displayed the hepatic vascular variations and the spatial structure of the CDC in pediatric patients with CDC. CONCLUSIONS Hepatic artery and portal vein variations can be detected in pediatric patients with CDC. Visual 3D technique can visually and stereoscopically display the anatomical variations of the hepatic artery and portal vein.
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Biswas SK, Basu KS, Biswas SK, Saha H, Chakravorty S, Soren JK. Biliary Reconstruction by Isolated Jejunal Interposition Loop: Our Experience after Excision of Choledochal Cyst. J Indian Assoc Pediatr Surg 2020; 25:213-218. [PMID: 32939112 PMCID: PMC7478276 DOI: 10.4103/jiaps.jiaps_95_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/23/2019] [Accepted: 12/21/2019] [Indexed: 11/26/2022] Open
Abstract
Background: Choledochal cyst is a fairly common hepatobiliary condition in pediatric surgical practice. For the most common type (type I), it is well established that the total excision of the cyst with an wide biliary-enteric anastomosis is key for long-term good result. Multiple options remain for biliary-enteric reconstruction after excision. Jejunal interposition loop reconstruction is thought to be the most physiologic. Materials and Methods: We have retrospectively reviewed the data of patients of type I choledochal cysts which were operated between January 2010 and September 2018 and undergone jejunal interposition loop reconstruction. Clinical presentation, investigations, operative procedure morbidity and complications were reviewed. Results: There were 33 patients, with a male-to-female ratio of 1:3 and a mean age of 4.63 years (mean ± standard deviation [SD] = 4.63 ± 2.98 years). The follow-up period ranged from 3 to 81 months (mean ± SD = 36.30 ± 19.24 months). There was no stricture or cholangitis. Reoperation required in one due to leak at biliary-enteric anastomosis leading to biliary peritonitis. One each had pancreatitis and prolonged ileus. Two bile leaks stopped spontaneously. Operative time and postoperative hospital stay were 228.78 ± 40.43 min (mean ± SD) and 8.96 ± 3.63 days (mean ± SD), respectively. Conclusion: Jejunal interposition loop reconstruction is safe and reproducible with acceptable morbidity. However, if this procedure is abandoned, the long-term benefits may remain ever elusive.
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Affiliation(s)
- Somak Krishna Biswas
- Department of Paediatric Surgery, Nilratan Sircar Medical College, Kolkata, West Bengal, India
| | - Kalyani Saha Basu
- Department of Paediatric Surgery, Nilratan Sircar Medical College, Kolkata, West Bengal, India
| | - Sumitra Kumar Biswas
- Department of Paediatric Surgery, Nilratan Sircar Medical College, Kolkata, West Bengal, India
| | - Hinglaj Saha
- Department of Paediatric Surgery, Nilratan Sircar Medical College, Kolkata, West Bengal, India
| | - Subhankar Chakravorty
- Department of Paediatric Surgery, Nilratan Sircar Medical College, Kolkata, West Bengal, India
| | - Jay Kishor Soren
- Department of Paediatric Surgery, Nilratan Sircar Medical College, Kolkata, West Bengal, India
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Choledochal cyst mimicker-When small bowel length matters. Int J Surg Case Rep 2020; 68:132-135. [PMID: 32145565 PMCID: PMC7058850 DOI: 10.1016/j.ijscr.2020.02.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/23/2020] [Accepted: 02/26/2020] [Indexed: 12/31/2022] Open
Abstract
The diagnosis and treatment of choledochal cysts (and conditions mimicking choledochal cysts) may prove difficult in patients with short bowel syndrome. Laparoscopic bile duct excision and reconstruction is a feasible and safe approach to bile duct excision in experienced hands. Hepatico-duodenostomy should be considered a safe alternative for biliary reconstruction in individuals with limited material for conduit.
Objective Due to the risk of malignancy, the established management of choledochal cysts mandates bile duct excision and biliary reconstruction. While the reconstructive procedure of choice for most surgeons has traditionally been hepatico-jejunostomy, this may not be feasible in selected cases due to immobility or inadequacy of the jejunum. The following case will outline the management of a 32-year-old woman with short bowel syndrome, who was diagnosed with choledocholithiasis and a type 1 choledochal cyst. Method and materials As a child, our patient suffered midgut volvulus secondary to malrotation which resulted in extensive bowel resection and developed short bowel syndrome. She presented with recurrent bouts of cholangitis. Imaging of her biliary tree confirmed common duct stones extending into the branched hepatic ducts, as well as a fusiform dilatation of the common bile duct, that appeared consistent with a type 1 choledochal cyst. Laparoscopic excision of the cyst with reconstruction using a hepatico-duodenostomy was planned. Results The patient underwent successful laparoscopic cholecystectomy, CBD clearance with excision of the bile duct and reconstruction with hepatico-duodenostomy. Recovery was uneventful and she is asymptomatic on subsequent follow-up. Histology is consistent with a markedly dilated bile duct rather than a choledochal cyst. Conclusions This case illustrates the dilemma of diagnosis and treatment of a dilated bile duct mimicking a choledochal cyst in the setting of short bowel syndrome and the feasibility of a laparoscopic approach in such cases. Also, it demonstrates that hepatico-duodenostomy may be a safe alternative in cases with limited material for conduit.
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Abstract
Pancreaticobiliary maljunction (PBM) is a congenital malformation in which the pancreatic and bile ducts join outside the duodenal wall, usually forming a long common channel. A major issue in patients with PBM is the risk of biliary cancer. Because the sphincter of Oddi does not regulate the pancreaticobiliary junction in PBM, pancreatic juice frequently refluxes into the biliary tract and can cause various complications, including biliary cancer. Most cancers arise in the gallbladder or dilated common bile duct, suggesting that bile stasis is related to carcinogenesis. Early diagnosis and prophylactic surgery to reduce the risk of cancer are beneficial. The diagnosis of PBM is made mainly on the basis of imaging findings. The development of diagnostic imaging modalities such as multidetector CT and MR cholangiopancreatography has provided radiologists with an important role in diagnosis of PBM and its complications. Radiologists should be aware of PBM despite the fact that it is rare in non-Asian populations. In this review, the authors present an overview of PBM with emphasis on diagnosis and management of PBM and its complications. For early diagnosis, the presence of extrahepatic bile duct dilatation or gallbladder wall thickening may provide a clue to PBM with or without biliary dilatation, respectively. The pancreaticobiliary anatomy should be closely examined if imaging reveals these findings. Radiologists should also carefully evaluate follow-up images in PBM patients even years after prophylactic surgery because residual bile ducts remain at risk for cancer.©RSNA, 2020.
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Affiliation(s)
- Ayako Ono
- From the Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Shigeki Arizono
- From the Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Hiroyoshi Isoda
- From the Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Kaori Togashi
- From the Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
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21
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Tannuri ACA, Hara LADA, Paganoti GDF, Andrade WDC, Tannuri U. Choledochal cysts in children: How to Diagnose and Operate on. Clinics (Sao Paulo) 2020; 75:e1539. [PMID: 32215454 PMCID: PMC7074585 DOI: 10.6061/clinics/2020/e1539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/18/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To identify the best mode for diagnosing and treating the patients with choledochal cysts. METHODS A retrospective study was performed with medical records of patients diagnosed with choledochal cysts from January 1994 to December 2017. In all cases, the diagnosis was based on ultrasound examination. All the patients underwent cyst resection and were divided in two groups: bile enteric anastomosis in the high portion of the common hepatic duct or in the dilated lower portion. RESULTS Eighty-one cases were studied. The age of presentation was 4 y 2 mo ± 4 y 1 mo, and the age for the surgical treatment was 5 y 5 mo ± 4 y 6 mo. In 61 cases, US was the only image examination performed. There were 67 cases of Todani type I (82.7%), 13 cases of type IV (16.0%) and one case of type III (1.2%). Nine patients (29.0%) in the first period and 2 patients (4.0%) in the second period presented with postoperative complications (p=0.016). CONCLUSION In patients with choledochal cysts, US is the only necessary diagnostic imaging. Performing the bile enteric anastomosis in the lower portion of the common hepatic duct is safer and has a lower risk of complications.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Lucas Arjona de Andrade Hara
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Guilherme de Freitas Paganoti
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Wagner de Castro Andrade
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Uenis Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
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Nio M, Wada M, Sasaki H, Tanaka H, Hashimoto M, Nakajima Y. Correctable biliary atresia and cholangiocarcinoma: a case report of a 63-year-old patient. Surg Case Rep 2019; 5:185. [PMID: 31784849 PMCID: PMC6884610 DOI: 10.1186/s40792-019-0748-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/11/2019] [Indexed: 11/10/2022] Open
Abstract
Background Although cancer occurrence following surgery for biliary atresia has gradually increased, the development of cholangiocarcinoma in a native liver survivor of biliary atresia is extremely rare. Case presentation A 3-month-old female patient with the correctable type of biliary atresia underwent a cystoduodenostomy. At 16 years of age, she underwent multiple surgeries including lysis of intestinal adhesions, ileostomy, and gastrojejunostomy at another hospital. At 54 years of age, she underwent lithotomy at the porta hepatis, resection of the residual cystic bile duct with gallbladder, and hepaticojejunostomy in Roux-en-Y fashion. As she approached the age of 63, her computed tomography scan showed no liver tumors. In the following year, she developed cholangiocarcinoma at the porta hepatis and underwent chemotherapy. However, the cancer progressed, and she died before she reached the age of 64 years. Conclusions Cholangiocarcinoma is extremely rare in patients with biliary atresia. However, physicians should follow up patients with biliary atresia as closely as possible, as malignant tumors secondary to biliary atresia may increase in number in the near future because of the growing number of long-term survivors with biliary atresia.
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Affiliation(s)
- Masaki Nio
- Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Motoshi Wada
- Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hideyuki Sasaki
- Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hiromu Tanaka
- Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masatoshi Hashimoto
- Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yudai Nakajima
- Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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Yeung F, Fung ACH, Chung PHY, Wong KKY. Short-term and long-term outcomes after Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy following laparoscopic excision of choledochal cyst in children. Surg Endosc 2019; 34:2172-2177. [DOI: 10.1007/s00464-019-07004-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/19/2019] [Indexed: 02/08/2023]
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Guzman JPS, Resurreccion III LL, Suntay MLR, Bernaldez RG. Comparison between hepaticojejunostomy and hepaticoduodenostomy after excision of choledochal cyst in children: a cohort study. WORLD JOURNAL OF PEDIATRIC SURGERY 2019. [DOI: 10.1136/wjps-2018-000029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
ObjectiveHepaticojejunostomy (HJ) and hepaticoduodenostomy (HD) are commonly used biliary reconstruction techniques after choledochal cyst excision. HD has been suggested to be a more physiologic alternative during reconstruction. The objective of this study is to compare operative time, hospital stay, morbidity (leak, cholangitis, ileus, and obstruction), and mortality between HJ and HD after cyst excision.MethodsThis is a 14-year retrospective cohort study of pediatric patients (≤18 years old) who underwent choledochal cyst excision and subsequent biliary reconstruction at the Philippine Children’s Medical Center. Data were taken from inpatient charts, operative technique, OPD logbook, readmission, and OPD charts.ResultsThere were 122 patients: 56% HD and 44% HJ. Majority were female (72%), with 1:2.6 male to female ratio. The average age was 36.1 months, with a mean follow-up of 32.8 months (range 6 months–14 years). The most common cyst was type I (87%). Operative time was longer for HJ compared with HD (321.3 vs 203.6 min; p=0.000). Hospital stay was longer with HJ compared with HD (7.7 vs 6.8 days; p=0.002). Mortality rate was low at 1.6% while morbidity was at 13.9% in both groups. Although morbidity was higher among those who underwent HD, there was no significant difference between the two procedures. Anastomotic leak (4%) and cholangitis (7.4%) were observed in HD, and ileus (7.4%) was observed in the HJ group.ConclusionsIn our series, HD provided less operative time and hospital stay than with HJ. We did not observe bile gastritis after HD as compared with others. It is suggested that longer follow-up is needed to confirm such findings.
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Aspelund G, Mahdi EM, Rothstein DH, Wakeman DS. Transitional care for patients with surgical pediatric hepatobiliary disease: Choledochal cysts and biliary atresia. J Gastroenterol Hepatol 2019; 34:966-974. [PMID: 30552863 DOI: 10.1111/jgh.14575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/13/2018] [Accepted: 12/09/2018] [Indexed: 12/14/2022]
Abstract
Choledochal cysts (CDCs) and biliary atresia (BA) are rare pediatric hepatobiliary anomalies that require surgical intervention due to increased risk of malignancy and liver failure, respectively. The underlying disease and operative procedures place patients at risk for long-term complications, which may continue to affect them into adulthood. Lack of a transitional care model in the health-care system potentiates the challenges they will face following aging out of their pediatric providers' care. We sought to elucidate the long-term complications and challenges patients with CDCs and BA face, review the current literature regarding transitioning care, and propose guidelines aiding adult providers in continued care and surveillance of these patients. A literature review was performed to assess short-term and long-term complications after surgery and the current standards for transitioning care in patients with a history of CDCs and BA. While transitional programs exist for patients with other gastrointestinal diseases, there are few that focus on CDCs or BA. Generally, authors encourage medical record transmission from pediatric to adult providers, ensuring accuracy of information and compliance with treatment plans. Patients with CDCs are at risk for developing biliary malignancies, cholangitis, and anastomotic strictures after resection. Patients with BA develop progressive liver failure, necessitating transplantation. There are no consensus guidelines regarding timing of follow up for these patients. Based on the best available evidence, we propose a schema for long-term surveillance.
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Affiliation(s)
- Gudrun Aspelund
- Department of Pediatric Surgery, Maria Fareri Children's Hospital, Valhalla, New York, USA
| | - Elaa M Mahdi
- Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - David H Rothstein
- Department of Pediatric Surgery, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Derek S Wakeman
- Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
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Friedmacher F, Ford KE, Davenport M. Choledochal malformations: global research, scientific advances and key controversies. Pediatr Surg Int 2019; 35:273-282. [PMID: 30406431 DOI: 10.1007/s00383-018-4392-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2018] [Indexed: 02/07/2023]
Abstract
Choledochal malformations (CMs) represent a spectrum of relatively rare and complex congenital anomalies, characterized by abnormal dilatation of the biliary tract in the absence of any acute obstruction. Today, almost 20% of CMs can be detected in-utero using maternal ultrasonography. Formal scientometric analysis was used to identify where modern CM research is taking place and perhaps where our attention should be directed in the future. Thus, this article offers a comprehensive review of recent scientific advances relating to CMs including the current understanding of etiology and classification, whilst also discussing key controversies such as risk of malignant transformation and the role of newer modalities of surgical treatment. Although laparoscopic excision of CMs and biliary reconstruction is nowadays feasible and safe, care should be taken before dispensing with standard open techniques, which have minimal complication rates and proven long-term benefit.
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Affiliation(s)
- Florian Friedmacher
- Department of Pediatric Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. .,Department of Pediatric Surgery, The Royal London Hospital, London, UK.
| | - Kathryn E Ford
- Department of Pediatric Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.,Department of Pediatric Surgery, Oxford University Hospitals, Oxford, UK
| | - Mark Davenport
- Department of Pediatric Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
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Chan EKW, Lee KH, Wong VHY, Tsui BSY, Wong SYS, Pang KKY, Mou JWC, Tam PYH. Laparoscopic management of choledochal cysts in infants and children: A review of current practice. SURGICAL PRACTICE 2018. [DOI: 10.1111/1744-1633.12310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Edwin Kin-Wai Chan
- Department of Surgery; The Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong
| | - Kim-Hung Lee
- Department of Surgery; The Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong
| | - Vicky Hei-Yi Wong
- Department of Surgery; The Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong
| | - Bess Siu-Yan Tsui
- Department of Surgery; The Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong
| | - Sammi Yuen-Shan Wong
- Department of Surgery; The Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong
| | - Kristine Kit-Yi Pang
- Department of Surgery; The Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong
| | - Jennifer Wai-Cheung Mou
- Department of Surgery; The Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong
| | - Peter Yuk-Him Tam
- Department of Surgery; The Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong
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Hamada Y, Hamada H, Shirai T, Nakamura Y, Sakaguchi T, Yanagimoto H, Inoue K, Kon M. Duodenogastric regurgitation in hepaticoduodenostomy after excision of congenital biliary dilatation (choledochal cyst). J Pediatr Surg 2017; 52:1621-1624. [PMID: 28410789 DOI: 10.1016/j.jpedsurg.2017.03.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/04/2017] [Accepted: 03/28/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE We examined the clinical significance of duodenogastric regurgitation (DGR) as a late complication in the long-term follow-up after hepaticoduodenostomy (HD) as a reconstruction surgery for congenital biliary dilatation (CBD). METHODS Seventeen patients with CBD were retrospectively analyzed for late complications (mean follow-up, 16.8 years). All patients had undergone total resection of the extrahepatic bile duct followed by HD. DGR was identified using endoscopic examination, intraluminal bile monitoring, and liver scanning. RESULTS DGR was found in all 17 patients by endoscopic examination and intraluminal bile monitoring. Fourteen of the 17 (82.4%) patients with DGR had experienced abdominal symptoms since a mean of 6.9 years postoperatively. Liver scanning also revealed apparent DGR in all 14 symptomatic patients. We converted 7 of the 14 patients to hepaticojejunostomy reconstruction at a mean of 13.0 years after the initial excisional surgery. Their symptoms were completely relieved postoperatively. CONCLUSIONS DGR is an important complication after HD. Examination of patients for the development of DGR is an essential part of long-term follow-up in patients with CBD who have undergone HD as a reconstruction surgery. Conversion surgery is recommended in patients with DGR accompanied by long-term abdominal symptoms. LEVELS OF EVIDENCE Level IV.
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Affiliation(s)
- Yoshinori Hamada
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Hirakata City, Osaka, Japan.
| | - Hiroshi Hamada
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Hirakata City, Osaka, Japan
| | - Takeshi Shirai
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Hirakata City, Osaka, Japan
| | - Yusuke Nakamura
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Hirakata City, Osaka, Japan
| | - Tatsuma Sakaguchi
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Hirakata City, Osaka, Japan
| | - Hiroaki Yanagimoto
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Hirakata City, Osaka, Japan
| | - Kentaro Inoue
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Hirakata City, Osaka, Japan
| | - Masanori Kon
- Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Hirakata City, Osaka, Japan
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Biliary duodenostomy. ANNALS OF PEDIATRIC SURGERY 2017. [DOI: 10.1097/01.xps.0000516075.68412.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Soares KC, Goldstein SD, Ghaseb MA, Kamel I, Hackam DJ, Pawlik TM. Pediatric choledochal cysts: diagnosis and current management. Pediatr Surg Int 2017; 33:637-650. [PMID: 28364277 DOI: 10.1007/s00383-017-4083-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2016] [Indexed: 02/07/2023]
Abstract
Choledochal cysts are rare congenital disorders first described by Vater and Ezler in 1723. Their exact etiology remains incompletely understood; however, an anomalous pancreaticobiliary union (APBDU) and subsequent reflux of biliary contents into the biliary tree are thought to play a role. Accordingly, APBDU-associated choledochal cyst patients are significantly more likely to have evidence of hepatitis, cholangitis or pancreatitis and pathologically confirmed inflammation. In 1977, Todani and colleagues modified the original Alonso-Lej classification to include five types of CC. Type I and IV are the most common and most likely to be associated with malignancy. The majority of choledochal cysts are diagnosed in childhood. Clinical presentation varies and most often consists of nonspecific abdominal pain. Diagnosis is typically accomplished using multimodality imaging techniques including computed tomography, magnetic resonance imaging, ultrasound and MRCP. The use of diagnostic PTC and ERCP in CC has been largely replaced by MRCP. Appropriate management consists of prompt, complete cyst excision followed by restoration of biliary enteric continuity when necessary. Minimally invasive CC resection in the pediatric population has demonstrated acceptable outcomes. Prognosis is generally excellent; however, malignancy risk remains higher than the general population even after complete surgical excision.
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Affiliation(s)
- Kevin C Soares
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins University School of Medicine, Blalock 688, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Seth D Goldstein
- Division of General Pediatric Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mounes A Ghaseb
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ihab Kamel
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David J Hackam
- Division of General Pediatric Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Department of Surgery, Wexner Medical Center, Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Laparoscopic management of choledochal cysts: is a keyhole view missing the big picture? Pediatr Surg Int 2017; 33:651-655. [PMID: 28424862 DOI: 10.1007/s00383-017-4089-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 12/14/2022]
Abstract
In recent years, numerous articles have promoted laparoscopic surgical treatment of choledochal cysts in children. Most of these reports assert that laparoscopic excision and biliary reconstruction are as safe as open surgery and achieve equivalent or better results. However, these conclusions are based on retrospective analyses with median follow-up periods that rarely exceed 5 years. Closer scrutiny of the laparoscopic literature indicates that the optimum procedure for treating type I and most type IVa choledochal cysts, namely radical excision of the extrahepatic bile ducts and reconstruction by wide hilar hepaticoenterostomy, preferably hepaticojejunostomy, is not being carried out in most cases. Performing a less radical excision exposes patients to a greater long-term risk of a bilioenteric stricture and its complications and malignant change in residual extrahepatic bile ducts. Currently, the long-term outcomes of surgery for choledochal cysts are being eclipsed by the short-term gains of laparoscopic techniques. The prime objective in the surgical management of choledochal cysts is the long-term health of the patient; laparoscopic techniques are simply another method of performing the surgery and they should not become the standard of care unless long-term outcomes are similar to best practice open surgery.
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Hepaticoduodenostomy as a technique for biliary anastomosis in children with choledochal cyst. ANNALS OF PEDIATRIC SURGERY 2017. [DOI: 10.1097/01.xps.0000508440.37104.0d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Ishibashi H, Shimada M, Kamisawa T, Fujii H, Hamada Y, Kubota M, Urushihara N, Endo I, Nio M, Taguchi T, Ando H. Japanese clinical practice guidelines for congenital biliary dilatation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:1-16. [PMID: 28111910 DOI: 10.1002/jhbp.415] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Until now, there have been no practical clinical guidelines for congenital biliary dilatation (CBD). In this review article, the Japanese Study Group on Congenital Biliary Dilatation (JSCBD) propose to establish clinical practice guidelines for CBD. Because the evidence-based literature is relatively small, we decided to create guidelines based on the consensus of experts, using the medical literature for reference. A total of 20 clinical questions (CQs) were considered by the members of the editorial committee responsible for the guidelines. The CQs included the distinct aspects of CBD: (1) Concepts and Pathology (three CQs); (2) Diagnosis (six CQs); (3) Pancreaticobiliary Complications (three CQs); Treatments and Prognosis (eight CQs). Each statements and comments for CQs were made by the guidelines committee members. CQs were finally approved after review by members of the editorial committee and the guidelines evaluation board of CBD. These guidelines were created to provide assistance in the clinical practice of CBD management; their contents focus on clinical utility, and they include general information on CBD to make this disease more widely recognized.
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Affiliation(s)
- Hiroki Ishibashi
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Mitsuo Shimada
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Hideki Fujii
- First Department of Surgery, University of Yamanashi, Kofu, Japan
| | - Yoshinori Hamada
- Department of Pediatric Surgery, Kansai Medical University, Hirakata, Japan
| | - Masayuki Kubota
- Department of Pediatric Surgery, Niigata University, Niigata, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Itaru Endo
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masaki Nio
- Department of Pediatric Surgery, Tohoku University, Sendai, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
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Changing trends in the management of choledochal cysts in children in an Egyptian institution. ANNALS OF PEDIATRIC SURGERY 2016. [DOI: 10.1097/01.xps.0000484008.42548.68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Laparoscopic Management of Choledochal Cyst-Technical Modifications and Outcome Analysis. World J Surg 2016; 39:2550-6. [PMID: 26067634 DOI: 10.1007/s00268-015-3111-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Choledochal cyst (CDC) is a well described albeit rare clinical entity. Complete cyst excision with biliary-enteric reconstruction is the recommended treatment for Todani type I, II, and IVA cysts to prevent complications. The aim of this study is to evaluate outcomes of laparoscopic CDC excision from a tertiary care center. METHODS This is a retrospective analysis of prospectively collected data of 110 patients who underwent laparoscopic cyst excision and biliary-enteric reconstruction for CDC type I and IVA from 1998 to 2013. RESULTS Out of 110 patients, 55 were children (<16 years) and 55 were adults (>16 years) with mean age 21.19 ± 17.75 years and male:female ratio of 1:2.14. Abdominal pain was the most common presenting symptom (59.09 %). Surprisingly, 32.73 % of adults presented with incidentally detected cyst. Type I cyst was the most common (71.82 %) with mean size of 4.67 ± 1.59 cm. Blood loss (56.0 ± 16.62 vs. 76.55 ± 26.61 ml) and operative time (199.8 ± 44.66 vs. 251.6 ± 54.25 min) were significantly low in pediatric group. Three adults required conversion. Overall complication rate was 10 %. Re-exploration rate was 1.81 % with one patient died post-operatively. Mean hospital stay was significantly low in children (5.9 ± 1.39 vs. 7.0 ± 2.66 days). Median follow-up was 60 months (8-110). Cholangitis developed in six patients with three having anastomotic stricture requiring intervention. CONCLUSION Laparoscopic excision of CDC is safe and feasible. Surgery should be performed early as outcomes are better in pediatric age as compared to adults.
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Weng R, Hu W, Cai S, Guo X, Luo Q. Prenatal diagnosis and prognosis assessment of congenital choledochal cyst in 21 cases. J OBSTET GYNAECOL 2015; 36:324-7. [DOI: 10.3109/01443615.2015.1050648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Choledochal Cyst in Adults: Etiopathogenesis, Presentation, Management, and Outcome-Case Series and Review. Gastroenterol Res Pract 2015; 2015:602591. [PMID: 26257778 PMCID: PMC4518150 DOI: 10.1155/2015/602591] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 06/14/2015] [Accepted: 06/16/2015] [Indexed: 02/07/2023] Open
Abstract
Background. Choledochal cyst, a rare congenital cystic dilatation of biliary tree, is uncommon in adults. Their presentations differ from children and surgical management has evolved. Methods. A retrospective review of the records of all the patients above 15 years, who underwent therapeutic intervention in our hospital, was carried out. Results. Ten cases of choledochal cyst were found; 8 female, with mean age 31 years. These included 8 cases of Todani type I and one case each of type II and type III. The predominant symptoms were abdominal pain and jaundice. Abdominal mass and past history of cholangitis and pancreatitis were seen in 2 patients. Investigations included ultrasound in 8 patients, CT in 7, ERCP in 3, and MRCP in 5. Surgical intervention included complete excision of the cyst with hepaticojejunostomy and cholecystectomy (type I), excision of the diverticulum (type II), and ERCP sphincterotomy (type III). Malignancy was not seen in any patients. The long-term postoperative complications included cholangitis in two patients. Conclusion. Choledochal cyst is rare in adults. The typical triad of abdominal pain, jaundice, and mass is uncommon in adults. The surgical strategy aims for single stage complete excision of the cyst with hepaticojejunostomy.
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Laparoscopic versus open surgery in children with choledochal cysts: a meta-analysis. Pediatr Surg Int 2015; 31:529-34. [PMID: 25895070 DOI: 10.1007/s00383-015-3705-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the safety and efficacy between laparoscopic and open cyst excision with hepaticojejunostomy for children with choledochal cysts using meta-analysis. METHODS Studies comparing the laparoscopic and the open choledochal cyst excision that met the inclusion criteria for data extraction were identified from electronic databases (PubMed, Embase, Science Citation Index, and the Cochrane Library) up to November 2014. The proceedings of relevant congress were also searched. The outcomes were operative time, intraoperative blood loss, time to food intake, postoperative morbidity and mortality, length of hospital stay. Outcomes were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) using RevMan 5.2. RESULTS Seven retrospective studies were finally included, involving a total of 1016 patients, of whom, 408 cases underwent laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy (LH) and 608 cases underwent open cyst excision and Roux-en-Y hepaticojejunostomy (OH). In LH group compared with OH group, the operative time was longer (MD = 59.11, 95% CI 27.61-90.61, P = 0.0002), while the length of postoperative hospital stay was less (MD = -2.01, 95% CI -2.49 to -1.54, P < 0.00001), the intraoperative blood loss was lower (MD = -37.14, 95% CI -66.69 to -7.60, P = 0.01) and time to food intake was less (MD = -1.14, 95% CI -1.61 to -0.67, P = 0.01). The rate of postoperative morbidity was more in the OH group, but there is no statistically significant difference between the two groups in postoperative morbidity (OR = 0.52, 95% CI 0.13-2.06, P = 0.35). CONCLUSION Laparoscopic surgery is a feasible, safe treatment of choledochal cyst with less postoperative morbidity, a shorter length of stay and a lower blood loss when compared with open approach. With the improvement of laparoscopic techniques and deftness of surgeons practice, laparoscopic surgery may become the first choice procedure for choledochal cyst.
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Yeung F, Chung PHY, Wong KKY, Tam PKH. Biliary-enteric reconstruction with hepaticoduodenostomy following laparoscopic excision of choledochal cyst is associated with better postoperative outcomes: a single-centre experience. Pediatr Surg Int 2015; 31:149-53. [PMID: 25433691 DOI: 10.1007/s00383-014-3648-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND With the advent of laparoscopic surgery, more choledochal cysts are excised laparoscopically. In this study, we compared the outcomes from laparoscopic hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD) for biliary-enteric reconstruction. METHODS A retrospective analysis of patients who had undergone laparoscopic choledochal cyst excision between February 2005 and January 2014 in a tertiary referral centre was performed. Demographics data, operative techniques and surgical outcomes were analysed according to the way of biliary-enteric reconstruction. RESULTS A total of 31 patients were identified, 20 of whom underwent HJ and 11 underwent HD. There were no significant differences in terms of demographics. Median operative time was significantly shorter in HD group (211.0 ± 96.4 vs. 386.0 ± 90.4 min, p = 0.001). Although postoperative enteral feeding was initiated later in HD group (5.0 ± 0.8 vs. 4.0 ± 3.6 days, p = 0.036), postoperative stay in intensive care unit (ICU) (0.7 ± 1.0 vs. 2.4 ± 1.7 days, p = 0.007) and overall hospital stay (9.1 ± 1.0 vs. 14.4 ± 12.2 days, p = 0.157) favoured HD group. There was no perioperative mortality. Median follow-up duration was 24.0 (±11.0) months in HD group and 67.5 (±23.7) months in HJ group. One patient in HJ group had postoperative cholangitis related to anastomotic stricture whereas no cholangitis noted in HD group. In total, five patients in HJ group required second operation for complications and residual diseases whereas none in HD group required reoperation. CONCLUSIONS Laparoscopic excision of choledochal cyst with hepaticoduodenostomy reconstruction is safe and feasible with shorter operative time, ICU stay and overall hospital stay. It is not inferior to HJ in terms of short-term postoperative outcomes.
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Affiliation(s)
- Fanny Yeung
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Choledochal cysts: presentation, clinical differentiation, and management. J Am Coll Surg 2014; 219:1167-80. [PMID: 25442379 DOI: 10.1016/j.jamcollsurg.2014.04.023] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/29/2014] [Accepted: 04/30/2014] [Indexed: 02/08/2023]
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Ng JL, Salim MT, Low Y. Mid-term Outcomes of Laparoscopic Versus Open Choledochal Cyst Excision in a Tertiary Paediatric Hospital. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2014. [DOI: 10.47102/annals-acadmedsg.v43n4p220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Paediatric laparoscopic choledochal cyst excision has increasingly gained acceptance as an alternative to open excision. Laparoscopic excision is feasible and safe in the short term, but long-term outcomes are not as well established. KK Women’s and Children’s Hospital started performing laparoscopic choledochal cyst excision in children since 2007. In this paper, we report our experience with the laparoscopic approach, and the early and mid-term outcomes in comparison with the conventional open approach. Materials and Methods: Thirty-five consecutive cases by a single surgeon between May 2006 and April 2012 were retrospectively reviewed. Patient characteristics and surgical outcomes were analysed. Results: There were 13 laparoscopic and 22 open cases. Baseline patient characteristics were similar. Operative time was longer in the laparoscopic group. Three cases in the laparoscopic group were converted to open in our early experience. There were no differences in time to feeds or length of hospitalisation. One laparoscopic case developed minor bile leak that resolved on conservative management. There were no complications in the laparoscopic group on median follow-up of 35 months. In the open group, there was 1 case of pancreatitis, cholangitis, and hypertrophic scarring respectively. There were 3 cases of suspected adhesive colic that resolved without surgery. Conclusion: Laparoscopic choledochal cyst excision enjoys excellent early and mid-term outcomes compared to open excision, even in centres with smaller patient volume. It should be the approach of choice where technical expertise is available.
Key words: Hepaticojejunostomy, Minimally invasive, Postoperative outcomes
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Affiliation(s)
- Jia Lin Ng
- KK Women’s and Children’s Hospital, Singapore
| | | | - Yee Low
- KK Women’s and Children’s Hospital, Singapore
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Escobar MA, Bond BJ, Schopp J. Solid pseudopapillary tumour (Frantz's tumour) of the pancreas in childhood. BMJ Case Rep 2014; 2014:bcr-2013-200889. [PMID: 24488660 DOI: 10.1136/bcr-2013-200889] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
An 11-year-old girl presented with acute pancreatitis and mass in the head of the pancreas. MRI revealed a heterogeneous right-upper quadrant retroperitoneal mass measuring 6.8×6.1×5.5 cm arising from the pancreatic head. Endoscopic ultrasound with fine-needle aspirate revealed a solid pseudopapillary tumour (SPT) of the pancreas. The patient underwent a pylorus-preserving Whipple procedure. Pathology confirmed SPT. First described by Frantz, SPT represents less than 3% of all exocrine tumours. It is especially rare in children and shows different clinical features compared with adults. In our patient, tumour cells were arranged at the periphery of fibrovascular cores, but they did not show definite gland formation, keratinisation or cytoplasmic pigment accumulation. A periodic acid-Schiff stain without diastase did not show appreciable glycogen within the tumour cells, classic for Frantz's tumour. The literature, diagnosis, management and pathogenesis on this rare entity in children are reviewed and discussed.
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Affiliation(s)
- Mauricio Antonio Escobar
- Department of Pediatric Surgical Services, Mary Bridge Children's Hospital & Health Center, Tacoma, Washington, USA
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Narayanan SK, Chen Y, Narasimhan KL, Cohen RC. Hepaticoduodenostomy versus hepaticojejunostomy after resection of choledochal cyst: a systematic review and meta-analysis. J Pediatr Surg 2013; 48:2336-42. [PMID: 24210209 DOI: 10.1016/j.jpedsurg.2013.07.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/31/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Excision has been established as a standard management practice for choledochal cysts in the last few decades. The two most commonly performed methods of reconstruction after excision are hepaticoduodenostomy (HD) and Roux-en-Y hepaticojejunostomy (HJ), of which the HJ is favored by most surgeons. Evidence concerning the optimal method of reconstruction is, however, sparse. MATERIALS AND METHODS Studies comparing outcomes from HD and HJ after choledochal cyst excision were identified by searching Medline, Ovid, Search Medica, Elsevier Clinicalkey, Google Scholar and Cochrane library. Suitable studies were chosen and data extracted for meta-analysis. Outcomes evaluated included operative time, hospital stay and incidence of postoperative bile leak, cholangitis, reflux/gastritis, anastomotic stricture, bleeding, intestinal obstruction and re-operative rate. Pooled odds ratios (OR) were calculated for dichotomous variables; pooled mean differences (MD) were measured for continuous variables. RESULTS Six retrospective studies were included in this meta-analysis, comprising a total of 679 patients, 412 of whom (60.7%) underwent HD, and the remainder, 267 (39.3%) underwent HJ. Although, HD group had slightly shorter hospital stay (MD: 0.30; 95% CI: -0.22-0.39; P < 0.00001) it showed a higher incidence of postoperative reflux/gastritis (OR: 0.08; 95% CI: -0.02-0.39; P = 0.002). However, the other outcomes such as bile leak, cholangitis, anastomotic stricture, bleeding, operative time, reoperation rate and adhesive intestinal obstruction did not differ between HD and HJ groups. CONCLUSIONS HD shows higher postoperative reflux/gastritis than HJ but a shorter hospital stay. There are few good-quality studies that compare the outcomes from HD and HJ, meaning that caution should be exercised in the generalization of the results of this meta-analysis, which suggests HD to be comparable with HJ in terms of other complications, operative benefits and outcomes.
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Affiliation(s)
- Sarath Kumar Narayanan
- Department of Pediatric Surgery, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia.
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Abstract
Laparoscopy enables surgeons to approach the surgical conditions from a new perspective. Laparoscopic surgery has revolutionized the treatment of choledochal cysts (CDC). Yet, this new technique requires objective evaluations. We have examined the controversies about the CDC dissection, distal common bile duct ligation, ductoplasty for hepatic duct stenosis, intrahepatic duct and common channel protein plug clearance, timing of surgery for antenatally diagnosed CDC, and the Roux loop length in CDC children. In the hands of experts, laparoscopic excision of the cyst and Roux-en-Y hepaticojejunostomy is a safe and effective approach. We provide our opinions on these issues based on our experience and publications. We conclude that the main outcomes comparable to those of the open surgery. The better wound cosmesis and reduction of surgical trauma are the advantages.
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Patil V, Kanetkar V, Talpallikar MC. Hepaticoduodenostomy for Biliary Reconstruction After Surgical Resection of Choledochal Cyst: a 25-Year Experience. Indian J Surg 2012; 77:240-4. [PMID: 26730001 DOI: 10.1007/s12262-012-0783-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 11/21/2012] [Indexed: 02/07/2023] Open
Abstract
We reviewed our experience of hepaticoduodenostomy done for choledochal cyst from 1982 to 2007 at our center. The aim of the study was to evaluate the efficacy of hepaticoduodenostomy as a mode of biliary reconstruction after surgical resection of choledochal cyst, to look for any complications associated with hepaticoduodenostomy, with review of the literature. A total of 56 patients underwent hepaticoduodenostomy after surgical resection of choledochal cyst, of which 54 patients underwent primary cyst excision with hepaticoduodenostomy and 2 patients underwent redo surgery (hepaticoduodenostomy). Most of the patients had an uneventful postoperative recovery. Early complications were biliary leak in three patients which subsided on conservative treatment. Long-term complication was seen in only one patient who developed anastomotic stricture 18 years after primary resection of choledochal cyst and hepaticoduodenostomy. Hepaticoduodenostomy is a relatively safe procedure with very low complication rates. It requires a single anastomosis and is simple to perform.
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Affiliation(s)
- Vijay Patil
- Vijay Clinic, Ashwini Hospital & Research Centre, Solapur, Maharashtra India
| | | | - Mahesh C Talpallikar
- Ashwini Hospital & Research Centre, 39/12, Sarvamangal Apartments, Railway Lines, Solapur, 413001 Maharashtra India
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Goessmann H, Lang SA, Fichtner-Feigl S, Scherer MN, Schlitt HJ, Stroszczynski C, Schreyer AG, Schnitzbauer AA. [Biliodigestive anastomosis: indications, complications and interdisciplinary management]. Chirurg 2012. [PMID: 23179515 DOI: 10.1007/s00104-012-2365-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Techniques for biliodigestive anastomoses are a frequent indication in primary surgical interventions. Moreover, they are required to manage secondary complications of hepatobiliary surgery. Evidence for the management of complications following biliodigestive anastomoses is low. Biliodigestive anastomoses can be performed as hepaticojejunostomy, hepatojejunostomy/portoenterostomy and hepaticoduodenostomy using running or single stitch suture techniques. Complication management in the hands of experienced hepatopancreatobiliary surgeons should consider a time delay to the primary operation and an interdisciplinary surgical and/or endoscopic or radiologic interventional approach. The therapy may be protracted and requires repeated critical reflection of the particular complication.
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Affiliation(s)
- H Goessmann
- Institut für Röntgendiagnostik, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Jabłońska B. Biliary cysts: Etiology, diagnosis and management. World J Gastroenterol 2012; 18:4801-10. [PMID: 23002354 PMCID: PMC3447264 DOI: 10.3748/wjg.v18.i35.4801] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 06/05/2012] [Accepted: 07/09/2012] [Indexed: 02/06/2023] Open
Abstract
Biliary cysts (BC) are rare dilatations of different parts of a biliary tract. They account for approximately 1% of all benign biliary diseases. BC occur the most frequently in Asian and female populations. They are an important problem for pediatricians, gastroenterologists, radiologists and surgeons. Clinical presentation and management depend on the BC type. Cholangiocarcinoma is the most serious and dangerous BC complication. The other complications associated with BC involve cholelithiasis and hepatolithiasis, cholangitis, acute and chronic pancreatitis, portal hypertension, liver fibrosis and secondary liver cirrhosis and spontaneous cyst perforation. Different BC classifications have been described in the literature. Todani classification dividing BC into five types is the most useful in clinical practice. The early diagnosis and proper treatment are very important, because BC are associated with a risk of carcinogenesis. A malignancy risk increases with the age. Radiological investigations (ultrasonography, computed tomography, endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography) play an important role in BC diagnostics. Currently, prenatal diagnosis using ultrasonography is possible. It allows to differentiate biliary disorders in fetals and to perform the early surgical treatment that improves results. In most patients, total cyst excision with Roux-Y hepaticojejunostomy is the treatment of choice. Surgical treatment of BC is associated with high success rate and low morbidity and mortality. The early treatment is associated with a lower number of complications. Patients following BC surgery require permanent and careful postoperative observation using laboratory and imaging investigations because of possibility of biliary anastomosis stricture and biliary cancer in tissue remnant.
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Hirano S, Tanaka E, Tsuchikawa T, Matsumoto J, Shichinohe T, Kato K. Techniques of biliary reconstruction following bile duct resection (with video). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 19:203-9. [PMID: 22081253 PMCID: PMC3311849 DOI: 10.1007/s00534-011-0475-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In several clinical situations, including resection of malignant or benign biliary lesions, reconstruction of the biliary system using the Roux-en-Y jejunum limb has been adopted as the standard procedure. The basic technique and the procedural knowledge essential for most gastroenterological surgeons are described in this article, along with a video supplement. Low complication rates involving anastomotic insufficiency or stricture can be achieved by using proper surgical techniques, even following small bile duct reconstruction. Using the ropeway method to stabilize the bile duct and jejunal limb allows precise mucosa-to-mucosa anastomosis with interrupted sutures of the posterior row of the anastomosis. Placement of a transanastomotic stent tube is the second step. The final step involves suturing the anterior row of the anastomosis. In contrast to the lower extrahepatic bile duct, the wall of the hilar or intrahepatic bile duct can be recognized within the fibrous connective tissue in the Glissonean pedicle. The portal side of the duct should be selected for the posterior wall during anastomosis owing to its thickness. Meticulous inspection to avoid overlooking small bile ducts could decrease the chance of postoperative intractable bile leakage. In reconstruction of small or fragile branches, a transanastomotic stent tube could work as an anchor for the anastomosis.
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Affiliation(s)
- Satoshi Hirano
- Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-Ku, Sapporo 060-8638, Japan.
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Kamisawa T, Ando H, Suyama M, Shimada M, Morine Y, Shimada H. Japanese clinical practice guidelines for pancreaticobiliary maljunction. J Gastroenterol 2012; 47:731-59. [PMID: 22722902 DOI: 10.1007/s00535-012-0611-2] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 05/02/2012] [Indexed: 02/07/2023]
Abstract
There have been no clinical guidelines for the management of pancreaticobiliary maljunction (PBM). The Japanese Study Group on Pancreaticobiliary Maljunction (JSPBM) has proposed to establish clinical practice guidelines on how to deal with PBM, with the support of the Japan Biliary Association (JBA). Because the body of evidence-based literature is relatively small, we decided to create guidelines based on the consensus of experts, using the medical literature for reference. A total of 46 clinical questions (CQs) were considered by the members of the editorial committee responsible for the guidelines. The CQs covered distinct aspects of PBM: (1) Concepts and Pathophysiology (10 CQs); (2) Diagnosis (10 CQs); (3) Pancreatobiliary complications (9 CQs); and (4) Treatments and prognosis (17 CQs). Statements and comments for each CQ were prepared by the guidelines committee members and collaborating partners. The CQs were completed after review by members of the editorial committee, meetings of this committee, public comments on the homepages of the JSPBM and the JBA, public hearings, and assessment and approval by the guidelines evaluation board. PBM includes cases where the bile duct is dilated (PBM with biliary dilatation) and those in which it is not (PBM without biliary dilatation). In these guidelines, PBM with biliary dilatation is defined as being identical to congenital biliary dilatation of Todani type I (except for type Ib) and type IV-A, both of which are accompanied by PBM in almost all cases. These guidelines are created to provide assistance in the clinical practice of PBM management; their contents focus on clinical utility, and they include general information on PBM to make this disease more widely recognized.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113 8677, Japan.
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Chang EY, Hong YJ, Chang HK, Oh JT, Han SJ. Lessons and tips from the experience of pediatric robotic choledochal cyst resection. J Laparoendosc Adv Surg Tech A 2012; 22:609-14. [PMID: 22693965 DOI: 10.1089/lap.2011.0503] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The laparoscopic surgery for a choledochal cyst in children is technically challenging because of its high degree of complexity despite its possibility. In an attempt to overcome this laparoscopic weakness and to facilitate the difficult steps in the minimally invasive surgery for choledochal cyst resection in children, we have performed the robot-assisted resection of the choledochal cyst. The aim of this study is to report lessons and tips obtained from our experience of the robot-assisted choledochal cyst resection in children. PATIENTS AND METHODS From July 2008 to October 2011, we have attempted robot-assisted resections of choledochal cyst for 14 children using the da Vinci Robotic Surgical System(®) (Intuitive Surgical, Sunnyvale, CA). We analyzed retrospectively reviewed medical records for patients' clinical characteristics, operative methods, and postoperative outcomes including operative time, hospital days, and complications. RESULTS In 3 early consecutive cases, we encountered serious technical problems and complications. However, after the operator underwent the robot system off-site training program, complete resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy were performed successfully without difficulty and any complication in the 11 later consecutive cases. The important technical developments of our late-period operations include placing the patient's body above the operative table, performing the extracorporeal jejunojejunostomy through an umbilical incision, omitting the operative cholangiography with magnetic resonance cholangiopancreatography substitution, exposure of the porta hepatis by lateral retractions of the gallbladder and the falciform ligament with anchoring sutures to the abdominal wall, and using a third robotic arm for counter-traction of tissues for careful dissection. CONCLUSION We believe that the techniques of pediatric robotic choledochal cyst resection have evolved from the previous experiences to be safer and easier.
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Affiliation(s)
- Eun Young Chang
- Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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