Introduction of resection of intrahepatic bile duct stenosis-causing membrane or septum into laparoscopic choledochal cyst excision

Laparoscopic Hepatic Ductoplasty in Pediatric Choledochal Cyst: What Is the Role, Feasibility, and Outcome?-Systematic Review and Meta-Analysis

Introduction: The pediatric choledochal cyst with hepatic duct stenosis occurs postoperative hepatolithiasis, recurrent cholangitis, or pancreatitis. The laparoscopic hepatic ductoplasty can prevent these incidences. Objectives: To determine the characteristic of hepatic duct stenosis, laparoscopic treatment, and outcomes in systematic review and meta-analysis. Methodology: We searched the published studies on PubMed, Scopus, and Cochrane Library databases from January 1985 to April 2022 in English language. This protocol was registered to PROSPERO (CRD42022332145). Results: Nine published studies and 412 patients were included. The meta-analysis revealed that the locations were the confluence of the left and right hepatic ducts 43.1%, the left or/and the right hepatic duct 8.3%, and the unclassified location 60.4%. These characteristics included a membranous/septum appearance (44.7%) and a circumferential/relative stenosis (22.7%). The laparoscopic techniques were the wide hilar Roux-en-Y hepaticojejunostomy (28.5%), the excision of membranes/septum (26.5%), and the mixed hepatic ductoplasty (45.0%). The outcomes revealed a minor bile leakage of 3.8% and minimal bleeding. The meta-analysis showed no statistical difference between laparoscopic and open techniques in hepatolithiasis (0% versus 2.00%), anastomosis stricture (4.83% versus 10.00%), and no recurrent cholangitis. There was no conversion rate but showed a trend the prolonged operating time in laparoscopy. Conclusion: Laparoscopic hepatic ductoplasty is safe and effective. The characteristics and location can be feasible laparoscopic procedures. So, hepatic ductoplasty decreases hepatolithiasis, anastomosis stricture, or recurrent cholangitis and may increase minor bile leakage. The systematic review registration was PROSPERO system with CRD42022332145.

Robotic versus laparoscopic radical surgery for pediatric congenital biliary dilatation: a comparison of surgical outcomes of a single surgeon's initial experience

PURPOSE

This study aimed to clarify the validity of robot-assisted surgery (RAS) for pediatric patients with congenital biliary dilatation (CBD).

METHODS

We retrospectively compared RAS and laparoscopic surgery (LS) for pediatric CBD performed by the same certified surgeon between 2016 and 2022.

RESULTS

We included 6 RAS and 12 LS cases in this study. One case of RAS with laparotomy was excluded from the analysis. The patients in the two groups had comparable ages and body weights. The median surgery duration, the suture time per stitch, and the time to drain removal were 385 min, 145 s, and 5 days in the RAS group and 370 min (p = 0.28), 177 s (p = 0.03), and 6 days (p = 0.03) in the LS group, respectively. The time to create the Roux-en-Y limb was significantly longer in the RAS group. Postoperative complications occurred in one RAS case and in four LS cases.

CONCLUSIONS

Less anastomotic time per stitch and less time to drain removal suggest that RAS may contribute to accurate suturing and fine intra-pancreatic bile duct dissection. In addition, RAS requiring large movements of forceps in a large surgical field, such as Roux-en-Y creation, is inferior to LS.

Clinical characteristics and prognosis of primary hepatolithiasis in hospitalized children

The purpose of this study is to evaluate the clinical characteristics and prognosis of primary hepatolithiasis in hospitalized children. This retrospective cohort study included 106 hospitalized patients with primary hepatolithiasis at Beijing Children's Hospital. Clinical data were derived from electronic inpatient (2010-2021) and outpatient (2016-2021) medical records. The prognosis was evaluated by outpatient ultrasounds after discharge and telephone interviews performed in December 2022. Intrahepatic bile duct stones in patients enrolled in the study were all found incidentally by abdominal ultrasound during hospitalization, with an incidence of 1.7 per 10,000 hospitalized children. The mean age at diagnosis was 9.3 ± 3.6 years, with male predominance (69/106, 65.1%). The right lobe of the liver (80/106, 75.5%) was preferentially affected. All patients underwent conservative observation. Seventy-eight patients (78/106, 73.6%) were followed up with a mean follow-up age of 17.1 ± 5.0 years, and 4 (4/78, 5.1%) had intermittent abdominal pain. From 2016 to 2021, 32 patients were diagnosed with primary hepatolithiasis, and follow-up abdominal ultrasounds were performed in 20 of them (20/32, 60.0%) with a median time of 2.1 (0.1, 3.5) years. The stones were present in 17 patients (17/20, 85.0%).

CONCLUSION

Primary hepatolithiasis in hospitalized children is rare, almost found accidentally; mostly affects the right lobe of the liver; and can be conservatively observed without surgical treatment in childhood.

WHAT IS KNOWN

• Primary hepatolithiasis in adults often presents with severe clinical symptoms and requires hepatectomy.. • There are few studies on primary hepatolithiasis in children.

WHAT IS NEW

• Primary hepatolithiasis in children is mostly found accidentally by abdominal ultrasound without associated symptoms during hospitalization. • Children with accidental primary hepatolithiasis can be conservatively observed without surgical treatment in childhood.

Laparoscopic definitive surgery for choledochal cyst is performed safely and effectively in infants

Background:

Laparoscopic definitive surgery for choledochal cyst (CC) in infants requires advanced skills because of their small size. If patients with a prenatal diagnosis of CC have any biliary symptoms, they need semi-emergency definitive surgery. This study aimed to estimate whether laparoscopic definitive surgery for CC can be performed safely and effectively in infants, especially when emergency surgery is required.

Patients and Methods:

From January 2006 to December 2019, 21 patients under 1 year of age underwent laparoscopically or open definitive surgery, and 16 patients aged 3–5 years underwent laparoscopic surgery for CC at our institution. In cases of prenatal diagnosis, elective surgery (EL) was performed at about 6 months of age for patients with no biliary symptoms; the semi-emergency surgery (EM) was performed when patients had any biliary symptoms. Surgical outcomes were retrospectively compared between the Lap <1 y and Op <1 y groups and between the Lap <1 y and Lap 3–5 y groups. In addition, the surgical outcomes of those who underwent EM were also evaluated.

Results:

Operative time was significantly longer, and blood loss was significantly lower in the Lap <1 y group than in the Op <1 y group. All surgical outcomes were similar between the Lap <1 y and Lap 3–5 y groups and between the EM and EL groups.

Conclusion:

Laparoscopic definitive surgery for CC in infants under 1 year of age is safe and feasible. Even semi-emergency laparoscopic surgery can be performed safely and effectively in small infants.

Laparoscopic definitive surgery for congenital biliary dilatation with aggressive hilar bile ductoplasty and complete resection of the intrapancreatic bile duct in pediatric patients is safe and effective, comparable to open surgery

BACKGROUND

After surgery for congenital biliary dilatation (CBD), hilar and hepatic bile duct stenosis and intrapancreatic bile duct remnants can cause many postoperative complications. We investigated the efficacy of laparoscopic surgery with aggressive bile ductoplasty and complete excision of the intrapancreatic bile duct in CBD patients compared to open surgery.

METHODS

Pediatric patients who underwent surgery for CBD at our institution between 2006 and 2020 were divided into two groups: laparoscopic surgery (Lap group) and open surgery (Op group). Surgical outcomes were compared between the two groups.

RESULTS

We enrolled 160 patients (85 in the Lap group and 75 in the Op group). Hilar bile ductoplasty was performed in 52 (61%) patients from the Lap group and 40 (53%) patients from the Op group. The operative time was significantly longer, the amount of blood loss was significantly lower, and the length of hospital stay was significantly shorter in the Lap group than in the Op group. Postoperative early and late complications occurred at a similarly low rate in both groups. When the surgical outcomes were compared between the group who underwent laparoscopic bile ductoplasty and the group that did not, postoperative early and late complications occurred similarly in both groups.

CONCLUSIONS

Laparoscopic surgery for CBD with aggressive hilar bile ductoplasty and complete excision of the intrapancreatic bile duct is safe and effective, comparable to open surgery. However, it is necessary to verify whether long-term occurrence of hepatolithiasis similar to open definitive surgery can be obtained in the future.

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

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

Risk factors and outcomes of bile leak after laparoscopic surgery for congenital biliary dilatation

PURPOSE

One of the main causes of stricture at hepaticojejunostomy site after surgery for congenital biliary dilatation is inflammation or infection associated with bile leak. The aim of this study was to determine the risk factors and outcomes of bile leak after laparoscopic surgery.

METHODS

We retrospectively reviewed the demographics and outcomes of patients who underwent laparoscopic surgery for congenital biliary dilatation between September 2013 and December 2019. Data from patients with bile leak were compared to data from patients without bile leak.

RESULTS

Fourteen of 78 patients had bile leak. Hepatic duct diameter at anastomosis was the only risk factor of bile leak. Patients with the diameter ≤ 10 mm had higher incidence of bile leak than in patients with the diameter > 10 mm (P = 0.0023). Among them, bile leak occurred more frequently in patients operated on by non-qualified surgeons based on the Japan Society for Endoscopic Surgery endoscopic surgical skill qualification system than by qualified surgeons (P = 0.027). However, none of the patients with bile leak developed anastomotic stricture afterwards.

CONCLUSION

Although good technical skill is necessary to avoid bile leak in narrow hepatic duct cases (≤ 10 mm), slight bile leak may not result in anastomotic stricture.