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Yaghi M, Jaafar R, Kanso M, Khalife M, Faraj W. Choledochal anomalies in adults: A 20-year single-center retrospective cohort experience in the Middle East. Arab J Gastroenterol 2022; 23:235-240. [PMID: 36371373 DOI: 10.1016/j.ajg.2022.10.003] [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: 08/04/2021] [Revised: 03/31/2022] [Accepted: 10/14/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Choledochal cysts are rare congenital cystic dilatations of the bile ducts that occur in fewer than 1% of individuals. The disease is common in East Asia, and most of the literature concerns those populations, but some data about Western populations have been published recently. Long-term reports about the disease in Middle Eastern populations, however, are currently lacking. We report a single-center 20-year experience in diagnosing and managing choledochal anomalies. PATIENTS AND METHODS Participants were adult patients in whom choledochal cysts were diagnosed over a 20-year (2000-2019) period at a single tertiary academic care center. Clinical data, including radiologic imaging findings, were retrieved from the patients' medical records. To describe the baseline characteristics of the population, we calculated descriptive statistics. RESULTS Choledochal anomalies were diagnosed in 19 adult patients, whose median age was 30 years (interquartile range [IQR], 23-67 years). Of the choledochal cysts 13 (68.4%) were classified as Todani type I, 4 (21.1%) as Todani type IV, and 3 (15.8%) as Todani type V (Caroli's disease). No patient had underlying chronic liver disease, and liver synthetic function was preserved in all. Eighteen patients (94.7%) underwent surgery: cyst excision with Roux-en-Y hepaticojejunostomy in 17 and liver transplantation in 1. All 18 survived surgery, and the median postoperative hospital stay was 11 days (IQR, 5-34 days). All 18 were alive 90 days after surgery, and the median follow-up period was 40 months (IQR, 12-140 months). Seven patients (36.8%) developed postoperative surgical complications; 2 patients required rehospitalization, and 1 required reoperation. CONCLUSION This description of adults with choledochal cysts is the latest long-term report about this disease in the Middle East. In our 20-year experience, the disease characteristics in our patients were moderately consistent with those described previously.
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Affiliation(s)
- Marita Yaghi
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Rola Jaafar
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Mariam Kanso
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Mohamed Khalife
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Walid Faraj
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon.
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Gündoğan E, Sümer F, Çolakoğlu MK, Çiçek E, Gökler C, Aydın MC, Kayaalp C. Laparoscopic resection of choledochal cysts in adults: a series from Turkey. Turk J Surg 2020; 35:223-226. [PMID: 32550332 DOI: 10.5578/turkjsurg.4331] [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: 10/12/2018] [Accepted: 11/20/2018] [Indexed: 11/15/2022]
Abstract
Objectives Choledochal cyst is a congenital disease in which surgical treatment is preliminary because of the potential for malignancy. In recent years, increase in technological developments and laparoscopic experience have popularised the use of laparoscopy in adult choledochal cyst surgery. This study aimed to present the results of eight adult patients undergoing laparoscopic choledochal excision surgery. Material and Methods Patients who underwent laparoscopic choledochal cyst excision and hepatico-jejunostomy anastomoses between the years 2013 and 2018 were evaluated retrospectively. Demographic characteristics, preoperative and postoperative findings, pathological results and final condition of the patients were examined. Results Of the eight patients, three were males and five were females. Median age was 41.5 years (22-49). One of the patients had Type IVa and the rest had Type I choledochal cysts. Laparoscopic choledochal cyst excision, cholecystectomy, and hepatico-jejunostomy anastomoses were performed on all of the patients. One patient was converted to open surgery. Three patients had postoperative biliary leakage. Duration of the operations was determined as median 330 (240-480) minutes and blood loss was 50 (10-100) mL. Hospitalization of the patients was median 6 (4-23) days and follow-up time was median 20 (2-65) months. In the late period, cholangitis occured in a patient who was treated with medical therapy and there was no mortality in the follow-up period. Conclusion We suggest that laparoscopic choledochal cyst excision in adults may be an alternative to open surgery due to the satisfactory results in the late period in spite of early problems like self-limiting bile leakage.
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Affiliation(s)
- Ersin Gündoğan
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | - Fatih Sümer
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | | | - Egemen Çiçek
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | - Cihan Gökler
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | - Mehmet Can Aydın
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | - Cüneyt Kayaalp
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
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Lee H, Kwon W, Han Y, Kim JR, Kim SW, Jang JY. Comparison of surgical outcomes of intracorporeal hepaticojejunostomy in the excision of choledochal cysts using laparoscopic versus robot techniques. Ann Surg Treat Res 2018; 94:190-195. [PMID: 29629353 PMCID: PMC5880976 DOI: 10.4174/astr.2018.94.4.190] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/19/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023] Open
Abstract
Purpose Increasing surgical expertise in minimally invasive surgery has allowed laparoscopic surgery to be performed in many abdominal surgeries. Laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy are challenging and sophisticated surgeries because of the difficult anastomosis. Recent advances in robotic surgery have enabled more delicate and precise movements, and Endowrist instruments allow for securing sutures during anastomosis. This study aimed to compare surgical outcomes of laparoscopic and robotic hepaticojejunostomy in choledochal cyst excision. Methods Sixty-seven patients who underwent laparoscopic or robotic-hybrid choledochal cyst excision from 2004 to 2016 were retrospectively analyzed and compared. In robotic surgery, dissection was performed laparoscopically, and hepaticojejunostomy was performed using a robotic platform. Results The mean operative time was significantly longer in robotic surgery than in laparoscopic surgery (247.94 ± 54.14 minutes vs. 181.31 ± 43.06 minutes, P < 0.05). The mean estimated blood loss (108.71 ± 15.53 mL vs. 172.78 ± 117.46 mL, respectively, P = 0.097) and postoperative hospital stay (7.33 ± 2.96 days vs. 6.22 ± 1.06 days, P = 0.128) were comparable between procedures. Compared to the laparoscopic approaches, robotic surgery had significantly less short-term complications (22.4% vs. 0%, P = 0.029). There were more biliary leakage (n = 7, 14.3%) observed during the first 30 days after surgery in laparoscopy while none were observed in the robotic method. Conclusion Robotic surgery allow for more precise and secure sutures during anastomosis thereby reducing biliary complications. With expanding knowledge and expertise, robotic surgery may offer more advantages over laparoscopy in the era of minimally invasive surgery.
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Affiliation(s)
- Hongeun Lee
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Ri Kim
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Ahmed B, Sharma P, Leaphart CL. Laparoscopic resection of choledochal cyst with Roux-en-Y hepaticojejunostomy: a case report and review of the literature. Surg Endosc 2016; 31:3370-3375. [PMID: 27873011 DOI: 10.1007/s00464-016-5346-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/09/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Choledochal cysts are associated with ductal strictures, stone formation, cholangitis, rupture, secondary biliary cirrhosis and increased incidence of cholangiocarcinoma. The surgical approach to choledochal cysts has evolved from the cyst-enterostomy to a complete excision with more recent use of minimally invasive approaches. We report a complete minimally invasive approach to a Type 1 choledochal cyst and summarize the literature containing large case series of similar approaches. METHODS AND OPERATIVE TECHNIQUE A 38-year-old female with a history of vague epigastric pain for multiple years was diagnosed with a Type 1 choledochal cyst on MRCP. The operative approach was an elective laparoscopic resection of choledochal cyst and Roux-en-Y hepaticojejunostomy. There were no intraoperative complications and discharge occurred on postoperative day three. Approximately 1 month after resection, she was diagnosed with a small retrohepatic fluid collection which was treated percutaneously and was diagnosed as a hematoma. A PubMed literature review focusing on surgical approaches to Type 1 choledochal cysts methods of repair and postoperative complications was performed and summarized. RESULTS AND DISCUSSION The literature search performed on the subject of choledochal cyst management in adults and laparoscopic approaches resulted in a review of twenty-one articles. Ten of the articles were review articles regarding surgical approach and management of the disease. An additional two were case reviews, and eight reported on laparoscopic approaches to management of choledochal cysts. In this paper, we summarize the eight articles that provide information on the laparoscopic management and outcomes for choledochal cysts. While operative times were longer on the laparoscopic procedures, hospital stay was shorter and there was no increase in complication rates. The most common complications reported were postoperative bile leak followed by anastomotic stricture. CONCLUSION This case highlights the management of laparoscopic resection of choledochal cyst as a viable, safe and feasible approach based on this case and a literature review.
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Affiliation(s)
- Bestoun Ahmed
- Department of Surgery, UPMC-University of Pittsburgh School of Medicine, 3380 Blvd of the Allies, Suite 305, Pittsburgh, PA, 15213, USA.
| | - Priya Sharma
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Cynthia L Leaphart
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
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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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Totally laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy for choledochal cyst in adults: a single-institute experience of 5 years. Surg Laparosc Endosc Percutan Tech 2016; 25:e65-8. [PMID: 25122485 DOI: 10.1097/sle.0000000000000091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE The present study aimed to describe the authors' experience and the intermediate-term outcome for totally laparoscopic choledochal cyst excision and Roux-en-Y hepatoenterostomy at a single center in a 5-year period. METHODS We retrospectively analyzed the clinical data of totally laparoscopic choledochal cyst excision and Roux-en-Y hepatoenterostomy on 31 adult patients from January 2009 to November 2013. RESULTS Thirty-one cases successfully underwent totally laparoscopic choledochal cyst excision laparoscopy and Roux-en-Y hepatoenterostomy. The operation time varied from 200 to 360 minutes. The intraoperative blood loss was 50 to 210 mL. The patients passed flatus in 3.0 ± 1.3 days. The mean time interval to resume oral intake from the time of surgery was 3.8 ± 1.4 days. The duration of postoperative intravenous fluids was 4 to 11 days. Postoperative ambulation varied from 2 to 4 days. The duration of hospital stay was 4 to 13 days. Follow-up observations lasted 3 to 59 months and complications were noted in 4 patients. Of these patients, 1 patient suffered postoperative respiratory tract infection, 1 patient had an episode of adhesive small bowel obstruction, biliary leakage occurred in 1 patient, and 1 patient developed an anastomotic stoma stricture and cholangitis. There were no perioperative deaths. CONCLUSIONS Totally laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy is a safe, efficacious, and minimally invasive procedure for the most instances of adult choledochal cyst. The key of success is skilled laparoscopic skills, good team cooperation, and stapler anastomosis.
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Laparoscopic cyst excision and Roux-Y hepaticojejunostomy for children with choledochal cysts in China: a multicenter study. Surg Endosc 2014; 29:140-4. [PMID: 25125091 DOI: 10.1007/s00464-014-3667-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 05/31/2014] [Indexed: 12/25/2022]
Abstract
AIMS Laparoscopic hepaticojejunostomy (LH) for children with choledochal cyst (CDC) has become feasible and popular recently. The purpose of this study is to evaluate the safety and efficacy of LH for CDC in a large multicenter series. PATIENTS AND METHODS Medical records of 956 consecutive patients who underwent LH for CDC at seven academic institutions from June 2001 to May 2012 were retrospectively analyzed. Ultrasonography, upper gastrointestinal contrast studies, and laboratory tests were performed during the follow-up period. RESULTS A total of 956 patients of CDC treated with LH were identified and included in this study. Of these patients, there were no significant differences in age, gender ratio, and the subtypes of CDC among the seven centers. The operative time of all patients decreased significantly as time went by. Interestingly, the centers that began to perform LH earlier, like cohort A, B, and C, took much more time in the initial cases than the later centers. The postoperative complications included 12 (1.3 %) intra-abdominal fluid collection, 6 (0.6 %) anastomotic stenosis, 14 (1.5 %) bile leak, 8 (0.8 %) Roux loop obstruction and 4 (0.4 %) gastrointestinal bleeding, and one case developed intrahepatic stone formation; two mortalities occurred; one died of hyperkalemia, and the other one died of postoperative bleeding. No other complication occurred during the mean follow-up of 5.7 years (ranged from 4 month to 11 years). CONCLUSIONS We reported a multi-institutional series of LH in children with CDC. Our findings suggested that LH represents a feasible treatment option for CDC by offering reliable middle and long-term outcome, low surgical morbidity.
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Comparison of therapeutic effects of laparoscopic and open operation for congenital choledochal cysts in adults. Gastroenterol Res Pract 2014; 2014:670260. [PMID: 24719612 PMCID: PMC3955616 DOI: 10.1155/2014/670260] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 12/25/2013] [Accepted: 12/26/2013] [Indexed: 01/08/2023] Open
Abstract
Background. Laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy for treating congenital choledochal cysts (CCCs) have proved to be efficacious in children. Its safety and efficacy in adult patients remain unknown. The purpose of this study was to determine whether the laparoscopic procedure was feasible and safe in adult patients. Methods. We reviewed 35 patients who underwent laparoscopic operation (laparoscopic group) and 39 patients who underwent an open procedure (open group). The operative time, intraoperative blood loss, time until bowel motion recovery, duration of drainage, postoperative stay, time until resumption of diet, postoperative complications, and perioperative laboratory values were recorded and analyzed in both groups. Results. The operative time was longer in the laparoscopic group and decreased significantly with accumulating surgical experience (P < 0.01). The mean intraoperative blood loss was significantly lower in the laparoscopic group (P < 0.01). The time until bowel peristalsis recovery, time until resumption of diet, abdominal drainage, and postoperative stay were significantly shorter in the laparoscopic group (P < 0.01). The postoperative complication rate was not higher in the laparoscopic group than in the open group (P > 0.05). Conclusions. Laparoscopic cyst excision and hepaticojejunostomy are a feasible, effective, and safe method for treating CCCs in adult patients.
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Laparoscopic surgery for choledochal cysts. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 20:487-91. [PMID: 23572286 DOI: 10.1007/s00534-013-0608-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Laparoscopic cystectomy has become a common procedure for choledochal cysts. The cyst should be removed completely just above the confluence of the common biliopancreatic channel at the distal end and approximately 5 mm from the confluence of the right and left hepatic ducts at the proximal end to avoid complications of the cystic remnant. The operation is feasible and safe. The rate of conversion to open surgery is low. The rate of complication under skill laparoscopic surgeons is also low, even lower than in open surgery. There was no difference between hepaticoduodenostomy and hepaticojejunostomy concerning the rate of cholangitis. Gastritis due to bilious reflux occurred with a low rate in hepaticoduodenostomy. Both techniques could be used for choledochal cysts; however, hepaticoduodenostomy should be applied for choledochal cysts without intrahepatic dilatation of biliary tract.
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Nseir M, Aughsteen AA, Mahmood MF, Al-Khayat M, Hawamdeh HM, Bani-Hani KA. Congenital Type 1C Choledochal Cyst: Clinical Presentation and Surgical Treatment. Indian J Surg 2014; 75:220-3. [PMID: 24426571 DOI: 10.1007/s12262-012-0653-y] [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: 08/06/2011] [Accepted: 06/21/2012] [Indexed: 11/24/2022] Open
Abstract
Choledochal cysts are uncommon developmental anomalies involving intrahepatic and extrahepatic biliary ducts, and their immediate complete excision is recommended to prevent chronic inflammatory and malignant changes. A diagnosis of a congenital type 1C choledochal cyst was made in an 8-year-old female patient admitted to the emergency unit with complaints of severe upper abdominal pain and vomiting. Under laparotomy, resection of the whole segment of choledochal cyst and gallbladder, assisted Roux-en-Y hepaticojejunostomy was performed. The laparotomy approach involving fine dissection and resection of choledochal cysts with Roux-en-Y hepaticojejunostomy remains superior to the endoscopic approach.
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Affiliation(s)
- Mazen Nseir
- Paediatric Surgery Unit, Prince Hamza Hospital, Amman, Jordan
| | - Adib A Aughsteen
- Department of Anatomy and Histology, College of Medicine, Hawler Medical University, Erbil, Iraq
| | - Mahmood F Mahmood
- Department of Surgery, Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - Muzahim Al-Khayat
- Department of Surgery, Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - Hasan M Hawamdeh
- Department of Community Medicine & Pathology, Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - Kamal A Bani-Hani
- Department of Surgery, Faculty of Medicine, Hashemite University, Zarqa, Jordan
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Shimizu T, Nakamura Y, Yoshioka M, Mizuguchi Y, Matsumoto S, Uchida E. Laparoscopic resection of choledochal cyst: report of a case. J NIPPON MED SCH 2013; 80:160-4. [PMID: 23657070 DOI: 10.1272/jnms.80.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We report a choledochal cyst that was successfully treated with laparoscopic surgery. A 32-year-old Japanese woman was referred to our hospital with a suspected choledochal cyst. Magnetic resonance cholangiopancreatography and computed tomography showed the common bile duct to be grossly dilated to the hepatic confluence. A diagnosis of type-Ia choledochal cyst in the Todani classification was made, and laparoscopic resection was performed. The patient was placed in the lithotomy position under general anesthesia, and 4 ports were inserted. After the cystic duct was dissected, the hepatoduodenal ligament was incised and a choledochal cyst was identified. Next, the common bile duct was mobilized and dissected away from the surrounding vessels and tissues. Taping of the common bile duct allowed better exposure and dissection of the surrounding tissues. Mobilization of the bile duct and dissection of the surrounding tissue was performed to the bifurcation of the common hepatic duct. Then the common hepatic duct was transected just distal to the choledochal cyst. The inferior common bile duct was dissected from the pancreas to identify the distal end of the choledochal cyst and the pancreaticobiliary junction behind the duodenum. The narrow segment of the choledochal cyst was identified and divided after distal closure with clips. After the gall bladder was dissected from the liver bed, the choledochal cyst and gallbladder were removed. A Roux limb was created extracorporeally via the umbilical incision. The jejunum 30 cm distal to the ligament of Treitz was removed through the transumbilical incision and transected. To create the Roux limb, the mesentery of the jejunum was also extracorporeally separated. A 50-cm Roux limb was made by means of side-to-side anastomosis with an endostapler. After a jejunostomy for hepaticojejunostomy anastomosis was created, the Roux limb was returned to the abdominal cavity. Then, pneumoperitoneum was started again, and the Roux limb was brought up laparoscopically in a retrocolic fashion. An end-to-side hepaticojejunostomy was intracorporeally established with a continuous, single-layer full-thickness 4-0 vicryl suture. Total operation time was 715 minutes. Intraoperative body fluid loss was 250 mL, and the postoperative course was uneventful with no major complications. The patient was discharged from hospital on the 12th postoperative day. She remains asymptomatic with normal liver function after 24 months of follow-up.
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Jang JY, Yoon YS, Kang MJ, Kwon W, Park JW, Chang YR, Ahn YJ, Cho JY, Han HS, Kim SW. Laparoscopic excision of a choledochal cyst in 82 consecutive patients. Surg Endosc 2012; 27:1648-52. [PMID: 23239299 DOI: 10.1007/s00464-012-2646-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Accepted: 09/29/2012] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite it being a benign disease, a choledochal cyst must be removed with the gallbladder (GB) due to the risk of cancer in the biliary tract. Most patients are young females or children, all of whom express strong interest in the cosmetic results in addition to the complete resolution of their medical problems. Here, we introduce a laparoscopic management technique for a choledochal cyst. METHODS Between 2003 and 2011, we performed a laparoscopic choledochal cyst excision procedure on 82 patients using a four-hole method. There were three open-conversion cases, one case involving robotic surgery, and one case involving combined laparoscopic liver resection because the cyst had affected the liver. Excision of the cyst and anastomosis were performed laparoscopically. We will present our method with a video. RESULTS The mean operation time was 230 min. The estimated blood loss was 197 ml. The average hospital stay was 8.6 days. The most common complications were minor bile leakage (7 %) and fluid collection (2.5 %), both of which were managed conservatively. CONCLUSIONS Laparoscopic management can be a treatment of choice for the most instances of choledochal cyst considering its good cosmetic results and its feasible level of operative safety.
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Affiliation(s)
- Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, South Korea.
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Liem NT, Pham HD, Dung LA, Son TN, Vu HM. Early and Intermediate Outcomes of Laparoscopic Surgery for Choledochal Cysts with 400 Patients. J Laparoendosc Adv Surg Tech A 2012; 22:599-603. [DOI: 10.1089/lap.2012.0018] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Nguyen Thanh Liem
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Hien Duy Pham
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Le Anh Dung
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Tran Ngoc Son
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Hoan Manh Vu
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
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Hwang DW, Lee JH, Lee SY, Song DK, Hwang JW, Park KM, Lee YJ. Early experience of laparoscopic complete en bloc excision for choledochal cysts in adults. Surg Endosc 2012; 26:3324-9. [PMID: 22549376 DOI: 10.1007/s00464-012-2299-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 04/04/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND For choledochal cyst, the treatment of choice is total excision of the cyst because there is a risk of biliary cancer including the gallbladder. The current report describes the authors' early experiences using their technique of laparoscopic en bloc excision of choledochal cysts with Roux-en-Y biliary reconstruction. METHODS Between September 2009 and July 2011, laparoscopic excision for choledochal cyst was attempted for 20 patients at the Division of Hepatobiliary and Pancreatic Surgery, Asan Medical Center. Clinical, radiologic, and surgical data were analyzed retrospectively. RESULTS The mean age of the patients was 37.8 ± 11.1 years (range, 18-65 years), and the male-to-female ratio was 1:4.0 (4:16). According to Todani's classification, there were four type 1a cases, seven type 1c cases, and nine type 4a cases. The mean operation time was 395.8 ± 58.7 min. No perioperative transfusions were required. The average body mass index was 23.5 ± 4.04 kg/m(2). Conversion to laparotomy was required for seven patients (35 %) due to bleeding (n = 1), Roux loop venous congestion (n = 1), abdominal obesity (n = 2), and severe fibrosis and inflammation around the cyst (n = 3). No malignancies were identified. Of the 13 patients who underwent laparoscopy, the jejunojejunostomy was created extracorporeally for the first 2 patients and intracorporeally for the subsequent 11 patients. All hepaticojejunostomies were performed intracorporeally. Oral feeding was resumed on postoperative day 3. The mean postoperative hospital stay was 9.3 days (range, 8-36 days). No major complications or mortalities occurred. CONCLUSIONS The morbidity and mortality rates for the authors' method are comparable with previously reported results. Although the conversion rate, mean operation time, and hospital stay were greater than reported in some studies, this probably reflected the authors' learning curve for this technically challenging procedure. They believe laparoscopic approaches will eventually become an advantageous treatment option for laparotomy offered to selected choledochal cyst patients.
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Affiliation(s)
- Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea.
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15
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Cho MJ, Hwang S, Lee YJ, Kim KH, Ahn CS, Moon DB, Lee SK, Kim MH, Lee SS, Park DH, Lee SG. Surgical experience of 204 cases of adult choledochal cyst disease over 14 years. World J Surg 2011; 35:1094-102. [PMID: 21360306 DOI: 10.1007/s00268-011-1009-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study presents our 14-year surgical experience with adult choledochal cyst disease (CCD), focusing on the clinical outcomes after surgical treatment. METHODS Medical records of 204 adult patients who had undergone surgery for CCD were reviewed retrospectively. RESULTS Median patient age was 40.2 years, and 157 (77%) of the patients were female. Todani classification was type I in 116 patients (56.9%), type II in 1 patient (0.5%), type IVa in 86 patients (42.2%), and type V in 1 patient (0.5%). Extrahepatic cyst excision and hepaticojejunostomy were performed in 185 patients (90.7%). Major perioperative complications occurred in 5 patients (2.5%), resulting in no mortality. Late complications occurred in 48 patients (23.6%). Concurrent cancer was diagnosed in 20 patients (9.8%). Mean age of patients with or without biliary cancer was 48.1±13.2 years and 39.1±11.8 years, respectively (P=0.001). Anomalous union of the pancreaticobiliary duct was more frequently associated with gallbladder cancer than with bile duct cancer. De novo malignancy at the cyst remnant occurred in 2 patients (1%). The survival outcomes in CCD patients with concurrent biliary cancer were comparable to those in cancer patients without CCD. CONCLUSIONS As a result of diverse features of adult CCD, various clinical problems occurred after surgical excision. Surgical treatment for adult patients with CCDs having complex features should be individualized to maintain a balance between risk of surgery and potential risk of late complications.
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Affiliation(s)
- Min-Jeong Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 138-736, Korea
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Liem NT, Pham HD, Vu HM. Is the Laparoscopic Operation as Safe as Open Operation for Choledochal Cyst in Children? J Laparoendosc Adv Surg Tech A 2011; 21:367-70. [DOI: 10.1089/lap.2010.0375] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Nguyen T. Liem
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Hien D. Pham
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Hoan M. Vu
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
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17
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Urushihara N, Fukuzawa H, Fukumoto K, Sugiyama A, Nagae H, Watanabe K, Mitsunaga M, Miyake H. Totally laparoscopic management of choledochal cyst: Roux-en-Y Jejunojejunostomy and wide hepaticojejunostomy with hilar ductoplasty. J Laparoendosc Adv Surg Tech A 2011; 21:361-6. [PMID: 21486149 DOI: 10.1089/lap.2010.0373] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cyst excision with hepaticojejunostomy is the treatment of choice for choledochal cyst. However, late complications after definitive surgery develop occasionally, including intrahepatic stones and cholangitis, because of bile stasis resulting from anastomotic stricture, intrahepatic bile duct stricture, and remnants of intrahepatic ductal dilatation. In type IV-A choledochal cysts in particular, biliary stricture is frequently observed around the hepatic hilum, and ductoplasty for stricture is necessary. In this article, we present our experiences with totally laparoscopic surgery comprising excision of the extrahepatic bile duct, Roux-en-Y jejunojejunostomy, and wide hepaticojejunostomy combined with hilar ductoplasty for choledochal cyst. METHODS We performed totally laparoscopic surgery on 8 children with choledochal cyst between June 2009 and October 2010. One of them had undergone bile drainage through gallbladder laparoscopically for biliary perforation. Four patients (1 Ic and 3 IV-A cysts) had hepatic duct stricture around the hepatic hilum. Laparoscopic surgery comprising excision of the extrahepatic bile duct and wide Roux-en-Y hepaticojejunostomy with ductoplasty was performed by using four trocars. RESULTS The operation was completed laparoscopically for all patients. The mean operation time was 390 minutes (range, 310-460). The mean postoperative stay was 8.4 days (range, 7-14). After surgery, the dilatation of the intrahepatic bile duct was remarkably reduced in size, and all patients are doing well. CONCLUSION Laparoscopic surgery comprising excision of the extrahepatic bile duct, Roux-en-Y limb formation, and wide hepaticojejunostomy with hilar ductoplasty appears to be feasible for children with choledochal cyst. When there is a stricture near the confluence of the hepatic ducts, laparoscopic ductoplasty appears to be feasible for the surgeon with an advanced laparoscopic skill set.
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Affiliation(s)
- Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan.
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18
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Liuming H, Hongwu Z, Gang L, Jun J, Wenying H, Wong KKY, Miao X, Qizhi Y, Jun Z, Shuli L, Li L. The effect of laparoscopic excision vs open excision in children with choledochal cyst: a midterm follow-up study. J Pediatr Surg 2011; 46:662-665. [PMID: 21496534 DOI: 10.1016/j.jpedsurg.2010.10.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Revised: 10/09/2010] [Accepted: 10/14/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Cyst excision with hepaticojejunostomy has been the classic procedure for treating choledochal cysts. Recently, laparoscopic treatment of the disease has gained popularity worldwide. The aim of this study is to evaluate whether laparoscopic management of choledochal cysts is as feasible and safe as conventional open surgery in children with this disease. METHODS A retrospective study comparing the laparoscopic and the open procedures was performed in 77 consecutive patients with choledochal cyst in our hospital. Thirty-nine patients operated on between June 2001 and September 2003 were in the laparoscopic group, whereas 38 patients in the open group were operated on between February 1999 and May 2001. RESULTS Patient demographics were similar between the 2 groups. The duration of operation was significantly longer in the laparoscopic group than in the open group (median, 230 vs 190 minutes; P < .001). In contrast, the durations of delayed oral feeding and hospital stay postoperatively were significantly shorter in the laparoscopic group (median, 4 vs 5 days [P < .01] and median, 5 vs 7 days [P < .01], respectively.) There were no differences in the early and late complication rates between the 2 groups. CONCLUSIONS Laparoscopic treatment of choledochal cyst in children is feasible and safe. For experienced centers, this procedure can be recommended.
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Affiliation(s)
- Huang Liuming
- Department of Pediatric Surgery, BaYi Children's Hospital, The military general hospital of Beijing, China
| | - Zhang Hongwu
- Department of Pediatric Surgery, the First Hospital, Peking University, Beijing, China
| | - Liu Gang
- Department of Pediatric Surgery, BaYi Children's Hospital, The military general hospital of Beijing, China
| | - Jia Jun
- Department of Pediatric Surgery, the First Hospital, Peking University, Beijing, China
| | - Hou Wenying
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing 100034, China
| | - Kenneth Kak Yuen Wong
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre; Hong Kong SAR, China
| | - Xiaoping Miao
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre; Hong Kong SAR, China
| | - Yu Qizhi
- Department of Pediatric Surgery, the First Hospital, Peking University, Beijing, China
| | - Zhang Jun
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing 100034, China
| | - Liu Shuli
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing 100034, China
| | - Long Li
- Department of Pediatric Surgery, the First Hospital, Peking University, Beijing, China.
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Gander JW, Cowles RA, Gross ER, Reichstein AR, Chin A, Zitsman JL, Middlesworth W, Rothenberg SS. Laparoscopic excision of choledochal cysts with total intracorporeal reconstruction. J Laparoendosc Adv Surg Tech A 2010; 20:877-81. [PMID: 20879872 DOI: 10.1089/lap.2010.0123] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE There are numerous published reports of laparoscopic resection of choledochal cysts (CDCs), but almost all involve extracorporeal reconstruction of a biliary drainage system. We describe and evaluate the technique of laparoscopic CDC resection with total intracorporeal reconstruction. METHODS We reviewed all patients who underwent a laparoscopic CDC resection from March 2005 to January 2010 at Rocky Mountain Children's Hospital and Children's Hospital of New York-Presbyterian. We obtained data on operative time, characteristics of reconstruction, time to initiation of diet, length of stay, complications, and outcome. RESULTS Thirteen patients (median age 5 years, range 1-16) underwent a laparoscopic CDC excision with total intracorporeal reconstruction. Four ports were used in all cases and no patients required conversion to an open procedure. Operative time ranged from 130 to 325 minutes (median 240 minutes). Median time to initiation of diet was 1 day (range 1-4 days). Median length of stay was 5 days (range 4-8 days). There were no cases of cholangitis; however, 1 patient developed a small bowel obstruction requiring re-operation. CONCLUSION Laparoscopic resection of CDCs with total intracorporeal reconstruction is a safe and effective technique. The minimal handling of the bowel appears to minimize postoperative ileus, allows for early postoperative feeding and discharge.
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Affiliation(s)
- Jeffrey W Gander
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, New York, USA
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20
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Tian Y, Wu SD, Zhu AD, Chen DX. Management of type I choledochal cyst in adult: totally laparoscopic resection and Roux-en-Y hepaticoenterostomy. J Gastrointest Surg 2010; 14:1381-8. [PMID: 20567928 DOI: 10.1007/s11605-010-1263-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 06/07/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND/OBJECTIVE Choledochal cysts are congenital dilations of the biliary tree. The accepted mode of treatment is total excision with hepaticojejunostomy. In this retrospective study, we present our technique and results of laparoscopic choledochal cyst excisions. METHODS We retrospectively studied 45 patients who had undergone laparoscopic choledochal cyst excision in our institutes from September 2006 to August 2009. Data including age, gender, type of cyst, symptoms, surgical technique, conversion rate, morbidity, and mortality were analyzed. RESULTS There were type Ic (cystic) choledochal cysts in 31 patients (68.9%) and type If (fusiform) in 14 patients (31.1%). An anomalous pancreaticobiliary duct junction union was found in 66.7%. Forty percent (18 out of 45) and 37.8% (17 out of 45) cases had stones within the cysts and gallbladders, respectively. The average size of the cysts was 40.3 +/- 16.9 cm(2). The mean operative time was 307.7 +/- 58.0 min, the estimated operative blood loss was 252.3 +/- 162.5 ml, and the conversion rate was 8.9%. The mean hospital stay was 8.3 +/- 3.2 days. The overall morbidity rate was 17.1%, the reoperation rate was zero, and the mortality rate was also zero. CONCLUSIONS Totally, laparoscopic management of type I choledochal cysts, although technically challenging, is safe and feasible in experienced hands.
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Affiliation(s)
- Yu Tian
- Biliary and Vascular Surgery Unit, Department of General Surgery, Shengjing Hospital, China Medical University, Shenyang, People's Republic of China
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21
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Tang ST, Yang Y, Wang Y, Mao YZ, Li SW, Tong QS, Cao GQ, Zhao ZX. Laparoscopic choledochal cyst excision, hepaticojejunostomy, and extracorporeal Roux-en-Y anastomosis: a technical skill and intermediate-term report in 62 cases. Surg Endosc 2010; 25:416-22. [DOI: 10.1007/s00464-010-1183-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 05/23/2010] [Indexed: 12/19/2022]
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22
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Nguyen Thanh L, Hien PD, Dung LA, Son TN. Laparoscopic repair for choledochal cyst: lessons learned from 190 cases. J Pediatr Surg 2010; 45:540-4. [PMID: 20223317 DOI: 10.1016/j.jpedsurg.2009.08.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 08/10/2009] [Accepted: 08/10/2009] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of this study is to report the technical details, early outcomes, and lessons learned from laparoscopic repair of 190 cases of choledochal cyst. METHOD The operation was performed using 4 ports. The cystic duct was identified and divided. The liver was elevated by 2 stay-sutures: one on the round ligament and the other on the distal cystic duct. The choledochal cyst was isolated and removed completely, and then biliary-digestive continuity was reestablished. RESULTS From January 2007 to April 2009, 190 patients were operated on. There were 144 girls and 46 boys. Ages ranged from 2 months to 16 years (mean, 46.9 +/- 29.3 months). Cyst diameter ranged from 10 to 184 mm. A total of 106 patients were classified as Todani type I cysts, and 84 were type IV. Cystic excision and hepaticoduodenostomy were performed in 133 patients and hepaticojejunostomy in 57 patients. The operating time varied from 70 to 505 minutes (mean, 186 minutes). Conversion to open surgery was required in 2 patients. Intraoperative blood transfusion was required in 4 patients. There were no perioperative deaths. Postoperative anastomotic leakage occurred in 7 patients, resolving spontaneously in 6 and requiring a second operation in 1. Postoperative hospital stay ranged from 5 to 27 days (mean, 7.2 +/- 3.3 days). Follow-up occurred between 1 and 24 months postdischarge (mean, 9 +/- 2.2 months) and was obtained in 161 patients (84.7%). Of these patients, cholangitis occurred in 4 patients (2.4%). CONCLUSION Laparoscopic repair is a safe and effective procedure for choledochal cyst.
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Affiliation(s)
- Liem Nguyen Thanh
- Department of Surgery, National Hospital of Pediatrics, Dong Da District, Hanoi, Vietnam.
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23
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Liem NT, Dung LA, Son TN. Laparoscopic complete cyst excision and hepaticoduodenostomy for choledochal cyst: early results in 74 cases. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S87-90. [PMID: 18999975 DOI: 10.1089/lap.2008.0169.supp] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To report the technical details and early outcomes of complete laparoscopic cyst excision and hepaticoduodenostomy for choledochal cyst. METHODS The operation was performed using four ports. The cystic duct was identified and divided. The liver was elevated by two stay sutures: one on the round ligament, and the other on the distal cystic duct. The choledochalcyst was isolated and removed completely and the duodenum was mobilized. Hepaticoduodenostomy was constructed 2 cm distal to the pylorus using two running sutures with 5-0 polydioxane sutures. RESULTS From January to December 2007, 74 patients were operated. There were 59 girls and 15 boys. Ages ranged from 2.5 months to 16 years old. The diameter of the cyst ranged from 10 mm to 184 mm. The operating time ranged from 90 minutes to 340 minutes (mean: 186 minutes). Conversion to open surgery was required in one patient. Blood transfusion was required in four patients. Postoperative anastomotic leakage occurred in three patients, resolving spontaneously in two patients and requiring a second operation in the third.Postoperative hospital stay ranged from 4 days to 21 days (average: 6.6 days). Follow-up from 3 months to 12 months was obtained in 56 patients (75.5%). Of these patients, cholangitis occurred in three patients (5.3%) and gastritis due to bilious reflux in eight patients (14.3%). CONCLUSION Laparoscopic complete cyst excision and hepaticoduodenostomy is a safe and physiologic procedure for choledochal cyst.
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Affiliation(s)
- Nguyen Thanh Liem
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam.
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Abstract
PURPOSE OF REVIEW Surgical treatment of bile duct cysts remains the mainstay to reduce cyst-related complications and risk of malignancy. Optimizing treatment outcomes is dependent upon a thorough preoperative evaluation and selecting the appropriate intervention. This review summarizes the recent progress in the evaluation and treatment of bile duct cysts, particularly in relation to contemporary operative approaches. RECENT FINDINGS Ongoing efforts continue in optimizing the evaluation, classification and management of bile duct cysts. The risk of cholangiocarcinoma is not limited to the bile duct cyst itself and appropriate management and surveillance is paramount. Recent advances in laparoscopic and endoscopic equipment have paralleled an increasing interest in minimally invasive approaches in the management of patients with bile duct cysts. Favorable results of laparoscopic approaches are increasingly reported and suggest the feasibility of this technique in select patients. SUMMARY Although the surgical premise of resection has not changed for the treatment of bile duct cysts, there has been an increasing utilization of minimally invasive approaches. Results thus far are promising, but long-term, controlled data is needed before this approach can be considered standard.
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Abstract
Choledochal cysts remain relatively uncommon in Western Europe and the US, although they are appreciably more common in Asia. Their aetiology remains obscure although abnormalities of the pancreaticobiliary junction may be the primary pathology in some, with biliary dilatation following reflux of activated pancreatic secretions. Most anomalies will present in childhood with obstructive jaundice or abdominal pain; a proportion may only present for the first time during adulthood, and some of these will show malignant transformation. The classical triad of pain, jaundice and a palpable mass is, however, not common. Complete cyst excision, where possible, and biliary reconstruction remain the aims for most types although there is still some controversy about the type of reconstruction. Laparoscopic reconstruction is possible but is still very much an advanced technique. The risk of long-term problems post-surgery is significant. Whether this is due to recurrent pancreatitis secondary to the retained common channel and/or a distal stump, or due to the development of biliary tract malignancy is still a cause for concern and indicates the need for adequate, prolonged follow-up.
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Affiliation(s)
- Natalie Dabbas
- Department of Paediatric Surgery, King's College Hospital, London, UK
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Shin SH, Han HS, Yoon YS, Chun KS, Cho JY, Jang JY, Kim SW, Park YH. Laparoscopically Assisted Extrahepatic Cyst Excision and Left Hemihepatectomy for a Type IV-A Choledochal Cyst. J Laparoendosc Adv Surg Tech A 2008; 18:831-5. [DOI: 10.1089/lap.2007.0127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Sang-Hyun Shin
- Department of Surgery, Seoul National University College of Medicine, Bundang Hospital, Seoul, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Bundang Hospital, Seoul, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University College of Medicine, Bundang Hospital, Seoul, Korea
| | - Kwang-Sik Chun
- Department of Surgery, Seoul National University College of Medicine, Bundang Hospital, Seoul, Korea
| | - Jai-Young Cho
- Department of Surgery, Seoul National University College of Medicine, Bundang Hospital, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Bundang Hospital, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University College of Medicine, Bundang Hospital, Seoul, Korea
| | - Yong-Hyun Park
- Department of Surgery, Seoul National University College of Medicine, Bundang Hospital, Seoul, Korea
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Liem NT, Dung LA, Son TN. Laparoscopic Complete Cyst Excision and Hepaticoduodenostomy for Choledochal Cyst: Early Results in 74 Cases. J Laparoendosc Adv Surg Tech A 2008. [DOI: 10.1089/lap.2008.0169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Laparoscopic management of choledochal cysts: technique and outcomes--a retrospective study of 35 patients from a tertiary center. J Am Coll Surg 2008; 207:839-46. [PMID: 19183529 DOI: 10.1016/j.jamcollsurg.2008.08.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 07/22/2008] [Accepted: 08/04/2008] [Indexed: 01/27/2023]
Abstract
BACKGROUND Choledochal cysts are congenital dilations of the biliary tree. The accepted mode of treatment is total excision with hepaticojejunostomy. In this retrospective study, we present our technique and results of laparoscopic choledochal cyst excision. STUDY DESIGN We retrospectively studied 35 patients who had undergone laparoscopic choledochal cyst excision in our institute from 1996 to 2008. Data about age, gender, type of choledochal cyst, symptoms, surgical technique, conversion rate, morbidity, and mortality were analyzed. RESULTS There were Type 1B choledochal cysts in 27 patients (77%) and Type IVA in 8 patients (23%). An anomalous pancreatobiliary junction was found in 40%. Mean operative time was 295 minutes. Total cyst excision could be done in 26 patients. The conversion rate in our series was 8.5%. The overall morbidity rate was 14.3%, the reoperation rate was 8.5%, the mortality rate was 0%, and the incidence of carcinoma was 8.5%. CONCLUSIONS To minimize the risk of malignancy, total excision of the cyst is ideal, but a small proximal cuff of cyst is retained for small-size ducts to aid in the hepaticojejunostomy anastomosis. A slit on one end of the small ducts will render the anastomosis in an oblique orientation, widening the lumen. Dissecting the posterior cyst wall from the underlying portal vein is the most crucial part of the procedure. Morbidity and mortality rates after laparoscopic management are comparable with published results of the open procedure. Laparoscopic surgery for choledochal cysts is feasible, safe, and even advantageous.
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