Choledochal cysts in infancy and childhood

External biliary drainage before choledochal cyst treatment in a very low birth weight infant

Choledochal cysts (CC) are congenital biliary tract dilatations. Infantile CC (IFCC) in very low birth weight (VLBW) infants is rare. This is a case of a huge IFCC presented in VLBW preterm infant managed with external biliary drainage prior to definitive treatment. Electrolyte imbalance, poor weight gain, and infections were managed during external biliary drainage maintenance. Choledochal cyst excision and Roux-en-Y hepaticoenterostomy were successfully performed when the infant weighed 4.9 kg 5 months later. Delayed definitive treatment with external biliary drainage could be a feasible alternative for managing CC in low-birth-weight infants.

Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy for biliary reconstruction after resection of congenital biliary dilatation: a systematic review and meta-analysis

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.

One- versus two-stage single-incision laparoscopic cyst excision and hepaticojejunostomy in patients with completely perforated choledochal cysts and good medical conditions

BACKGROUND

The aim of the current study was to evaluate the efficacy of one- and two-stage single-incision laparoscopic hepaticojejunostomy (SILH) for perforated CDCs with good medical conditions.

METHODS

Between June 2015 and December 2020, 57 patients were reviewed: Group 1: patients who underwent one-stage SILH (n = 16); Group 2: patients who underwent two-stage SILH (n = 41). The demographic characteristics, operational details, postoperative outcomes and postoperative complications were evaluated.

RESULTS

The mean follow-up durations of group 1 and 2 were 39.3 and 38.6 months, respectively. One patient (6.3%) in group 1, and 4 patients (9.8%) in group 2 were converted to laparotomy (p = 0.67). No statistical significance was found in operative time, blood transfusion, time to resume full diet, duration of drainage after definitive surgery and postoperative hospital stays between the two groups. Four patients in group 2 developed bile leakage, which was higher than that in group 1 (9.8% vs 0, p = 0.20). None suffered incidental injury, bleeding, anastomotic stenosis, cholangitis, cholelithiasis, pancreatic leakage, pancreatitis, Roux-loop obstruction, adhesive intestinal obstruction or wound infection. Liver function normalized within 1 year postoperatively in both groups.

CONCLUSIONS

In experienced hands, one-stage single-incision laparoscopic hepaticojejunostomy is safe and effective for patients with complete perforations and good medical conditions.

Our Experience with Cyst Excision and Hepaticoenterostomy for Choledocal Cyst: A Single Center Case Review of 16 Patients

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.

[Cyst of the broken common bile duct: literature review]

Les malformations kystiques des voies biliaires sont des affections congénitales rares évaluées à environ 1/2 000 000 naissances. C'est une affection qui peut se révéler gravement par une complication notamment l'angiocholite, la pancréatite chronique, cirrhose biliaire progressive, l'hypertension portale ou les lithiases biliaires. Sa perforation spontanée est l'une des rares complications, décrite pour la première fois en 1934 par Weber. Nous rapportant le cas d'un garçon de 18 mois admis pour syndrome sub-occlusif avec une péritonite biliaire. Une échographie a été réalisée montrant un épanchement abdominal avec formation kystique communicante des voies biliaires associée à un épanchement sous capsulaire du foie confirmé par scanner. L'intervention a consisté en une toilette péritonéale avec mise en place d'un drain de redon au niveau de la perforation et un drain sous hépatique sans excision du kyste. Le patient a été réadmis 6 mois après cet incident pour sa cure définitive.

Characteristics, management, and outcomes of congenital biliary dilatation in neonates and early infants: a 20-year, single-institution study

BACKGROUND

The aim of the present study was to investigate the characteristics, management, and outcomes of congenital biliary dilatation (CBD) in neonates and infants (<1 year old) in a single institution over the past 20 years.

METHODS

From 1997 to 2016, 21 patients <1 year old underwent definitive surgery for CBD. Open surgery (OS) was performed between 1997 and 2008, and laparoscopic surgery (LS) has been performed since 2009.

RESULTS

The bile duct showed cystic dilatation in all patients. Sixteen (76.2%) of the 21 patients were diagnosed prenatally, and the incidence increased with time (OS 63.6%, LS 90%). Fourteen patients (66.7%) were symptomatic before surgery, with jaundice in 11 (52.4%), acholic stool in seven (33.3%), and vomiting in three (14.3%). There were no significant differences in operation time and blood loss, but the postoperative fasting period and hospital stay were significantly shorter in the LS group (P < 0.05). There were no intraoperative complications, but there was one postoperative early complication in one LS group patient, who had bile leakage and was treated with redo hepaticojejunostomy.

CONCLUSION

The incidences of prenatally diagnosed and asymptomatic patients increased with time. Although longer follow-up is needed, LS for CBD could be safely performed even in neonates and early infants.

Spontaneous gallbladder perforation in a child secondary to a gallbladder cyst: a rare presentation and review of literature

Spontaneous gallbladder perforation is rare in children. The etiology of gallbladder perforation varies greatly and is often unknown. Identified causes include infection, congenital, stones or choledochal cysts. Presently there are only five reported cases of spontaneous gallbladder perforation in children in the English literature. As such, the optimal method of diagnosis and management remains controversial. We report the case of a 2-year-old girl who presented with peritonitis secondary to spontaneous gallbladder perforation.

Clinical value of ultrasound in diagnosing pediatric choledochal cyst perforation

OBJECTIVE. The objective of our study was to evaluate ultrasound images of pediatric patients with choledochal cyst perforation and establish imaging findings that can be used as the basis for timely surgical intervention. MATERIALS AND METHODS. Our study group was composed of 23 pediatric patients who presented with various symptoms of acute abdomen and were admitted to our institution between 1996 and 2013. All had undergone preoperative ultrasound examination and had a final diagnosis of choledochal cyst perforation that was confirmed at exploratory laparotomy. The imaging and surgical data were reviewed and analyzed retrospectively. RESULTS. The 23 patients included nine males and 14 females with a mean age of 2.55 years and mean disease duration of 12.48 days. The most common initial diagnoses were intestinal obstruction and peritonitis. Real-time ultrasound imaging with multislice views revealed characteristics of choledochal cyst perforation, including changes in the shape of the bile duct, loss of local gallbladder tension, thickened gallbladder wall, changes in the morphology of the gallbladder, and peritoneal effusion. The inability to visualize the gallbladder, gallbladder enlargement, the presence of gallbladder sludge and of pebblelike stones, and dilatation of the intrahepatic ducts were also noted on ultrasound. Choledochectasia was present in a majority of the patients (17/23), and ascites was seen in all 23 patients. The ultrasound signs corresponded to the surgical findings, thus showing the high clinical diagnostic value of ultrasound in this setting. CONCLUSION. Real-time ultrasound imaging-with its multislice views and good reproducibility-allows definitive preoperative diagnosis of pediatric choledochal cyst perforation.

Hepaticoduodenostomy versus hepaticojejunostomy after resection of choledochal cyst: a systematic review and meta-analysis

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.

Choledochal cysts in infants and children: experiences over a 20-year period at a single institution

This analysis was undertaken to compare the clinicopathological features of infants with choledochal cysts to those of older children with these entities and to evaluate the surgical outcomes for both subject groups. The medical records of all children admitted to the Cathay General Hospital with choledochal cysts over a 20-year period were retrospectively reviewed. Twenty-five subjects were included and divided into the infant (<1 year at presentation; 8 subjects) and classical pediatric (1-18 years at presentation; 17 subjects) groups. Anatomical subtypes were: IA (16), IC (6), and IVA (3). The median biliary amylase value was markedly elevated for the pediatric group but not for the infant group. Most (82.4%) patients in the pediatric group, but none in the infant group, presented with abdominal pain. Jaundice and clay-colored stool were present in all patients in the infant group but only 35% of those in the pediatric group. All patients underwent choledochocystectomy and Roux-en-Y hepaticojejunostomy with good outcomes. Neonates/infants with choledochal cysts present differently from older children with these entities. Amylase measurements may serve to distinguish biliary atresia with cystic dilatation from choledochal cyst in neonates/infants. Prognosis following radical cyst excision and reconstruction with Roux-en-Y hepaticojejunostomy is excellent.

Hydatid cyst of head of pancreas mimicking choledochal cyst

A 5-year-old girl presented with abdominal pain, intermittent jaundice and a gall bladder lump. Clinical examination and preoperative imaging suggested the diagnosis of a type I choledochal cyst (CDC). During surgery, this was found to be a hydatid cyst (HC) occupying the head of pancreas causing obstruction to the common bile duct (CBD). A pancreatic HC mimicking a CDC and presenting with CBD obstruction is unusual.

Hepaticoduodenostomy vs hepaticojejunostomy for reconstruction after resection of choledochal cyst

PURPOSE

Roux-en-Y hepaticojejunostomy (HJ) is currently the favored reconstructive procedure after resection of choledochal cysts. Hepaticoduodenostomy (HD) has been argued to be more physiologically and technically easier but is feared to have associated complications. Here we compare outcomes of the 2 procedures.

METHODS

A retrospective chart review identified 59 patients who underwent choledochal cyst resection within our institution from 1999 to 2009. Demographic and outcome data were compared using t tests, Mann-Whitney U tests, and Pearson χ(2) tests.

RESULTS

Fifty-nine patients underwent repair of choledochal cyst. Biliary continuity was restored by HD in 39 (66%) and by HJ in 20 (34%). Open HD patients required less total operative time than HJ patients (3.9 vs 5.1 hours, P = .013), tolerated a diet faster (4.8 days compared with 6.1 days, P = .08), and had a shorter hospital stay (7.05 days for HD vs 9.05 days for HJ, P = .12). Complications were more common in HJ (HD = 7.6%, HJ = 20%, P = .21). Three patients required reoperation after HJ, but only one patient required reoperation after HD for a stricture (HD = 2.5%, HJ = 20%, P = .037).

CONCLUSIONS

In this series, HD required less operative time, allowed faster recovery of bowel function, and produced fewer complications requiring reoperation.