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Yang D, Li L, Diao M, Xie X, Ming A, Gao R, Tian Y. Risk factors analysis for clinical symptoms of prenatally diagnosed choledochal cysts: a retrospective study. BMC Surg 2023; 23:217. [PMID: 37542233 PMCID: PMC10403877 DOI: 10.1186/s12893-023-02115-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/21/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND This study aimed to screen the impact factors for clinical symptoms of prenatally diagnosed choledochal cysts (CDCs), to warn about the occurrence of clinical symptoms and the timing of surgery. METHODS Medical records of patients with prenatally diagnosed CDCs admitted to our hospital from April 2013 to April 2018 were retrospectively reviewed. Fetal hilar or abdominal cysts were found by prenatal ultrasonogram. All patients underwent laparoscopic cyst excision and hepaticojejunostomy in our center. Univariate analysis and multivariate logistic regression analysis were performed to screen the factors related to clinical symptoms intimately. RESULTS Two hundred eighteen cases were included. One hundred thirty-four patients (134/218, 61.5%) presented clinical symptoms before surgery. The results of univariate analysis showed that patients with clinical symptoms had earlier time of prenatal diagnosis (P = 0.002), higher values of GGT, TBIL, DBIL (P < 0.001, P < 0.001, P < 0.001, respectively) and larger maximum diameter of cyst before surgery (P = 0.012). Multivariate logistic regression analysis suggested that the time of prenatal diagnosis (P = 0.001, OR = 0.898, 95% CI: 0.845 ~ 0.955) and the GGT value within one week of life (P = 0.028, OR = 1.002, 95% CI: 1.000 ~ 1.003) were independent influencing factors for symptoms. CONCLUSIONS For children with prenatally diagnosed CDCs, approximately 2/3 patients presented noticeable clinical symptoms before surgery. The time of prenatal diagnosis and the GGT value within 1 week of life were independent impact factors for the occurrence of clinical symptoms.
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Affiliation(s)
- Dan Yang
- Department of Pediatric Surgery, Children's Hospital Capital Institute of Pediatrics, Chinese Academy of Medical Sciences & Peking Union Medical College, Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences 2021RU015, 100020, Beijing, China
| | - Long Li
- Department of Pediatric Surgery, Children's Hospital Capital Institute of Pediatrics, Chinese Academy of Medical Sciences & Peking Union Medical College, Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences 2021RU015, 100020, Beijing, China.
- Department of Pediatric Surgery, Tsinghua University Affiliated Beijing Tsinghua Changgung Hospital, 102218, Beijing, China.
| | - Mei Diao
- Department of Pediatric Surgery, Children's Hospital Capital Institute of Pediatrics, Chinese Academy of Medical Sciences & Peking Union Medical College, Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences 2021RU015, 100020, Beijing, China
| | - Xianghui Xie
- Department of Pediatric Surgery, Children's Hospital Capital Institute of Pediatrics, Chinese Academy of Medical Sciences & Peking Union Medical College, Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences 2021RU015, 100020, Beijing, China
| | - Anxiao Ming
- Department of Pediatric Surgery, Children's Hospital Capital Institute of Pediatrics, Chinese Academy of Medical Sciences & Peking Union Medical College, Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences 2021RU015, 100020, Beijing, China
- Department of Pediatric Surgery, Tsinghua University Affiliated Beijing Tsinghua Changgung Hospital, 102218, Beijing, China
| | - Ruyue Gao
- Department of Pediatric Surgery, Children's Hospital Capital Institute of Pediatrics, Chinese Academy of Medical Sciences & Peking Union Medical College, Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences 2021RU015, 100020, Beijing, China
| | - Yu Tian
- Department of Pediatric Surgery, Children's Hospital Capital Institute of Pediatrics, Chinese Academy of Medical Sciences & Peking Union Medical College, Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences 2021RU015, 100020, Beijing, China
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2
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Zhang X, Jin J, Qiu T, Zhou J, Che G, Ji Y, Xu Z. The strategy of laparoscopic surgery for asymptomatic antenatally diagnosed choledochal cyst. BMC Surg 2023; 23:204. [PMID: 37464354 DOI: 10.1186/s12893-023-02095-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The aim was to investigate the characteristics, surgical management, and outcomes of asymptomatic patients with antenatally diagnosed choledochal cysts (ADCCs) and to justify the strategy of laparoscopic surgery (LS) for them in our hospital. METHODS We developed our LS strategy for asymptomatic ADCCs. Patients with asymptomatic ADCCs who underwent LS or open surgery (OS) during January 2010 and January 2020 were included. Patients with recorded symptomatic ADCCs were exclude. All data of group LS and group OS were statistically compared and analyzed. RESULTS Twenty-five patients received LS and 18 patients received OS were included. There was no significant difference in baseline characteristics between the groups. A total of 65.1% of biliary sludge formation was detected preoperatively by ultrasonography (US) (72.0% in group LS, 55.6% in group OS, P = 0.26). Compared to the OS group, the LS group had a longer operative time (313.4 ± 27.2 vs. 154.0 ± 11.9 min, P = 0.02), shorter postoperative fasting period (3.1 ± 1.2 vs. 6.2 ± 2.3 days, P = 0.03), and shorter postoperative hospital stay (5.1 ± 1.9 vs. 9.2 ± 1.1 days, P = 0.03). The incidence of late complications, such as reflux cholangitis, adhesive intestinal obstruction, and biliary enteric anastomotic stricture with stone formation, was not significantly different between the two groups. The liver function and liver stiffness of all patients in the two groups were normal. CONCLUSIONS Based on the strategy for asymptomatic ADCCs in our hospital, the perioperative safety and midterm follow-up results after LS were satisfactory and comparable to those after OS.
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Affiliation(s)
- Xuepeng Zhang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jianli Jin
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Tong Qiu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China
| | - Jiangyuan Zhou
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yi Ji
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China.
| | - Zhicheng Xu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, #37 Guo- Xue-Xiang, Chengdu, 610041, China.
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3
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Xie X, Li K, Xiang B. Total versus conventional robotic-assisted cyst excisions and hepaticojejunostomies in children with choledochal cysts: a case-control study. J Robot Surg 2023; 17:869-876. [PMID: 36324048 DOI: 10.1007/s11701-022-01484-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/16/2022] [Indexed: 05/25/2023]
Abstract
The current study's primary aim is to compare the safety and effectiveness between total and conventional robot-assisted cyst excisions and hepaticojejunostomies in children with choledochal cysts (CCs). Patients suffering from CCs treated with either total or conventional robot-assisted procedures (TRAS or CRAS) between December 2019 and February 2021 were analyzed retrospectively. Data collected included the characteristics, operative and postoperative details. The risk factors for conversion of TRAS to CRAS were analyzed by logistic regression analysis. There were 50 patients who underwent TRAS and CRAS, respectively, and 19 patients were transferred to CRAS. The operation time in the TRAS group was significantly higher than that of the CRAS group, while the time to taking water and hospital stay were significantly shorter (p < 0.05). No significant difference was observed in complications between the groups (p = 0.325). The risk factors for conversion of TRAS to CRAS were age ≥ 48 months, thickness of abdominal wall (TAW) ≥ 1.3 cm and upper abdominal length (UAL) ≥ 9.5 cm. Both TRAS and CRAS are safe and feasible. Performing TRAS is recommended for patients whose age ≥ 48 months, TAW ≥ 1.3 cm and UAL ≥ 9.5 cm, while for others, it is recommended to perform CRAS.
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Affiliation(s)
- Xiaolong Xie
- Department of Pediatric Surgery, West China Hospital, Sichuan University, No.37, Guoxue Alley, Chengdu, Sichuan Province, China
| | - Kewei Li
- Department of Pediatric Surgery, West China Hospital, Sichuan University, No.37, Guoxue Alley, Chengdu, Sichuan Province, China.
| | - Bo Xiang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, No.37, Guoxue Alley, Chengdu, Sichuan Province, China.
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4
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Surgical outcomes of robotic-assisted cyst excisions and hepaticojejunostomies in patients with perforated choledochal cysts: a single-center retrospective study. Updates Surg 2022; 75:571-580. [PMID: 36441481 DOI: 10.1007/s13304-022-01435-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
Perforated choledochal cysts is usually treated by open approach through a one- or two-stage procedure. Laparoscopic procedures are gradually being used more commonly with advancements in minimally invasive technology, while the level of difficulty and conversion rate are still high due to adhesions and deranged anatomy. Robot-assisted choledochal cyst excisions have been proposed as another minimally invasive procedure that is thought to improve operability and precision compared with laparoscopic surgery. However, there is still a lack about the use of robotic assistance for bilio-enteric reconstruction in pediatric patients with perforated choledochal cyst excisions. The aim of this current study was to investigate the safety and effectiveness of robotic-assisted procedures in pediatric perforated choledochal cyst excisions. Patients suffering from perforated choledochal cysts and treated with surgical procedures including open, laparoscopic, and robotic procedures between January 2009 and December 2021 were retrospectively analyzed. Robotic cyst excisions and hepaticojejunostomies were mainly used to a one-stage procedure (the pseudocyst formation or intra-mural perforation) or in stage 2 of two-stage procedures (complete perforation). Data collection included patient characteristics, intraoperative outcomes, and postoperative complications. There were a total of 64 patients suffering from perforated choledochal cysts were treated at our institution. Thirty-one cases of cyst excisions and hepaticojejunostomies were completed by open procedures. Twenty-two cases of cyst excisions and hepaticojejunostomies were completed by laparoscopic procedures and 11 cases were completed by robotic procedures. The operating times were significantly longer in the laparoscopic procedures group (214.32 ± 51.33 min) than found with either the open procedures group (130.55 ± 10.51 min) or the robot-assisted procedures group (188.82 ± 16.55 min) (p < 0.001). The time to oral intake, total complication, and hospital stay were similar among all three groups (3.53 ± 0.28 days vs 3.47 ± 0.30 days vs 3.46 ± 0.29 days, 19.35% vs 27.27% vs 18.18%, 11.48 ± 1.29 days vs 11.95 ± 2.75 days vs 11.55 ± 2.38 days, respectively) (p > 0.05). The number of biliary complications was higher in the laparoscopic procedures group (18.18%) than in both the open procedures and robot-assisted procedures groups (0.00%) (p = 0.016). Robotic-assisted cyst excision and hepaticojejunostomy procedures in patients with perforated choledochal cysts are both safe and feasible. What is more, they can achieve the same results as open procedures and also reduce the level of difficulty of operations and bring fewer biliary complications compared with laparoscopic procedures.
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5
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Li X, Su Y, Tian H, Lu T, Gong S, Miao C, Song S, Lei T, Tan Y, Xu Y, Huang X, Yang K, Guo T. Clinical efficacy and safety of robot assisted surgery for choledochal cysts excisions: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2022; 16:787-796. [PMID: 35939040 DOI: 10.1080/17474124.2022.2109464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND This study aimed to evaluate the safety and therapeutic effect of Robot-assisted surgery (RAS) for choledochal cysts (CCs) excisions. RESEARCH DESIGN AND METHODS PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, WanFang, VIP, and CBM were searched from database inception to 1 May 2022. The Newcastle-Ottawa scale (NOS) was used to conduct quality assessments, and RevMan (Version 5.4) was used to perform the meta-analysis. RESULTS In all, 9 studies, involving 623 patients, were analyzed. RAS compared with LAS was associated with less intraoperative blood loss, shorter time to start solid diets, shorter postoperative hospital stay, and lower complications. There was no significant difference in operative time between the two groups, but the total costs were higher in RAS. Our subgroup analysis showed that RAS had significant advantages over LAS in the child group: minor bleeding, shorter length of hospital stay, and fewer postoperative complications. CONCLUSIONS The available evidence indicates that the RAS system has the advantages of less intraoperative blood loss, minor tissue damage, quick recovery, and sound healing in treating choledochal cyst, which proves that the RAS is safely feasible. Especially in children, RAS tends to be a better choice.
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Affiliation(s)
- Xiong Li
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, Ningxia, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Institution of Clinical Research and Evidence-Based Medicine, The Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Yunan Su
- Department of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Hongwei Tian
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Department of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Tingting Lu
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Institution of Clinical Research and Evidence-Based Medicine, The Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Shiyi Gong
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, Ningxia, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Institution of Clinical Research and Evidence-Based Medicine, The Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Changfeng Miao
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Shaoming Song
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Institution of Clinical Research and Evidence-Based Medicine, The Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China.,Department of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Ting Lei
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China.,Department of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Yangyang Tan
- Department of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, Chengguan, China
| | - Yongcheng Xu
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Department of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, Chengguan, China
| | - Xianbin Huang
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Department of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Kehu Yang
- Institution of Clinical Research and Evidence-Based Medicine, The Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China.,Department of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China.,Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, China
| | - Tiankang Guo
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, Ningxia, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Department of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
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6
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Tainaka T, Shirota C, Sumida W, Yokota K, Makita S, Amano H, Okamoto M, Takimoto A, Kano Y, Yasui A, Nakagawa Y, Hinoki A, Uchida H. Laparoscopic definitive surgery for choledochal cyst is performed safely and effectively in infants. J Minim Access Surg 2022; 18:372-377. [PMID: 35708382 PMCID: PMC9306120 DOI: 10.4103/jmas.jmas_98_21] [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] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamune Okamoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aitaro Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoko Kano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiro Yasui
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Scalise PN, Yang A, Neumeyer C, Perez-Atayde AR, Robinson JR, Kim HB, Cuenca AG. Prenatal diagnosis of rapidly enlarging choledochal cyst with gastric outlet obstruction. J Surg Case Rep 2021; 2021:rjab547. [PMID: 34992767 PMCID: PMC8718373 DOI: 10.1093/jscr/rjab547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 11/21/2022] Open
Abstract
Choledochal cysts are congenital malformations of the biliary tract that involve aberrant configurations of the pancreaticobiliary ductal system. The pathology exists on a spectrum from fusiform dilation of the common bile duct to multiple dilations involving the intra- and extrahepatic bile ducts with potential risks of malignant transformation and hepatic fibrosis. Advancements in ultrasound technology have increased the incidence of prenatal diagnosis of choledochal cysts. Here, we present the case of a prenatally diagnosed initially asymptomatic Type I choledochal cyst with rapid progression in the neonatal period to a complete gastric outlet obstruction within the first month of life. We demonstrate the feasibility of cyst resection and reconstruction with Roux-en-Y hepaticojejunostomy in the neonatal age group. Finally, we discuss management of the case based on evolving imaging findings and laboratory evidence of impending liver dysfunction.
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Affiliation(s)
- P Nina Scalise
- Department of General Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Alex Yang
- Department of General Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Corinne Neumeyer
- Department of General Surgery, Boston Children’s Hospital, Boston, MA, USA
| | | | - Jamie R Robinson
- Department of General Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Heung Bae Kim
- Department of General Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Alex G Cuenca
- Department of General Surgery, Boston Children’s Hospital, Boston, MA, USA
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8
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Total robot-assisted choledochal cyst excision using da Vinci surgical system in pediatrics: Report of 10 cases. J Pediatr Surg 2021; 56:553-558. [PMID: 32829883 DOI: 10.1016/j.jpedsurg.2020.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/29/2020] [Accepted: 07/20/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND The robotic surgery has been proposed as another adjunct for pediatric minimal surgery for choledochal cyst. However, the Roux-en-Y jejunal limb in most reports on robot-assist choledochal cyst resection is usually created extracorporeally in children. The pediatric surgery team of West China Hospital of Sichuan University had completed 10 cases of total robot-assisted choledochal cyst resection. The aim of this current study was to present our initial experience in total robot-assisted surgery and discuss the technical points. METHODS Between January 2015 and February 2020, patients with choledochal cysts treated with total robot-assisted procedures were retrospectively analyzed. The data collected included demographic information of all patients, type and size of cyst, operative details and postoperative outcomes. RESULTS A total of 10 episodes of patients were enrolled in the study. The median age of the patient was 69.50 months with a mean weight of 20.50 kg. The most common symptoms were abdominal pain, vomiting, and jaundice (60%, 30%, and 30%, respectively). The types of cyst included 2 Ia, 7 Ic and 1 IV. The mean operation time was 218.70 min and there were no red blood cell transfusion and conversion in the 10 patients. The mean time to taking water was 3.37 days and mean time to starting liquid diet was 3.77 days. And the average length of postoperative hospital stay was 7.92 days. All 10 patients were eventually discharged and made uneventful recoveries after the operation. CONCLUSIONS Total robot-assisted choledochal cyst excision comprising Roux-en-Y limb formation, excision of the cyst and hepaticojejunostomy appears to be safe and feasible in pediatrics. Our initial experience shows that it is recommended to perform total robot-assisted choledochal cyst excision for patients over 4 years while a Roux-en-Y jejunojejunal anastomosis is recommended to be performed extracorporeally by prolapsing the jejunum out of abdominal cavity for patients under 4 years old. LEVEL OF EVIDENCE Treatment Study. TYPE OF STUDY Retrospective Study.
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9
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Xie X, Wu Y, Li K, Ai C, Wang Q, Wang C, Chen J, Xiang B. Preliminary Experiences With Robot-Assisted Choledochal Cyst Excision Using the Da Vinci Surgical System in Children Below the Age of One. Front Pediatr 2021; 9:741098. [PMID: 34631631 PMCID: PMC8496349 DOI: 10.3389/fped.2021.741098] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/16/2021] [Indexed: 02/05/2023] Open
Abstract
The purpose of this study is to introduce our preliminary experiences with using the da Vinci surgical system to treat choledochal cysts in children under 1 year old and discuss the application of this robot-assisted surgery. We retrospectively analyzed all available clinical data of children below the age of 1 who underwent surgery for choledochal cysts using the da Vinci robotic surgical system between January 2015 and December 2020. Data collection mainly included demographic information, imaging data, perioperative details, and postoperative outcomes. Ten patients were included in this study. The average patient age was 8.5 months, and the average weight was 9.11 kg. Half of these patients suffered from abdominal pain, while 30% exhibited vomiting and 10% jaundice. Eight of them were type Ia, and two were Ic. The average operation time among the patients was 219.5 min. None of the 10 patients had to receive a blood transfusion or conversion. The average time of the patients' subsequent fluid diet was 3.28 days, and the solid diet was 3.76 days. Meanwhile, the average length of hospital stay was 7.6 days. All 10 patients recovered and were eventually discharged. We believe that the da Vinci surgical system is a safe and feasible form of treatment for choledochal cysts in children <1 year old.
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Affiliation(s)
- Xiaolong Xie
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yang Wu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Kewei Li
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chengbo Ai
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qi Wang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chuan Wang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Chen
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Xiang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
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10
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Xie X, Feng L, Li K, Wang C, Xiang B. Learning curve of robot-assisted choledochal cyst excision in pediatrics: report of 60 cases. Surg Endosc 2020; 35:2690-2697. [PMID: 32556766 DOI: 10.1007/s00464-020-07695-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 06/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Little data are available to assess the learning curve for robot-assisted surgery on choledochal cysts. The aim of this current study is to investigate the characteristics of the learning curve for robot-assisted choledochal cyst excisions using the da Vinci (SI) surgical system in pediatrics. METHODS A retrospectively collected database comprising all medical records of the first 60 consecutive patients undergoing a robot-assisted choledochal cyst excision and Roux-en-Y hepaticojejunostomy using the da Vinci (SI) surgical system performed by one individual surgeon was studied. Baseline information and postoperative outcomes were collected and then learning curves were analyzed using the cumulative sum (CUSUM) method. Patients were divided into two groups including group A and group B according to the cutoff points of the learning curve. Intraoperative characteristics and short-term outcomes were compared between the two groups. RESULTS CUSUM plots revealed that the cutoff point of the learning curve was 14 cases. Comparison of the operative time between the two groups revealed that the total operative time (203.71 ± 15.27, 171.28 ± 3.62 min, P < 0.001), docking time (23.79 ± 5.81, 14.50 ± 0.98 min, P < 0.001), and console time (151.86 ± 9.77, 129.15 ± 2.96 min, P < 0.001) were decreased significantly. The intraoperative bleeding (20.36 ± 7.46 vs. 20.43 ± 9.18, P = 0.977), time to taking water (2.89 ± 0.22 vs. 3.04 ± 0.34, P = 0.115), time to starting solids diet (3.73 ± 0.17 vs. 3.79 ± 0.26, P = 0.387), hospital stay (7.51 ± 1.12 vs. 7.54 ± 0.95, P = 0.910), and the postoperative complications did not differ significantly between the two groups. CONCLUSIONS The learning curve for the robot-assisted choledochal cyst excision and Roux-en-Y hepaticojejunostomy in children is 14 cases. This learning curve can be used as the basis for performance guidance during training in future.
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Affiliation(s)
- Xiaolong Xie
- Department of Pediatric Surgery, West China hospital, Sichuan University, No.37, Guoxue Alley, Chengdu, Sichuan, China
| | - Liwei Feng
- Department of Pediatric Surgery, West China hospital, Sichuan University, No.37, Guoxue Alley, Chengdu, Sichuan, China
| | - Kewei Li
- Department of Pediatric Surgery, West China hospital, Sichuan University, No.37, Guoxue Alley, Chengdu, Sichuan, China
| | - Chuan Wang
- Department of Pediatric Surgery, West China hospital, Sichuan University, No.37, Guoxue Alley, Chengdu, Sichuan, China
| | - Bo Xiang
- Department of Pediatric Surgery, West China hospital, Sichuan University, No.37, Guoxue Alley, Chengdu, Sichuan, China.
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11
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Comparison of pediatric choledochal cyst excisions with open procedures, laparoscopic procedures and robot-assisted procedures: a retrospective study. Surg Endosc 2020; 34:3223-3231. [DOI: 10.1007/s00464-020-07560-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 04/10/2020] [Indexed: 02/07/2023]
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12
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Hukkinen M, Björnland K, Gatzinsky V, Iber T, Johansen LS, Qvist N, Stenström P, Svensson JF, Pakarinen MP. Management strategies and treatment results of pediatric choledochal malformations in the Nordic countries. HPB (Oxford) 2020; 22:161-168. [PMID: 31371244 DOI: 10.1016/j.hpb.2019.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/28/2019] [Accepted: 07/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Incidence and long-term outcomes of choledochal malformations (CMs) in children remain unclear. METHODS Clinical characteristics, operative details, complications, and follow-up data were collected from eight pediatric surgical centers in Sweden, Norway, Denmark, and Finland, which also answered a questionnaire addressing management practices. RESULTS During 2000-2017, 126 pediatric CMs were diagnosed, corresponding an incidence of 1:37,400. Diagnostic, treatment, and follow-up practices varied markedly. Of patients with complete clinical data (n = 119), 85% and 11% had type I and IV CMs and were managed by open hepaticojejunostomy at median age of 2.5 (interquartile range 0.46-5.8) years. Associated malformations were more common in fusiform and type IV (23%) than cystic CMs (8%, p = 0.043). Pancreaticobiliary maljunction was more frequently confirmed in patients presenting with pancreatitis (26% vs. 7%, p = 0.005) and with fusiform CMs (56% vs. 25%, p = 0.001). Cholangitis/pancreatitis episodes, occurring in 12% during postoperative follow-up of 4.0 (2.0-7.9) years, associated with longer surveillance (OR 1.32, 95% CI 1.13-1.54, p < 0.001). However, only two thirds of centers continued follow-up until adulthood. No malignancies were reported. CONCLUSIONS CM incidence was higher than traditionally reported among Western populations. Although open hepaticojejunostomy carries good short-term outcomes, long-term morbidity is noteworthy. Standardized evidence-based management strategies and long-term follow-up are encouraged.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group and Section of Pediatric Surgery, Helsinki University Children's Hospital, Helsinki, Finland
| | - Kristin Björnland
- Section of Pediatric Surgery, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Vladimir Gatzinsky
- Section of Pediatric Surgery, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Tarja Iber
- Section of Pediatric Surgery, Tampere University Hospital, Tampere, Finland
| | | | - Niels Qvist
- Surgical Department A, Odense University Hospital, Odense, Denmark
| | - Pernilla Stenström
- Section of Pediatric Surgery, Skåne University Hospital, Lund University
| | - Jan F Svensson
- Section of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Mikko P Pakarinen
- Pediatric Liver and Gut Research Group and Section of Pediatric Surgery, Helsinki University Children's Hospital, Helsinki, Finland.
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13
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Kamisawa T, Kaneko K, Itoi T, Ando H. Pancreaticobiliary maljunction and congenital biliary dilatation. Lancet Gastroenterol Hepatol 2018; 2:610-618. [PMID: 28691687 DOI: 10.1016/s2468-1253(17)30002-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/27/2016] [Accepted: 01/03/2017] [Indexed: 02/07/2023]
Abstract
Pancreaticobiliary maljunction is a congenital malformation in which the pancreatic and bile ducts join outside the duodenal wall, usually forming a long common channel. Because the action of the sphincter of Oddi does not regulate the function of the pancreaticobiliary junction in patients with pancreaticobiliary maljunction, two-way regurgitation occurs. Reflux of pancreatic juice into the biliary tract is associated with a high incidence of biliary cancer. Biliary carcinogenesis in patients with pancreaticobiliary maljunction is thought to follow the hyperplasia, dysplasia, then carcinoma sequence due to chronic inflammation caused by pancreatobiliary reflux. Pancreaticobiliary maljunction is diagnosed when an abnormally long common channel is evident on imaging studies. Congenital biliary dilatation involves both local dilatation of the extrahepatic bile duct, including the common bile duct, and pancreaticobiliary maljunction. Extrahepatic bile duct resection is the standard surgery for congenital biliary dilatation. However, complete excision of the intrapancreatic bile duct and removal of stenoses of the hepatic ducts are necessary to prevent serious complications after surgery.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan.
| | - Kenitiro Kaneko
- Division of Pediatric Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Hisami Ando
- Department of Pediatric Surgery, Aichi Prefectural Colony, Kasugai, Japan
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14
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Wang XQ, Xu SJ, Wang Z, Xiao YH, Xu J, Wang ZD, Chen DX. Robotic-assisted surgery for pediatric choledochal cyst: Case report and literature review. World J Clin Cases 2018; 6:143-149. [PMID: 30079341 PMCID: PMC6068812 DOI: 10.12998/wjcc.v6.i7.143] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/23/2018] [Accepted: 04/22/2018] [Indexed: 02/05/2023] Open
Abstract
Our paper describes the key surgical points of pediatric choledochocystectomy performed completely by Da Vinci robotic system. A choledochocystectomy was safely carried out for a girl at our hospital, and without any complication. Then systematic literature review was done to discuss the methods of intestine surgery and intestinal anastomosis, the use of 3rd robotic arm, the surgical safety and advantages comparing open and laparoscopic surgery. We systematically reviewed choledochocystectomy for children performed by robotic surgery. We included a total of eight domestic and foreign reports and included a total of 86 patients, whose average age was 6.3 (0.3-15.9) years; the male-to-female ratio was 1:3.5 (19:67). Seven patients experienced conversion to open surgery, and the surgery success rate was 91.9% (79/86). The average total operation time was 426 (180-520) min, the operation time on the machine was 302 (120-418) min, 11 cases used the number 3 arm, and the remaining mainly used the hitch-stitch technique to suspend the stomach wall and liver. Forty-seven patients underwent pull-through intestine and intestinal anastomosis, and 39 patients underwent complete robotic intestine surgery and intestinal anastomosis. The hospitalization time of robotic-assisted choledochocystectomy was 8.8 d. Eight patients had biliary fistula and were all cured by conservative treatment and continuous observation. One patient had anastomotic stenosis, and one patient had wound dehiscence, both cured by surgery. Choledochocystectomy for children performed by completely robotic surgery and Roux-en-Y hepaticojejunostomy is safe and feasible. The initial experience shows that this surgical approach has a clearer field than the traditional endoscopy, and its operation is more flexible, the surgery is more accurate, and the injury is smaller. With the advancement of technology and the accumulation of surgeons’ experience, robotic surgery may become a new trend in this surgical procedure.
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Affiliation(s)
- Xian-Qiang Wang
- Department of Pediatrics, PLA General Hospital, Beijing 100853, China
| | - Shu-Juan Xu
- Center of Anesthesia and Operation, PLA General Hospital, Beijing 100853, China
| | - Zheng Wang
- Department of Pediatrics, PLA General Hospital, Beijing 100853, China
| | - Yuan-Hong Xiao
- Department of Pediatrics, PLA General Hospital, Beijing 100853, China
| | - Jing Xu
- Center of Anesthesia and Operation, PLA General Hospital, Beijing 100853, China
| | - Zhen-Dong Wang
- Department of Pediatrics, PLA General Hospital, Beijing 100853, China
| | - Di-Xiang Chen
- Department of Pediatrics, PLA General Hospital, Beijing 100853, China
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15
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Mori H, Iida H, Maehira H, Kitamura N, Shimizu T, Tani M. Synchronous primary gallbladder and pancreatic cancer associated with congenital biliary dilatation and pancreaticobiliary maljunction. Surg Case Rep 2017; 3:113. [PMID: 29098452 PMCID: PMC5668217 DOI: 10.1186/s40792-017-0388-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/27/2017] [Indexed: 02/07/2023] Open
Abstract
Introduction Synchronous double cancer of the gallbladder and pancreas that is associated with congenital biliary dilatation (CBD) and pancreaticobiliary maljunction (PBM) is extremely rare. PBM is frequently reported in Asia, particularly in Japan. We report a surgical case of synchronous double cancer in a patient with primary gallbladder and pancreatic cancer. Presentation of case A 72-year-old woman with epigastralgia underwent subtotal stomach-preserving pancreaticoduodenectomy and gallbladder bed resection for synchronous primary gallbladder and pancreatic head cancer. Histopathological examination revealed moderately differentiated ductal adenocarcinoma of the pancreatic head and well-differentiated tubular adenocarcinoma at the bottom of the gallbladder. Conclusion Synchronous gallbladder and pancreatic cancer is extremely rare. It is necessary to determine the optimal surgical course taking into consideration the degree of tumor progression. This is the second case of synchronous primary gallbladder and pancreatic cancer associated with CBD accompanied by PBM.
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Affiliation(s)
- Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-chou, Ootsu, Shiga, 520-2192, Japan.
| | - Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-chou, Ootsu, Shiga, 520-2192, Japan
| | - Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-chou, Ootsu, Shiga, 520-2192, Japan
| | - Naomi Kitamura
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-chou, Ootsu, Shiga, 520-2192, Japan
| | - Tomoharu Shimizu
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-chou, Ootsu, Shiga, 520-2192, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-chou, Ootsu, Shiga, 520-2192, Japan
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16
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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: 76] [Impact Index Per Article: 10.9] [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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Sica M, Molinaro F, Angotti R, Bindi E, Brandigi E, Messina M. Choledochal cyst: Early experience by laparoscopic approach. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2016.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Frank SJ, Kurian J. Three-Dimensional Sonography of Biliary Tract Disorders. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:791-804. [PMID: 26931791 DOI: 10.7863/ultra.15.04044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 07/10/2015] [Indexed: 06/05/2023]
Abstract
In this pictorial essay, we review the 3-dimensional sonographic appearance of the normal gallbladder and biliary tree, as well as the appearance of congenital and acquired biliary tract disorders. Using examples, we demonstrate the advantage of 3-dimensional scanning compared with 2-dimensional sonography and, even in certain cases, magnetic resonance cholangiopancreatography.
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Affiliation(s)
- Susan J Frank
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York USA
| | - Jessica Kurian
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York USA
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19
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Ford KE, Cooper LRL, Davenport M. Growth in children with choledochal malformations: effect of the Roux loop. Pediatr Surg Int 2015; 31:1015-9. [PMID: 26266756 DOI: 10.1007/s00383-015-3759-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 01/16/2023]
Abstract
PURPOSE Excision and biliary reconstruction using a Roux loop is the current standard for choledochal malformation (CM). This is un-physiological, delivering bile beyond the duodenum and excluding a significant length of the jejunum from intestinal absorption. We investigated whether this had an effect on post-operative growth. METHODS Retrospective case-note analysis of children surgically treated for CM. Growth variables were converted to standard deviation scores (SDS) and compared against population norms. P < 0.05 was significant. RESULTS From 1994 to 2014, 135 children (<16 years) were identified. Median age at surgery was 3.3 (IQR 1.5-7) years. Morphology included: type 1 Cystic (n = 54, 40%), type 1 Fusiform (n = 58, 43%) and type 4 (intra and extra-hepatic) (n = 22, 16%). There was pre-operative growth failure [median weight SDS = -0.4 (-1.2 - 0.4), P = 0.0004] with a similar trend for height [SDS = -0.38 (-1.2 - 0.5), P = 0.08)]. This correlated with presentation bilirubin (r s = -0.24, P = 0.004), GGT (r s = -0.27, P = 0.002) and AST (r s = -0.27, P = 0.002) but not morphology (P = 0.82) or presentation (P = 0.4). Median follow-up was 1.9 (0.6-4.7) years, during which time both height (P = 0.73) and weight (P = 0.45) reverted to normal. CONCLUSION This is the first report of growth in children with CM following a Roux-loop reconstruction and showed pre-operative growth failure probably attributed to a period of biliary obstruction but catch-up growth when corrected.
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Affiliation(s)
- Kathryn E Ford
- Department of Paediatric Surgery, King's College Hospital, London, SE5 9RS, UK
| | | | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, SE5 9RS, UK.
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Xia HT, Dong JH, Yang T, Liang B, Zeng JP. Selection of the surgical approach for reoperation of adult choledochal cysts. J Gastrointest Surg 2015; 19:290-7. [PMID: 25373703 DOI: 10.1007/s11605-014-2684-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 10/15/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND/PURPOSE Our purpose was to evaluate the reasons for reoperations and outcomes in patients with choledochal cysts (CCs). METHODS The records of patients with CCs who underwent reoperations from 1995 to 2012 were retrospectively reviewed. RESULTS Of 165 patients with a mean age of 42.54 ± 14.05 years, 62 had Todani type I (37.6 %), 84 type IV-A (50.9 %), and 19 had unknown type CCs (11.5 %). Previous surgery was internal or external drainage alone in 66.1 % of patients with type I and 23.8 % of patients with type IV-A CCs. Partial cyst excision and Roux-en-Y cyst-jejunostomy or cyst excision and choledochoplasty by jejunal interposition were performed in 16.1 and 11.3 % of patients with type I and IV-A CCs, respectively. Reoperations at our hospital were maximal cyst excision and Roux-en-Y hepaticojejunostomy. Radical cyst excision was achieved in 93.5 % of patients with type I and 44.0 % of patients with type IV-A CCs. With an average follow-up of 48.23 ± 12.30 months, recurrent cholangitis and biliary-enteric anastomotic stenosis occurred in 18 (13.2 %) and 9 patients (6.6 %), respectively. Long-term biliary function was excellent or good in 83.8 % of patients. CONCLUSIONS Radical cyst excision and Roux-en-Y hepaticojejunostomy provide good outcomes in patients with CCs.
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Affiliation(s)
- Hong-Tian Xia
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Chinese PLA Medical School, 100853, Beijing, China,
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21
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Sugandhi N, Agarwala S, Bhatnagar V, Singh MK, Sharma R. Liver histology in choledochal cyst- pathological changes and response to surgery: the overlooked aspect? Pediatr Surg Int 2014; 30:205-11. [PMID: 24370791 DOI: 10.1007/s00383-013-3453-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Histological changes in the liver in cases of choledochal cyst are seldom reported. The severity of liver pathology has an impact on the presentation, course and prognosis of hepatobiliary lesions. This study aims to record the histological changes in the liver and response to surgery in patients with choledochal cyst and to correlate these with the clinical symptoms and recovery. MATERIALS AND METHODS All children <12 years diagnosed with choledochal cyst were evaluated clinically, radiologically and biochemically at presentation. Excision of the cyst with intra-operative liver biopsy was done. Liver biopsy was repeated after 6 months of surgery. Both the liver biopsies were compared objectively in terms of hepatocellular damage, cholestasis, parenchymal inflammation, bile duct inflammation, bile duct proliferation, portal fibrosis and central venous distension with appropriate statistical tests. Clinical presentation and recovery were correlated with grades of liver pathology. RESULTS Forty-six patients were included. Pathological damage was observed in all the livers preoperatively. Post-operatively, significant resolution of histological changes was seen in hepatocellular damage (p < 0.0001), parenchymal inflammation (p = 0.0001), cholestasis (p = 0.0003) and bile duct proliferation (p = 0.0001). Portal fibrosis did not resolve. Central venous distension worsened. Severity of damage correlated significantly with younger age, symptom severity, anomalous pancreatico-biliary junction (APBJ) and obstructive biliary clearance on Tc-99 HIDA scan. Post-operative bile duct proliferation, bile duct inflammation and portal fibrosis were associated with cholangitis, re-do surgery and obstructive Tc-99 HIDA scan clearance in the post-operative period. CONCLUSIONS All patients with choledochal cyst show pathological changes in liver of varying severity. More severe symptoms, younger age and APBJ are associated with higher degree of liver damage. Except portal fibrosis and central venous distension, all other pathological changes regress after surgery. Regression can be hindered by post-op cholangitis, obstructive biliary clearance and post-op IHBR dilatation.
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Affiliation(s)
- N Sugandhi
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India,
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22
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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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Abstract
BACKGROUND Choledochal cysts are congenital cystic dilatations of the extrahepatic or intrahepatic portion of the biliary tree. Complete excision of choledochal cysts is currently regarded as the gold standard treatment, while less extensive procedures including cystoduodenostomy have become obsolete due to the potential for malignant change in the remnant cyst. For type-1 choledochal cysts, which sometimes extend to the main pancreatic duct closely, some surgeons may adopt a less aggressive approach in order to avoid damage to the main pancreatic duct as such damage can lead to serious consequences. However, incomplete excision of choledochal cysts may also cause problems. METHOD Here we report on a reoperation treating incomplete excision of a choledochal cyst with focus on the technical aspect. RESULTS In the reoperation, meticulous dissection of the liver hilum which had been previously operated on was performed. The hepaticojejunostomy was left intact. With the assistance of intraoperative cholangiography, the residual pancreatic portion of the choledochal cyst was completely excised. The pancreatic opening and the lower end of the common bile duct were reconstructed. Whipple operation was avoided. CONCLUSION Careful planning with the aid of precise imaging before and during the operation largely enhanced the accuracy of the excision of the choledochal cyst.
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Yasufuku M, Hisamatsu C, Nozaki N, Nishijima E. A very low-birth-weight infant with spontaneous perforation of a choledochal cyst and adjacent pseudocyst formation. J Pediatr Surg 2012; 47:E17-9. [PMID: 22813825 DOI: 10.1016/j.jpedsurg.2012.03.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 03/06/2012] [Accepted: 03/14/2012] [Indexed: 11/16/2022]
Abstract
Spontaneous perforation of a choledochal cyst with ensuing pseudocyst formation is a very rare complication. We report the development of a pseudocyst adjacent to a choledochal cyst in a very low-birth-weight infant at 2 months of age. Elective excision of the choledochal cyst and biliary tract reconstruction were successfully performed 2 months later when the infant weighed 3 kg. Delayed primary repair may be a viable alternative treatment for low-birth-weight infants with choledochal cysts.
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Affiliation(s)
- Masao Yasufuku
- Department of Pediatric Surgery, Kakogawa West City Hospital, 384-1 Hiratsu, Yoneda-cho, Kakogawa-shi, Hyogo, 675-8611, Japan.
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25
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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: 117] [Impact Index Per Article: 9.8] [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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Diao M, Li L, Cheng W. Timing of surgery for prenatally diagnosed asymptomatic choledochal cysts: a prospective randomized study. J Pediatr Surg 2012; 47:506-12. [PMID: 22424346 DOI: 10.1016/j.jpedsurg.2011.09.056] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 09/18/2011] [Accepted: 09/21/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND/PURPOSE Choledochal cysts (CDCs) are increasingly being diagnosed antenatally. The timing of surgery in this group of patients is unclear. We undertook a prospective randomized trial to establish the optimal timing of surgery for prenatally diagnosed asymptomatic CDCs. METHODS Between 2003 and 2011, 68 fetuses with ultrasound-detected subhepatic cysts (ie, potential CDC) were randomized into 2 groups: (1) early (≤1 month) operation group (n = 34) and (2) late (>1 month) operation group (LO; n = 34). Operative time, postoperative hospital stay, drainage duration, postoperative complications, and perioperative ultrasonographic and laboratory results were analyzed. RESULTS During the first month of life, 32 infants became symptomatic (eg, became jaundiced) and were excluded from the trial. This left 36 neonates who were asymptomatic (early operation, n = 16; LO, n = 20) and constituted the study group. It is noteworthy that a further 9 infants in the LO group then became symptomatic after 1 month of age. Grades III and IV hepatic fibroses were significantly more common in the LO group and in patients who were diagnosed during early pregnancy. Interestingly, liver functions in patients diagnosed at early fetal stage were only moderately deranged. Median follow-up period was 36 months. Neither mortality nor complications of bile leak or anastomotic stricture were encountered. However, complete liver function normalization was significantly delayed in the LO group and in patients with high-grade hepatic fibrosis. CONCLUSION Prenatally diagnosed CDC is a distinct group with a tendency of developing liver fibrosis immediately after birth. Early surgical intervention is warranted in the neonatal period.
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Affiliation(s)
- Mei Diao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing 100020, PR China
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Tongprasert F, Traisrisilp K, Tongsong T. Prenatal diagnosis of choledochal cyst: a case report. JOURNAL OF CLINICAL ULTRASOUND : JCU 2012; 40:48-50. [PMID: 21688273 DOI: 10.1002/jcu.20856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 05/02/2011] [Indexed: 05/30/2023]
Abstract
Choledochal cyst is one of the intra-abdominal abnormalities of the biliary ducts that present as a cystic mass in the right upper quadrant abdomen. Prenatal diagnosis has been achieved by the demonstration of a connection between a dilated common bile duct and a cystic lesion. In this report, we describe a pregnant woman in whom routine fetal anomaly scan strongly suggested a choledochal cyst at 29 weeks of gestation by demonstrating a round cystic mass in the right upper quadrant of the abdomen, completely separated from the stomach, bowel loops, and gall bladder, and which showed a connection with the dilated common bile duct.
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Affiliation(s)
- Fuanglada Tongprasert
- Department of Obstetrics and Gynecology, Faculty of Medicine Chiang Mai University, Thailand
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Shah OJ, Shera AH, Zargar SA, Shah P, Robbani I, Dhar S, Khan AB. Choledochal cysts in children and adults with contrasting profiles: 11-year experience at a tertiary care center in Kashmir. World J Surg 2010; 33:2403-11. [PMID: 19701664 DOI: 10.1007/s00268-009-0184-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Choledochal cyst is a surgical problem usually related to infancy and childhood. Despite advancements in management, a large number of cases still present during adulthood. The clinical course and outcome in children varies from that in adults. This study focuses on these variations in terms of presentation, management, histopathology, and outcome. METHODS An in-depth retrospective analysis was carried out on 79 patients presenting with choledochal cysts between December 2007 and January 1997. The patients were segregated into two groups: group A comprising 32 children and group B with 47 adults. The presentation, clinical evaluation, radiologic, and biochemical findings; operative details; pathologic findings; and early and long-term complications in the two groups were studied on a comparative basis. RESULTS The male/female ratios were 1:3 and 1.0:2.3 in groups A and B, respectively. A history of previous biliary surgery, pancreatitis, cholangitis, peroperative difficulties, and early and late postoperative complications were 5.1, 5.4, 6.4, 5.4, 2.0, and 3.3 times more common in group B than in group A. However, the classic triad of jaundice, abdominal pain, and a mass was 6.7 times more common in group A than in group B. The classic triad and cholangitis were the only parameters that were statistically significant. Rare presentations of spontaneous perforation of the cyst or cachexia manifested only in group A patients. The methods of detection and operative treatment were identical for both groups. Histologically, fibrosis of the cyst wall was a feature peculiar to group A, whereas signs of inflammation and hyperplasia were predominantly seen in group B. In the group B series, one patient had cholangiocarcinoma and another gallbladder carcinoma; one more patient developed malignancy during follow-up. Long-term complications were seen in 29.7% of patients in group B versus 9.3% in group A; the most rampant complication was a type IVa cyst, seen in 68.7% of patients. CONCLUSIONS Choledochal cysts present differently in adults and children; whereas children present with the classic triad, adults present with common biliary or infective complications. Although the methods of detection and surgical treatment are similar for the two groups, the type IVa cyst typically seen in the adult group creates a marked deviation with respect to long-term complications such as ascending cholangitis, anastomotic strictures, stone formation, and development of cholangiocarcinoma. These are areas of grave concern that can be addressed to a large extent by providing an access loop during the initial surgery especially for type IVa cysts. The glaring differences in terms of presentation, histologic picture, and outcome urges us to consider choledochal cysts in children as a separate entity.
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Affiliation(s)
- Omar J Shah
- Department of Surgical Gastroenterology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India.
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She WH, Chung HY, Lan LCL, Wong KKY, Saing H, Tam PKH. Management of choledochal cyst: 30 years of experience and results in a single center. J Pediatr Surg 2009; 44:2307-11. [PMID: 20006015 DOI: 10.1016/j.jpedsurg.2009.07.071] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Accepted: 07/31/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Choledochal cyst is usually diagnosed in childhood. Early treatment can prevent further complication. We report on our series of patients over the past 30 years. METHODS A retrospective study was performed on all pediatric patients who presented with choledochal cyst from January 1978 to December 2008. The main outcome measures recorded were the clinical presentation, management, and long-term outcome of the patients. RESULTS Eighty-three patients presented to us during the caption period with a mean age at diagnosis of 45 months (0 month to 16 years). Diagnoses were made antenatally in 15 patients. The most common symptoms were abdominal pain (n = 39) and jaundice (n = 35). Seventy-five patients had surgery, in which 72 patients had resection of the cyst and Roux-en-Y hepaticojejunostomy. Ten were performed by laparoscopic means. We categorized the cysts based on the Todani classification. There was no mortality. No malignant change was documented. For those 4 who had Caroli disease, 2 underwent liver transplantation and 2 had hepatectomy. Overall early complication rate was 5.3% (4/75). CONCLUSIONS Complete excision of cyst with Roux-en-Y hepaticojejunostomy is the treatment of choice, and the late result is good. Laparoscopic surgery is feasible. Long-term follow-up is necessary. There is no evidence to suggest that some type IV cysts are the result of disease progression from type I cysts.
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Affiliation(s)
- Wong-Hoi She
- Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
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30
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Ruiz-Elizalde AR, Cowles RA. A practical algorithm for accurate diagnosis and treatment of perinatally identified biliary ductal dilation: three cases that underscore the importance of an individualised approach. J Matern Fetal Neonatal Med 2009; 22:622-8. [DOI: 10.1080/14767050902755486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Foo DCC, Wong KKY, Lan LCL, Tam PKH. Impact of prenatal diagnosis on choledochal cysts and the benefits of early excision. J Paediatr Child Health 2009; 45:28-30. [PMID: 19208062 DOI: 10.1111/j.1440-1754.2008.01424.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIM To evaluate the clinical outcomes of patients with prenatally diagnosed choledochal cysts compared with those diagnosed after birth and the optimal timing of definitive treatment. METHODS Retrospective review of all patients who underwent primary choledochal cyst excision and Roux-en-Y hepaticojejunostomy from 1996 to 2006 at a single institution. RESULTS A total of 45 patients were included. Ten (22.2%) of the patients had prior prenatal diagnosis. The mean age at operation for this group was 4.4 months and mean follow up was 55.9 months. There was no operative complication or late morbidity. For the post-natal diagnosis group, the mean age at operation was 5.7 years (P < 0.000) and mean follow up period was 69 months. The most common presentation in this group was abdominal pain (31.4%), followed by pancreatitis (28.6%) and symptoms of cholestasis (25.7%). Early post-operative morbidities occurred in two (5.7%) patients. On long-term follow up, two (5.7%) further patients in the post-natal group developed complications. CONCLUSION Prenatal diagnosis of choledochal cysts results in earlier definitive surgery. More adverse complications were seen in those who had surgery at an older age. We therefore recommend early excision of choledochal cysts.
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Affiliation(s)
- Dominic C C Foo
- Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
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Lee HC, Yeung CY, Fang SB, Jiang CB, Sheu JC, Wang NL. Biliary cysts in children--long-term follow-up in Taiwan. J Formos Med Assoc 2006; 105:118-24. [PMID: 16477331 DOI: 10.1016/s0929-6646(09)60332-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND This study analyzed the clinical presentation, postoperative morbidity and mortality and incidence of associated extrahepatic biliary atresia in children with biliary cysts in Taiwan. METHODS We retrospectively reviewed the records of 158 pediatric patients with biliary cysts seen between June 1981 and July 2004, with follow-up ranging from 12 months to 22 years (mean, 11.2 +/- 6.1 years). Patients were divided into three groups: biliary atresia-associated biliary cyst (BABC, 21 patients), non-biliary atresia-associated choledochal cyst (NBACC) in infancy (37 patients), and late NBACC (> 1 year of age, 100 patients). RESULTS BABC accounted for 36.2% of the infantile biliary cysts in this study. Extrahepatic cysts in late NBACC had a greater mean diameter than those in infantile NBACC and BABC (21.5 mm vs. 16.0 mm vs. 7.9 mm, p < 0.001). Cholangitis was the most serious complication within 3 months postoperatively in all three groups, resulting in four deaths (two in the infantile NBACC group and one each in the other two groups). Liver cirrhosis developed during long-term follow-up in nine of the 21 patients with BABC, four of whom died. Three of these nine patients underwent liver transplantation and remained well during follow-up. Chronic complications in NBACC occurred mainly in late IVa cases, with persistent intrahepatic dilatation developing in 12 of 35 patients and intrahepatic stones in five. Elevation of serum alanine aminotransferase (ALT) was found preoperatively in 85% of late NBACC and 35% of infantile NBACC cases. Postoperative normalization of ALT occurred after a mean of 152 +/- 23 days and 158 +/- 67 days in late NBACC and infantile NBACC, respectively. Higher ALT levels before operation were associated with a longer period until normalization. CONCLUSION The possibility of BABC must be included in the differential diagnosis when a small extrahepatic cyst (< 8 mm in diameter) with prolonged jaundice is found in infancy. Postoperative follow-up is essential for patients with NBACC due to their frequently prolonged elevation of serum ALT and possibility of residual intrahepatic dilatation. Cholangitis was the major cause of death within 3 months postoperatively in this study.
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Affiliation(s)
- Hung-Chang Lee
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan, ROC.
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Wong AMC, Cheung YC, Liu YH, Ng KK, Chan SC, Ng SH. Prenatal diagnosis of choledochal cyst using magnetic resonance imaging: A case report. World J Gastroenterol 2005; 11:5082-3. [PMID: 16124073 PMCID: PMC4321937 DOI: 10.3748/wjg.v11.i32.5082] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Choledochal cysts are congenital anomalies of the biliary ducts, characterized by cystic dilatation of the ducts. Prenatal diagnosis of this anomaly using ultrasonography (US) has been well documented. Magnetic resonance imaging (MRI) has recently become an important complement to US in prenatal diagnosis of fetal anomalies. We herein report a patient in whom at 24 wk’ gestation US suggested a right upper quadrant abdominal cyst and in whom at 26 wk’ gestation MRI more clearly delineated the cyst and its surrounding structures and suggested a choledochal cyst, which was confirmed at postnatal surgery and histopathology.
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Affiliation(s)
- Alex Mun-Ching Wong
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, China
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Okada T, Sasaki F, Ueki S, Hirokata G, Okuyama K, Cho K, Todo S. Postnatal management for prenatally diagnosed choledochal cysts. J Pediatr Surg 2004; 39:1055-8. [PMID: 15213898 DOI: 10.1016/j.jpedsurg.2004.03.054] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE The aim of this study was to determine an appropriate postnatal management plan for prenatally diagnosed congenital biliary dilatation (CBD). METHODS Between 1962 and 2002, 5 (5.9 %) of 85 patients had CBD diagnosed prenatally and were examined clinically. Of these 5 patients, 2 (group A) underwent delayed primary definitive surgery after percutaneous transhepatic cholangiodrainage (PTCD), 1 (group B) underwent early definitive surgery in the neonatal period, and 2 (group C) underwent delayed primary definitive surgery without PTCD in early infancy (within 6 months after birth). The clinical data, operative findings, intra- and postoperative complications, and follow-up were evaluated in these 3 groups. RESULTS There were no postoperative complications, such as catheter-related complications, in group A. However, there was adhesion around the choledochal cyst, and the operation was therefore difficult in group A. The diameter of the anastomosis in the hepaticojejunostomy was small, and the cyst wall was thin in group B. Consequently, anastomotic leakage of the hepaticojejunostomy occurred in group B. Neither operative nor postoperative complications such as anastomotic leakage or stenosis occurred in group C. Slight fibrosis of Glisson's sheath was seen in 2 patients of groups A and C. No liver cirrhosis was seen in any group. CONCLUSIONS The authors propose that asymptomatic patients should undergo elective definitive surgery by 6 months of age. For symptomatic patients, especially when a differential diagnosis of type I cystic biliary atresia is doubtful, early definitive surgery is needed before 2 months of age. PTCD appears to be indicated only under certain circumstances, and delayed primary definitive surgery should be performed as early as possible thereafter.
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Affiliation(s)
- Tadao Okada
- Department of Pediatric Surgery, Hokkaido University School of Medicine, Sapporo, Japan
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Chen CJ. Clinical and Operative Findings of Choledochal Cysts in Neonates and Infants Differ From Those in Older Children. Asian J Surg 2003; 26:213-7. [PMID: 14530107 DOI: 10.1016/s1015-9584(09)60306-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Significant differences in the clinical and pathological presentation of choledochal cysts between infants and older children have been noted. We developed a new management strategy according to these differences. METHODS Between 1990 and 2001, we managed 34 cases of type I choledochal cyst. Nineteen patients were more than 1 year old. Fifteen patients underwent surgery before the age of 1 year, and eight before the age of 2 months. One patient was diagnosed prenatally. All patients underwent choledochal cyst excision and hepaticojejunostomy. Symptoms and signs, and findings from physical examination, laboratory tests, and pathology were recorded and analysed. Follow-up periods ranged from 6 months to 11 years. RESULTS Eight cases who were less than 1 year old suffered from painless jaundice, and choledochal cysts in this group usually ended as a blind pouch. Their cystic amylase and lipase concentrations were within normal limits. Biliary cirrhosis was diagnosed by liver biopsy in three of these patients. In contrast, 17 of the 19 patients who were more than 1 year old had abdominal pain, and 15 of their cysts were connected to the pancreatic duct. Cystic amylase and lipase concentrations were often elevated. All patients had an excellent outcome. CONCLUSION Diseases with different pathogeneses may cause different clinical manifestations and pathology of choledochal cysts in infants and older children. Some patients develop biliary cirrhosis in the early months of life. Our findings show that it is safe and imperative to treat neonates and infants with choledochal cysts as soon as possible, as delayed surgery may cause severe complications.
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Affiliation(s)
- Chau-Jing Chen
- Division of Pediatric Surgery, Department of Surgery, National Cheng-Kung University Hospital, Tainan, Taiwan.
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Yamashita H, Otani T, Shioiri T, Takayama T, Kakiuchi C, Todani T, Makuuchi M. Smallest Todani's type II choledochal cyst. Dig Liver Dis 2003; 35:498-502. [PMID: 12870737 DOI: 10.1016/s1590-8658(03)00224-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A choledochal cyst is defined as an isolated or combined congenital dilation of the extra hepatic or intrahepatic biliary tree. Todani and colleagues proposed the five types of congenital choledochal cysts which have gained widespread acceptance. Type II choledochal cyst, a diverticulum of common bile duct, is rarest, and most reported cases of Type II were as large as several centimeters in size. We herein report the case of a small Type II choledochal cyst which was resected at pancreatoduodenectomy for carcinoma of the papilla of Vater. A 58-year-old Japanese male was referred to our hospital for the evaluation of jaundice. Preoperative cholangiogram via the percutaneous transhepatic biliary drainage tube revealed a complete obstruction at the narrow terminal segment. Furthermore, a small diverticular protrusion was demonstrated on the lower part of the common bile duct. The resected specimen showed a 2.2 x 1.7 x 1.2 cm carcinoma of the major papilla, and a deep, 2 mm in diameter and 5 mm in depth, depression on the posterior wall of the common bile duct. The anomalous pancreatobiliary duct was not seen. The deep depression was confirmed microscopically to penetrate the fibromuscular layer of the common bile duct and diagnosed as a Todani's Type II choledochal cyst. To our knowledge, the current case is the smallest Type II choledochal cyst which was completely resected.
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Affiliation(s)
- H Yamashita
- Department of Hepato-Biliary-Pancreatic Surgery and Pathology, University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan
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Ohtsuka Y, Yoshida H, Matsunaga T, Kouchi K, Okada T, Ohnuma N. Strategy of management for congenital biliary dilatation in early infancy. J Pediatr Surg 2002; 37:1173-6. [PMID: 12149696 DOI: 10.1053/jpsu.2002.34466] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The aim of this study was to establish the optimal management strategy of congenital biliary dilatation (CBD) in early infancy. METHODS Over the last 15 years, 14 patients with CBD in early infancy (within 5 months), including 3 antenatally diagnosed patients, were treated in the authors' department. Of the 14 patients, 7 (50%) underwent early definitive surgery (E group), and the other 7 (50%) underwent delayed primary definitive surgery after percutaneous transhepatic cholangiodrainage (PTCD; D group). Both groups were compared retrospectively using clinical data. RESULTS Pretreatment status and backgrounds of the patients were clinically homogeneous between the 2 groups. The total length of hospital stay was significantly longer in the D group. As short-term complications, 1 patient in the E group was compromised with hepatolithiasis, and 3 patients in the D group were compromised with catheter-related complications. Other clinical data, such as age at definitive surgery, blood loss, pathologic fibrosis of the liver, jaundice-free day, and long-term complications were not significantly different between the 2 groups. CONCLUSIONS The authors propose that the standard of management should be early definitive surgery with wide anastomosis before 2 months of age. However, PTCD might be used under strict consideration of indication and careful management for patients with extremely poor surgical risk.
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Affiliation(s)
- Yasuhiro Ohtsuka
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Kobayashi S, Asano T, Yamasaki M, Kenmochi T, Nakagohri T, Ochiai T. Risk of bile duct carcinogenesis after excision of extrahepatic bile ducts in pancreaticobiliary maljunction. Surgery 1999; 126:939-44. [PMID: 10568195 DOI: 10.1016/s0039-6060(99)70036-x] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A reflux of pancreatic juice into the biliary tract caused by pancreaticobiliary maljunction (PBM) has been considered important in the development of biliary tract carcinogenesis in choledochal cysts. We excised extrahepatic bile ducts in patients with choledochal cysts to terminate the reflux of pancreatic juice. We investigated whether this surgery could stop the development of the residual bile duct carcinoma. METHODS Fifty-six patients with a diagnosis of PBM with choledochal dilatation underwent surgical excision of extrahepatic bile ducts. We applied a person-year method to compare the relative risks (observed number/expected number) of biliary tract carcinoma before and after surgery. RESULTS In 3 patients, bile duct carcinoma developed in residual dilated segments 19 years 6 months, 8 years 8 months, and 2 years 5 months, respectively, after surgery. Although the relative risk in the post-surgery group was slightly decreased by surgery, it was still high compared with that of the general population. CONCLUSIONS The incidence of bile duct carcinoma is still high, even after excision of extrahepatic bile ducts in PBM patients with choledochal dilatation. For these patients, careful long-term follow-up is necessary, especially after operations that leave the dilated bile ducts, such as cases of Todani's type IV-A.
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Affiliation(s)
- S Kobayashi
- Second Department of Surgery, Chiba University School of Medicine, Japan
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Shukri N, Hasegawa T, Wasa M, Higaki J, Nakamura T, Okada A. Characteristics of infantile cases of congenital dilatation of the bile duct. J Pediatr Surg 1998; 33:1794-7. [PMID: 9869053 DOI: 10.1016/s0022-3468(98)90287-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE This study was performed to clarify whether infants with congenital dilatation of the bile duct (CDBD) have any specific characteristics in comparison with older children. METHODS Of 153 cases with CDBD treated at our institution between 1959 and 1997, 34 (22.2%) were infants less than 1 year of age. The control group consisted of 46 children between 1 and 4 years of age. Symptoms, laboratory data, and histological findings were compared between these two groups. RESULTS As the initial symptoms, abdominal pain was not present in infantile cases, with a significant difference from the older children, and a significantly higher incidence of abdominal mass and acholic stools was noted in infantile cases. Laboratory data of serum aspartate transaminase and amylase level and amylase concentration in the bile of the common bile duct were significantly lower in the infant group than in the older children. The ratio of morphological type of cystic to cylindrical dilatation was 33 to 1 in infants with a significant difference from the control group. CONCLUSION Infantile cases of CDBD, which mostly have cystic type dilatation, in contrast to older children, are likely to present with abdominal mass. Pancreatitis with abdominal pain related to reflux of pancreatic juice into the biliary duct appears to be uncommon in infantile cases.
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Affiliation(s)
- N Shukri
- Department of Pediatric Surgery, Osaka University Medical School, Japan
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Lenriot JP, Gigot JF, Ségol P, Fagniez PL, Fingerhut A, Adloff M. Bile duct cysts in adults: a multi-institutional retrospective study. French Associations for Surgical Research. Ann Surg 1998; 228:159-66. [PMID: 9712559 PMCID: PMC1191455 DOI: 10.1097/00000658-199808000-00003] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To review the features of adult patients undergoing surgery for bile duct cysts, focusing on the anatomy of the biliary tree as well as the long-term outcome. SUMMARY BACKGROUND DATA Bile duct cysts (BDCs) are uncommon in Western countries, and the majority of reported cases originate from Asia. Japanese authors have emphasized the frequent association of extra- and intrahepatic bile duct dilatations, but grading of patients based on Todani's classification is often hindered by the absence of an accurate definition of types IC and IVA cysts. Moreover, despite the increasing use of extrahepatic cyst excision, little is known about the long-term outcome in patients with intrahepatic bile duct involvement. METHODS Forty-two adult patients with BDC were treated between 1980 and 1992 in 17 institutions of the French Associations for Surgical Research. Clinical presentation, radiologic presurgical evaluation, and surgical procedures were analyzed. The long-term postsurgical outcome was derived from patient charts, attending physicians, or direct patient contact. RESULTS Twelve patients (30%) had recurrent abdominal pain or jaundice from childhood. Seven (17%) had undergone prior cystenterostomy. Twenty-one (50%) had a Todani-type IVA cyst with extra- and intrahepatic bile duct involvement. Of these, nine had segmental, exclusively left-sided intrahepatic bile duct dilatation. Biliary carcinoma was encountered in five patients (12%). Extrahepatic cyst excision with a Roux-en-Y hepaticojejunostomy was performed in 34 patients with type I or IV cysts. The overall operative mortality rate was 2.4%. Long-term results were clearly correlated with cyst type: during a mean follow-up of 8.4 years, 11 of 12 patients (92%) treated by cyst excision for type I cyst remained free of symptoms, whereas 31% of patients who underwent surgery for type IV cyst had episodic or severe cholangitis with intrahepatic stones. CONCLUSIONS In patients with BDC, particular attention must be given to the associated intrahepatic bile duct dilatations. We propose a modification of Todani's classification to distinguish cystic, segmental, and fusiform dilatations of the intrahepatic biliary tree in type IV cysts. In patients with segmental left intrahepatic cystic dilatations, combined left liver lobectomy and extrahepatic cyst excision is suggested to decrease late postsurgical biliary complications.
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Affiliation(s)
- J P Lenriot
- Department of Surgery, Centre Hospitalier Longjumeau, France
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Abstract
BACKGROUND The accuracy of the technique of antenatal ultrasonography in the diagnosis of congenital bile duct lesions is unknown. METHODS Thirteen patients with proven biliary disease who had abnormal antenatal scans were reviewed. Two infants had type I cystic biliary atresia and one had a noncommunicating segmental dilatation of the bile duct in a type 3 biliary atresia. The remainder had choledochal cysts and included two patients with intrahepatic cysts. The correct diagnosis was made antenatally in only two (15%) cases. Of the remaining patients, seven received a diagnosis of intraabdominal cysts of unknown etiology, three of duodenal atresia, and one ovarian cyst. The median gestational age at the antenatal diagnosis was 20 weeks. RESULTS Jaundice developed in 11 infants, and dilatation of intrahepatic biliary radicals was noted in four of the choledochal cysts. Obstructive jaundice and increasing cyst size were indications for early surgery, and twelve infants underwent a laparotomy at a median age of 4 weeks. During the median follow-up period of 2 years, 12 of the 13 patients have lost their jaundice or remained anicteric. Antenatal diagnosis offers the possibility of early definitive surgery for uncomplicated choledochal dilatation and the chance of improved outcome for surgically treated biliary atresia. An algorithm is suggested for the management of antenatally detected cystic biliary lesions.
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Affiliation(s)
- R Redkar
- Department of Pediatric Surgery, King's College Hospital, London, England
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Abstract
Unrecognized biliary tract obstruction due to choledochal cysts or biliary atresia can result in significant morbidity and mortality. Diagnosis in utero of choledochal cyst allows prompt postnatal diagnostic evaluation and appropriate surgical therapy to be instituted early in life. This may minimize the potential complications of cholangitis, cirrhosis, and liver failure in infants with choledochal cysts.
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Affiliation(s)
- E K Gallivan
- Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts, USA
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Burnweit CA, Birken GA, Heiss K. The management of choledochal cysts in the newborn. Pediatr Surg Int 1996; 11:130-3. [PMID: 24057535 DOI: 10.1007/bf00183744] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/1995] [Indexed: 01/23/2023]
Abstract
Choledochal cysts are now being diagnosed before birth on routine maternal sonography (US). There is no report in the literature outlining the management of newborns with choledochal cysts, many of whom are asymptomatic. Our study details the diagnosis, treatment and outcome of six such children, four girls and two boys. Five had antenatal US revealing cystic abdominal masses. One had intermittent vomiting and US suggested a choledochal cyst. Four of six had normal serum bilirubin levels; two had elevations. In five babies the choledochal cyst was correctly diagnosed from the preoperative studies; in one the preoperative diagnosis was an ovarian cyst. The children underwent an operation at an average of 6 weeks of age (range 5 days to 17 weeks). At exploration, cholangiography showed Alonso-Lej type I cysts in all cases. Treatment consisted of resection of the cyst with Roux-en-Y choledochojejunostomy in five and with a valved jejunal choledochoduodenal conduit in one. In no case was the dissection of the choledochal cyst off the portal vein and hepatic artery difficult. There were no intra- or early postoperative complications. Mean hospital stay was 8 days (range 5 to 9 days). Presently, all 6 patients have normal bilirubin levels at an average length of follow-up of 35 months (range 16 to 70 months) after operation. We conclude that operative treatment of choledochal cysts in early infancy, even in asymptomatic children, is safe and effective and may prevent serious complications later in life.
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Abstract
The incidence of subhepatic cysts later confirmed as choledochal cyst has changed with the use of prenatal ultrasonography. A new group has emerged: the neonatal patient with an antenatal diagnosis. Optimal timing for cyst excision depends on variables such as gestational age, weight, associated conditions, biochemical liver alterations, development of complications, and the sonographic surveillance of size. The author's experience (1992) with an antenatally diagnosed choledochal cyst prompted this literature review. The present case showed an abnormal choledochopancreatic ductal junction, high amylase content, and a linear pattern of growth over time (2 mm/wk). Management consisted of cyst excision and bilio-enteric reconstruction. Fourteen cases (including the present one) have been reported in the world literature. All were females. Seventy-two percent of the ultrasound examinations were performed for dating purposes. Subhepatic cysts were identified at a mean gestational age of 26.9 weeks (range, 15 to 37 weeks). Excision and bilio-enteric reconstruction were performed at a mean age of 45 days (range, 9 hours to 6 months). Clinically, 50% of the babies were anicteric, 43% were jaundiced, and 7% had a palpable mass. Evidence of cyst growth was present in 56% of cases, and 60% had liver fibrosis that reverted to normal. The indications for surgery were jaundice (43%), cyst growth (21%), delayed HIDA excretion (7%), and elective (29%). Recommendations for managing the asymptomatic, anicteric neonate are discussed, entailing a rational approach based on growth potential, biochemical liver alterations, and the development of obstructive jaundice.
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Tsuchida Y, Kawarasaki H, Iwanaka T, Uchida H, Nakanishi H, Uno K. Antenatal diagnosis of biliary atresia (type I cyst) at 19 weeks' gestation: differential diagnosis and etiologic implications. J Pediatr Surg 1995; 30:697-9. [PMID: 7623232 DOI: 10.1016/0022-3468(95)90694-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
At 19 weeks' gestation, two cystic structures were first identified in the abdomen of a fetus. A repeat ultrasonography at 34 weeks confirmed a definite cyst communicating with the liver. The baby was born at 39 weeks, and serum direct bilirubin started to rise to 4.1 mg/dL. An operative cholangiogram at 23 days of life showed a cystically dilated choledochus with distal atresia and a relatively smooth yet hypoplastic intrahepatic biliary tree. Complete obliteration of the cystic duct was also noted. After excision of the cystic common bile duct, hepatico-jejunal anastomosis was performed, and the patient did well for 8 months postoperatively. Liver biopsy showed proliferation of the bile ductules, but no interlobular bile ducts were observed in any portal triad. A diagnosis of biliary atresia was established. Including the present case, five cases of antenatally diagnosed biliary atresia have been reported. All of them had type I cyst, and antenatal diagnosis was made at 19 to 32 weeks' gestation. Differential diagnosis between biliary atresia of type I cyst and choledochal cyst with complete distal obstruction has been a matter of discussion, and recognition of the entity of antenatally diagnosed biliary atresia is of significant importance from an etiological point of view.
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Affiliation(s)
- Y Tsuchida
- Department of Pediatric Surgery, University of Tokyo, Japan
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Dudin A, Abdelshafi M, Rambaud-Cousson A. Choledochal cyst associated with rare hand malformation. AMERICAN JOURNAL OF MEDICAL GENETICS 1995; 56:161-3. [PMID: 7625438 DOI: 10.1002/ajmg.1320560209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We report on an 8-year-old boy with choledochal cyst associated with most unusual hand malformation. Review of the literature and possible etiopathogenesis are discussed.
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Affiliation(s)
- A Dudin
- Makassed Hospital, Jerusalem, Israel
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Tsang TM, Tam PK, Chamberlain P. Obliteration of the distal bile duct in the development of congenital choledochal cyst. J Pediatr Surg 1994; 29:1582-3. [PMID: 7877036 DOI: 10.1016/0022-3468(94)90224-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The authors report the first case of antenatally diagnosed choledochal cyst having evidence of early fetal bile drainage and complete obliteration of the distal bile duct. This disputes the traditional hypothesis of reflux of pancreatic enzymes and supports the recent theory of primary obstruction as the etiologic cause of choledochal cyst. Coexisting congenital hypothyroidism and pulmonary stenosis had not been reported previously.
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Affiliation(s)
- T M Tsang
- Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, England
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48
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Abstract
Hospital records of 24 Chinese infants and children (7 males and 17 females) with choledochal cysts were reviewed. The patients were aged 1 day to 17 years. Abdominal pain, palpable abdominal mass and jaundice, either alone or in combination, accounted for most of the initial presentations. Twenty-two patients were classified as type I with surgery, while the other two patients were type V without surgery. Ultrasonography is a rapid and accurate diagnostic method in the initial evaluation. Cyst excision with Roux-en-Y hepaticojejunostomy was the treatment of choice in this series. Chronic cholecystitis with or without inflammation of choledochal cyst was the most common pathological finding. Five patients underwent liver biopsies, showing four biliary cirrhosis and one portal fibrosis. So far, there is no evidence of malignancy in any patient.
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Affiliation(s)
- W J Shian
- Department of Pediatrics, Taichung Veterans General Hospital, Taiwan, Republic of China
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49
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Abstract
Since 1959 when Alonzo-Lej and colleagues introduced the modern era of treatment of choledochal cysts, much information has come to light, particularly from Japan where the incidence of choledochal cyst is much higher than in occidental countries. While the original classification of Alonzo-Lej is still in use, additional forms of the anomaly have been identified by modern imaging techniques. Antenatal ultrasound studies and accurate cholangiography have made it possible not only to better define these anomalies but also to provide information regarding etiology. It seems most likely that choledochal cysts are the result of pancreatic reflux into the biliary tree from an anomalous junction of the main pancreatic duct with the common bile duct. Ultrasound, radioscintigraphic studies, and various forms of cholangiography have made the diagnosis straightforward. Although many approaches to treatment have been tried over the years, the most successful approach is total cyst excision with Roux-en-Y hepaticojejunostomy. This provides excellent long-term results with minimal complications. Nonetheless, lifelong follow-up is necessary to avoid potential problems such as biliary cirrhosis. Other forms of choledochal cysts, such as choledochocele and Caroli's disease, are treated as the anatomy dictates and these individuals must be followed long term as well. The overall results are most gratifying.
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Affiliation(s)
- J A O'Neill
- University of Pennsylvania School of Medicine, Philadelphia
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50
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Cohen SM, Kurtz AB. Biliary Sonography. Radiol Clin North Am 1991. [DOI: 10.1016/s0033-8389(22)02472-1] [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]
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