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

Biliary Reconstruction with Hepaticoduodenostomy Versus Hepaticojejunostomy After Choledochal Cyst Resection: A Narrative Review

Choledochal cysts (CCs), a congenital anomaly resulting in the abnormal dilation of the biliary ductal system, are most often identified in patients younger than 10 years of age. Regardless of clinical presentation, the cornerstone of therapy for CCs is complete surgical excision with reconstruction with either hepaticoduodenostomy or hepaticojejunostomy. Although both procedures are used by surgeons for the correction of CCs, evidence on clinical outcomes following both approaches is inconclusive as to which may offer superior reconstruction. This narrative review aims to compare the current literature regarding both approaches by evaluating their anatomic and operative considerations, as well as their perioperative, postoperative, and long-term outcomes. Future studies should closely focus on long-term, comparative outcomes, including the risk of biliary malignancy, and refine techniques to minimize complications, such as biliary reflux and bowel obstruction, in order to improve care for pediatric patients undergoing treatment for CCs.

Preliminary Experience with Continuous Submucosal Anastomosis in Small-Diameter Hepaticojejunostomy during Single-Port Laparoscopic Choledochal Cyst Surgery in Children

PURPOSE

 Hepaticojejunostomy anastomosis (HJA) is the most challenging aspect in single-port laparoscopic choledochal cystectomy and Roux-en-Y hepaticojejunostomy (SPCH) in children, especially in small-diameter anastomoses (diameters less than 5 mm), which are more susceptible to anastomotic stricture. We developed the continuous submucosal technique for HJA (CS-HJA) to lessen postoperative complications. The purpose of this study is to introduce our preliminary experiences with CS-HJA.

METHODS

 We retrospectively analyzed all available clinical data of children who underwent SPCH surgery between March 2020 and October 2022. We operated with CS-HJA on 10 children who were diagnosed with small-diameter hepaticojejunostomy (diameter less than 5 mm). 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 55.2 months; the age range was 3 to 120 months, and the average weight was 11.6 kg; male-female ratio was 1:9. The choledocho had fusiform dilatation in five cases and cystic dilatation in five cases. There was no dilatation of the left and right hepatic ducts or intrahepatic bile ducts in all patients. All patients had no dilatation of the left and right hepatic ducts or intrahepatic bile ducts. All patients underwent a single-port laparoscopic bile-intestinal anastomosis using a submucosal jejunal anastomosis technique. Analysis of the duration of the bile-intestinal anastomosis, the length of the child's stay in the hospital after surgery, the intraoperative complications, and the postoperative complications was performed.

RESULTS

 All the 10 patients underwent successful SPCH by CS-HJA technique. The average length of time for hepaticojejunostomy ranged from 22 to 40 minutes, and the postoperative hospital stay was 5.2 to 9.2 days. There were no instances of bile leakage following the operation. At 17 to 30 months of follow-up, there was no abdominal pain or jaundice, and the reexamination of transaminases, bilirubin, and amylase were normal. Ultrasonography showed no bile duct stricture or dilated bile ducts, and the incision is elegant, and the families of the patients were satisfied.

CONCLUSION

 In SPCH surgery in children, the CS-HJA technique is safe and feasible for small-diameter hepaticojejunostomy.

Contemporary trends in choledochal cyst excision: An analysis of the pediatric national surgical quality improvement program

BACKGROUND

Choledochal cysts are rare congenital anomalies of the biliary tree that may lead to obstruction, chronic inflammation, infection, and malignancy. There is wide variation in the timing of resection, operative approach, and reconstructive techniques. Outcomes have rarely been compared on a national level.

METHODS

We queried the Pediatric National Surgical Quality Improvement Program (NSQIP) to identify patients who underwent choledochal cyst excision from 2015 to 2020. Patients were stratified by hepaticoduodenostomy (HD) versus Roux-en-Y hepaticojejunostomy (RNYHJ), use of minimally invasive surgery (MIS), and age at surgery. We collected several outcomes, including length of stay (LOS), reoperation, complications, blood transfusions, and readmission rate. We compared outcomes between cohorts using nonparametric tests and multivariate regression.

RESULTS

Altogether, 407 patients met the study criteria, 150 (36.8%) underwent RNYHJ reconstruction, 100 (24.6%) underwent MIS only, and 111 (27.3%) were less than one year old. Patients who underwent open surgery were younger (median age 2.31 vs. 4.25 years, p = 0.002) and more likely underwent RNYHJ reconstruction (42.7% vs. 19%, p = 0.001). On adjusted analysis, the outcomes of LOS, reoperation, transfusion, and complications were similar between the type of reconstruction, operative approach, and age. Patients undergoing RNYHJ had lower rates of readmission than patients undergoing HD (4.0% vs. 10.5%, OR 0.34, CI [0.12, 0.79], p = 0.02).

CONCLUSIONS

In children with choledochal cysts, most short-term outcomes were similar between reconstructive techniques, operative approach, and age at resection, although HD reconstruction was associated with a higher readmission rate in this study. Clinical decision-making should be driven by long-term and biliary-specific outcomes.

Outcome of Biliary-enteric Reconstruction with Hepaticoduodenostomy Following Choledochal Cyst Resection: A Prospective Study

BACKGROUND

The two most commonly performed methods of biliary-enteric reconstruction following choledochal cyst resection are Roux-en-Y hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD). There is a lack of consensus regarding the better technique between them. This study aimed to evaluate the outcomes, efficacy and early complications of HD as a mode of biliary reconstruction after surgical resection of a choledochal cyst.

MATERIALS AND METHODS

This was a multi-institutional prospective study carried out in high-volume tertiary care teaching institutes from January 2010 to December 2022. All children managed with HD following choledochal cyst resection were analysed for their early complications and outcomes.

RESULTS

A total of 74 patients were included in this study. There were 59 (79.73%) females and 15 (20.27%) males. Thirty-nine (52.70%) patients had jaundice at the time of presentation. Magnetic resonance cholangiopancreatography was performed in 57 (77.03%) patients following ultrasonography. Intraoperatively, malrotation was present in 2 (2.70%) patients. In our study, operating time ranged from 60 to 195 min (mean: 118 min). Hospital stays ranged from 8 to 17 days (mean: 11.5 days). The post-operative biliary leak was seen in 7 (9.50%) patients, out of which 6 (8.11%) minor leaks were managed conservatively. Roux-en-Y HJ was performed on 1 (1.35%) patient with a major leak. In our series, 4 (5.40%) patients developed cholangitis; post-operative haemorrhagic nasogastric aspirate 5 (6.76%), post-operative pancreatitis 3 (4.05%) and wound infection 4 (5.40%) were observed and managed conservatively. None of the patients in our study developed an anastomotic stricture, bile gastritis and adhesive small bowel obstruction.

CONCLUSION

Resection of choledochal cyst with HD reconstruction is safe and feasible with short operative time. HD is a viable option for operative management of choledochal cyst with low complication rates and faster recovery.