Clinical comparison between the presence and absence of protein plugs in pediatric choledochal cysts: experience in 390 patients over 30 years in a single center

Pancreaticobiliary maljunction (PBM)-associated pancreatitis: a case report and a new treatment strategy proposed for PBM

Background

Pancreaticobiliary maljunction (PBM) is a rare cause of recurrent pancreatitis. During the past 10 years, treatment protocols for PBM have been progressively improved and revised; however, the latest therapeutic strategies have not been comprehensively summarized in the literatures. Herein, we present a typical case of PBM-related recurrent pancreatitis which highlights the role of PBM in the pathogenesis of pancreatitis and prompts us to revisit and optimize current therapeutic strategies for PBM.

Case Description

A 59-year-old female patient was admitted to the hospital with abdominal pain, vomiting and cessation of defecation. The patient had an previous episode of pancreatitis three years ago. Laboratory tests revealed an elevated blood amylase level of 4,418.2 U/L (normal range, 35-135 U/L) and an upper abdominal computed tomography (CT) scan suggested the possibility of pancreatitis. After treatment with dietary restriction, inhibition of gastric acid secretion, inhibition of pancreatic fluid secretion, and rehydration, the patient was relieved of the abdominal pain, and the blood amylase level decreased to 118.8 U/L. However, 6 months after discharge, the patient was readmitted to the hospital because of abdominal pain. Laboratory tests showed that amylase level was >1,200.0 U/L. An upper abdominal CT scan and an upper abdominal dynamic contrast-enhanced magnetic resonance (MR) scan indicated a possibility of autoimmune pancreatitis (AIP). An ultrasonographic endoscopy showed the presence of PBM and the histopathologic findings of the pancreas obtained were the key basis for our diagnosis of PBM, as well as our final exclusion of AIP suggested by upper abdominal CT and upper abdominal dynamic contrast-enhanced magnetic resonance imaging (MRI). Considering the patient's recurrent episodes of PBM-associated pancreatitis, we suggest that the patient could undergo endoscopic retrograde cholangiopancreatography (ERCP) or surgery. However, the patient refused to undergo ERCP and surgery, was discharged from the hospital after experiencing relief of abdominal pain, and continued to be followed up in the outpatient clinic.

Conclusions

Based on a case of PBM-related recurrent pancreatitis diagnosed using ultrasonographic endoscopy, we comprehensively reviewed PBM-related literatures. In addition to the classical therapeutic strategy of selecting different surgical procedures based on the morphology of the extrahepatic bile ducts, ERCP, a minimally invasive treatment, has unique advantages in PBM treatment. For symptomatic patients with PBM, ERCP can significantly reduce patient discomfort and facilitate favorable surgical conditions. Furthermore, when the effect of surgery is unclear, or patients do not wish to undergo surgery, ERCP can be used as a complementary or palliative treatment option to provide patients with more therapeutic possibilities. In this study, we propose and describe a new treatment strategy for PBM: combining traditional radical surgical program with ERCP to provide useful experiences and references for future treatment of PBM.

Characteristics and outcomes of minimally invasive surgery for congenital biliary dilatation in children aged <6 years: Comparison between children and adults

BACKGROUND/PURPOSE

We evaluated the minimally invasive surgery for congenital biliary dilatation (CBD) in adults and children and analyzed the surgical outcomes, especially in children aged <6 years.

METHODS

Characteristics and surgical outcomes of patients with CBD who underwent minimally invasive surgery at our hospital between 2013 and 2023 were retrospectively reviewed.

RESULTS

Overall, 129 patients (89 children aged <6 years, 9 children aged between 6 and 18 years, and 21 adults) were included in this study. Children exhibited more protein plug presence and abnormal biochemical data than adults. Incidence of postoperative pancreatic fistulas was highest in the adult group (3.4%, 11%, and 33%, respectively, p < .01). In children aged <6 years, postoperative bile leakage and pancreatic fistulas occurred in 9.0% and 3.4% of patients, respectively. Multivariate logistic regression analysis revealed that the Todani IVA was associated with a decrease in postoperative bile leakage (odds ratio: -1.7; 95% confidence interval: (-3.3)-(-0.22), p = .03).

CONCLUSION

Adults with CBD required prolonged operative times and had more short-term complications than children with CBD. In children aged <6 years, minimally invasive surgery for CBD can be safely performed; however, a small diameter of the bile duct may be associated with bile leakage.

An observational study on the prevalence of choledochal cyst with pancreatitis: Geographical implications and management

The objective of this study was to analyse the prevalence, risk factors and need for intervention in a sample of Indian children with choledochal cyst (CDC) complicated by pancreatitis with a special focus on chronic pancreatitis. A retrospective review of medical records of children admitted with CDC over 11 years was done and pancreatitis identified using INSPPIRE guidelines. Children were divided into two groups-one having choledochal cyst alone and the other choledochal cyst along with pancreatitis to determine associated risk factors. 40.2% of children with CDC had pancreatitis based on elevation of enzymes or radiological imaging. Age, total bilirubin and indirect bilirubin, requirement of intervention was significantly higher in the group with pancreatitis. 47% of those with radiological features of pancreatitis had imaging features of chronic pancreatitis. Chronic pancreatitis has not been reported previously in children with CDC and maybe peculiar to the Indian subcontinent.

Using machine learning models to predict the surgical risk of children with pancreaticobiliary maljunction and biliary dilatation

PURPOSE

To develop machine learning (ML) models to predict the surgical risk of children with pancreaticobiliary maljunction (PBM) and biliary dilatation.

METHODS

The subjects of this study were 157 pediatric patients who underwent surgery for PBM with biliary dilatation between January, 2015 and August, 2022. Using preoperative data, four ML models were developed, including logistic regression (LR), random forest (RF), support vector machine classifier (SVC), and extreme gradient boosting (XGBoost). The performance of each model was assessed via the area under the receiver operator characteristic curve (AUC). Model interpretations were generated by Shapley Additive Explanations. A nomogram was used to validate the best-performing model.

RESULTS

Sixty-eight patients (43.3%) were classified as the high-risk surgery group. The XGBoost model (AUC = 0.822) outperformed the LR (AUC = 0.798), RF (AUC = 0.802) and SVC (AUC = 0.804) models. In all four models, enhancement of the choledochal cystic wall and an abnormal position of the right hepatic artery were the two most important features. Moreover, the diameter of the choledochal cyst, bile duct variation, and serum amylase were selected as key predictive factors by all four models.

CONCLUSIONS

Using preoperative data, the ML models, especially XGBoost, have the potential to predict the surgical risk of children with PBM and biliary dilatation. The nomogram may provide surgeons early warning to avoid intraoperative iatrogenic injury.