Laparoscopic-assisted cyst excision and ductoplasty plus widened portoenterostomy for choledochal cysts with a narrow portal bile duct

Abstract

Background Complete cyst excision with Roux-en-Y hepaticojejunostomy is the standard procedure for choledochal cysts (CCs). In recent years, neonates have been increasingly diagnosed with CCs prenatally. Earlier treatment has been recommended to avoid complications. For type IVa malformation without extensive intrahepatic bile duct dilatation, laparoscopic hepaticojejunostomy is technically challenging, and anastomotic stricture is a concern. Therefore, we propose laparoscopic synthetical techniques—laparoscopic excision of cyst and ductoplasty plus widened portoenterostomy to avoid stricture in CCs with a narrow hilar duct. Methods An anastomosis was created around the transected end of the common bile duct in 12 minipigs (Group A), and another 12 minipigs (Group B) received conventional cholangiojejunostomy. Anastomotic diameter measurements and cholangiography were conducted at different times. Histological findings of inflammation and scarring were compared. The expression levels of TGF-β1 and type I collagen were detected by real-time quantitative PCR. Between January 2012 and January 2016, laparoscopic excision of cyst and ductoplasty plus widened portoenterostomy were performed on 29 children with confirmed CCs with a narrow portal bile duct who were followed up for 12–48 months. Results Group A survived well without obstruction. Slight inflammation and fibrotic tissue were confined to the bile duct periphery. In Group B, five pigs developed stricture. Severe inflammation and diffuse fibrosis affected the whole layer of the anastomosis. Fibrotic biomarkers were significantly higher postoperatively in Group B. Clinically, 29 patients exhibited satisfactory outcomes. No anastomotic stricture has been observed to date. Conclusions Laparoscopic synthetical techniques may be a superior option to prevent anastomotic stricture in treating CCs with a narrow portal bile duct. Electronic supplementary material The online version of this article (10.1007/s00464-018-06635-4) contains supplementary material, which is available to authorized users.

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

“…[23] longitudinally split the anterior wall of the small hepatic duct in the anterior direction, and intermittently performed anastomosis under the suspension of both ends. During a 3-year follow-up, ultrasound reexamination showed no signs of bile duct stenosis or dilation in 4 of the patients [22] . These follow-up data indicate that the above methods are beneficial for bile drainage in patients with portal biliary dilation or a low convergence position of the left and right hepatic ducts, and can prevent postoperative bile duct stones and anastomotic strictures.…”

“…This approach is employed when the diameter of the hepatic duct is small, followed by choledochoenterostomy.. Chang XP et al [22] treated 47 patients with choledochal cysts by burying the jejunal loop into the hepatic portal, and no postoperative complications such as cholangitis, bile duct stones or anastomotic stricture occurred .…”

A giant biliary cyst of Todani IA in a young woman

“…Total BC excision (with cholecystectomy) and Roux-Y hepaticojejunostomy is the treatment method of choice in most patients. [ 1 , 9 ]…”

Experience in the Treatment of Choledochal Cyst with Robot-Assisted Surgery in Children: and "The Current State of Minimally Invasive Surgery in this Anomaly”

“…Prenatal ultrasound diagnosis can be established or suspected, especially in the third trimester of pregnancy. With the development of imaging techniques and the prenatal screening, an increasing number of asymptomatic cases have been diagnosed [4].…”

“…propose a different way to perform hepaticojejunostomy to reduce the risk of anastomotic stenosis, an anastomosis created around the transected end of the common bile duct with the seromuscular layer of the common bile duct was sutured interruptedly to the whole layer of the jejunum[4].In the detailed non-systematic review of previous publications in children, from the first case of choledochal cyst resection with robotic assistance that was reported in 2006, until Jul-2019, that Pham., et al reported 39 pediatric patients, we found 13 previous publications in total, totaling 134 previous cases[15,[18][19][20][21][22][23][24][25][26][27][28][29], with our patients, make a total of 138 cases of choledochal cyst treated with robotic surgery reported. The analysis of the publications provides the following: informed patients from 1 to 39 cases, average age 4.45 years, gender ratio 1: 3.85 female, average surgical times: total 408 min (range 180 to 570), console surgery time 246 min (range 110 to 418), conversions 5% (range 0 to 100%), complications 8.2% (range 0 to 100%) and average postoperative stay 8.12 days (range 4 to 20 days) and 0% mortality.…”