Non-stapled, total laparoscopic Roux-en-Y anastomosis: A safe and effective procedure for radical pediatric choledochal cyst excision.

Background: Laparoscopic or robot-assisted surgery has become the main pediatric minimal invasive surgery for a choledochal cyst (CDC). However, the Roux-en-Y jejunal limb was created extracorporeally in most reports and intracorporeally in a few reports using an endoscopic stapler. Objectives/methods: To investigate the safety and feasibility of non-stapled laparoscopic Roux-en-Y reconstruction in the radical treatment of congenital choledochal cysts (CDC). Between January 2019 and February 2023, 40 patients diagnosed with CDC underwent non-stapled laparoscopic Roux-en-Y reconstruction (non-stapled totally laparoscopic radical treatment, NTLR), 40 patients underwent conventional reconstruction (conventional laparoscopic radical treatment, CLR) included as control. Their clinical data such as intraoperative blood loss, proportion of transit laparotomy, length of operation, postoperative fasting times, postoperative drainage time, postoperative hospital stay, hospitalization cost, and postoperative complications were retrospectively analyzed. Conclusion: non-stapled laparoscopic Roux-en-Y reconstruction is feasible and safe in total laparoscopic radical treatment of CDC. It may have the following advantages: rapid recovery of postoperative gastrointestinal function, short hospitalization, no age limit on the patient and no additional hospitalization costs, which is worthy of promotion and application.

Comparison of open and laparoscopic outcomes of adult Type-I congenital choledochal cysts.

Objective: To compare open and laparoscopic outcomes of adult Type-I congenital choledochal cysts. Methods: Clinical data of 78 adult patients with Type-I congenital choledochal cysts, who had undergone cyst resection and Roux-en-Y hepaticojejunostomy in Chenzhou First People's Hospital from September 1, 2021 to August 31, 2022, were retrospectively analyzed. Patients who received open approach and Roux-en-Y hepaticojejunostomy constituted the open group (n=35,) and patients who received laparoscopic approach and Roux-en-Y hepaticojejunostomy were assigned into the laparoscopic group (n=43,). The intraoperative and postoperative conditions, relevant laboratory indicators, and the rate of complications were compared between the two groups. Results: Intraoperative blood loss, postoperative time to first flatus, diet recovery time, time to drainage tube removal, and length of hospitalization of the laparoscopic group were lower in the laparoscopic group compared to the open group (P<0.05). One day after the operation, serum amylase (SAMY) levels in both groups were significantly lower, while the levels of total bilirubin(TBIL), alanine aminotransferase(ALT), and C-reactive protein(CRP) were higher than before the operation. Postoperative SAMY level in the laparoscopic group was significantly higher, while the postoperative TBIL and CRP levels were significantly lower than those in the open group (P<0.05). The incidence of postoperative complications in the laparoscopy group (4.65%) was significantly lower than the open group (20.00%) (P<0.05). Conclusions: Laparoscopic cyst resection combined with Roux-en-Y hepaticojejunostomy is associated with lower extent of trauma, faster recovery, less inflammation, and fewer complications than open surgery in adult patients with Type-I congenital choledochal cysts.

Timing of operation in children with a prenatal diagnosis of choledochal cyst: A single-center retrospective study.

BACKGROUND/PURPOSE: There is currently no consensus on the timing of operative correction for patients with a prenatal diagnosis of choledochal cyst (CDC). This study aims to retrospectively analyze patients with prenatally diagnosed CDCs to identify the optimal timing of operative correction and the importance of cyst size as a predictor of the appearance of symptoms related to the CDC. METHODS: We reviewed 125 patients with a prenatal diagnosis of CDC who were admitted to Guangzhou Women and Children's Medical Center from July 2015 to July 2020. After dividing the patients into a symptomatic group (n = 37) and an asymptomatic group (n = 88), according to whether they had any clinical symptoms at the time of their operation, we compared their clinical data and postoperative outcomes. The asymptomatic group was divided into a <1 month group; a ≥1 month and <4 months group; and a ≥4 months group according to their postnatal age at operation; postoperative complications of the three groups were then compared. We were also interested in the effect of cyst size (width and length) for predicting the development of symptoms related to the CDC. RESULTS: The time of onset of symptoms after birth was mainly concentrated in the first 3 months (48.6%). The median width and length of cysts measured by preoperative magnetic resonance cholangiopancreatography in the symptomatic group were greater than those in the asymptomatic group (43 mm vs 28 mm and 71 mm vs 45 mm, respectively; P < .05). The serum levels of the liver-related enzymes ALT, AST, and GGT, and the serum level of DBIL, were greater in the symptomatic group than in the asymptomatic group (P < .05). The operative time, intraoperative blood loss, and duration of postoperative hospital stay in the symptomatic group were greater than those in the asymptomatic group (P < .05). In the asymptomatic group, there were no statistically significant differences in the surgical data and postoperative complications between the <1 month group, the ≥1 month and <4 months group, and the ≥4 months group. The area under the receiver operating characteristic curve (AUROC) of the length of the cyst in predicting symptoms was 0.747, the best cut-off point was 5.2 cm, and the sensitivity and specificity were 78% and 70%, respectively. The AUROC of the width of the cyst was 0.704, the best cut-off point was 4.1 cm, and the sensitivity and specificity were 68% and 75%, respectively. CONCLUSION: We maintain that it is advantageous to receive surgical treatment in the asymptomatic period for patients with a prenatally diagnosed CDC. A cyst size of length >5.2 cm and width >4.1 cm suggested that clinical symptoms might appear, and that surgery should be carried out as soon as possible, even in the neonatal period.

Laparoscopic and robot-assisted surgery for adult congenital biliary dilatation achieves favorable short-term outcomes without increasing the risk of late complications.

PURPOSE: Minimally invasive surgery (MIS) is the optimal treatment for congenital biliary dilatation (CBD), but few studies on adults have been reported. We compared the postoperative outcomes of MIS with those of open surgery (OS) in adult patients with CBD. METHODS: The subjects of this retrospective study were 36 adult patients who underwent surgery for CBD. We compared the postoperative outcomes of 20 patients who underwent laparoscopic (n = 15) or robotic (n = 5) surgery with those of 16 patients who underwent OS. RESULTS: MIS was associated with a significantly higher rate of type I (p < 0.001), significantly less blood loss (p < 0.001), a significantly lower rate of internal stents (p = 0.048), significantly longer operation times (p = 0.009), and a significantly shorter postoperative hospital stay (p = 0.007) than OS. The postoperative outcomes of MIS for type I CBD were similar to those of the whole cohort. There were no significant differences in late complications between the groups. The robotic procedure had a significantly shorter operative time than laparoscopic surgery for hepaticojejunostomy (HJ; p = 0.029). CONCLUSIONS: MIS achieved favorable short-term outcomes without compromising mid-term outcomes compared to OS and is appropriate for adult patients with CBD. Robotic HJ may be more ideal than its laparoscopic counterpart.

Three-dimensional visualization technique compared with magnetic resonance cholangiopancreatography for evaluation of anatomic variants of pediatric congenital choledochal cysts.

OBJECTIVE: The aim of this study was to compare the application of a three-dimensional (3D) visualization technique and magnetic resonance cholangiopancreatography (MRCP) for diagnosis of pediatric congenital choledochal cysts. METHODS: Thin slices of coronal heavily T2-weighted pulse sequences of MRI pertaining to 35 patients were retrospectively used to reconstruct 3D models. Diagnoses and variants of the biliary system were evaluated based on the 3D models and MRCP imaging. The quality of delineation of the biliary duct system and the Todani classification were evaluated. Wilcoxon and Chi-squared tests were used for statistical analysis. RESULTS: Two cases that were diagnosed as type II congenital choledochal cysts using the 3D model were diagnosed as type I using MRCP imaging. Significant differences were observed between the two modalities with respect to the delineation of the right anterior bile duct, right posterior bile duct, and left hepatic duct. The excellent and good rates obtained with the 3D model (65.7%) were much better than that obtained with MRCP (37.1%) imaging. Two cases with accessory hepatic ducts (5.7%), one case with an accessory pancreatic duct (2.8%), and two cases with biliary strictures at the hepatic hilum (5.7%) were detected using the 3D models. In contrast, only one case with an accessory hepatic duct and one case with a biliary stricture at the hepatic hilum were detected using MRCP. CONCLUSION: The 3D visualization technique facilitated more precise morphological evaluation of congenital choledochal cysts and provided comprehensive spatial anatomic information for diagnosis.

Retroperitoneal mesothelial cyst misdiagnosed as a congenital choledochal cyst for an infant patient: A case report and literature review.

INTRODUCTION: Mesothelial cyst (MC) is very uncommon in clinic, which could occasionally occur in peritoneal, retroperitoneal or even pleural cavity. PRESENTATION OF CASE: We hereby described an infant patient with retroperitoneal MC who was misdiagnosed as congenital choledochal cyst by both radiologists and clinicians. A choledochal cyst resection with hepatojejunostomy under the da Vinci surgical system was routinely prepared for this patient but a local resection for the whole lesion was unexpectedly performed during the operation. The diagnosis of retroperitoneal MC was confirmed by the pathological analysis from surgical specimens. DISCUSSION: MC in small size is usually asymptomatic and sometimes detected by imaging examinations which manifests a well-boundary, watery-density and cystic lesion with no enhancement and is often misdiagnosed as lymphangioma or pancreatic pseudocyst. For pediatric patients, MC can occur in the diaphragm and liver in the literature, while retroperitoneal MC around hepatoduodenal ligament for an infant has never been mentioned before. We reported the first case of a retroperitoneal MC around hepatoduodenal ligament for an infant who was preoperatively misdiagnosed as choledochal cyst surgically treated by the da Vinci surgical system. CONCLUSION: Retroperitoneal MC around hepatoduodenal ligament should also be considered and resected for an infant.

A Study of Three-Dimensional Versus Two-Dimensional Laparoscopic Surgery in Resection of Congenital Choledochal Cyst of Children and Jejunum Roux-en-Y Anastomosis.

Background: This study aimed to explore the clinical efficacy of three-dimensional (3D) laparoscopic surgery in the treatment of congenital choledochal cysts (CCCs) by comparing it with two-dimensional (2D) laparoscopic surgery. Patients and Methods: We retrospectively reviewed data of 155 pediatric patients who underwent surgical treatment of choledochal cysts between January 2014 and December 2017. We divided the patients into two groups according to the surgical method used-a 3D laparoscopic group (N = 42) and a 2D laparoscopic group (N = 113). The 3D laparoscopic group was further divided into two subgroups based on age-Group 1 (age ≤12 months, N = 11) and Group 2 (age >12 months, N = 31). We analyzed data in terms of the following characteristics: patient demographics, perioperative and follow-up conditions, and complications. Moreover, we also recorded and analyzed the surgeon's assessment on laparoscopic system usage. Results: Cyst excision and Roux-en-Y hepaticojejunostomy (HJ) was successfully completed in all the patients. Intergroup differences in operating time and blood loss were statistically significant. There were no significant differences between the two groups in early and late complications, such as the incidence of wound infection, HJ stricture, or adhesive ileus. There were no significant differences in the operative data and outcomes between the two subgroups of patients who underwent 3D laparoscopic treatment. Based on surgeon's assessment, the 3D laparoscopic system had better depth perception and accuracy than the 2D laparoscopic system; however, there was no difference in the adverse effect on surgeons. Conclusions: Compared with the traditional 2D laparoscopic surgery, 3D laparoscopic surgical resection of CCCs combined with jejunum Roux-en-Y anastomosis is a safer and more effective procedure that can shorten operative time and reduce intraoperative bleeding with no increase in surgical strain. The 3D laparoscopic surgery technique may provide a better choice for CCC operations.

Prenatal diagnosis and prognosis assessment of congenital choledochal cyst in 21 cases.

To investigate the clinical significance of prenatal diagnosis and prognosis evaluation of congenital choledochal cyst (CCC), we reviewed CCC cases of diagnosed antenatally in our hospital from 2007 to 2013, summarised and analysed prenatal sonographic features and clinical outcomes, and followed these cases up to six months after birth. We found that induced labour was conducted in 7 cases, and term labour progressed smoothly in 14 cases among the 21 cases. Operations were completed within 3 months after birth and all the operation cases received a good prognosis. We suggest that CCC is one kind of non-lethal congenital malformation which can be treated after birth. Prenatal diagnosis is important for its treatment after birth, because early surgery after birth is associated with good treatment outcomes and prognosis.

Laparoscopic surgery for adult congenital choledochal cyst / 中华肝胆外科杂志

ObjectiveTo study the feasibility,safety and efficacy of laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy for adult congenital choledochal cyst.MethodA retrospective study was conducted on 7 adult patients with congenital choledochal cyst who received total laparoscopic cyst excision and Roux-en-y hepaticojejunostomy from May 2008 to February 2011 in the Department of General Surgery of Shengjing Hospital,China Medical University.ResultsAll the laparoscopic surgery was successful.The mean operation time was 210 minutes.The average intraoperative blood loss was 80 ml.All patients were out of bed within the first 24 h after surgery.The mean time to first flatus/bowel motion was 2.4 days.Except 1 patient who had small amount of bile leakage,all patients recovered smoothly without any major postoperative complications.The average hospital stay was 8.1 days.No patients suffered from abdominal pain,fever or jaundice during follow-up from 3 to 30 months.ConclusionTotal laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy was a safe,efficacious,and minimally invasive procedure.

Expression of survivin in congenital choledochal cyst and cholanglocarcinoma / 中华肝胆外科杂志

Objective To investigate the expression of survivin and its significance in congenital choledochal cyst and cholangiocarcinoma.Methods Immunohistochemical (S-P) techique was used to detect survivin in 37 patients with congenital choledochal cyst (children,n=20,adult,n=7),and 10 patients with cholangiocarcinoma.Ten patients with normal or benign bile duct lesions were used as control.Results In congenital choledochal cyst,the tissue was strongly positive for 2 patients,positive for 9 patients,weakly positive for 15 patients,and negative for 11 patients.In cholangiocarcinoma,the tissue was strongly positive in 5 patients and positive in 5 patients.In normal bile duct the tissue was weakly positive in 1 patient.The difference among the groups was significant (P＜0.01).The difference in expression of survivin between adults and children with congenital choledochal cyst was significant.Conclusions Survivin may play a pivotal role in malignant change,tumorigenesis,and tumor progression in congenital choledochal cyst.

Endoscopic diagnosis of pancreaticobiliary maljunction.

Pancreaticobiliary maljunction (PBM) is a congenital anomaly defined as a junction of the pancreatic and bile ducts located outside the duodenal wall, usually forming a markedly long common channel. As the action of the sphincter of Oddi does not functionally affect the junction in PBM patients, continuous pancreatobiliary reflux occurs, resulting in a high incidence of biliary cancer. PBM can be divided into PBM with biliary dilatation (congenital choledochal cyst) and PBM without biliary dilatation (maximal diameter of the bile duct ≤ 10 mm). The treatment of choice for PBM is prophylactic surgery before malignant changes can take place. Endoscopic retrograde cholangiopancreatography (ERCP) is the most effective examination method for close observation of the pattern of the junction site. When the communication between the pancreatic and bile ducts is maintained, despite contraction of the sphincter on ERCP, PBM is diagnosed. In these patients, levels of pancreatic enzymes in the bile are generally elevated, due to continuous pancreatobiliary reflux via a long common channel. Magnetic resonance cholangiopancreatography and 3D-computed tomography can diagnose PBM, based on findings of an anomalous union between the common bile duct and the pancreatic duct, in addition to a long common channel. Endoscopic ultrasonography and intraductal ultrasonography can demonstrate the junction outside the duodenal wall, and are useful for the diagnosis of associated biliary cancer. Gallbladder wall thickness on ultrasonography can be a screening test for PBM.

Management Strategy for Congenital Choledochal Cyst with Co-existing Intrahepatic Dilation and Aberrant Bile Duct As Well As Other Complicated Biliary Anomalies

The purpose of this study was to investigate and discuss imaging methods and management strategies for congenital choledochal cyst with co-existing intrahepatic dilation and aberrant bile duct as well as other complicated biliary anomalies. In this study we reviewed and analyzed 72 patients with congenital choledochal cyst, ranging in age from 15 days to 12 years old and who were seen at our hospital during the past 12 years, from January 1993 to October 2005. The image manifestation and clinical significance of patients with co- xisting intrahepatic biliary dilation and aberrant bile duct were carefully examined during operation via MRCP, cholangiography and choledochoscope. Twenty-two cases (30.1%) presented with intrahepatic bile duct dilation and 12 of these were of the cystic type. That is, the orifice of the dilated intrahepatic tract that converged into the common hepatic duct showed membrane or septum-like stenosis. In 10 cases the dilation tapered off from the porta hepatis to the initiating terminals of the intra-hepatic bile ducts and was not accompanied by stenosis. An aberrant bile duct was observed in 2 of the cases. In 3 cases, the right and left hepatic ducts converged at the choledochal cyst. In conclusion, the imaging methods for intrahepatic bile duct dilation possess important clinical significance. Further, for hepatojejunostomy with radical excision of a choledochal cyst, additional operative procedures for intrahepatic stenosis, possible bile duct malformation and pancreaticobiliary common duct calculi can potentially reduce postoperative complications.

Management Strategy for Congenital Choledochal Cyst with Co-existing Intrahepatic Dilation and Aberrant Bile Duct As Well As Other Complicated Biliary Anomalies

The purpose of this study was to investigate and discuss imaging methods and management strategies for congenital choledochal cyst with co-existing intrahepatic dilation and aberrant bile duct as well as other complicated biliary anomalies. In this study we reviewed and analyzed 72 patients with congenital choledochal cyst, ranging in age from 15 days to 12 years old and who were seen at our hospital during the past 12 years, from January 1993 to October 2005. The image manifestation and clinical significance of patients with co- xisting intrahepatic biliary dilation and aberrant bile duct were carefully examined during operation via MRCP, cholangiography and choledochoscope. Twenty-two cases (30.1%) presented with intrahepatic bile duct dilation and 12 of these were of the cystic type. That is, the orifice of the dilated intrahepatic tract that converged into the common hepatic duct showed membrane or septum-like stenosis. In 10 cases the dilation tapered off from the porta hepatis to the initiating terminals of the intra-hepatic bile ducts and was not accompanied by stenosis. An aberrant bile duct was observed in 2 of the cases. In 3 cases, the right and left hepatic ducts converged at the choledochal cyst. In conclusion, the imaging methods for intrahepatic bile duct dilation possess important clinical significance. Further, for hepatojejunostomy with radical excision of a choledochal cyst, additional operative procedures for intrahepatic stenosis, possible bile duct malformation and pancreaticobiliary common duct calculi can potentially reduce postoperative complications.

Resection of Congenital Choledochal Cyst,Hepaticojejunostomy,and Extra-Abdominal Roux-en-Y Anastomosis:Middle-term Results of 50 Cases / 中国微创外科杂志

Objective To assess the middle-term results of laparoscopy in resection of congenital choledochal cyst,hepaticojejunostomy,and extra-abdominal Roux-en-Y anastomosis. Methods We retrospectively studied 50 patients who had undergone laparoscopic choledochal cyst excision in our institute from 2005 to 2008.For large cysts,we dissected and separated the cyst at the middle portion,and then opened the inferior wall of the cyst to dissect the posterior wall of the cyst from the portal vein.For small cysts,we divided the cysts circumferentially and then completely excised the dilated bile duct.When the cyst was intensely inflamed,excision of the cysts was performed as Lilly's technique.Roux-en-Y jejunojejunostomy was performed extracorporeally through an umbilical incision(1.5 cm),afterwards,end-to-side anastomosis was carried out intracorporeally.The conversion to open surgery,and morbidity and mortality rates of the patients was analyzed.Results The cysts were completely excised in 16 cases,and Lilly's technique was performed on 34 cases.One patient was converted to open surgery due to hemorrhage resulted from recurrent inflammatory-caused tight adhesion between the cyst and surrounding tissues.The mean operation time was 226 minutes(range: 190 to 450 minutes).Eight patients received blood transfusion during the operation.The children were discharged from hospital in 6 to 16 days after the surgery(mean,8 days).A mean of 26 months follow-up was achieved in 49 patients(ranged 3 to 39 months).Four patients developed complications: one of them showed bile leakage and then were cured by intra-abdominal drainage;one patient developed acute pancreatitis and one suffered from adhesive small bowel obstruction,both recovered after conservative treatment;intestinal necrosis was detected in one patient,who received another operation for resection of the necrotic bowel and anastomosis of the bile duct and intestine.In the other 45 patients,no abdominal pain,fever,jaundice,etc.were detected.No patient showed bile duct stenosis or reflux gastritis,no one died because of the surgery.Conclusions Laparoscopic approach is effective for congenital choledochal cyst,hepaticojejunostomy,and extra-abdominal Roux-en-Y anastomosis.Dissection of the posterior cyst wall to avoid injury to the portal vein is the key to the procedures,while extra-abdominal Roux-en-Y anastomosis is one of the most difficult steps.

Modern surgical treatments for congenital choledochal cysts complicated with anomalous junction of pancreaticobiliary ductal system: an analysis of 30 cases / 中华肝胆外科杂志

Objective To discuss the modern surgical treatments for congenital choledochal cysts complicated with anomalous junction of pancreaticobiliary ductal system through analyzing data in 30 cases. Methods The 30 cases were diagnosed with ERCP, MRCP, cholangiography or dissection, respectively. Then 28 of them were treated with external drainage (n=2), internal drainage (n=9) and Roux-en-Y hepaticojejunostomy (n=22), respectively. Of the 28, 5 received operations twice. Results External drainage was helpful in emergency cases while internal drainage frequently resulted in recurrent cholangitis, choledocholith, anastomotic stenosis or cyst malignancy that needed to be operated on again. Choledochocyst resection and pancreaticobiliary shunt achieved satisfactory results. Conclusions Congenital choledochal cyst is usually complicated with anomalous junction of pancreaticobiliary ductal system (88.2%). As for its treatment, choledochocyst resection, pancreaticobiliary shunt and hepaticojejunostomy should be of the first choice.

Diagnosis and treatment of 43 cases of children with congenital chole dochal cyst / 实用儿科临床杂志

Objective To study the diagnosis and treatment of ch ildren with congenital choledochal cyst (CCC).Methods From Janu ary 1998 to January 2003, data from 43 cases children with CCC were used for thi s study. Their parameters included sex, age, diagnosis , types of CCC, time of surgery and style of surgery were retrospectively analyzed. Results The incidence of patients whose age under 2 years old was 72 %.The ratio o f gender (male:female) was 1:3. The children were examined by B-ultrasonic(B-u s),computed tomography(CT), and MRCP with the accuracy of 83.7 %, 78.9 % and 80. 0 % respectively.Forty cases underwent biliary reconstruction, cystectomy and Ro ux-en -Y bilioenteric anastomosis. There was no mortality, pre or postoperative compli cation. Conclusion B-us examination is the best method to diag nose the disease.Cystectomy and biliary reconstruction are effect to treat this disease.

A Case of Congenital Choledochal Cyst

We experienced a case of congenital choledochal cyst in a 6 months old korean female infant with complaints of abdominal distension, jaundice, loose stool and a large mass of the abdomenin the right upper quadrant since about 3 months prior to admission. The diagnosis was confirmed by clinical symptoms and signs, physical examination, radiological findings and surgical findings. She was operated with good result and discharged in well condition 28 days after. The review of the related literature was made briefly.