Current Practice of Laparoscopic Surgery for Choledochal Cyst in Children -a Survey on Opinion and Experience Among IPEG Members.

PURPOSE: Laparoscopic resection of choledochal cyst (CC) has become a popular approach. As the discussion about optimal treatment and technical strategies continues, we aimed to investigate perspectives of IPEG members. METHODS: An online survey was conducted in 2023 on behalf of the IPEG Research Committee. IPEG members were asked to complete an anonymous questionnaire that included 36 items on the management of CC. RESULT: 148 members responded to the survey (North America:49/Asia:44/Europe:23/South America:21/Others:11) and 116 completed all questions. Most surgeons (92.5%) operate on less than 5 cases annually. Diagnostic tools of choice were Magnetic Resonance Imaging (MRI, 95.9%) and ultrasonography (US, 74.5%). Regarding fusiform-type CC, operative indications were cyst size greater than 10 mm (68.9%), typical symptoms (78.5%), or anomalous pancreatico-biliary junction (63.8%). In unilateral intrahepatic biliary cysts (type IVa) cases, 81.3% of respondents do not perform a simultaneous liver resection with the initial cyst resection. While 22.0% resect the CC at diagnosis, even if asymptomatic, a larger group of surgeons (41%; 49/118) wait until the infant reaches six months. Intraoperative cholangiography and choledochoscopy are performed routinely by 38.9% and 13.7%, respectively. The majority (52.5%) ligates the common bile duct stump just below the CC. Laparoscopic reconstructions are performed by retrocolic hepatico-jejunostomy (48.3%) or hepatico-duodenostomy (45.8%) at similar rates, but when done open, 71.2% of respondents prefer retrocolic hepatico-jejunostomy. For the laparoscopic anastomosis, interrupted sutures with intracorporeal knot tying were most often utilized (48.3%). CONCLUSION: Inidividual pediatric surgeons treat a small number of patients with CC each year. Laparosopic and open reconstruction techniques vary, likely due to technical challenges. LEVEL OF EVIDENCE: III.

Bile duct injury after cholecystectomy: timing of surgical repair should be based on clinical presentation. The experience of a tertiary referral center with Hepp-Couinaud hepatico-jejunostomy.

Impact of timing of repair on outcomes of patients repaired with Hepp-Couinaud hepatico-jejunostomy (HC-HJ) after bile duct injury (BDI) during cholecystectomy remains debated. This is an observational retrospective study at a tertiary referral hepato-biliary center. HC-HJ was always performed in patients without sepsis or bile leak and with dilated bile ducts. Timing of repair was classified as: early (≤ 2 weeks), intermediate (> 2 weeks, ≤ 6 weeks), and delayed (> 6 weeks). 114 patients underwent HC-HJ between 1994 and 2022: 42.1% underwent previous attempts of repair at referring institutions (Group A) and 57.9% were referred without any attempt of repair before referral (Group B). Overall, a delayed HC-HJ was performed in 78% of patients; intermediate and early repair were performed in 17% and 6%, respectively. In Group B, 10.6% of patients underwent an early, 27.3% an intermediate, and 62.1% a delayed repair. Postoperative mortality was nil. Median follow-up was 106.7 months. Overall primary patency (PP) attainment rate was 94.7%, with a 5- and 10-year actuarial primary patency (APP) of 84.6% and 84%, respectively. Post-repair bile leak was associated with PP loss in the entire population (odds ratio [OR] 9.75, 95% confidence interval [CI] 1.64-57.87, p = 0.012); no correlation of PP loss with timing of repair was noted. Treatment of anastomotic stricture (occurred in 15.3% of patients) was performed with percutaneous treatment, achieving absence of biliary symptoms in 93% and 91% of cases at 5 and 10 years, respectively. BDI can be successfully repaired by HC-HJ regardless of timing when surgery is performed in stable patients with dilated bile ducts and without bile leak.

Risk factors and treatment strategy for clinical hepatico-jejunostomy stenosis defined with intrahepatic bile duct dilatation after pancreaticoduodenectomy: A retrospective study.

BACKGROUNDS/PURPOSE: The purpose of this study was to identify risk factors and establish a treatment strategy for clinical hepatico-jejunostomy stenosis defined with intrahepatic bile duct dilatation after pancreaticoduodenectomy. METHODS: The 443 patients who underwent PD from April 2006 to December 2015 were analyzed. Clinical characteristics were compared between patients with and without clinical HJ stenosis, and risk factors for clinical HJ stenosis were analyzed. In addition, the treatment and clinical course of patients with clinical HJ stenosis were retrospectively reviewed. RESULTS: Clinical HJ stenosis defined with intrahepatic bile duct dilatation was identified in 40 patients (9.0%). Multivariate analysis revealed that the independent risk factor for clinical HJ stenosis was the hepatic duct at surgery ≤8 mm. Endoscopic HJ stenosis was identified in 36 patients, and 31 patients were treated successfully with double balloon endoscopic retrograde cholangiography; five patients required re-anastomosis (n = 3) and percutaneous transhepatic biliary drainage (n = 2). Complete obstruction of HJ was found in five patients, and treatment with DB-ERC was successful in only one patient. CONCLUSION: The independent risk factor for clinical HJ stenosis was hepatic duct diameter ≤8 mm. Most cases of endoscopic HJ stenosis were treated successfully with DB-ERC, except in patients with complete obstruction.

Surgical Duct-to-Duct Reconstruction: an Alternative Approach to Late Biliary Anastomotic Stricture After Deceased Donor Liver Transplantation.

BACKGROUND: Bilio-enteric diversion is the current surgical standard in patients after deceased donor liver transplantation (DDLT) with a biliary anastomotic stricture failing interventional treatment and requiring surgical repair. In contrast to this routine, the aim of this study was to show the feasibility and safety of a duct-to-duct biliary reconstruction. PATIENTS: Between 2012 and 2019, we performed a total of 308 DDLT in 292 adult patients. The overall biliary complication rate was 20.5%. Patients with non-anastomotic or combined strictures were excluded from this analysis. Out of 273 patients after a primary duct-to-duct reconstruction, 20 (7.3%) developed late isolated AS. Seven of these patients failed interventional biliary treatment and required a surgical repair. RESULTS: Duct-to-duct reconstruction was feasible and successful in all patients. Liver function tests fully normalized and no patient required any form of biliary intervention after surgery. One patient with intraoperative cholangiosepsis was ICU bound for 5 days, and another patient with a subhepatic abscess required percutaneous drainage. There was no perioperative death. The median length of hospital stay was 8 (5-17) days. The median time of follow-up after relaparotomy was 1593 (434-2495) days. CONCLUSION: Duct-to-duct reconstruction is a feasible and safe option in selected patients requiring surgical repair for isolated AS after DDLT. This approach preserves the biliary anatomy and avoids the potential side effects of a bilio-enteric diversion.

Percutaneous transhepatic cholangiography in the era of magnetic resonance cholangiopancreatography: A prospective comparative analysis in preoperative evaluation of benign biliary stricture.

BACKGROUND AND AIM: Accurate anatomical delineation is the key before definitive repair for benign biliary stricture (BBS). The role of percutaneous transhepatic cholangiography (PTC) as a road map is less studied in the era of magnetic resonance cholangiopancreatography (MRCP). METHODS: A prospective observational study, performed between July 2012 and December 2013. All patients of post-cholecystectomy BBS were evaluated with MRCP and PTC prior to definitive repair. Findings of MRCP and PTC were compared with intraoperative details. RESULTS: Thirty patients with BBS were included in the study. MRCP was performed in all but PTC was amenable in 28 of 30 (93.3%) patients. PTC was comparable to MRCP in diagnosing stricture type (96.4% vs 89.3%), intrahepatic stones (75% vs 75%), and biliary anomalies (95.6% vs 100%). Additionally, PTC revealed internal biliary fistula in 4 (85.7% vs 61.4%; P value 0.04). PTC-related minor complications were noted in 2 (7.1%) patients. CONCLUSION: PTC is comparable to MRCP in diagnosing the stricture type, intrahepatic biliary stones, and biliary anomalies. Though comparable to MRCP, the authors could not reveal any additional information that could change the course of management in BBS.

Laparoscopic resection of choledochal cysts in adults: a series from Turkey.

OBJECTIVES: Choledochal cyst is a congenital disease in which surgical treatment is preliminary because of the potential for malignancy. In recent years, increase in technological developments and laparoscopic experience have popularised the use of laparoscopy in adult choledochal cyst surgery. This study aimed to present the results of eight adult patients undergoing laparoscopic choledochal excision surgery. MATERIAL AND METHODS: Patients who underwent laparoscopic choledochal cyst excision and hepatico-jejunostomy anastomoses between the years 2013 and 2018 were evaluated retrospectively. Demographic characteristics, preoperative and postoperative findings, pathological results and final condition of the patients were examined. RESULTS: Of the eight patients, three were males and five were females. Median age was 41.5 years (22-49). One of the patients had Type IVa and the rest had Type I choledochal cysts. Laparoscopic choledochal cyst excision, cholecystectomy, and hepatico-jejunostomy anastomoses were performed on all of the patients. One patient was converted to open surgery. Three patients had postoperative biliary leakage. Duration of the operations was determined as median 330 (240-480) minutes and blood loss was 50 (10-100) mL. Hospitalization of the patients was median 6 (4-23) days and follow-up time was median 20 (2-65) months. In the late period, cholangitis occured in a patient who was treated with medical therapy and there was no mortality in the follow-up period. CONCLUSION: We suggest that laparoscopic choledochal cyst excision in adults may be an alternative to open surgery due to the satisfactory results in the late period in spite of early problems like self-limiting bile leakage.

Comparative analysis of different hepatico-jejunostomy techniques for treating adult type I choledochal cyst.

OBJECTIVE: To compare Roux-en-Y hepatico-jejunostomy with complete resection of the cyst or incomplete resection with 1-cm remnant proximal cyst wall in treating adult type I choledochal cyst (CC). METHODS: The medical records of 267 adult patients with type I CC from January 1998 to December 2015 were reviewed retrospectively. Among them, 171 underwent Roux-en-Y hepatico-jejunostomy with complete resection (PBD 0-cm group) and 96 underwent Roux-en-Y hepatico-jejunostomy with 1-cm proximal cyst wall left (PBD 1-cm group). The short- and long-term post-operative complications were compared between the two groups. RESULTS: No significant difference was observed in operative time or anastomotic diameter between the two groups. The incidence of perioperative complications was significantly higher in the PBD 1-cm group than that in the PBD 0-cm group (28.1% vs 14.0%, p=0.005), especially post-operative cholangitis (7.3% vs 1.2%, p=0.021). The incidence of long-term post-operative complications was not significantly different, including anastomotic stricture, reflux cholangitis, intra-hepatic bile duct stones and bile leak (all p >0.05). Post-operative intra-pancreatic biliary malignancy occurred in one patient in the PBD 0-cm group at 25 months and one patient in the PBD 1-cm group at 5 month, respectively. Anatomical site malignancy was observed in one patient in the PBD 1-cm group at 10 months. CONCLUSION: Ease of performing anastomosis does not justify retaining a segment of choledochal cyst in type I CC due to its higher risk of post-operative complication and malignancy. A complete excision of the CC with anastomosis to the healthy proximal bile duct is necessary in treatment of type I CC.

Robotic Roux-en-Y Bilioenteric Reconstruction.

The authors report technical details of robotic bilioenteric reconstruction done for variable indications: choledochal cyst and biliary stricture. Robotic bilioenteric anastomosis as alternative to open reconstruction, offers advantages of minimal access surgery without compromising the precision of open surgery for hilar dissection and reconstruction. Both patients recovered uneventfully and remain symptom-free 18 and 15 months after surgery.

Transhepatic metallic stenting for hepaticojejunostomy stricture following laparoscopic cholecystectomy biliary injury: A case of successful 20 years follow-up.

Laparoscopic cholecystectomy is still associated with a considerable rate of biliary injuries and related strictures. Advances in interventional endoscopy and percutaneous techniques have made stenting a preferred treatment modality for the management of these strictures. We report successful 20 years of follow-up of a case of trans-hepatic metallic stenting (2 Gianturco(®) prostheses, 5 cm long, 2 cm in diameter) done for stenosed hepatico-jejunostomy anastomosis after laparoscopic CBD injury. Percutaneous transhepatic stenting and long-term placement of metallic stents need to be re-evaluated as a minimally invasive definitive treatment option for benign biliary strictures in patients with altered anatomy such as hepatico-jejunostomy or in whom re-operation involves high risk.

Iatrogenic bile duct injuries in kashmir valley.

Cholecystectomy is one of the commonest operations performed throughout the world and bile duct injury is the worst complication of this procedure. In a prospective and retrospective study 25 patients were seen in a tertiary care hospital over a period of 10 years. 72% of patients were referred from other hospitals. 48% of patients presented within one month of injury. Pain was the commonest presentation (92%) followed by jaundice (80%). Liver functions were deranged in 70% of patients, USG revealed biliary dilatation in 69.6% of patients. ERCP was done in 16 patients and revealed cut off of the common hepatic duct in 43.8% of patients. Intraoperative findings revealed adhesions in 96% of patients. 48% of patients had bile duct stricture. Roux-en-Y hepaticojejunostomy was the commonest procedure performed. All patients showed improvement in liver function after surgery. Wound infection was the commonest complication seen in 32% patients. 3 patients died in our series.

Surgical Treatment of Bile Duct Cancer at Hepatic Hilum: A Clinical Analysis of 60 Cases / 第三军医大学学报

The incidence ot bile duct cancer at hepatic hilum has a tendency to increase in recent years. This paper is to report 60 cases during a 10-year-period from 1975 to -1985. The cancer at the hepatic hilum (60 cases) made up 73% of all extrahepatic bile duct cancers(82 cases),and accounted for 1.65% of 3626 biliary operations done at the same period. The clinical manifestations of the patients could be categorized into three types, the presenting symptoms were obstructive jaundice in 29 cases, of which 25 had been misdiagnosed as infectious hepatitis; the symptoms of acute cholangitis were found in 12 cases; and in 14 cases, various symptoms and signs of biliary diseases had been found for a long time before the diagnosis was established as cancer. In the remaining 5 cases, miscellaneous manifestaions were revealed. The patients were examined with B-US(19 cases), ERCP(10 cases) and PTC(39 cases). The final diagnosis was established according to the findings of PTC and / or ERCP, surgical exploration, or histopathological examination.Surgery was performed on 56 cases. Only 6 out of the 56 received radical resection of the cancer with hemi-hepatectomy; palliative internal drainage of the bile duct was done on 15 cases, external drainage on 23 cases, and other palliative measures on 12 cases. The average survival time after operation was 24.5 months iu 6 cases with radical resection, 8.7 months in 48 cases with palliative measures, and only 5 months in 4 cases without surgical intervention. Ear- ly diagnosis is imperative if successful therapy is expected. It is suggested that a patient over 40 years of age, suffering from "infectious hepatitis" or obstructive jaundice, be watched out for the possibility of hilum cancer, and appropriate examinations such as B-US,CT,ERCP or PTC be carried out. It is emphasized that PTC plays an important role izi the diagnosis of hilum cancer. In severe cases, the intrahepatic bile ducts could be examined with PTC of the two sides at oae time. Exploratory laparotomy should be performed on suspected cases.

Cisto de colédoco: experiência de cinco anos com o tratamento cirúrgico no hospital municipal JESUS-RJ / Choledochal cyst: five-year experience with surgical treatment at hospital municipal JESUS-RJ

OBJETIVO: Relatar a experiência no diagnóstico e tratamento do cisto de colédoco no Hospital Municipal Jesus em cinco anos (1996-2001) e a experiência brasileira publicada para o tratamento do cisto de colédoco em crianças. MÉTODO: Avaliação prospectiva dos pacientes operados com o diagnóstico de cisto de colédoco em cinco anos no Hospital Municipal Jesus. RESULTADOS: Houve predomínio de casos diagnosticados pela presença de dor abdominal recorrente, icterícia e/ou massa abdominal palpável. Apenas dois pacientes apresentavam a tríade completa. Todos os pacientes foram submetidos à ultra-sonografia e houve dúvida no diagnóstico ultra-sonográfico em apenas dois. Todos eram cistos do tipo 1 de Todani tratados através de ressecção completa e anastomose biliodigestiva em Y Roux. Houve complicações pós-operatórias imediatas em três pacientes: um caso de hemorragia digestiva alta e dois casos de fístula biliar, um deles relacionado a problemas técnicos na anastomose que necessitou de reoperação. O seguimento variou de quatro meses a cinco anos, sem detecção de complicação tardia em nenhum caso. CONCLUSÕES: O tratamento do cisto de colédoco através da ressecção completa na criança é seguro, relacionado a poucas complicações e capaz de resolver por completo a sintomatologia pré-operatória dos pacientes.

BACKGROUND: Our objective is to evaluate prospectively the treatment and diagnosis of choledochal cysts in Hospital Municipal Jesus in a five-year period (1996-2001). METHOD: Prospective evaluation of patients operated on for choledochal cysts in Hospital Municipal Jesus during a five-year period. RESULTS: Patients generally presented recurring abdominal pain, jaundice or an abdominal tumor, but only two presented the complete triad. One patient was asymptomatic and was diagnosed fortuitouslly. All patients could be diagnosed by ultrasonography, and the method accomplished a doubtful diagnosis in only two cases. All cases were Todani's type 1 treated by total resection. There were three post-operative complications: an episode of digestive hemorrhage and two biliary fistulae, one clinically treated with success and one reoperated. Follow up varied between 4 months and 5 years and there weren't any late complications. CONCLUSION: Choledochal cysts must be treated electively by total resection as soon as they are diagnosed, and surgical resection is safe in children.