Early and Intermediate Outcomes of Laparoscopic Surgery for Choledochal Cysts with 400 Patients

Early and Intermediate Outcomes of Laparoscopic Surgery for Choledochal Cysts with 400 Patients

Early and Intermediate Outcomes of Laparoscopic

Surgery for Choledochal Cysts with 400 Patients

Nguyen Thanh Liem, MD, PhD, Hien Duy Pham, MD, Le Anh Dung, MD,

Tran Ngoc Son, MD, PhD, and Hoan Manh Vu, MD

Abstract

Objective: The aim of this study is to report early and intermediate outcomes of laparoscopic surgery for choledochal cysts with 400 cases

Patients and Methods: The operation was performed using four ports The cystic duct was identified and divided The liver was suspended by two stay-sutures: one on the round ligament and the other on the distal cystic duct The choledochal cyst was isolated and removed completely, and biliary–digestive continuity was reestablished by hepaticoduodenostomy (HD) or hepaticojejunostomy (HJ)

Results:From January 2007 to June 2011, 400 patients were operated on There were 305 girls and 95 boys Ages ranged from 1 month to 16 years (mean, 47.5 – 2.1 months) Cystic excision and HD were performed in 238 patients and HJ in 162 patients The mean operating time was 164.8 – 51 minutes for the HD group and 220 – 60 minutes for the HJ group Conversion to open surgery was required in 2 patients There were no perioperative deaths Postoperative biliary leakage occurred in 8 patients (2%), resolving spontaneously in 7 and requiring a second operation in 1 patient The mean postoperative hospital stay was 6.4 – 0.3 days for the HD group and 6.7 – 0.5 days for the HJ group Follow-up between 5 months and 57 months postdischarge (mean, 24.2 – 2.7 months) was obtained in 342 patients (85.5%) Cholangitis occurred in 5 patients (1.5%) in the HD group and 1 patient (0.6%) in the HJ group Gastritis due to bilious reflux was 3.8% in the HD group

Conclusions:Laparoscopic repair is a safe and effective procedure for choledochal cyst The rate of cholangitis and anastomotic stenosis is low

Introduction

Choledochal cyst is a rare diseasein Europe and the

United States but is a common one in Asia Cystectomy

and biliodigestive anastomosis have become a standard

treatment for this condition Laparoscopic operation for

cho-ledochal cyst was first introduced by Farello et al.1in 1995

Since then, this approach has been used in many centers.2–17

Since 2007, laparoscopic surgery has been routinely used in

our hospital for choledochal cyst.11The aim of this study is to

present early and intermediate outcomes of laparoscopic

surgery for choledochal cyst with 400 cases

Patients and Methods

Criteria for inclusion

All children from 1 month to 16 years old with choledochal

cyst of Type I or IVa according to the Todani classification

who underwent laparoscopic repair for choledochal cyst from

January 2007 to June 2011 at the National Hospital of Pedia-trics, Hanoi, Vietnam, were included

Criteria for exclusion Patients with biliary atresia Type I were excluded La-paroscopic operation was not indicated for patients with perforated cyst or previous biliary surgery

Procedures From January 2007 to November 2007, cystectomy plus hepaticoduodenostomy (HD) was carried out From Decem-ber 2007 to June 2010, both techniques of HD and hepatico-jejunostomy (HJ) were performed Cystectomies were performed by one of four senior laparoscopic surgeons All biliary–digestive anastomoses were performed by the same (most experienced) surgeon The main variables studied were patient age, cyst diameter, surgical technique, conversion rate,

Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam.

Volume 22, Number 6, 2012

ª Mary Ann Liebert, Inc.

DOI: 10.1089/lap.2012.0018

599

operative time, perioperative complications, and follow-up

results

Surgical techniques

Cystectomy plus HD The patient was placed in a 30

head-up supine position, with the surgeon standing at the

lower end of the table between the patient’s legs (Fig 1) A

10-mm trocar was inserted through the umbilicus for the

scope Three additional 5-mm trocars (or 3-mm for infants)

were placed for instruments: one at the right flank, one at the

left flank, and the fourth 2 cm below the left costal margin

A carbon dioxide pneumoperitoneum was maintained at a

pressure of 8–12 mm Hg The liver was suspended from the

abdominal wall by a suture placed at the round ligament The

cystic artery was isolated, clipped, and divided The cystic

duct was also isolated, clipped, and divided A second

trac-tion suture was placed at the distal cystic duct and gallbladder

to elevate the liver and to expose the liver hilum (Fig 2) The

midportion of the cyst was dissected circumferentially

Se-paration of the left and posterior wall of the cyst from the

hepatic artery and portal vein was meticulously and

pro-gressively carried out until a dissecting forceps could be

passed through the space between the posterior wall of the

cyst and the portal vein, going from the left to the right side

(Fig 3)

The duodenum was retracted downward using an

intesti-nal grasper inserted through the left flank trocar The lower

part of the cyst was detached from surrounding tissue and

pancreatic tissue using a 3-mm dissecting forceps for

dissec-tion and cautery The distal cyst was removed progressively

and then opened longitudinally to identify the opening of the

choledochus to the common biliopancreatic channel A small

catheter was inserted into the common channel to irrigate

with normal saline to eliminate debris and biliary stones

(Fig 4) The distal choledochus was then clipped and divided

(Fig 5) The upper part of the cyst was further dissected up to

the common hepatic duct and divided under the cystic duct

The orifices of the common hepatic duct and the right and left

hepatic ducts were inspected internally and identified The

upper part of the cyst was then divided from the common

hepatic duct 5–10 mm under the hepatic bifurcation The

hepatic ducts were also irrigated via the small catheter to eliminate debris and biliary stones The duodenum was mo-bilized, and an HD was constructed 2 cm from the pylorus using running sutures (if the diameter of the common hepatic duct was larger than 1 cm) or with polydioxanone 5/0 inter-rupted suture (if the diameter was smaller than 1 cm)

A cholecystectomy was then carried out Different parts of the cyst were removed through the 10-mm trocar A sub-hepatic drain was inserted

Cystectomy plus HJ The patient and trocars were posi-tioned the same way as for complete cyst excision plus HD The ligament of Treitz was identified by laparoscopy A 5/0 silk stay-suture was placed 30.0 cm distal to the ligament of Treitz A second 5/0 polydioxanone suture was placed 2.0 cm below the first suture to mark the jejunal limb, which would later be anastomosed to the hepatic duct The jejunal segment with two sutures was grasped with an intestinal grasper The trocar at the umbilicus was withdrawn The transumbilical vertical incision was extended 1.0 cm above the umbilicus The jejunum was exteriorized, and the jejunojejunostomy was

FIG 1 Patient position

FIG 2 Second traction suture

FIG 3 A dissecting forceps passes through the space be-tween the posterior wall of the cyst and portal vein

carried out extracorporeally The jejunum was then

re-introduced into the abdominal cavity The extended incision

was closed The laparoscopic instruments were repositioned,

and the choledochal cyst was dissected and removed The

Roux limb was brought retrocolic to the porta hepatis An HJ

was fashioned

Results

From January 2007 to June 2010, laparoscopic cystectomy

and biliodigestive anastomosis were performed for 400

chil-dren with choledochal cysts, including 305 girls and 95 boys

The patient mean age was 47.5 – 2.1 months (range, 1 month–

192 months) Clinical manifestations on admission are

pre-sented in Table 1

The mean diameter of choledochal cysts on ultrasound was

47.8 mm (range, 10–170 mm) One hundred sixty-three

pa-tients had preoperative associated intrahepatic dilatation of

biliary ducts, and 237 had no associated intrahepatic

dilata-tion Cystic diameter was not different between patients in the

HD and HJ groups (47.5 – 15.4 mm versus 48.3 – 16 mm,

respectively)

Cystectomy plus HD was performed in 238 patients and cystectomy plus HJ in 162 patients

Three different techniques of cystectomy were carried out:

 Dissection and division of the cyst in the middle before removing the distal and proximal parts in 249 patients (62.2%)

 Opening the front wall of the cyst and separating the cyst from the portal vein while viewing inside and outside the cyst in 105 patients (26.3%)

 Dissection and division of the cyst from the distal end before dissecting the middle and upper parts in 46 pa-tients (11.5%)

Perforation of the right hepatic duct occurred in 1 patient and was laparoscopically closed with 6/0 Vicryl

suture (Ethicon) Transection of two hepatic ducts was done in 3 patients, and ductoplasty was carried out before performing

HD in 2 patients Laparoscopic HJ at two different sites was performed in the third patient, in whom the distance between the two hepatic ducts was too great to bring them together A twist of the Roux limb was detected and repaired lapar-oscopically during operation in 2 patients

Conversion to open surgery was required in 2 patients because of a common hepatic duct tear while performing HD

in one patient and because of long operative time in the other patient with a large and highly adhesive cyst

Mean operative time was 164.8 – 51 minutes in the HD group and 212 – 61 minutes in the HJ group The difference is significant (P < 01)

Intraoperative transfusion was required in 4 patients Postoperative biliary leakage occurred in 8 patients (2.0%):

4 patients in the HD group (1.7%) and 4 patients in the HJ group (2.5%) The difference is not significant (P = 31) One patient in the HD group required a second operation The leakage resolved with medical treatment in the remaining 7 patients Subhepatic fluid collection was seen in 2 patients (0.5%), which resolved after fluid aspiration under ultrasound guidance

All biliary leakage and fluid collection occurred before

2009 Pancreatic fistula occurred in 4 patients (1.0%) but re-solved with medical treatment There were no operative or postoperative deaths

Postoperative stay was 6.4 – 0.3 days in the HD group and 6.7 – 0.5 days in the HJ group The difference is not significant (P = 11)

Follow-up of 5–57 months (mean, 24.2 – 2.7 months) was obtained for 342 children (85.5%), including 207 patients in the HD group and 135 patients in the HJ group Cholangitis occurred in 5 patients in the HD group Of these 5 patients, 3 patients required a second operation (2 patients due to

FIG 4 A small catheter is inserted into the common

channel

FIG 5 The distal choledochus is clipped and divided

Table1 Clinical Manifestations (n = 400)

anastomotic stricture and 1 patient due to stenosis of the

he-patic bifurcation and intrahehe-patic stones) One patient with

anastomotic stenosis was successfully treated by

transcutane-ous balloon dilatation All anastomotic stenoses happened in

patients who underwent their first operation before January

2008

One patient in the HJ group had cholangitis The rate of

cholangitis is not significantly different between the two

groups (P = 24) Duodenal bleeding due to ulcer occurred in 1

patient in the HJ group but resolved with medical treatment

Gastritis owing to bilious reflux occurred in 8 patients in the

HD group (3.8%)

Discussion

Results from these 400 laparoscopic operations reveal that

laparoscopic surgery is feasible for choledochal cyst Only

2 cases (0.05%) required conversion to open surgery The

laparoscopic operation is indicated for most choledochal cysts

of Todani Type I and Type IVa except patients with previous

biliary surgery or perforated cyst Our results also

demon-strate that laparoscopic surgery is a safe approach for

chole-docal cysts The intraoperative complication rate is favorable

in comparison with open surgery.18All intraoperative

com-plications could be managed laparoscopically

Twisting of the Roux limb happened in the HJ group This

complication has also been reported in other series.19Careful

inspection of the Roux limb before performing the

anasto-mosis could prevent it A shorter intestinal loop is also

re-commended to avoid this complication.19

Transection of two hepatic ducts occurred in 3 patients in

our series and has also been reported in other series.6,7

Duc-toplasty in a double-barrel fashion could be carried out if the

distance between the two ducts is not too great HJ in two

different sites is an alternative when two hepatic ducts cannot

be brought together Internal inspection of the upper remnant

of the cyst to identify the orifice of the common hepatic duct

and right and left hepatic ducts is necessary to avoid this

complication

The rate of biliary leakage in our series was 2.0% and

de-creased with operator experience This complication has not

been seen in our center since 2009

Postoperative bleeding requiring reoperation did not occur

in any patient, possibly because of improved hemostasis

un-der laparoscopic magnification

The rate of postoperative complications in our series is

lower in comparison with open surgery.18,20

Follow-up varied from 5 to 57 months, demonstrating that

intermediate outcomes of laparoscopic operations for

chole-dochal cyst are satisfactory The rate of anastomotic stenosis

in our series was 0.87% This rate has varied from 9% to 24% in

different reports of results with open surgery.21–23All patients

with anastomotic stenosis underwent operation between

January 2007 and July 2008 This fact suggests that the rate of

anastomotic stenosis may depend on the surgeon’s skill

Ascending cholangitis is a great concern in HD However,

this rate was low in our series and not significant different in

comparison with that in HJ Gastritis due to bilious reflux was

only seen in the HD group

We presently perform HD at 3 cm instead of 2 cm from the

pylorus Whether the rate of reflux would be lower because of

this modification is a question for further research

Upper gastrointestinal bleeding due to duodenal ulcer oc-curred in 1 patient in the HJ group This complication was also reported by Martino et al.24

From our results we can conclude that laparoscopic surgery

is a safe approach for choledochal cyst The postoperative rates of cholangitis and anastomotic stenosis are low Acknowledgments

The authors thank Dr John Taylor, Clinical Associate Professor, Department of Pediatrics, School of Medicine, University of Washington, for his careful reading and valu-able comments on the manuscript

Disclosure Statement

No competing financial interests exist

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Address correspondence to: Nguyen Thanh Liem, MD, PhD

Department of Surgery National Hospital of Pediatrics 18/ 879 La Thanh Road Dong Da District, Hanoi

Vietnam

E-mail: liemnhp@hotmail.com