Surg Endosc DOI 10.1007/s00464-014-3667-7
and Other Interventional Techniques
Laparoscopic cyst excision and Roux-Y hepaticojejunostomy for children with choledochal cysts in China: a multicenter study Guoliang Qiao • Long Li • Suolin Li • Shaotao Tang • Bin Wang • Hongwei Xi Zhigang Gao • Qinlin Sun
•
Received: 16 December 2013 / Accepted: 31 May 2014 Ó Springer Science+Business Media New York 2014
Abstract Aims Laparoscopic hepaticojejunostomy (LH) for children with choledochal cyst (CDC) has become feasible and popular recently. The purpose of this study is to evaluate the safety and efficacy of LH for CDC in a large multicenter series. Patients and methods Medical records of 956 consecutive patients who underwent LH for CDC at seven academic institutions from June 2001 to May 2012 were retrospectively analyzed. Ultrasonography, upper gastrointestinal
G. Qiao L. Li (&) Department of Pediatric Surgery, The Capital Institute of Pediatrics, No. 2 Ya Bao Road, Beijing 100020, People’s Republic of China e-mail: [email protected] S. Li The Second Affiliated Hospital of Hebei Medical University, Shijiazhuang, People’s Republic of China S. Tang Xiehe Hospital of Huazhong University, Wuhan, People’s Republic of China B. Wang Shenzhen Children’s Hospital, Shenzhen, People’s Republic of China H. Xi Shanxi Provincial Children’s Hospital, Taiyuan, People’s Republic of China Z. Gao Zhejiang Provincial Children’s Hospital, Hangzhou, People’s Republic of China Q. Sun Suzhou Children’s Hospital, Suzhou, People’s Republic of China
contrast studies, and laboratory tests were performed during the follow-up period. Results A total of 956 patients of CDC treated with LH were identified and included in this study. Of these patients, there were no significant differences in age, gender ratio, and the subtypes of CDC among the seven centers. The operative time of all patients decreased significantly as time went by. Interestingly, the centers that began to perform LH earlier, like cohort A, B, and C, took much more time in the initial cases than the later centers. The postoperative complications included 12 (1.3 %) intra-abdominal fluid collection, 6 (0.6 %) anastomotic stenosis, 14 (1.5 %) bile leak, 8 (0.8 %) Roux loop obstruction and 4 (0.4 %) gastrointestinal bleeding, and one case developed intrahepatic stone formation; two mortalities occurred; one died of hyperkalemia, and the other one died of postoperative bleeding. No other complication occurred during the mean follow-up of 5.7 years (ranged from 4 month to 11 years). Conclusions We reported a multi-institutional series of LH in children with CDC. Our findings suggested that LH represents a feasible treatment option for CDC by offering reliable middle and long-term outcome, low surgical morbidity. Keywords Laparoscopy Hepaticojejunostomy Choledochal cysts Multicenter study
Choledochal cyst (CDC) is congenital dilatations of the extra and/or intrahepatic bile ducts that cause various hepatobiliary and pancreatic disorders. CDC is more prevalent in Asian countries than in western countries. The incidence of CDC and the estimated incidence of anomalous pancreatobiliary ductal union, which is thought to be the etiology of CDC, are high in Asian countries [1, 2]. Complete excision of the choledochal cyst is the first-line
123
Surg Endosc
and curative approach. Compared with the conventional open surgery for children with CDC, Laparoscopic cyst excision and hepaticojejunostomy (LH) for children with CDC have been becoming feasible and popular recently [3–5]. With the advent of finer instruments and the development of novel techniques, Laparoscopic cyst excision and hepaticojejunostomy, even the single-incision laparoscopic hepaticojejunostomy (SILH) have been increasingly applied in children with CDC [6–8]. However, in the whole country of China, LH has just been performed for a few years and began to replace the conventional open surgery. The purpose of this study was to investigate and compare the operation procedures and outcomes of the LH in children with CDC in seven different centers in China, and then confirm the safety and efficacy of LH for children with CDC in the whole country.
Patients and methods Study population In this retrospective multicentre study, data were collected in the period from June 1, 2001, to May 1, 2012. The study population consisted of 956 consecutive Chinese patients with CDC who underwent laparoscopic hepaticojejunostomy at seven major hospitals in various geographical areas of China. These hospitals were located in different cities throughout China, including Beijing, Shi jiazhuang, Wuhan, Shenzhen, Taiyuan, Hangzhou, and Suzhou. We analyzed clinical characteristics including sex, age at diagnosis, clinical symptoms at presentation, perioperative and postoperative laboratory values, postoperative complications, and disease related or other outcomes. Laparoscopic cyst excision and Rouxen-Y hepaticojejunostomy techniques These academic centers began to perform the LH at different time points. In our institution (the capital institute of pediatrics), we began to carry out the LH and SILH at 2001 and 2011, respectively. To our knowledge, we were the first center to perform LH and SILH in China, and therefore, we developed a project named laparoscopic surgery studying sessions (LSSS) to train pediatric laparoscopic surgeons around China. With respect to the LH techniques, almost all patients were operated by the same laparoscopic surgical approach performed by surgeons who had participated and learned at the LSSS, although they came from different cities and different surgical teams. The surgical techniques of LH and SILH were reported in our previous studies [6, 9].
123
Follow-up All patients were followed up 1, 3, 6, and 12 months postoperatively and at 6 months thereafter. Physical examination, abdominal ultrasonography, and laboratory tests were performed at each visit. The postoperative complications, such as pancreatitis, anastomotic stenosis, intrahepatic stone formation, and pancreatic calculi formation, were evaluated clinically and with appropriate investigations. Upper gastrointestinal contrast studies were performed 1, 6, and 12 months postoperatively to assess the presence and the extent of reflux from the loop into the biliary system. The age, operative time, postoperative complications, and perioperative laboratory values were analyzed. Statistic analysis Student’s t tests were used to compare the mean of the age, operative time in different time periods, and preoperative and postoperative laboratory values in each cohort. Chi-square tests were applied to compare the morbidities of postoperative complications among the seven cohorts. The data were analyzed using the GraphPad Prism 5 (Version 5.01, GraphPad Software, Inc., USA), and a two-sided p value of \0.05 was considered to be statistically significant.
Results Patients’ characteristics A total of 956 patients (255 males, 701 females) were included from seven different pediatric hospitals in the study. The mean age was 4.01 years (range 7 days–18 years). The demographic data for the seven centers are summarized in Table 1. Operation time Of the 956 patients, the mean operation time was 3.52 h (range 2.21–5.75 h). The operation time decreased significantly as the time went by in all the seven cohorts (Fig. 1). Of interest, the centers that began to perform LH earlier, like cohort A, B, and C, took much more time in the initial cases than the later centers (Fig. 1). This may be attributed to our project of LSSS and the accumulation of experiences of the earlier centers. After the year of 2010, the operation time in all seven centers took almost 3 h, except for a few cases with severe inflammation or extra bleeding. Short-term and long-term complications Postoperative liver function tests and serum amylase levels returned to normal after the LH in all the seven centers
2.75:1
4.3 (6 months –7 years)
22 (73.3 %)
2 (6.7 %)
6 (20 %)
2.56:1
4.5 (11 months –7 years)
24 (75 %)
2 (6.3 %)
6 (18.7 %)
3.14:1
4.2 (7 months–8 years)
41 (70.7 %)
7 (12.1 %)
10 (17.2 %)
2.29:1
3.5 (3 months–9 years)
44 (63.7 %)
9 (13.1 %)
16 (23.2 %)
(Fig. 2). Of 956 patients, there were 45 (4.7 %) postoperative complications within postoperative hospital stays. The incidences of complications in the different cohorts, including intra-abdominal fluid collection, anastomotic stenosis, bile leak, intrahepatic stone formation, intrahepatic reflux, cholangitis, pancreatic leak, pancreatic calculi formation, pancreatitis, adhesive intestinal obstruction, Roux loop obstruction, and gastrointestinal bleeding were showed in Table 2, respectively. In addition, there were no significant differences among these cohorts with respect to the incidence of complications.
27 (15.3 %)
V
IV
III
II
76 (17.7 %) Ic
22 (14.5 %)
139 (79.0 %)
10 (5.7 %) 12 (7.8 %) 23 (5.3 %) Ib
119 (77.7 %) 339 (77 %) Ia
Todani types
2.91:1
4.5 (4 months–12 years) 3.2 (2 months–8 years)
2.40:1 2.88:1
Fig. 1 Changing curves of operative time in different time periods of CDC children undergone laparoscopic hepaticojejunostomy (LH) in seven cohorts
Discussion
4.1 (7 days –18 years)
Female/male
Age at operation
Cohort E (58) Cohort D (69) Cohort C (176) Cohort B (153) Cohort A (438) Variables
Table 1 Demographic features of CDC children undergone laparoscopic hepaticojejunostomy (LH) in seven cohorts
Cohort F (32)
Cohort G (30)
Surg Endosc
Choledochal cysts are more prevalent in Asian countries than in western countries, according to the previous studies in Korea, Japan, and China [1, 2, 10]. Despite Farello et al. [11], first reported laparoscopic-assisted excision of cyst and hepaticojejunostomy in 1995, Laparoscopic hepaticojejunostomy was still challenging in the following decade, due to limitations of small operative space, risk of injury to vital structures, and poor tolerance in small children. After increasing number of centers started to adopt LH to treat CDC in children in recent years [3, 12, 13], LH has become popular and evolved at an unprecedented pace in the treatment of CDC in children. In China, since we reported the first larger series with 35 CDC children in 2004 [10], there have been many reports of laparoscopic surgery for CDC [14–16]. However, no study had been performed over the national level. For this purpose, we performed a multicenter study to evaluate the safety and efficacy of LH for CDC in China. Comparing with the conventional open surgery for children with CDC, laparoscopic excision of CDC has certain advantages [17]. Laparoscopy with its umbilicus-to-hepatic hilum direction of view provides a better vision of the deep anatomic structures, such as hepatic hilum, portal vein, and hepatic
123
Surg Endosc
Fig. 2 Perioperative liver function parameters and jaundice in patients undergone laparoscopic hepaticojejunostomy (LH) in seven cohorts. A Comparison of preoperative and postoperative of alanine (ALT) (p \ 0.001). B Comparison of preoperative and postoperative of total bilirubin (TBIL) (p \ 0.001)
Table 2 The incidences of postoperative complications of CDC children undergone laparoscopic hepaticojejunostomy (LH) in seven cohorts Variables
Cohort A (438)
Cohort B (153)
Cohort C (176)
Cohort D (69)
Cohort E (58)
Cohort F (32)
Cohort G(30)
Intra-abdominal fluid collection
2 (0.46 %)
1 (0.65 %)
3 (1.71 %)
1 (1.45 %)
3 (5.17 %)
1 (3.13 %)
1 (3.33 %)
Anastomotic stenosis
0 (0 %)
1 (0.65 %)
2 (1.14 %)
1 (1.45 %)
2 (3.45 %)
0 (0 %)
0 (0 %)
Bile leak
3 (0.68 %)
2 (1.31 %)
3 (1.71 %)
1 (1.45 %)
3 (5.17 %)
1 (3.13 %)
1 (3.33 %)
Intrahepatic stone formation
0 (0 %)
1 (0.65 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Intrahepatic reflux
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Cholangitis
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Pancreatic juice leak
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Pancreatic calculi formation
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Pancreatitis
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Adhesive intestinal obstruction
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Roux loop obstruction
2 (0.46 %)
1 (0.65 %)
2 (1.14 %)
2 (2.90 %)
1 (1.72 %)
0 (0 %)
0 (0 %)
Gastrointestinal bleeding
2 (0.46 %)
2 (1.31 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
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Surg Endosc
arteries. The magnified view from this direction (1) enables meticulous dissection, excision, and ligature and therefore prevents injuries to the biliary and pancreatic ducts; (2) promotes hemostasis and minimizes blood loss; and (3) facilitates anastomosis with precision and hence reduces bile leak, anastomotic stenosis, intrahepatic stone formation, and cholangitis. In our previous study, we have confirmed that LH is comparable or even superior to the conventional open surgery for children with CDC [9, 14], including reducing the period of intestinal exposure, decreasing postoperative ileus that leads to earlier commencement of feeding, and shortening the postoperative hospital stay and duration of drainage. Traditionally, the LH often is challenged by significantly prolonged operative time, which may be associated with increased operative and anesthetic risks and the postoperative complications. However, in this study, we explored the changing trends of the operative time in seven centers during more than 10 years. Admittedly, LH took long operative time at the beginning in the early cases, which was mainly due to caution and lack of experiences. The operative time gradually shortened after the surgical teams further mastered the surgical techniques. In order to promote the LH in the other central hospitals, we started the training project after we confirmed the safety and efficacy of LH in our institution. Until nowadays, in the more recent cases in the seven centers in different areas, the complete operation could be accomplished within 3 h, and the incidence of various complications are quite low. In conclusion, laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy can be done safely with good cosmetic and functional results by the experienced laparoscopic and biliary surgeons. The operative time has been shortened, and LH could be accomplished with lower morbidities of intraabdominal fluid collection, anastomotic stenosis, bile leak, intrahepatic stone formation, intrahepatic reflux, cholangitis, pancreatic leak, pancreatic calculi formation, pancreatitis, adhesive intestinal obstruction, Roux loop obstruction, and gastrointestinal bleeding. Our results also demonstrated that the overall level of LH for children with CDC have been raised in the whole country of China. In the future, SILH and robotic-assisted cyst excision and Roux-en-Y hepaticojejunostomy are likely to be adopted as an alternative way. Disclosures Drs. Guoliang Qiao, Long Li, Suolin Li, Shaotao Tang, Bin Wang, Hongwei Xi, Zhigang Gao, Qinlin Sun have no conflict of interest.
References 1. Miyano T, Yamataka A (1997) Choledochal cysts. Curr Opin Pediatr 9(3):283–288 2. Jang JY, Yoon YS, Kang MJ, Kwon W, Park JW, Chang YR, Ahn YJ, Cho JY, Han HS, Kim SW (2013) Laparoscopic excision
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of a choledochal cyst in 82 consecutive patients. Surg Endosc 27(5):1648–1652. doi:10.1007/s00464-012-2646-0 Jang JY, Kim SW, Han HS, Yoon YS, Han SS, Park YH (2006) Totally laparoscopic management of choledochal cysts using a four-hole method. Surg Endosc 20(11):1762–1765. doi:10.1007/ s00464-005-0565-z Santore MT, Deans KJ, Behar BJ, Blinman TA, Adzick NS, Flake AW (2011) Laparoscopic hepaticoduodenostomy versus open hepaticoduodenostomy for reconstruction after resection of choledochal cyst. J Laparoendosc Adv Surg Tech A 21(4):375–378. doi:10.1089/lap.2010.0478 Liem NT, Pham HD, le Dung A, Son TN, Vu HM (2012) Early and intermediate outcomes of laparoscopic surgery for choledochal cysts with 400 patients. J Laparoendosc Adv Surg Tech A 22(6):599–603. doi:10.1089/lap.2012.0018 Diao M, Li L, Dong N, Li Q, Cheng W (2012) Single-incision laparoscopic Roux-en-Y hepaticojejunostomy using conventional instruments for children with choledochal cysts. Surg Endosc 26(6):1784–1790. doi:10.1007/s00464-011-2110-6 Diao M, Li L, Cheng W (2013) Single-incision laparoscopic hepaticojejunostomy using conventional instruments for neonates with extrahepatic biliary cystic lesions. Surg Innov 20(3):214–218. doi:10.1177/1553350612446355 Diao M, Li L, Li Q, Ye M, Cheng W (2013) Single-incision versus conventional laparoscopic cyst excision and Roux-Y hepaticojejunostomy for children with choledochal cysts: a casecontrol study. World J Surg 37(7):1707–1713. doi:10.1007/ s00268-013-2012-y Diao M, Li L, Cheng W (2011) Laparoscopic versus Open Roux-enY hepatojejunostomy for children with choledochal cysts: intermediate-term follow-up results. Surg Endosc 25(5):1567–1573. doi:10. 1007/s00464-010-1435-x Li L, Feng W, Jing-Bo F, Qi-Zhi Y, Gang L, Liu-Ming H, Yu L, Jun J, Ping W (2004) Laparoscopic-assisted total cyst excision of choledochal cyst and Roux-en-Y hepatoenterostomy. J Pediatr Surg 39(11):1663–1666 Farello GA, Cerofolini A, Rebonato M, Bergamaschi G, Ferrari C, Chiappetta A (1995) Congenital choledochal cyst: video-guided laparoscopic treatment. Surg Laparosc Endosc 5(5):354–358 Lee H, Hirose S, Bratton B, Farmer D (2004) Initial experience with complex laparoscopic biliary surgery in children: biliary atresia and choledochal cyst. J Pediatr Surg 39(6):804–807 discussion 804-807 Ure BM, Schier F, Schmidt AI, Nustede R, Petersen C, Jesch NK (2005) Laparoscopic resection of congenital choledochal cyst, choledochojejunostomy, and extraabdominal Roux-en-Y anastomosis. Surg Endosc 19(8):1055–1057. doi:10.1007/s00464-0042191-6 Liuming H, Hongwu Z, Gang L, Jun J, Wenying H, Wong KK, Miao X, Qizhi Y, Jun Z, Shuli L, Li L (2011) The effect of laparoscopic excision vs open excision in children with choledochal cyst: a midterm follow-up study. J Pediatr Surg 46(4):662–665. doi:10.1016/j.jpedsurg.2010.10.012 Tang ST, Yang Y, Wang Y, Mao YZ, Li SW, Tong QS, Cao GQ, Zhao ZX (2011) Laparoscopic choledochal cyst excision, hepaticojejunostomy, and extracorporeal Roux-en-Y anastomosis: a technical skill and intermediate-term report in 62 cases. Surg Endosc 25(2):416–422. doi:10.1007/s00464-010-1183-y Wang B, Feng Q, Mao JX, Liu L, Wong KK (2012) Early experience with laparoscopic excision of choledochal cyst in 41 children. J Pediatr Surg 47(12):2175–2178. doi:10.1016/j.jped surg.2012.09.004 Diao M, Li L, Cheng W (2013) Role of laparoscopy in treatment of choledochal cysts in children. Pediatr Surg Int 29(4):317–326. doi:10.1007/s00383-013-3266-z
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and Other Interventional Techniques
Laparoscopic cyst excision and Roux-Y hepaticojejunostomy for children with choledochal cysts in China: a multicenter study Guoliang Qiao • Long Li • Suolin Li • Shaotao Tang • Bin Wang • Hongwei Xi Zhigang Gao • Qinlin Sun
•
Received: 16 December 2013 / Accepted: 31 May 2014 Ó Springer Science+Business Media New York 2014
Abstract Aims Laparoscopic hepaticojejunostomy (LH) for children with choledochal cyst (CDC) has become feasible and popular recently. The purpose of this study is to evaluate the safety and efficacy of LH for CDC in a large multicenter series. Patients and methods Medical records of 956 consecutive patients who underwent LH for CDC at seven academic institutions from June 2001 to May 2012 were retrospectively analyzed. Ultrasonography, upper gastrointestinal
G. Qiao L. Li (&) Department of Pediatric Surgery, The Capital Institute of Pediatrics, No. 2 Ya Bao Road, Beijing 100020, People’s Republic of China e-mail: [email protected] S. Li The Second Affiliated Hospital of Hebei Medical University, Shijiazhuang, People’s Republic of China S. Tang Xiehe Hospital of Huazhong University, Wuhan, People’s Republic of China B. Wang Shenzhen Children’s Hospital, Shenzhen, People’s Republic of China H. Xi Shanxi Provincial Children’s Hospital, Taiyuan, People’s Republic of China Z. Gao Zhejiang Provincial Children’s Hospital, Hangzhou, People’s Republic of China Q. Sun Suzhou Children’s Hospital, Suzhou, People’s Republic of China
contrast studies, and laboratory tests were performed during the follow-up period. Results A total of 956 patients of CDC treated with LH were identified and included in this study. Of these patients, there were no significant differences in age, gender ratio, and the subtypes of CDC among the seven centers. The operative time of all patients decreased significantly as time went by. Interestingly, the centers that began to perform LH earlier, like cohort A, B, and C, took much more time in the initial cases than the later centers. The postoperative complications included 12 (1.3 %) intra-abdominal fluid collection, 6 (0.6 %) anastomotic stenosis, 14 (1.5 %) bile leak, 8 (0.8 %) Roux loop obstruction and 4 (0.4 %) gastrointestinal bleeding, and one case developed intrahepatic stone formation; two mortalities occurred; one died of hyperkalemia, and the other one died of postoperative bleeding. No other complication occurred during the mean follow-up of 5.7 years (ranged from 4 month to 11 years). Conclusions We reported a multi-institutional series of LH in children with CDC. Our findings suggested that LH represents a feasible treatment option for CDC by offering reliable middle and long-term outcome, low surgical morbidity. Keywords Laparoscopy Hepaticojejunostomy Choledochal cysts Multicenter study
Choledochal cyst (CDC) is congenital dilatations of the extra and/or intrahepatic bile ducts that cause various hepatobiliary and pancreatic disorders. CDC is more prevalent in Asian countries than in western countries. The incidence of CDC and the estimated incidence of anomalous pancreatobiliary ductal union, which is thought to be the etiology of CDC, are high in Asian countries [1, 2]. Complete excision of the choledochal cyst is the first-line
123
Surg Endosc
and curative approach. Compared with the conventional open surgery for children with CDC, Laparoscopic cyst excision and hepaticojejunostomy (LH) for children with CDC have been becoming feasible and popular recently [3–5]. With the advent of finer instruments and the development of novel techniques, Laparoscopic cyst excision and hepaticojejunostomy, even the single-incision laparoscopic hepaticojejunostomy (SILH) have been increasingly applied in children with CDC [6–8]. However, in the whole country of China, LH has just been performed for a few years and began to replace the conventional open surgery. The purpose of this study was to investigate and compare the operation procedures and outcomes of the LH in children with CDC in seven different centers in China, and then confirm the safety and efficacy of LH for children with CDC in the whole country.
Patients and methods Study population In this retrospective multicentre study, data were collected in the period from June 1, 2001, to May 1, 2012. The study population consisted of 956 consecutive Chinese patients with CDC who underwent laparoscopic hepaticojejunostomy at seven major hospitals in various geographical areas of China. These hospitals were located in different cities throughout China, including Beijing, Shi jiazhuang, Wuhan, Shenzhen, Taiyuan, Hangzhou, and Suzhou. We analyzed clinical characteristics including sex, age at diagnosis, clinical symptoms at presentation, perioperative and postoperative laboratory values, postoperative complications, and disease related or other outcomes. Laparoscopic cyst excision and Rouxen-Y hepaticojejunostomy techniques These academic centers began to perform the LH at different time points. In our institution (the capital institute of pediatrics), we began to carry out the LH and SILH at 2001 and 2011, respectively. To our knowledge, we were the first center to perform LH and SILH in China, and therefore, we developed a project named laparoscopic surgery studying sessions (LSSS) to train pediatric laparoscopic surgeons around China. With respect to the LH techniques, almost all patients were operated by the same laparoscopic surgical approach performed by surgeons who had participated and learned at the LSSS, although they came from different cities and different surgical teams. The surgical techniques of LH and SILH were reported in our previous studies [6, 9].
123
Follow-up All patients were followed up 1, 3, 6, and 12 months postoperatively and at 6 months thereafter. Physical examination, abdominal ultrasonography, and laboratory tests were performed at each visit. The postoperative complications, such as pancreatitis, anastomotic stenosis, intrahepatic stone formation, and pancreatic calculi formation, were evaluated clinically and with appropriate investigations. Upper gastrointestinal contrast studies were performed 1, 6, and 12 months postoperatively to assess the presence and the extent of reflux from the loop into the biliary system. The age, operative time, postoperative complications, and perioperative laboratory values were analyzed. Statistic analysis Student’s t tests were used to compare the mean of the age, operative time in different time periods, and preoperative and postoperative laboratory values in each cohort. Chi-square tests were applied to compare the morbidities of postoperative complications among the seven cohorts. The data were analyzed using the GraphPad Prism 5 (Version 5.01, GraphPad Software, Inc., USA), and a two-sided p value of \0.05 was considered to be statistically significant.
Results Patients’ characteristics A total of 956 patients (255 males, 701 females) were included from seven different pediatric hospitals in the study. The mean age was 4.01 years (range 7 days–18 years). The demographic data for the seven centers are summarized in Table 1. Operation time Of the 956 patients, the mean operation time was 3.52 h (range 2.21–5.75 h). The operation time decreased significantly as the time went by in all the seven cohorts (Fig. 1). Of interest, the centers that began to perform LH earlier, like cohort A, B, and C, took much more time in the initial cases than the later centers (Fig. 1). This may be attributed to our project of LSSS and the accumulation of experiences of the earlier centers. After the year of 2010, the operation time in all seven centers took almost 3 h, except for a few cases with severe inflammation or extra bleeding. Short-term and long-term complications Postoperative liver function tests and serum amylase levels returned to normal after the LH in all the seven centers
2.75:1
4.3 (6 months –7 years)
22 (73.3 %)
2 (6.7 %)
6 (20 %)
2.56:1
4.5 (11 months –7 years)
24 (75 %)
2 (6.3 %)
6 (18.7 %)
3.14:1
4.2 (7 months–8 years)
41 (70.7 %)
7 (12.1 %)
10 (17.2 %)
2.29:1
3.5 (3 months–9 years)
44 (63.7 %)
9 (13.1 %)
16 (23.2 %)
(Fig. 2). Of 956 patients, there were 45 (4.7 %) postoperative complications within postoperative hospital stays. The incidences of complications in the different cohorts, including intra-abdominal fluid collection, anastomotic stenosis, bile leak, intrahepatic stone formation, intrahepatic reflux, cholangitis, pancreatic leak, pancreatic calculi formation, pancreatitis, adhesive intestinal obstruction, Roux loop obstruction, and gastrointestinal bleeding were showed in Table 2, respectively. In addition, there were no significant differences among these cohorts with respect to the incidence of complications.
27 (15.3 %)
V
IV
III
II
76 (17.7 %) Ic
22 (14.5 %)
139 (79.0 %)
10 (5.7 %) 12 (7.8 %) 23 (5.3 %) Ib
119 (77.7 %) 339 (77 %) Ia
Todani types
2.91:1
4.5 (4 months–12 years) 3.2 (2 months–8 years)
2.40:1 2.88:1
Fig. 1 Changing curves of operative time in different time periods of CDC children undergone laparoscopic hepaticojejunostomy (LH) in seven cohorts
Discussion
4.1 (7 days –18 years)
Female/male
Age at operation
Cohort E (58) Cohort D (69) Cohort C (176) Cohort B (153) Cohort A (438) Variables
Table 1 Demographic features of CDC children undergone laparoscopic hepaticojejunostomy (LH) in seven cohorts
Cohort F (32)
Cohort G (30)
Surg Endosc
Choledochal cysts are more prevalent in Asian countries than in western countries, according to the previous studies in Korea, Japan, and China [1, 2, 10]. Despite Farello et al. [11], first reported laparoscopic-assisted excision of cyst and hepaticojejunostomy in 1995, Laparoscopic hepaticojejunostomy was still challenging in the following decade, due to limitations of small operative space, risk of injury to vital structures, and poor tolerance in small children. After increasing number of centers started to adopt LH to treat CDC in children in recent years [3, 12, 13], LH has become popular and evolved at an unprecedented pace in the treatment of CDC in children. In China, since we reported the first larger series with 35 CDC children in 2004 [10], there have been many reports of laparoscopic surgery for CDC [14–16]. However, no study had been performed over the national level. For this purpose, we performed a multicenter study to evaluate the safety and efficacy of LH for CDC in China. Comparing with the conventional open surgery for children with CDC, laparoscopic excision of CDC has certain advantages [17]. Laparoscopy with its umbilicus-to-hepatic hilum direction of view provides a better vision of the deep anatomic structures, such as hepatic hilum, portal vein, and hepatic
123
Surg Endosc
Fig. 2 Perioperative liver function parameters and jaundice in patients undergone laparoscopic hepaticojejunostomy (LH) in seven cohorts. A Comparison of preoperative and postoperative of alanine (ALT) (p \ 0.001). B Comparison of preoperative and postoperative of total bilirubin (TBIL) (p \ 0.001)
Table 2 The incidences of postoperative complications of CDC children undergone laparoscopic hepaticojejunostomy (LH) in seven cohorts Variables
Cohort A (438)
Cohort B (153)
Cohort C (176)
Cohort D (69)
Cohort E (58)
Cohort F (32)
Cohort G(30)
Intra-abdominal fluid collection
2 (0.46 %)
1 (0.65 %)
3 (1.71 %)
1 (1.45 %)
3 (5.17 %)
1 (3.13 %)
1 (3.33 %)
Anastomotic stenosis
0 (0 %)
1 (0.65 %)
2 (1.14 %)
1 (1.45 %)
2 (3.45 %)
0 (0 %)
0 (0 %)
Bile leak
3 (0.68 %)
2 (1.31 %)
3 (1.71 %)
1 (1.45 %)
3 (5.17 %)
1 (3.13 %)
1 (3.33 %)
Intrahepatic stone formation
0 (0 %)
1 (0.65 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Intrahepatic reflux
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Cholangitis
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Pancreatic juice leak
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Pancreatic calculi formation
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Pancreatitis
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Adhesive intestinal obstruction
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
Roux loop obstruction
2 (0.46 %)
1 (0.65 %)
2 (1.14 %)
2 (2.90 %)
1 (1.72 %)
0 (0 %)
0 (0 %)
Gastrointestinal bleeding
2 (0.46 %)
2 (1.31 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
0 (0 %)
123
Surg Endosc
arteries. The magnified view from this direction (1) enables meticulous dissection, excision, and ligature and therefore prevents injuries to the biliary and pancreatic ducts; (2) promotes hemostasis and minimizes blood loss; and (3) facilitates anastomosis with precision and hence reduces bile leak, anastomotic stenosis, intrahepatic stone formation, and cholangitis. In our previous study, we have confirmed that LH is comparable or even superior to the conventional open surgery for children with CDC [9, 14], including reducing the period of intestinal exposure, decreasing postoperative ileus that leads to earlier commencement of feeding, and shortening the postoperative hospital stay and duration of drainage. Traditionally, the LH often is challenged by significantly prolonged operative time, which may be associated with increased operative and anesthetic risks and the postoperative complications. However, in this study, we explored the changing trends of the operative time in seven centers during more than 10 years. Admittedly, LH took long operative time at the beginning in the early cases, which was mainly due to caution and lack of experiences. The operative time gradually shortened after the surgical teams further mastered the surgical techniques. In order to promote the LH in the other central hospitals, we started the training project after we confirmed the safety and efficacy of LH in our institution. Until nowadays, in the more recent cases in the seven centers in different areas, the complete operation could be accomplished within 3 h, and the incidence of various complications are quite low. In conclusion, laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy can be done safely with good cosmetic and functional results by the experienced laparoscopic and biliary surgeons. The operative time has been shortened, and LH could be accomplished with lower morbidities of intraabdominal fluid collection, anastomotic stenosis, bile leak, intrahepatic stone formation, intrahepatic reflux, cholangitis, pancreatic leak, pancreatic calculi formation, pancreatitis, adhesive intestinal obstruction, Roux loop obstruction, and gastrointestinal bleeding. Our results also demonstrated that the overall level of LH for children with CDC have been raised in the whole country of China. In the future, SILH and robotic-assisted cyst excision and Roux-en-Y hepaticojejunostomy are likely to be adopted as an alternative way. Disclosures Drs. Guoliang Qiao, Long Li, Suolin Li, Shaotao Tang, Bin Wang, Hongwei Xi, Zhigang Gao, Qinlin Sun have no conflict of interest.
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