Choledochal Cyst Research Articles

Comparison of Surgical Outcomes of Laparoscopic and Robotic Surgery in Adult Choledochal Cysts.

Background: Minimally invasive surgery (MIS) for cyst excision and Roux-en-Y hepaticojejunostomy (HJ) is widely performed for adult choledochal cysts. Few articles compared the robotic and laparoscopic approaches for choledochal cysts. Methods: Between 2014 and 2022, 157 patients who underwent MIS for choledochal cysts were retrospectively analyzed. Perioperative outcomes of patients who underwent totally robotic surgery, robot-assisted surgery, and laparoscopic surgery were compared, respectively. Also, postoperative outcomes of patients with robotic reconstruction and laparoscopic reconstruction during HJ were compared. Results: Perioperative outcomes were comparable between robotic and laparoscopic groups. The suturing technique for the anterior and posterior walls of the HJ differed significantly between the robotic and laparoscopic reconstruction groups (P = .001). However, there were no significant differences in postoperative outcomes, including total complications (P = .304), major complications (P = .411), and postoperative interventions (P = .411), between the two groups. Conclusions: The robotic and laparoscopic approaches for adult choledochal cysts have comparable surgical outcomes. In the MIS era, robotic surgery could be an alternative surgical option for adult choledochal cysts.

Whole-Course Intraperitoneal Robot-Assisted Choledochal Cyst Excision with a Hidden Incision in Children Under 1 Year Old.

Background: Whole-course intraperitoneal robot-assisted choledochal cyst resection in children under 1 year of age is controversial due to its technical challenges. Current Pfannenstiel incision is widely used in adults for its cosmetic effects but is rarely used in children. Materials and Methods: We conducted a prospective, single-center study to assess the feasibility, safety, and cosmesis of whole-course intraperitoneal robot-assisted choledochal cyst resection with Pfannenstiel incision in children under 1 year of age. Results: Ten patients were treated with our surgical protocol, and there was no conversion to laparotomy. The average total operation time was 223 minutes. The average duration of anesthesia was 260.2 minutes. The average docking time between the robot arm and Trocar was 17.5 minutes. The average intraoperative blood loss was 16 mL. No postoperative complications occurred in the 10 patients. The mean time to start drinking water after surgery was 2.4 days. The mean postoperative drainage tube removal time was 2.6 days. The average length of stay was 8.5 days. The scar assessment scale total scores of the 2 observers were (6.8 ± 1.23) and (7.4 ± 1.84), respectively. For every patient, there are only four abdominal surgery scars of which 75% of scars were hidden by underpants and 25% of scars were not covered. Conclusion: It is feasible and safe to perform whole-courses intraperitoneal robot-assisted choledochal cyst resection with Pfannenstiel incision in children under 1 year old. It also has a hidden incision effect and is worthy of promotion.

Laparoscopic Hepatic Ductoplasty in Pediatric Choledochal Cyst: What Is the Role, Feasibility, and Outcome?-Systematic Review and Meta-Analysis.

Introduction: The pediatric choledochal cyst with hepatic duct stenosis occurs postoperative hepatolithiasis, recurrent cholangitis, or pancreatitis. The laparoscopic hepatic ductoplasty can prevent these incidences. Objectives: To determine the characteristic of hepatic duct stenosis, laparoscopic treatment, and outcomes in systematic review and meta-analysis. Methodology: We searched the published studies on PubMed, Scopus, and Cochrane Library databases from January 1985 to April 2022 in English language. This protocol was registered to PROSPERO (CRD42022332145). Results: Nine published studies and 412 patients were included. The meta-analysis revealed that the locations were the confluence of the left and right hepatic ducts 43.1%, the left or/and the right hepatic duct 8.3%, and the unclassified location 60.4%. These characteristics included a membranous/septum appearance (44.7%) and a circumferential/relative stenosis (22.7%). The laparoscopic techniques were the wide hilar Roux-en-Y hepaticojejunostomy (28.5%), the excision of membranes/septum (26.5%), and the mixed hepatic ductoplasty (45.0%). The outcomes revealed a minor bile leakage of 3.8% and minimal bleeding. The meta-analysis showed no statistical difference between laparoscopic and open techniques in hepatolithiasis (0% versus 2.00%), anastomosis stricture (4.83% versus 10.00%), and no recurrent cholangitis. There was no conversion rate but showed a trend the prolonged operating time in laparoscopy. Conclusion: Laparoscopic hepatic ductoplasty is safe and effective. The characteristics and location can be feasible laparoscopic procedures. So, hepatic ductoplasty decreases hepatolithiasis, anastomosis stricture, or recurrent cholangitis and may increase minor bile leakage. The systematic review registration was PROSPERO system with CRD42022332145.

Acute pancreatitis in childhood - a comparative international study and tale of two cities.

To compare factor(s) contributing to aetiology, management and clinical outcome(s) of paediatric patients acquiring acute pancreatitis (AP) at two major university paediatric surgical centres in Liverpool and Bangkok. All patients (<18 years) with an index diagnosis of AP (ICD 10 coding) during 2006-2016 were studied. 121 patients included n = 79 (65.3%) in Thailand versus n = 42 (34.7%) in the UK centre with no difference(s) in age at diagnosis at 10.4 ± 4.5 and 11.7 ± 6 years. (P = 0.12). Major AP aetiology(s) in Thailand were medications (39.2%) and choledochal cysts (8.9%). In the UK-gallstone disease (21.4%), and medications (16.7%) were leading factors (P < 0.01). Ultrasonography was deployed more frequently in the UK versus Thai centre (74.3% vs. 49.1%; P < 0.01). Pancreatitis was confirmed by imaging in 67.9% (Thai) and 62.9% (UK) patients (P = 0.47). Most patients at both centres had a mild-grade pancreatitis illness (95% Thai vs. 90.5% UK; P = 0.28) while 12.7% of Thai and 19% of UK children developed pancreatitis-related complication (P = 0.37). Overall mortality rate (%) was significantly higher in the Thai versus UK centre (27.8% vs. 9.5%; P = 0.02). Aetiology of acute pancreatitis appears to vary between UK and Thailand children. Timely early diagnosis and healthcare pathways may be driven by local patient-related factor(s). The higher mortality (%) observed in Thailand versus UK in this comparative study was linked to underlying co-existent chronic medical condition(s) in vulnerable patient cohorts.

The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience.

Benign biliary disease (BBD) is a prevalent condition involving patients who require extrahepatic bile duct resections and reconstructions due to nonmalignant causes. This study followed all patients who underwent biliary resections for BBD between 2015 and 2023. We excluded those with malignant conditions and patients who had an 'open' operation. Based on the patient's anatomy, the procedures employed were either robotic Roux-en-Y hepaticojejunostomy (RYHJ) or robotic choledochoduodenostomy (CDD). From the 33 patients studied, 23 were female, and 10 were male. Anesthesiology (ASA) class was 3±0.5; the MELD score was 9±4.1; the Child-Pugh score was 6±1.7. The primary indications for undergoing the operation included iatrogenic bile duct injuries, biliary strictures, and type 1 choledochal cysts. The average surgical duration was about 272min, and the average blood loss amounted to 79mL. Postoperatively, three patients experienced major complications, all attributed to anastomotic leaks. The average hospital stay was 4days, with a readmission rate of 15% within 30days. During an average follow-up period of 33months, one patient had to undergo a revision at 18months due to stricture. This necessitated further duct resection and reanastomosis. Notably, there were no reported hepatectomies, no conversion to the 'open' method, no intraoperative complications, and no mortalities. Robotic extrahepatic bile duct resection and reconstruction with Roux-en-Y hepaticojejunostomy or choledochoduodenostomy is safe with an acceptable postoperative morbidity, short hospital length of stay, and low postoperative stricture rate at intermediate duration follow-up.

Association Among Cystic Volume, Intracystic Pressure, and Histopathological Changes in the Liver in Patients With Choledochal Cyst.

Background Choledochal cyst is a congenital cystic dilatation of the biliary tree. Various aspects of pathophysiology are unclear, particularly with reference to intracholedochal cystic pressure (ICCP) and liver histopathology. This study aimed to determine the relationship among cystic volume, ICCP, and histopathological changes in the liver in patients with choledochal cysts. Methods This cross-sectional study was carried out among 21 patients diagnosed with choledochal cysts, who attended the Department of Pediatric Surgery at Bangabandhu Sheikh Mujib Medical University (BSMMU) from April 2021 to August 2022. Cystic volume was measured pre-operatively using ultrasonography, while ICCP was measured per-operatively with a pressure gauge. Liver histology was assessed through an intraoperative liver biopsy and graded using the meta-analysis of histological data in viral hepatitis (METAVIR) scoring system. The data were analyzed using SPSS version 25.0 (IBM Corporation, Armonk, New York). Frequency and percentages were calculated to present categorical variables, and for quantitative variables, mean, standard deviation (SD), median, and interquartile range (IQR) were calculated. Fisher's exact tests were performed to determine the association between cystic volume, ICCP, and the grading of hepatic fibrosis. A p-value of <0.05 was considered statistically significant. Results The age of the patients ranged from 1 to 12 years, with a mean of 5.0±3.4 years. The male-to-female ratio was 1:4.3. Type I cysts were the most prevalent (71.4%). The median and IQR for cystic volume were 3.4 ml and 1.1-8.2 ml, respectively. The median and IQR for ICCP were 7.46 mmHg and 4.67-9.33 mmHg, respectively. The most frequent grade of fibrosis was F1 (38.1%), followed by F2 (23.8%) and F3 (23.8%). A negative relationship between cystic volume and ICCP was observed, which was statistically significant (p=0.008). A positive relationship was also observed between ICCP and the grading of liver fibrosis, which was statistically significant (p=0.002). Although a negative correlation between cystic volume and grading of liver fibrosis was noted, it was not statistically significant (p=0.198). Conclusions This study reveals significant associations between cystic volume, ICCP, and the grading of liver fibrosis in patients with choledochal cysts. Smaller volume cysts may exhibit higher ICCP, resulting in more pronounced fibrotic changes in the liver.

Choledochal Cyst (CC) Todani type I in two years old girl: a case report

Backgrounds: Choledocal cyst (CC) is a rare congenital cystic dilation of the bile duct and can be associated with severe complications, including malignancy and inflammation of the surrounding anatomy. Approximately 80% of CC is diagnosed in infants and young children in the first decade of life. Complete surgical resection is recommended in patients with choledochal malformations with excellent outcomes. Case Presentation: A two-year-old girl had intermittent abdominal pain in the upper right quadrant. This complaint was accompanied by fever, nausea and vomiting, decreased appetite and drinking. The physical examination revealed jaundice on the sclera and palpable liver, two fingers below the costal arch. Abdominal ultrasound revealed a cystic mass in the right lower lobe suggestive of the hepatic cyst with inflammation of the cystic head of the pancreas and minimal free fluid per lumen. An abdominal C.T. scan without contrast showed a choledochal cyst classified as Todani Type IV. A cyst in the bile duct was found during the surgical procedure Conclusion: Choledocal cyst is one of the differential diagnoses in children with symptoms of abdominal pain. Appropriate surgical measures should be undertaken to avoid complications.

Percutaneous Ultrasound Cholangiography With Microbubbles in Children With Biliary Diseases.

The application of intracavity contrast-enhanced ultrasound in the evaluation of biliary disease has been confirmed valuable among pediatric population. This pictorial essay aims to demonstrate the role of percutaneous ultrasound cholangiography (PUSC) with microbubbles in the diagnosis of different pediatric biliary diseases in our center. The biliary system's morphologic characteristics in PUSC mode of neonatal hepatitis, biliary atresia, choledochal cysts, and biliary complications of hepatobiliary surgery are presented.

Prospective evaluation of common hepatic duct histopathology at the time of choledochal cyst excision ranging from children to adults.

To evaluate common hepatic duct just distal to the HE anastomosis (d-CHD) prospectively for mucosal damage, inflammation, fibrosis, dysplasia, carcinoma in situ, malignant transformation, effects of serum amylase, and symptoms at presentation in CC cases ranging from children to adults. Cross-sections of d-CHD obtained at cyst excision 2018-2023 from 65 CC patients; 40 children (< 15years old), 25 adults (≥ 15) were examined with hematoxylin and eosin, Ki-67, S100P, IMP3, p53, and Masson's trichrome to determine an inflammation score (IS), fibrosis score (FS), and damaged mucosa rate (DMR; damaged mucosa expressed as a percentage of the internal circumference). Mean age at cyst excision ("age") was 18.2years (range: 3months-74years). Significant inverse correlations were found for age and DMR (p = 0.002), age and IS (p = 0.011), and age and Ki-67 (p = 0.01). FS did not correlate with age (p = 0.32) despite significantly increased IS in children. Dysplasia was identified in a 4-month-old girl with cystic CC. Serum amylase was elevated in high DMR subjects. High DMR, high IS, and evidence of dysplasia in pediatric CC suggest children are at risk for serious sequelae best managed by precise histopathology, protocolized follow-up, and awareness that premalignant histopathology can arise in infancy.

Optimal timing of surgery for prenatally diagnosed choledochal cysts

ObjectiveCholedochal cysts are increasingly being diagnosed antenatally. The appropriate time of surgical treatment has the greatest impact on the prognosis of choledochal cyst treatment. The purpose of this study was to compare the clinical outcomes of prenatally diagnosed choledochal cysts in infants according to the surgical treatment timing.MethodsWe retrospectively reviewed the medical records of infants who underwent surgery for choledochal cysts with antenatal diagnoses. We investigated each patient's demographic information, type of choledochal cyst, serum liver enzyme levels, and surgical outcomes according to the surgical intervention timing.ResultsBetween May 2006 and December 2020, 93 infants underwent surgery to treat choledochal cysts; among them, 68 had antenatally suspected choledochal cysts. Of the 68 patients, 21 developed symptoms directly after birth. While 38 patients remained asymptomatic, 9 developed symptoms before operation. To compare surgical outcomes, asymptomatic patients were divided into early (13 cases) and late (25 cases) operation groups based on an age benchmark of 30 days. The early surgical group experienced longer times to resume a full diet (6.0 ± 1.6 vs. 4.5 ± 0.7, p &amp;lt; 0.001) and longer postoperative hospital stays (11 ± 3.9 vs. 7.5 ± 0.8, p &amp;lt; 0.001). Surgical complications occurred in two patients in the early operation group. Minimally invasive surgery was performed in 12 patients in the late operation group. In both groups, postoperative liver function recovered at 6 months, with no significant difference.ConclusionThe results of this study showed longer hospital stays, increased diet durations, and postoperative complications in early surgery patients. However, liver function recovery was not different between the early and late operation groups. Thus, asymptomatic patients should be closely monitored, and we recommend that definitive surgical intervention be postponed until 4 months of age or until weight reaches 7 kg.

Comparison of robotic assistance and laparoscopy for pediatric choledochal cyst: advantages of robotic assistance.

Surgery for pediatric choledochal cyst (CC), complete excision (CE), and Roux-en-Y hepaticojejunostomy anastomosis (HJA) can be performed using laparoscopy (Lap), robotic-assistance (Rob; da Vinci Xi/Si), or both (Lap/Rob). Lap was used exclusively between 2009 and 2021 (n = 31) and Rob was introduced in 2017 (n = 23). All subjects were matched for age, weight, BMI, and episodes of preoperative pancreatitis. For Rob, the first 15/23 were Lap-CE/Rob-HJA and the last 8/23 were Rob-CE/Rob-HJA. Total anastomotic time (TAT), TAT per suture during HJA, and time taken for dissection during CE were significantly shorter with less variance for Rob, although overall operative times were similar. Serum amylase on postoperative days 3, 5, and 7 were significantly higher for Lap. Times taken to ambulate, for return of bowel sounds, and discharge home were all significantly shorter for Rob. All postoperative complications occurred after Lap; HJA leak (n = 1; 3.2%), HJA stricture (n = 1; 3.2%), both treated by open re-HJA; and pancreatic fistula (n = 6; 19%), all treated conservatively. Dissection and recovery were faster with Rob while overcoming Lap-associated shortcomings to prevent complications associated with suturing. Both CE and HJA were safer and more reliable with Rob, a reflection of Rob's superiority.

Extrahepatic bile duct fibroma in an infant: a case report

BackgroundExtrahepatic bile duct tumor in neonates and infants is extremely rare. Fibroma in neonates and infants has been reported in different body parts but not in the bile duct. We report a 2-month-old girl with common bile duct (CBD) fibroma.Case presentationA 2-month-old girl presented with jaundice and pale stool for 15 days. Her perinatal period was uneventful. On examination, we found the girl deeply icteric and having hepatomegaly but no palpable lump. Laboratory investigations revealed direct hyperbilirubinemia with elevated liver enzymes. Ultrasonography revealed hepatomegaly with focal dilatation of the extrahepatic bile duct (2.1 × 0.5 cm). Our preliminary diagnosis was a type I choledochal cyst. Considering the clinical scenario, we planned for exploration without further imaging. On exploration, we found the liver blackish and a hard mass involving the common CBD and cystic duct. The gall bladder was filled with clear mucus. After excising the mass, the gall bladder, and CBD, we reconstructed the anatomy with Roux-N-Y hepaticojejunostomy. The postoperative period was uneventful except for minor bile leakage during the first four postoperative days, which stopped spontaneously. Histopathology revealed spindle-shaped fibrous tissue admixed with collagenous tissue, compatible with a fibroma. A liver biopsy showed the features of cirrhosis. However, liver function tests were normal 2 weeks after surgery. The baby was thriving at 6 months of follow-up, hepatomegaly was resolved, and there was no clinical or radiological sign of recurrence.ConclusionsCBD fibroma is a rare cause of obstructive jaundice in neonates and infants. The earliest possible excision of the tumor and bile drainage restoration are necessary to halt the progression of liver damage.

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

Hepaticojejunostomy anastomosis (HJA) is the most challenging aspect in single-port laparoscopic choledochal cystectomy and Roux-en-Y hepaticojejunostomy (SPCH) in children, especially in small-diameter anastomoses (diameters less than 5 mm), which are more susceptible to anastomotic stricture. We developed the continuous submucosal technique for HJA (CS-HJA) to lessen postoperative complications. The purpose of this study is to introduce our preliminary experiences with CS-HJA. We retrospectively analyzed all available clinical data of children who underwent SPCH surgery between March 2020 and October 2022. We operated with CS-HJA on 10 children who were diagnosed with small-diameter hepaticojejunostomy (diameter less than 5 mm). Data collection mainly included demographic information, imaging data, perioperative details, and postoperative outcomes. Ten patients were included in this study. The average patient age was 55.2 months; the age range was 3 to 120 months, and the average weight was 11.6 kg; male-female ratio was 1:9. The choledocho had fusiform dilatation in five cases and cystic dilatation in five cases. There was no dilatation of the left and right hepatic ducts or intrahepatic bile ducts in all patients. All patients had no dilatation of the left and right hepatic ducts or intrahepatic bile ducts. All patients underwent a single-port laparoscopic bile-intestinal anastomosis using a submucosal jejunal anastomosis technique. Analysis of the duration of the bile-intestinal anastomosis, the length of the child's stay in the hospital after surgery, the intraoperative complications, and the postoperative complications was performed. All the 10 patients underwent successful SPCH by CS-HJA technique. The average length of time for hepaticojejunostomy ranged from 22 to 40 minutes, and the postoperative hospital stay was 5.2 to 9.2 days. There were no instances of bile leakage following the operation. At 17 to 30 months of follow-up, there was no abdominal pain or jaundice, and the reexamination of transaminases, bilirubin, and amylase were normal. Ultrasonography showed no bile duct stricture or dilated bile ducts, and the incision is elegant, and the families of the patients were satisfied. In SPCH surgery in children, the CS-HJA technique is safe and feasible for small-diameter hepaticojejunostomy.

New epidemiologic trends in cholangiocarcinoma.

Cholangiocarcinoma (CCA) is the most common biliary tract malignancy and the second most frequent primary hepatic malignancy after hepatocellular carcinoma. During the past three decades, the incidence of intrahepatic cholangiocarcinoma (iCCA) has risen in Western Europe, while the incidence of extrahepatic cholangiocarcinoma (eCCA) has remained stable or fallen. The mortality rates of iCCA, which are greater than those of eCCA, showed also an increasing trend, while those of eCCA remained stable. Well-known risk factors like hepatobiliary flukes, hepatolithiasis and choledochal cysts are important in the development of iCCA particularly in Asian countries. In Western countries, the primary sclerosing cholangitis is the most common risk factor for CCA. Hepatitis B virus (HBV) or hepatitis C virus (HCV) infection and cirrhosis are considered to be risk factors for iCCA. Emergent risk factors such as obesity, diabetes and MAFLD are increasingly associated mostly with iCCA.

Multidetector computed tomography evaluation of obstructive jaundice: a cross-sectional study from a tertiary hospital of Nepal

Background: The utilization of advanced multidetector computed tomography (MDCT) technology along with postprocessing reconstruction techniques has significantly enhanced the clarity of visualization of the hepato-biliary tree. Therefore, this study was conducted to evaluate the diagnostic statistics of MDCT and its associated features in the evaluation of obstructive jaundice, with respect to surgical or histopathological diagnoses. Methods and methodology: The authors conducted a cross-sectional study among 30 participants with obstructive jaundice using purposive sampling. The authors calculated the diagnostic statistics of non-neoplastic and neoplastic types, along with specific etiologies of obstructive jaundice identified through MDCT using a statistical package for social sciences (SPSS) v21 and MedCalc v12.3.0. The ethical clearance was obtained from the institutional review committee of BPKIHS, Nepal (Ref no: Acd/291/075/076-IRC). Results: The sensitivity and the negative predictive value of MDCT for non-neoplastic cause to detect obstructive jaundice were 100% (95% CI: 79.41–100.00) and 100% (95% CI: 75.29–100.00), while the specificity and the positive predictive value for neoplastic cause to detect obstructive jaundice were 100% (95% CI: 79.41–100.00) and 100% (95% CI: 75.29–100.00), respectively. Similarly, the accuracy for either non-neoplastic or neoplastic cause was 96.67% (95% CI: 82.78–99.92). The most common cause of obstructive jaundice was choledocholithiasis (33.34%) followed by cholangiocarcinoma (20%), ampullary carcinoma (13.33%), and choledochal cyst (13.33%). The diagnostic accuracy of the individual etiology of common causes of obstructive jaundice ranged from 82.78 to 100%. Biliary obstruction was most frequently observed in the periampullary region (83.33%), followed by the proximal common bile duct (6.67%), hilar region (6.67%), and intrahepatic region (3.33%). Conclusion: The MDCT could serve as the initial and time-efficient excellent imaging modality for diagnosing various causes of obstructive jaundice with greater accuracy. It can differentiate non-neoplastic from neoplastic causes of obstructive jaundice.

Common Presentation of Choledochal Cyst in Adult Female – A Case Report

The Choledochal cyst is a rare disease of unknown etiology. Incidence of diagnosis of choledochal cyst is much higher in children (80%) than in adult (20%). It is prevalent among Asian &amp; female populations &amp; the incidence is 1:100000-150000. We are reporting one such case, a 57-year-old female presenting with recurrent pain with right hypochondriac region and investigations revealed type -1 choledochal cyst. This case was managed successfully by complete excision of cyst &amp; Roux-en-Y hepatico-jejunostomy. Sir Salimullah Med Coll J 2023; 31: 120-123

Assessment of Matrix Metalloprotease – 7 (MMP7) Immunohistochemistry in Biliary Atresia and Other Pediatric Cholestatic Liver Diseases

Background and aims: Biliary atresia (BA) is a progressive fibro-obliterative cholangiopathy. The histopathological diagnosis is often challenging and an immunohistochemical marker is often sought as an adjunct. We evaluated MMP7 immunohistochemistry in BA and other non-BA pediatric cholestatic liver diseases. Materials and methods: MMP7 immunohistochemistry was applied in 5 age-matched normal control, 23 cases of BA and 43 cases of non-BA pediatric cholestasis including 16 cases of choledochal cyst (CC), and a multiplication score was obtained by multiplying the intensity and percentage positivity in the cholangiocytes. Results: BA showed a high mean MMP7 multiplication score which was significantly different from the normal control and other non-BA pediatric cholestatic diseases including CC (p value < 0.001). The sensitivity, specificity, positive, and negative predictive values of MMP7 immunohistochemistry were 91.3%, 93.02%, 87.5%, and 95.2% respectively. Conclusion: MMP7 immunohistochemistry may be an adjunct to histomorphology in BA.

The impact of pre-operative cholecystostomy on laparoscopic excision of choledochal cyst in paediatric patients.

This aim of this study was to identify the pre-operative risk factors for conversion during laparoscopic excision of choledochal cyst in paediatric patients. A retrospective single-centre study was carried out. All paediatric patients (< 18years) who had undergone laparoscopic excision of choledochal cyst between 2004 and 2021 were reviewed. The outcome was conversion to open surgery and pre-operative factors that affected the conversion rate were analyzed. Sixty-one patients were included. Conversion was required in 24 cases (39.3%). There was no difference in the conversion rate between the first (before 2012, n = 30) and second (after 2012, n = 31) half of the series (36.7% vs. 42.0%, p = 0.674). Majority was type 1 cyst (86.8%) and the median cyst size was 4.6cm (IQR: 2.2-6.4cm). Antenatal diagnosis was available in 18 patients (29.5%). The median age at operation was 23.0months (IQR: 8.0-72.0months). Pre-operatively, 19 patients (31.1%) suffered from cholangitis and 5 (8.2%) of them required cholecystostomy. Comparing patients with successful laparoscopic surgery (L) and converted cases (C), there were no differences in the age at operation (p = 0.74), cyst size (p = 0.35), availability of antenatal diagnosis (p = 0.23) and cholangitic episodes (p = 0.40). However, a higher percentage of patients required cholecystostomy in the converted group (L vs. C = 2.7% vs. 16.7%, p = 0.05). Using logistic regression analysis, it was also a risk factor for conversion (OR = 3.5 [1.37-5.21], p = 0.05). Pre-operative cholecystostomy is a potential risk factor for conversion during laparoscopic excision of choledochal cyst in children.

Cholangiocarcinoma: Risk Factors, Diagnostic Tools, and Current Treatment Options

Cholangiocarcinoma is a disease caused by the differentiation of cells in the bile epithelium or liver parenchyma into malignant cells called cholangiocytes. This literature review presents the current risk factors, diagnostic tools, and treatment choices of cholangiocarcinoma. Publication about the current risk factors, diagnostic tools, and treatment choices of cholangiocarcinoma were collected from the Pubmed database until August 25, 2022. The keywords of the research were “cholangiocarcinoma”, “risk factor”, “diagnostic”, and “treatment”. Cholangiocarcinoma has many risk factors, from choledochal cysts, and primary sclerosing cholangitis, to asbestos exposure. The diagnosis of cholangiocarcinoma is difficult and requires the combined interpretation of different diagnostic modalities. Examinations that can be done for the diagnosis and staging of cholangiocarcinoma are MRI and CT. However, if the diagnosis remains uncertain, endoscopic examination and tissue sampling may be performed. After the diagnosis, there are several treatments, namely surgical therapy (surgical excision of bile duct tumors), endoscopic therapy (endoscopic biliary dilatation), radiological therapy (percutaneous transhepatic palliative biliary dilatation), chemotherapy and radiotherapy, and photodynamic therapy. Cholangiocarcinoma is a malignancy of cells in the biliary epithelium or liver parenchyma (cholangiocytes) that has many risk factors. The diagnosis of cholangiocarcinoma is difficult and requires a combined interpretation of the different diagnostic modalities, including MRI, CT, endoscopy, and tissue sampling. After the diagnosis, there are several treatments, namely surgical therapy, endoscopy, radiology therapy, chemotherapy and radiotherapy, and photodynamic therapy.

Analysing Factors Prolonging Hospital Stay After Excision of Choledochal Cyst-A Pathway Towards Enhanced Recovery After Surgery.

To evaluate factors affecting length of stay (LOS) after choledochal cyst resection in paediatric patients. This was a retrospective study on patients operated between 2004 and 2021. Associations between clinical factors and LOS were evaluated by bivariate analysis, multiple regression, and equivalence test. Sixty-two patients were included. Twenty-four underwent hepaticoduodenostomy as biliary reconstruction. Five suffered from major complications. The median (25th-75th percentile) operation time was 279 (182-378) min. Median LOS, time to enteral feeding, and time to abdominal drain removal were 8(6-10), 2(1-3), and 5(4-7) days, respectively. Seven factors were found significantly associated with a shorter LOS in bivariate analysis and were included in multiple regression. It revealed that early abdominal drain removal (p < 0.001), early enteral feeding (p = 0.042), and the absence of major complications (p < 0.001) were significantly associated with shorter LOS. Equivalence test suggested that age and preoperative cholangitis had no practical effect on LOS. Early enteral feeding, early drain removal, and avoidance of major complications are associated with a shorter LOS.