Resection Of Choledochal Cyst Research Articles

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

PurposeLaparoscopic 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. MethodsAn 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. Result148 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%). ConclusionInidividual 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 EvidenceIII.

Robot-assisted resection of choledochal cyst in neonates

ObjectiveLaparoscopic choledochectomy and hepatojejunostomy have been reported in children since 1995, but this procedure is technically demanding. Robotic surgical systems can simplify complex minimally invasive procedures. Currently, few reports have been made on neonates. We present the experience of 6 cases of neonatal CC(choledochal cysts).Study designBetween January 2022 and December 2023, 6 neonates underwent robotic resection of choledochal cyst and hepaticojejunostomy using the Da Vinci surgical system at Children’s Hospital, Zhejiang University School of Medicine, a high-volume hepatobiliary disease center. demographic data of the patients and surgical outcomes were collected and analyzed.ResultsAll 6 patients were successfully treated by robotic cystectomy and hepaticojejunostomy. The mean age was 17.3 days (range 4–25) and the mean weight was 3.6 kg (range 2.55–4.4). 5 cysts were type Ia and 1 was type Iva. The mean diameter of the cysts was 3.8 cm (range 1.25-5). The mean time to establish feeding was 4.83 days (range 4–6), and patients were discharged after a median time of 16.83 days (range 7–42) without postoperative complications.ConclusionsThis procedure is safe and effective for neonates. The authors found that the use of robot-assisted surgery has ergonomic advantages in this delicate, minimally invasive procedure.

A trans-umbilical single-site plus one robotic-assisted surgery for choledochal cyst resection in children.

The purpose of this study is to compare the intraoperative and postoperative outcomes of a trans-umbilical single-site plus one robot-assisted surgery and a trans-umbilical single-site laparoscopic surgery in the treatment of choledochal cysts. We retrospectively analyzed clinical data from 49 children diagnosed with choledochal cysts who were admitted to our hospital between June 2020 and December 2023. Among these patients, 24 underwent a trans-umbilical single-site plus one Da Vinci robot-assisted surgery (the robot group) and 25 underwent a trans-umbilical single-site laparoscopic-assisted surgery (the laparoscopic group). We compared differences in intraoperative and postoperative outcomes between the two groups. There was no significant difference between the two groups of patients in terms of gender, age, weight, clinical symptoms, maximum cyst diameter, type, postoperative complications, and facial expression, leg movement, activity, crying, and comfortability (FLACC) scoring (p > 0.05). Compared with the patients in the laparoscopic group, those in the robot group had less intraoperative bleeding [10 (8-12) vs. 15 (11.5-18) ml, p < 0.001] and required less postoperative drainage tube indwelling time [5 (4-6) vs. 7 (5.5-8) day, p < 0.001], less postoperative fasting time [4 (3-4) vs. 6 (5-7) days, p < 0.001], and less postoperative hospitalization time [6 (6-7) vs. 8 (6-10) days, p < 0.001], but they required more operative time [385.5 (317.0-413.3) vs. 346.0 (287.0-376.5) min, p = 0.050] and consumed more hospitalization expenses (79,323 ± 3,124 vs. 31,121 ± 2,918 yuan, p < 0.001). The results of this study showed a shorter hospitalization time, quicker postoperative recovery, and less tissue damage but a higher cost and a longer operation time in patients who chose robotic surgery rather than laparoscopic surgery. With the continuous expansion of the scale of installed robot-assisted surgical systems and the gradual accumulation of the technical experience of surgeons, robot-assisted surgery may slowly surpass, and shows a trend to replace, laparoscopy because of its advantages.

Narrative review in learning curve and pediatric robotic training program.

Studying learning curve (LC) for robotic procedures and developing an adequate training program are two fundamental steps to standardize robotic procedures. With this aim, we analyzed the literature to study the LCs of different robotic procedures and the availability of standardized training problems. The PubMed database was searched in the period from January 1995 to September 2022. Articles presenting LC and potential training programs in the pediatric population were chosen. Twenty papers were screened describing LC of robotic-assisted laparoscopic pyeloplasty (n=12), fundoplication (n=4), cholecystectomy (n=2), choledochal cyst resection (n=1), nephrectomy/partial nephrectomy (n=1) and lingual tonsillectomy (n=1), with a total of 1,251 procedures. In 10 studies there was only one single surgeon; nine had more than one; one did not specify how many surgeons participated. Twelve papers were retrospective single-center, three multicentric retrospective, four prospective and one was compared a retrospective case series to a prospective cohort. Most of these studies focused on operative time as the primary outcome. It was analyzed as the only outcome in three articles, along with complications in 14, time to discharge in eight, blood loss in three and pain killer use in three. The selected studies analyzed LC impacting operative planning (n=20), training (n=10) and costs (n=2). There is still a long way to go to complete a standardized functional training for robotic surgery procedures in pediatric surgery. Moreover, the progressive reduction in costs expected in the years to come will play a key role in progressing the diffusion of this technology enabling the collection of data necessary to create a standardized pediatric surgery robotic training program.

Outcome of Biliary-enteric Reconstruction with Hepaticoduodenostomy Following Choledochal Cyst Resection: A Prospective Study.

The two most commonly performed methods of biliary-enteric reconstruction following choledochal cyst resection are Roux-en-Y hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD). There is a lack of consensus regarding the better technique between them. This study aimed to evaluate the outcomes, efficacy and early complications of HD as a mode of biliary reconstruction after surgical resection of a choledochal cyst. This was a multi-institutional prospective study carried out in high-volume tertiary care teaching institutes from January 2010 to December 2022. All children managed with HD following choledochal cyst resection were analysed for their early complications and outcomes. A total of 74 patients were included in this study. There were 59 (79.73%) females and 15 (20.27%) males. Thirty-nine (52.70%) patients had jaundice at the time of presentation. Magnetic resonance cholangiopancreatography was performed in 57 (77.03%) patients following ultrasonography. Intraoperatively, malrotation was present in 2 (2.70%) patients. In our study, operating time ranged from 60 to 195 min (mean: 118 min). Hospital stays ranged from 8 to 17 days (mean: 11.5 days). The post-operative biliary leak was seen in 7 (9.50%) patients, out of which 6 (8.11%) minor leaks were managed conservatively. Roux-en-Y HJ was performed on 1 (1.35%) patient with a major leak. In our series, 4 (5.40%) patients developed cholangitis; post-operative haemorrhagic nasogastric aspirate 5 (6.76%), post-operative pancreatitis 3 (4.05%) and wound infection 4 (5.40%) were observed and managed conservatively. None of the patients in our study developed an anastomotic stricture, bile gastritis and adhesive small bowel obstruction. Resection of choledochal cyst with HD reconstruction is safe and feasible with short operative time. HD is a viable option for operative management of choledochal cyst with low complication rates and faster recovery.

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.

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.

Robot-assisted resection of choledochal cyst in children.

The emergence of the robotic surgery system has assisted the further development of minimally invasive surgery by facilitating more delicate and precise complex procedures. The purpose of this study was to present a study of robot-assisted resection of the choledochal cyst and to discuss the technical points. In total, 133 patients who were diagnosed with a choledochal cyst and underwent surgery from April 2020 to February 2022 in the Children's Hospital, Zhejiang University School of Medicine, were retrospectively analyzed. The data were collected including the clinical information of the patients, operative details, and postoperative outcomes. Among these 133 patients, 99 underwent robot-assisted surgery and 34 underwent laparoscopic assisted surgery. The median operation time was 180 min, with an interquartile range (IQR) of 170-210 min for the robot-assisted group and 180 min with an IQR of 157.5-220 min in the laparoscopic assisted group (P = 0.290). The detection rate of 82.5% for the distal opening of the cystic type of choledochal cyst was higher in the robot-assisted group than that in the laparoscopic assisted group at 34.8% (P = 0.000). The postoperative hospital stay was shorter (P = 0.009) and the hospitalization expense was higher (P = 0.000) in the robot-assisted group than that of the laparoscopic assisted group. There was no significant difference between the two groups in terms of complications, postoperative indwelling days of the abdominal drainage tube, intraoperative blood loss, and postoperative fasting time (P > 0.05). Robot-assisted resection of choledochal cyst is safe and feasible, it is ideal for the patient requiring a meticulous operation, and its postoperative recovery was shorter than for traditional laparoscopy.

Preemptive resection of choledochal cyst during redo resection of gallbladder cancer following laparoscopic cholecystectomy

Preemptive resection of choledochal cyst during redo resection of gallbladder cancer following laparoscopic cholecystectomy

Curative effect and technical key points of laparoscopic surgery for choledochal cysts in children.

The purpose of this study was to investigate the curative effect of and experience with laparoscopic surgery for congenital choledochal cysts in children. This is a retrospective analysis of 33 children diagnosed with congenital choledochal cyst in the pediatric surgery department of the Affiliated Hospital of Southwest Medical University between January 2019 and December 2021. The cohort included 8 males and 25 females aged 0.25-13.7 years (median age, 3.2 years), including 21 cases of type I and 12 cases of type IV choledochal cyst (Todani classification). Laparoscopic choledochal cyst resection and hepaticojejunostomy with Roux-en-Y anastomosis were performed in all the patients. Laparoscopy without transit opening was successfully performed in the 33 cases. The duration of the procedure was 235-460 min (mean ± SD, 316 ± 61 min), and intraoperative blood loss volume was 15-40 ml (23 ± 7.6 ml). Postoperative hospital stay was 7-14 days (9 ± 1.8 days). Postoperative biliary fistula and pancreatitis occurred in two cases each, and all four patients were successfully treated with conservative treatment. No anastomotic stenosis, delayed bleeding, cholangitis, intestinal obstruction, or other complications occurred. All the children were followed up for 2-36 months (median period, 17.2 months). The clinical symptoms disappeared, and no obvious hepatic dysfunction was found on abdominal color ultrasound and liver function examination. Laparoscopic surgery for congenital choledochal cyst in children is safe and effective, as it is a minimally invasive surgery that is associated with a low degree of trauma and bleeding, rapid postoperative recovery, and satisfactory aesthetic appearance.

Laparoscopic and robotic approaches for treatment of choledochal cysts in adults

Background: While well-described for hepatic and pancreatic resection, the minimally invasive (MIS) approach in the treatment of choledochal cysts (CC) has been under-reported. Due to the technical complexity and steeper learning curve of minimally invasive biliary reconstruction, the MIS approach has not been as widely adopted in biliary surgery. We herein review the use of laparoscopic and robotic-assisted surgery in the treatment of CC. Methods: A comprehensive review of the literature was performed on the use of laparoscopic and robotic-assisted surgery in the treatment of CC. Results: Similar morbidity and mortality rates were noted among patients undergoing laparoscopic choledochal cyst resection (LCCR) compared with previous data from patients in the literature who had undergone an open approach (OCCR, open choledochal cyst resection); however, LCCR was associated with longer operative times and high conversion rates, largely attributable to the learning curve given the technically challenging nature of the procedure. The robotic platform (RCCR, robotic choledochal cyst resection) has been shown to offer an advantage in the hepaticojejunostomy anastomosis portion of CC resection vs. laparoscopy while providing comparable short-term outcomes compared with the LCCR approach. Conclusion: A minimally invasive approach to CC likely has improved perioperative outcomes with shorter LOS, return to baseline function, as well as improved cosmesis vs. OCCR. Longer operative times with minimally invasive approaches to CC have been attributed to steep learning curves, which have improved over time as surgeons become more facile with this technique. Both LCCR and RCCR have demonstrated similar rates of long-term postoperative complications and overall survival when compared to OCCR.

Impact of prior cholecystectomy on diagnosis and outcomes of choledochal cyst resection in adults

Background: The diagnosis of choledochal cysts in the Western adult population remains challenging. This is further complicated in the post-cholecystectomy setting due to expected physiologic dilation of the common bile duct. Data on the diagnosis and management of choledochal cysts in the post-cholecystectomy setting are limited. We aimed to compare patients who underwent surgical resection of choledochal cysts with and without prior cholecystectomy.

Outcomes of laparoscopic versus open resection of pediatric choledochal cyst

BackgroundUntreated pediatric choledochal cyst (CC) is associated with complications including cholangitis, pancreatitis, and risk of malignancy. Therefore, CC is typically treated by surgical excision with biliary reconstruction. Both open and laparoscopic (lap) surgical approaches are regularly used, but outcomes have not been compared on a national level. MethodsThe Nationwide Readmissions Database was used to identify pediatric patients (age 0–21 years, excluding newborns) with choledochal cyst from 2016 to 2018 based on ICD-10 codes. Patients were stratified by operative approach (open vs. lap). Demographics, operative management, and complications were compared using standard statistical tests. Results were weighted for national estimates. ResultsCholedochal cyst excision was performed in 577 children (75% female) via lap (28%) and open (72%) surgical approaches. Patients undergoing an open resection experienced longer index hospital length of stay (LOS), higher total cost, and more complications. Anastomotic technique differed by approach, with Roux-en-Y hepaticojejunostomy (RYHJ) more often utilized with open cases (86% vs. 29%) and hepaticoduodenostomy (HD) more common with laparoscopic procedures (71% vs. 15%), both p < 0.001. There was no significant difference in post-operative cholangitis or mortality. ConclusionsAlthough utilized less frequently than an open approach, laparoscopic choledochal cyst resection is safe in pediatric patients and is associated with shorter LOS, lower costs, and fewer complications. HD anastomosis is more commonly performed during laparoscopic procedures, whereas RYHJ more commonly used with the open approach. While HD is associated with more short-term gastrointestinal dysfunction than RYHJ, the latter is more commonly associated with sepsis, wound infection, and respiratory dysfunction. Level of evidenceLevel III: Retrospective Comparative Study.

A proposed feasible classification of common bile duct duplications based on a newly described variant and review of existing literature

BackgroundDuplication of the common bile duct (CBD) is extremely rare among the anatomical variations in the biliary tract system, which presents a septum within the CBD or an accessory CBD. In our study, we report a rare case of duplication of the common bile duct combined congenital biliary dilatation.we present a rare case of a septum in the dilated biliary tract.Case presentationWe reported a 5-year-old Asian girl who had history of repeated abdominal pain for 4 days and aggravated for 1 day. Magnetic resonance cholangiopancreatography (MRCP) examination revealed duplicated common bile duct (DCBD) malformation with congenital biliary dilatation and distal cholelithiasis. The patient underwent choledochal cyst resection and biliary tract reconstruction and abdominal cavity irrigation and drainage under general anesthesia. A septum was found within the common bile duct during the operation. The septum divided the extrahepatic bile duct into two parts connected to the left and right hepatic ducts respectively and the gallbladder is attached to the repeated right bile duct which was not previously reported in the literature.ConclusionsWe complement and adjust the classification of common bile duct duplication by reviewing the literature.

S1907 A Rare Case of Type 1 Choledochal Cyst With Type C Anomalous Pancreaticobiliary Maljunction in a 52-Year-Old Patient

Introduction: Choledochal cysts are rare anomalies of the bile duct that generally present in childhood but can rarely be delayed until adulthood in 20% of cases. They are often diagnosed incidentally or present with acute pancreatitis or cholangitis. We report a case of a type 1 choledochal cyst (T1CC) and type C anomalous pancreaticobiliary maljunction (PBM), successfully managed by a multidisciplinary approach. Case Description/Methods: A 52-year-old woman presented with right upper quadrant pain, jaundice and vomiting. Labs revealed elevated lipase, bilirubin, AST, ALT and alkaline phosphatase. A CT of the abdomen showed no gallstones but a marked dilation of extrahepatic bile duct with a transition point in the distal intrapancreatic portion (Figure a). An endoscopic retrograde cholangiopancreaticogram (ERCP) showed fusiform dilation of the CBD consistent with T1CC (Figure b). Spyglass cholangioscopy revealed focal stenosis in the distal CBD joining above the ventral pancreatic duct opening within the long common channel, suggestive of type C anomalous PBM (Figure c). A plastic biliary stent was placed into the CBD. EUS guided fine needle biopsy of the stricture showed no evidence of malignancy. Her clinical course was complicated by multiple admissions due to stent occlusion. After multidisciplinary discussion, the patient underwent choledochal cyst resection with hepaticojejunostomy, cholecystectomy and biliary reconstruction. Intraoperative gallbladder specimen revealed poorly differentiated adenocarcinoma with plan for chemotherapy. Discussion: Choledochal cysts are a rare congenital anomaly characterized by enlargement of the CBD. There are five types of choledochal cysts (Table). Etiology remains unclear and while some believe these cysts are congenital in nature, others propose they arise from anomalous PBM. PBM is defined as congenital malformation in which the pancreatic and bile duct join outside the duodenal wall forming a long common channel. This leads to reflux of biliary secretions leading to chronic inflammation, increasing the risk of developing cholangiocarcinoma and gallbladder cancer, as seen in our patient. Placement of biliary stents can temporarily alleviate symptoms, but surgical excision is the definitive treatment. Our case highlights the importance of including type 1 choledochal cyst in the differential diagnosis even in adult patients with a significantly dilated CBD. A thorough endoscopic and radiological work up should be done to prevent progression to malignancy.Figure 1.: A. CT of the abdomen showing marked dilatation of extrahepatic bile duct with a transition point in the distal intrapancreatic portion. B. Cholangiogram showing Type 1 Choledochal Cyst and Type C Anomalous Pancreaticobiliary Maljunction. C. Spyglass cholangioscopy showing JagwireTM within the CBD (yellow arrow) revealing focal stenotic CBD joining the common channel just above the ventral pancreatic duct (blue arrow). Table 1. - Types of Choledochal Cysts Type Description Type I Fusiform dilation of the CBD Type II Bile duct diverticulum Type III Saccular dilation of the intraduodenal portion of the CBD Type IVa Multiple cysts at intra and extrahepatic ducts Type IVb Multiple cysts at extrahepatic ducts only Type V Fusiform or saccular cystic dilation of the intrahepatic bile duct

Defining an optimal surveillance strategy for patients following choledochal cyst resection: results of a systematic review.

Choledochal cysts should be treated with complete surgical resection, or, rarely liver transplantation. Treated patients can remain at risk of developing metachronous cholangiocarcinomas and lifelong follow up is indicated. However, there is no agreement on what constitutes an acceptable follow up strategy. This review was undertaken to develop an evidenced based surveillance strategy. A systematic review of MEDLINE, EMBASE, PubMed, Web of Science, and Google Scholar was undertaken for reports (published up to 10 September 2021) describing late biliary complications and development of metachronous cholangiocarcinoma following choledochal cyst resection. Twenty-five publications described 74 metachronous cholangiocarcinomas occurring in 3911 patients (overall incidence 2%). Cancers developed commonly at the hepatic hilus and were diagnosed after a median interval of 92 months (range 9-249 months) after the initial resection. While reporting is incomplete, the majority of cholangiocarcinomas developed following resection of type I and type IV cysts with few metachronous cancers recorded after treatment of type II or III cysts. Peak age range for presentation with metachronous cholangiocarcinoma is in the twenties following cyst resection in childhood suggesting that patients are at greatest risk for metachronous tumour development for up to 20 years (240 months). A surveillance strategy is proposed for patients treated primarily for cyst types I and IV and unresected type V using annual liver function tests, Ca 19-9 measurement and biannual ultrasound assessment for 20 years post cyst resection, with biannual liver function testing, Ca 19-9 measurement and three yearly ultrasound assessment thereafter.

Delay in Resection of Choledochal Cysts Highlights the Significance of Malignancy Potential: A Case Report

Risks of choledochal cysts include obstructive jaundice, cholangitis, and malignancy. Therefore, cysts are typically resected especially if symptomatic. A 69 year old female who presented with cholangitis due to a common bile duct stone. Past medical history significant for type III choledochal cyst and recurrent cholangitis. Previous surgical interventions included biliary bypass at age 10 and revision in early 20s; choledochal cyst was not resected at either surgery. Imaging suggested hepaticojejunostomy stricture leading to recurrent cholangitis. Initially patient was very hesitant to undergo any further surgical intervention and opted for close surveillance. Shortly after patient develop rigors and while still reluctant to undergo large procedure did consent to choledochal cyst resection and hepaticojejunostomy revision. During the operation, choledochal cyst identified, mobilized and approximately 80% of it was excised. Hepaticojejunostomy appeared to incorporate remnant gallbladder based on intraoperative evaluation. Cholangiogram was attempted through duct of Luschka but was not completed due to difficult angle and subsequently ligated. New hepaticojejunostomy was created using original roux limb and good biliary drainage of right and left hepatic lobes demonstrated on completion cholangiogram. Final pathology significant for poorly differentiated adenocarcinoma, biliary type in choledochal cyst and remnant gallbladder; additionally bile duct margin showed invasive adenocarcinoma. Patient then underwent a completion pancreaticoduodenectomy with partial hepatectomy for complete oncologic resection. In adults presenting with a symptomatic choledochal cyst, excision should be recommended treatment. Risk of malignancy is present in biliary tree despite resection. Thus, the entire biliary tree should be inspected for multiple areas of neoplasm.

Usefulness of indocyanine green fluorescence in laparoscopic resection of choledochal cyst in children

Image-guided surgery using indocyanine green allows the delineation of anatomical structures during laparoscopic surgery. Dye excretion through the bile duct has also facilitated complicated cholecystectomies. However, there have been few reports of its application in children. To date, its use for minimally invasive treatment of choledochal cyst in children has not been reported. The adequate treatment of this condition requires careful dissection to avoid vascular and visceral lesions as well as biliary digestive reconstruction according to the morphology of the hepatic duct. In the presented case, the application of this technique allowed for the complete dissection of the cyst without vascular injury, the safe ligation of the duodenal segment of the cyst, and a successful duodenal hepatic anastomosis. These were accomplished through laparoscopy by visualizing the passage towards the duodenum and ruling out the presence of fistulas. • The use of indocyanine green has allowed for choledochal cyst excision in this case. • Indocyanine green delineated the dilated common bile duct from the normal structures. • Indocyanine green also confirmed the absence of leaks in the anastomosis.

Postoperative Surveillance of Bile Duct Cysts through Modified "Roux en Y" Hepaticojejunostomy by Transgastric Endoscopic Access

Background: Choledochal cyst is a congenital dilatation of extra or intrahepatic bile ducts and is usually associated with pancreaticobiliary malformation, risk of choledocholithiasis, and biliary tract cancer. The standard treatment consists of complete cystic resection with biliodigestive anastomosis; the hepaticojejunostomy is the preferred type of reconstruction. Methods: A survey of all choledochal cyst cases operated by the Pancreas Group of our service was carried out from July 1984 to March 2020, and 27 patients who underwent surgical treatment were identified. Based on the need for subsequent access to biliodigestive anastomosis for intrahepatic lithiasis treatment, biliary stricture, and further cancer surveillance on remnant intrahepatic cysts, a modified "Roux-en-Y" hepaticojejunostomy was proposed providing surveillance of remnant choledochal cyst and treatment for postoperative anastomotic or intra-hepatic complications by less invasive strategy. Results: A surveillance strategy must be considered. All the current procedures depend on advanced radiology, generate discomfort to the patient in ostomy cases, or rely on more invasive and repeated biliary surgical procedures. The new technique proposes a jejunal segment of approximately 10,0 to 15,0 cm kept far from the anastomosis allowing its placement, without tension, in the anterior gastric wall below the small curvature between the body the stomach antrum, which enables access to the bile ducts through Endoscopy (ERCP), guided by Endoscopic Ultrasound (EUS). Conclusion: The modified "Roux en Y" hepaticojejunostomy is a new and straightforward technique that allows surveillance of patients submitted to the biliodigestive anastomosis of any kind and are useful in patients submitted to choledochal cyst resection.

Changes in outcomes and operative trends with pediatric robot-assisted resection of choledochal cyst.

This study aimed to report our experience with a robot-assisted resection of choledochal cysts (CCs) in pediatric patients, especially focusing on changes in outcomes and operative trends. We retrospectively reviewed medical records of all 158 patients under 18years of age who underwent robot-assisted resection of CC in a single tertiary center between July 2008 and January 2021. Patients were divided into the first period (P1, July 2008-March 2016; N = 79) and second period (P2, April 2016-January 2021; N = 79) with equal number of participants. The patients of P2 were compared with those of P1 to assess clinical outcomes with operative details. Operative characteristics and postoperative prognosis were compared for each group. The mean operative time was 383.6min for the P2 group and 462.6min for the P1 group (p < 0.001). The mean estimated blood loss was 28mL in the P2 group and 63mL in the P1 group (p = 0.025). The rate of emergency department visit after the operation was lower in the P2 group (3.8% vs. 13.9%, respectively, p = 0.047). The two groups showed no significant differences in the rate of late postoperative complications and reoperations. With the increase in the center's experience, robot-assisted resection of CC can be safely adopted and feasible, especially for pediatric patients. Treatment Study, Level III.