| Background:Congenital biliary duct cysts (BDC, also named as bile duct cysts) are congenitalanomalies of the biliary tree which are characterized by cystic dilatation of the extra-and/orintra-hepatic biliary ducts. Unlike Western countries, the morbidity of congenital bile ductcyst is much higher in Asia. Congenital biliary duct cysts are also known as varied,comprehensive high complication and recurrence rate.Years ago, the primary treatment of cysts was simple internal drainage (ID) bycystenterostomy or partial cyst excision. However, several serious clinical outcomes,including stomal stenosis, cholestasis, cholangiolithiasis (CL), and evencholangiocarcinoma, led to poor prognosis, and even secondary surgical operation. It isacknowledged that total cyst excision (TCE) with Roux-en-Y cholangiojejunostomy (CJS)is a safe and ideal surgical treatment for congenital biliary duct cyst, compared to simpleinternal drainage. Our previous study has also confirmed that the total cyst excision hasbetter prognosis than single internal drainage by comparing therapeutic efects of differentsurgical treatments of congenital cystic dilatation of the bile duct. In this study, we foundthat the therapeutic effect of the total cysts resection group was obviously better than that inother subresection and simple internal drainage groups. The latter was easily complicatedhighly related with secondary cholangiolithiasis, cholangitis and malignant transformation.The congenital biliary duct cysts have a long course of disease, which may lead toincreasing morbidity of several complications, including cholestatis, cholangiolithiasis, andeven cholangiocarcinoma. Thus, total cyst excision should be performed as early as possible,however, considering the growth and development of the patients and the surgical risks,operation at childhood may increase life-threatening risks, most surgeons suggest that theinfants should not undergo the surgical treatment until they have grown up. Thus, the bestsurgical timing for this disease remains controversial. To determine the optimal surgeryoccasion, we divided these subjects into three groups, the infant group (age≤3years), theimmaturity group (3<age≤18years), and the maturity group (age>18years), and then evaluated the feasibility, risk and long-term outcome after surgery in the three groups.In addition, congenital biliary duct cysts are commonly diagnosed in young women(the female to male ratio is3:1). As these patients value the cosmetic results as well ascure of this disease, minimally invasive surgery (MIS) becomes more prevalent andappropriate. In addition to the cosmetic effect, the laparoscopic technology can relieve andeven eliminate tissue adhesion, and early postoperative pain, prevent aparocele and promoteresumption of peristalsis, excellent esthetics, and resumption of activities. In recent years,laparoscopic resection has been applied for congenital billiary duct cysts, however, its cureeffect is still not clear. Thus, in this study, we divided the patients into the laparoscopy andthe open surgery groups, evaluated the feasibility, risk and long-term outcome after surgeryin the two groups, to analyze the effect of laparoscopic technique on congenital biliary ductcyst.Methods:All reviewed cases of congenital biliary duct cysts come from data base managementsystem (DBMS). Relative information of cases was tabulated and inputted enter an Excelsystem, and then analyze them.We collect all patients' demographic data and preoperative status (likes clinicalsymptoms, pre-operation complications, etc.) which were collected prospectively, and thenanalyze them retrospectively. In addition, we also collect all patient' imaging findings(ultrasonography, computed tomography (CT) scan, magnetic resonancecholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography(ERCP)) and analyze all patients' cyst classification by Todani classification. Then, on thebasis of total cyst excision, we collect all patients' post-operation complications,intraoperative blood loss and operation time, post-operative hospitalization time andlong-term follow-up outcomes.To determine the optimal surgery occasion, we divided these subjects into three groups,the infant group (age≤3years), the immaturity group (3<age≤18years), and the maturitygroup (age>18years), and then, we analyzed all patients' pre-operation and post-operationcomplications, intraoperative blood loss and operation time, and long-term follow-upoutcomes, and analyze their discrepancy among three groups.To analyze the effect of laparoscopic technique on congenital biliary duct cyst we divided the patients into the laparoscopy and the open surgery groups, and then, we collectall patients' pre-operation and post-operation complications, intraoperative blood loss andoperation time, post-operative hospitalization time and long-term follow-up outcomes, andanalyze their discrepancy among two groups.Results:1) Among the three groups, the morbidity from cholangiolithiasis before surgicaltreatment had obvious discrepancy (p <0.05), and lowest was in the infant group, inaddition,8patients had cholangiocarcinoma, of whom1belonged to the immaturity groupand7to the maturity group. However, no significant discrepancy was observed between thethree groups (p=0.459>0.05), probably due to the small sample size.And intraoperative blood loss also had apparent diversity (p <0.05), the smallest valuein the infant group. Furthermore, long-term outcomes (secondary cholangiolithiasis, stomastenosis and cholangiocarcinoma) showed no significant difference between differentgroups (p>0.05). These findings suggest that total cyst excision should be performed asearly as possible, the optimal treatment timing is during infancy.However, our data have shown a significant difference in the postoperativecomplications among the three groups (p=0.012<0.05), with the morbidity ofpostoperative complications in the immaturity and maturity groups significantly lower thanin the infant group (p=0.036<0.05). All three patients in the infant group have pulmonaryinfection. However, these postoperative complications are not lifethreatening andunresolvable, and they may be due to the difficulty in the respiratory management of infants,indicating that preventing pulmonary infection is very important after total cyst excision ininfants.2) There was not any discrepancy in the morbidity of preoperative cholangiolithiasis (p>0.05) between the laparoscopic and the open surgery groups, which suggesting that therewas no difference between two groups.Referring to operation time, there were significant difference between two groups (p <0.05), the operation time in the laparoscopic group (397.0±181.9min) was higher than theopen surgery group (312.4±96.2). However, there was no significant discrepancy inintraoperative blood loss between two groups (p>0.05). And the post-operativehospitalization time in the laparoscopic group (10.3±3.9days) was signifucant lower than the open surgery group (12.9±5.8days)(p <0.05).No significant discrepancy was observed in the morbidity from postoperativecomplications or long-term postoperative complications (p>0.05) between the laparoscopicand the open surgery groups.Conclusion:1) we domonstrate that the infants with congenital biliary duct cyst have lowermorbidity of cholangiolithiasis before surgical treatment and lower intraoperative blood losswhen undergoing total cyst excision than the immaturity and the maturity groups. Inaddition, long-term follow-up data indicate that there is no significant difference among thethree groups. These findings suggest that total cyst excision should be performed as early aspossible, the optimal treatment timing is during infancy, and preventing pulmonaryinfection is very important after total cyst excision in infants.2) The totally laparoscopic resection (TLR) for congenital biliary duct cysts can relieveand even eliminate tissue adhesion, and early postoperative pain, promote resumption ofactivities, decrease the post-operative hospitalization time. Furthermore, compared to theopen surgery group, there is no higher risk of postoperative complications or long-termpostoperative complications. So, we domonstrate that The totally laparoscopic resection forcongenital biliary duct cysts may be a safer and more feasible minimally invasive surgery.
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