Surgical Timing And Complication Management Of Choledochal Cyst In Children

PART 1 Surgical Timing of Prenatally Diagnosed Choledochal CystPurpose: To discuss the appropriate management and surgical timing of prenatally diagnosed choledochal cyst.Materials and methods: 49 antenatally diagnosed choledochal cyst patients were treated in our department from 2013 to 2015.Their clinical data were retrospectively reviewed,including symptoms and complications,operation age,intraoperative findings and postoperative complications.Logistic regression were applied to figure out the risk factors of liver fibrosis.Results: 49 choledochal cyst patients were prenatally diagnosed at gestational age of 20-37 weeks.24 patients presented symptoms after birth,including jaundice,clay stool and vomiting.26 patients had complications including obstructive jaundice,liver function impairment,and one case of biliary perforation when 3 months old.61.5% of the complications occured within the first 3 months.Multifactor logistic analysis revealed that aspartate aminotransferase(AST)and cyst diameter were risk factors of liver fibrosis.For prenatally diagnosed asymptomatic patients without laboratory or graphic sign of obstruction,there is no significant relation between operation age and liver fibrosis.Conclusions: Prenatally diagnosed choledochal cyst patients should be closely monitored with liver function test and ultrasound.Once they present abnormal elevation of liver enzyme,obstructive jaundice,massive or progressively enlarging cyst,and when biliary atresia can’t be ruled out,prompt surgical intervention should be taken.Patient without these signs can be observed and complete surgery within 1-3 months.PART 2 Application of ERCP in Pediatric Choledochal CystPurpose: To review the indications,effects and benefits of ERCP in the treatment and diagnosis of choledochal cyst.Materials and methods: From 2013 to 2015,32 pediatric patients of choledochal cyst underwent ERCP before surgery.Their clinical presentations,indications for ERCP,pre-and post-ERCP lab test and imaging,choice of surgery(laparoscopic or open)and hospital stay were retrospectively reviewed.Results: 32 children with choledochal cyst underwent pre-operative ERCP [median age was 3(range 0.5-9.3)years;lowest weight was 7kg].The cannulation success rate in overall procedures was 33/34.The indications of ERCP were as follow: choledochal cysts with complicated conditions,e.g.acute biliary infection,obstructive jaundice,biliary pancreatitis(24/32),differential diagnosis with compensated biliary dilatation by relieving obstruction(8/32),diagnostic only(2/32).Therapeutic interventions were performed in 32 procedures(96.9%),including papillary dilation,sphincterotomy,endoscopic nasobiliary drainage,endoscopic retrograde biliary drainage and stone extraction.Abnormally elevated liver transaminase,bilirubin,and amylase significantly reduced after ERCP.Ultrasound showed that biliary diameter decreased.All symptoms got improved.No major post-ERCP complication occurred.All patients were performed resection of choledochal cyst and Roux-en-Y hepaticojejunostomy after ERCP,with median time interval of 10 days(range 4-35 days).The laparoscopy rate and length of post-surgery hospital stay of post-ERCP patients were comparable to that of non-drainage patients.Conclusions: When choledochal cyst complicated with biliary infection,obstructive jaundice,biliary pancreatitis and liver function impairment,ERCP can effectively relieve biliary obstruction and improve symptoms which avoids external drainage and keeps the chance of laparoscopic definitive surgery with short interval time post-ERCP.ERCP also maintain some advantages in diagnosis of APBDJ and differentiate obstructive biliary dilatation.PART 3 Clinical Management of Choledochal Cyst Complicated with Biliary PerforationPurpose: To summarize the clinical management of choledochal cyst complicated with biliary perforation.Materials and methods: Among 196 choledochal cyst treated in our department from 2013 to 2015,7 were complicated with biliary perforation,age ranging from 3 months to 5.5 years old.4 cases had biliary peritonitis,all diagnosed preoperatively;1 case formed pseudocyst,2 were sealed peroforation.4 cases of biliary peritonitis and 1 pseudocyst underwent external biliary drainage,and followed definitive surgery in 95-108 days,no postoperative complications occurred.2 cases of sealed perforation underwent one-stage laparoscopic surgery,with 1 converted to open because of serious cyst infection.One patient underwent reoperation because of postoperative bleeding.Conclusions: Early diagnosis and treatment is recommended for choldochal cyst patients.Biliary perforation should be alerted and avoided.Once perforation happens,prompt surgical intervention should be taken.One-stage or two-stage management depend on surgeon’s experience and the condition of patient.