Therapeutic Effictiveness Of Three Laparoscopically Assisted Biliary Reconstruction For Congenital Choledochal Cyst

Objective:Congenital choledochal cyst(CCC),also known as congenital biliary dilatation,is a frequent and developmental deformity in biliary tract in children.It is mainly characterized with cystic or fusiform choledochal dilatation;In this regard,it is known to be associated with dilation of intrahepatic bile duct.As anomalous junction of pancreaticobiliary ducts and inadequate drainage of bile or pancreatic fluid could be seen in most of CCC children,the frequent recurrence of biliary tract infection,severe bilious pancreatitis and cholelithiasis,as well as the canceration would be presented in them.Currently,the widely accepted surgical procedure is resection of extrahepatic bile ducts combined with biliary tract reconstruction,aiming to remove the lesion and reconstruct the bile drainage.However,various procedures for biliary tract reconstruction with differential clinical characteristics could be seen in many pediatric surgery centers in the world.In recent years,laparoscopic resection of choledochal cyst and biliary tract reconstruction have been gradually developed and widely known by many pediatric surgeons.Due to complicated and difficult operating and saturation under laparoscope,precise biliary tract reconstruction after resection of extrahepatic bile ducts would be an essential concern.In this regards,pediatric surgeons not only needed to consider the differential clinical characteristics and early/late complications,but also balance the feasibility of laparoscopic access and its influence on biliary tract reconstruction.Therefore,in this study,we targeted three frequent laparoscopic biliary tract reconstruction procedures,involving Roux-en-Y hepaticojejunostomy(RY group),hepaticoduodenostomy(HD group)and modified Warren loop hepaticojejunostomy(MW group),to retrospectively compared the operating time and perioperative complications,and analysis the clinical therapeutic effictiveness of them,aiming to provide ideal clinical evidences for the option of laparoscopic biliary tract reconstruction.Method:Between July 2012 and June 2015,a total of 70 cases with CCC undertook laparoscopic resection of extrahepatic bile ducts,followed by Roux-en-Y hepaticojejunostomy(RY group),hepaticoduodenostomy(HD group)and modified Warren loop hepaticojejunostomy(MW group)respectively in The Second Hospital of Hebei Medical University.Their clinical data were retrospectively summarized and analyzed,including the operation time,the estimated blood loss during operation,the recovery time of postoperative intestinal functions,abdominal drainage tube time,hospital stay,perioperative complications(anastomotic fistula,seroperitoneum and wound infection)and upper gastrointestinal contrast image after operations.Furthermore,we compared potential differences of long~term of complications,involving anastomotic stenosis,reflux cholangitis,cholangiolithiasis,and pancreatitis,as well as reflux gastritis among three groups through follow~up study.Student t~test and Fisher exact test were conducted for data analysis among groups,and P<0.05 was regarded as statistically significant difference.1 RY group: After laparoscopic resection of choledochal cyst,15~20cm length of jejunum away from Treitz ligament was exteriorized via umbilical incision.The distal end of jejunum was anastomosed and 20~30cm length of jejunum bile loop was preserved.The end~to~side Y type of anastomosis between proximal end of jejunum and jejunum bile loop was conducted,followed by interrupted seromuscular suture between two proximal intestinal loops for anti~reflux.The anastomotic intestinal duct was again put back into abdomen and retromesocolic hepaticojejunostomy was conducted.2 HD group: After laparoscopic resection of choledochal cyst,the duodenal descending part and horizontal part were mobilized.The incision similar with common hepatic duct diameter was created on duodenal lateral wall at 3cm site away from pylorus.The interrupted hepaticoduodenostomy was conducted(ligature located outside of anastomosis).The distal duodenal of anastomosis was fixed through saturation with gallbladder bed connective tissue,duodenal tissue around gastric sinus and ligamenta teres hepatis around hepatic portal.aiming to reduce the anastomotic tension.3 MW group: After laparoscopic resection of choledochal cyst,a segment jejunum from 20 cm to 60 cm away from Treitz ligament was exteriorized via umbilical incision and the jejunum was not cut,only ligated at the afferent loop.The side~to~side anastomosis between 20 cm and 60 cm site of jejunum away from Treitz ligament was engaged using Endo~GIA,followed by interrupted seromuscular suture on contralateral mesenteric margin was conducted to create biliary~jejunal overlap loops.Loops were further lifted to hepatic portal along retro~colic hepatic flexure and hepaticojejunostomy was conducted.Results:1 The laparoscopic resection of choledochal cyst and biliary~enteric reconstruction was completed successfully in all 70 patients,including 27 cases in RY group,22 cases in HD group and 21 cases in MW group.No complications were seen during operations and no conversion to open surgery.2 The operating time(OT): The average OT was 211.30 ± 40.85 min in RY group,151.00 ± 32.26 min in HD group and 160.81 ± 43.92 min in MW group.Compared with HD group and MW group,the OT for RY group was significantly prolonged(P<0.05),but no difference could be noted between HD group and MW group.3 The estimated blood loss(EBL): The average EBL was 19.81 ± 4.74 ml in RY group,18.59 ± 6.23 ml in HD group,and 18.14 ± 8.73 ml in MW group.No difference could be found among three groups(P>0.05).4 Recovery time of postoperative intestinal functions: the average recovery time was 2.07 ± 1.27 d in RY group,1.32 ± 1.84 d in HD group and 1.05 ± 0.97 d in MW group.Compared with RY group,the MW group and HD group was respectively significantly short(P<0.05).5 The abdominal drainage tube time: Average 3.78±1.95 days in RY group,3.91 ± 2.11 days in HD group,and 3.00 ± 1.90 days in MW group.No difference could be found among three groups(P>0.05).6 Hospital stay(HS): The average HS was 7.52 ± 1.63 days in RY group,7.23 ±3.35 days in HD group,and 6.38 ± 3.58 days in MW group.No difference could be found among three groups(P>0.05).7 Perioperative accidents: 1 case of bile leak could be seen in RY group(3.7%);1 case of bile leak and 1 case of hepatic portal effusion were found in HD group(9.1%)and no perioperative accidents were seen in MW group.Fisher exact test indicated no difference among three groups(P > 0.05).8 Upper gastrointestinal series: 26 patients under contrast examination in RY group and 2 cases of reflux(7.7%)were found.21 patients under contrast examination in HD group and 7 cases of reflux(33.3%)were found.21 patients under contrast examination in MW group and 1 case of reflux(4.8%)was found.Fisher exact test indicated compared with RY and MW groups,the HD group presented bad anti~reflux efficacy(P<0.05);no difference could be seen between RY and MW groups(P > 0.05).9 Postoperative complications: There are 5 cases of postoperative pneumobilia(2 cases were manifested with reflux cholangitis)and 1 case of secondary surgery due to hepatic portal anastomotic stenosis associated with cholelithiasis in RY group(22.2%);there are 7 cases of postoperative pneumobilia(3 cases were presented with reflux cholangitis),2 cases of reflux gastritis,and 2 cases of hepatic portal anastomotic stenosis undertaking balloon dilatation or stent drainage in HD group(50%);there are 2 cases of postoperative pneumobilia,1 case undertook reoperation due to bile~jejunum input loop obstruction in MW group(14.3%).Fisher exact test indicated compared with RY and MW groups,the HD group presented bad outcomes after surgery(P<0.05);no difference could be seen between RY and MW groups(P > 0.05).Conclusions:1 In this study,all patients undertook successfully laparoscopic resection of choledochal cyst and biliary tract reconstruction.No intraoperative complications and conversion to open can be seen,which has proved the feasibility of laparoscopic choledochal cyst surgery.2 The operation time in HD is shorter than that in RY group,furthermore,it is not necessary to pull intestine outside via umbilical incision and the bile drainage is anatomically much more similar with those normal ones,and can be successfully completed under guidance of laparoscope.However,incidence of postoperative complications is higher compared with other two groups,especially for those older children or those with intrahepatic dilation.Although it is easy to operate through smaller incision,it is not suitable for older children with intrahepatic dilation.3 As the most common bile tract reconstruction approach at present,laparoscopic Roux-en-Y hepaticojejunostomy presents better and comprehensive efficacy,and it is more suitable for reconstruction after hepatic portal biliary duct stenosis;however,after the jejunum is cut,its normal electrophysiological features will be destroyed,which lead to slowed postoperative intestinal peristalsis recovery,and potential abdominal pain,distention and vomiting.Also,the pneumobilia and refluxing cholangitis are still problems which need to be solved.4 Compared with laparoscopic Roux-en-Y hepaticojejunostomy,the jejunum will not be cut in laparoscopic modified Warren loop hepaticojejunostomy and much time will be saved and normal electrophysiological rhythms of the jejunum will be preserved,which cause less impact on recovery of postoperative intestinal peristalsis.However,the bile branch jejunum input loop is excluded,and some children patients will suffer from input loop stasis.5 Three biliary-entreic reconstructive procedures in this study will inevitably cause postoperative reflux cholangitis.Therefore,avoided stenosis after hepatic portal anastomosis is crucial for successful operation,and personalized biliary tract reconstructing method should be adopted according to different types of biliary dilation and ages for children.