| Objective(s): choledochal dilatation,also known as choledochal cyst,is a complex condition with unclear etiological factors,the majority of which are congenital.Therefore,the pathological changes associated with choledochal dilatation should have developed in children and even in infants.Indeed,approximately 80% of cases are diagnosed in childhood,while the remaining 20% of cases in adulthood are only diagnosed when they present with symptoms or receive a physical examination,some even seek medical service when cancer develops.This phenomenon suggests the differences between the children and adults.The aim of our study is to raise the awareness of this disease for early diagnosis and treatment based on the clinical data collection and comparative analysis between the pediatric and adult patients.Methods: From October 2015 to October 2021,clinical data of adult patients with choledochal dilatation from hepatobiliary and pancreatic surgery of the Second Affiliated Hospital of Kunming Medical University and pediatric patients with choledochal dilatation from general surgery of Kunming Children’s Hospital were retrospectively analyzed.The demographic characteristics,clinical manifestations,family history,laboratory examinations,imaging examinations,operation conditions,and postoperative pathology of the two groups were analyzed statistically to understand the clinical differences between the two groups.Results: There were 122 cases in the adult group with a median age of 44 years and a male to female ratio of 31/91(1:2.94),while there were 427 cases in the pediatric group with a median age of 27 months(2 years and 3 months)and a male to female ratio of 118/309(1:2.62).Abdominal pain was the most common symptoms for adult patients(77%),as well as the pediatric patients(57.8%),following with the jaundice(28.8%)and vomit(24.4%).The proportion of abdominal pain was higher in adults than that in children(P=0.001),while the proportions of jaundice and vomit were higher in children than those in adults(P<0.001),as well as the proportion of fever(P=0.038).In laboratory examinations,the white blood cell count,glutamic-pyruvic transaminase,glutamic-oxaloacetic transuuaminase,total bilirubin,direct bilirubin,total bile acid and glutamyl transpeptidase in pediatric group were higher than those in adult group which were all statistically different(P<0.05),while there was no significant difference in albumin(P=0.44).In imaging MRCP,there was no significant difference in morphology of choledochal cyst(cystic type,fusiformis)(P=0.486),but the prevalence of biliary duct calculus was higher in children(66.7%)than that in adults(53.3%)with significant difference(P=0.006).In terms of Todani type,there were more Ia type in children than in adults(P<0.001),but less Ic than in adults(P=0.001).And in adult group,there were patients identified type II and III,but none in pediatric group,which had a statistical significance(P<0.05).There was no difference in other types(P>0.05).Since no pancreatic duct shadows,giant cysts interrupted the junction of bile ducts,and liquid-gas interference,and other factors in MRCP,there were 57 cases with pancreaticobiliary maljunction in pediatric group,and 33 in adult group.99 cases in adult group received the operative treatment,of which 12 underwent partial hepatectomy due to intrahepatic bile duct stones,1underwent palliative operation of gastrojejunostomy due to extensive abdominal metastasis of adenocarcinoma of duodenum after radical surgery for choledochal dilatation,1 underwent resection of the head of pancreas due to pancreatic duct stone,3 underwent pancreaticoduodenectomy due to secondary cholangiocarcinoma,while the others underwent resection of choledochal cyst and biliary reconstruction.There were 2 cases underwent EST,and 2 underwent PTCD drainage under ultrasound guidance,the other patients did not receive operation.In pediatric group,427 cases all received operative treatment,of which 1 underwent internal drainage due to pancreatic pseudocyst found before operation,1 underwent cholecystostomy only,1underwent(6 months)liver biopsy but no radical operation due to cirrhosis,while the others underwent resection of choledochal cyst and biliary reconstruction.In pediatric group,there were 18(4.22%)cases with perforation of choledochal dilatation who underwent second operation of T-tube drainage of the bile duct or primary radical operation.The percentage of neutrophils and C-reactive protein in the perforation group were higher than those in the non-perforation group(P<0.05),while the alanine aminotransferase and albumin were higher in non-perforation group than those in perforation group(P<0.05).There was no difference between the age,gender,white cell count,glutamic-oxaloacetic transaminase,total bilirubin,total bile acid and glutamyl transpeptidase between the two group(P>0.05).There were 7 cases with cancer in adult group(5.74%),cholangiocarcinoma in 6 cases and gallbladder cancer in 1 case.No perforation was found.There were 420 cases in pediatric group and 99 cases in adult group have pathologic results.The pathological results in pediatric group were inflammation of bile duct and gallbladder,and there was no cancer.The pathological results in adult patients were inflammation of bile duct and gallbladder(90.9%)in most of the cases,but the pathological results of adult patients were more complicated: gallbladder adenomyosis in 13 cases(13.13%),gallbladder polyp in 1case(1.01%),pancreatic duct stone in 1 case(1.01%),intrahepatic bile duct stone in 7cases(7.07%),intraepithelial neoplasia in 34 cases(34.34%),gallbladder cancer in 1case(1.01%),and cholangiocarcinoma in 6 cases(6.06%),of which there were more cases of intraepithelial neoplasia with PBM(38.23%).Conclusion(s):Abdominal pain is the main symptom of adult patients with common bile duct dilation.There are less stones,but the stimulation of long-term chronic inflammation of biliary duct increases the risk of cancer.Abdominal pain and jaundice are the main symptoms of pediatric patients with choledochal dilatation,the proportion of bile duct stones are higher,and they are more likely to have perforation of bile duct.The increase of CRP and neutrophil and the decrease of the ALT and albumin in laboratory examinations before operation are suspected to have perforation of bile duct.Both adults and children with biliary dilatation should be treated with operation in early stage,with the main operative methods of complete resection of the bile duct with dilation,pancreaticobiliary shunt and Roux-en-Y cholangjojejunostomy.All patients should be followed up for a long time. |
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