The Clinical Research Of The Treatment Of Congenital Choledochal Cyst Assisted By Laparoscopy

Aim:Congenital Choledochal Cyst(CCC),also known as Congenital Biliary Dilatation(CBD),is a rarely occurred congenital dilatation of the bile duct.CCC is more prevalent in Asian countries than in western countries,mainly in female neonates and children with the male to female ratio as 1:3-1:4.25%patients are diagnosed within one year after birth while 60%are diagnosed within the first decade,and only 20%are diagnosed in adulthood.In 1723 Vater firstly reported a young patient with dilatation of the bile duct.In 1852 Douglas firstly published an article about a child with dilatation of the bile duct and suggested that it might be congenital.Then only a few cases were reported.At the end of the 20th century,Todani classified CCC into 5 main types according to patients' clinical characteristics and their bile duct angiography.The mechanism of CCC has not been fully elucidated yet,but 30%-70%CCC patients are companied with anomalous pancreaticobiliary duct union(APBDU),whose common duct and pancreas duct converge outside the duodenum.With an abnormally long pancreaticobiliary duct,the choledochal joins the pancreas duct as a perpendicular outside the Vater ampulla sphincter,causing parenzyme to reflux into the bile duct system and to destroy membrane and elastic fibers of the bile duct wall,finally resulting in dilatation of the bile duct.Moreover,unbalanced bile duct epithelial hyperplasia and virus infection are also suggested to be the possible mechanisms.Main clinical symptoms include occasional upper abdominal pain.upper right abdominal mass and obstructive jaundice,which are also named as the CCC triad.Furthermore,CCC could be companied by nausea,vomiting,anorexia,chill,fever etc..CCC could also cause severe complications such as cholangitis,pancreatitis,cholelithiasis,with a high risk of developing cholangiocarcinoma.The earliest surgical treatment of CCC involved external cyst drainage which might lead to electrolyte disturbance,malnutrition,low quality of life and survival rate as a consequence.In 1960s,researchers suggested to carry out the anastomosis of cyst and duodenum.This treatment is convenient to operate with low risk while the obstruction is solved.Consequently,it soon became the prior surgical approach for CCC.But the long term follow-up showed a high postoperative morbidity which would become more frequent as the length of follow-up increased.The main complication is cholangitis,which is believed to be caused by the reflux of duodenum content and anastomosis stricture.Therefore,after a decade,Roux-en-Y anastomosis of cyst and duodenum was carried out to avoid the reflux.Even though this treatment decreased the occurrence of postoperative cholangitis,APBDU remained unsolved and pancreas fluid reflux still existed,which stimulates the bile duct and increase the risk of malignancy.Thereby treatment was further improved to include cyst excision and Roux-en-Y hepaticojejunostomy.Limited by the surgical technique at that time,this approach was hard to perform with a higher rate of mortality.Nowadays,as the technique,preoperative preparation and postoperative supervision better,the safety to perform cyst excision and Roux-en-Y hepaticojejunostomy is more and more guaranteed.The surgery excises dilatation of bile duct,changes the way as to how bile flows and avoids the reflux,effectively reducing cholangiocarcinoma.As a result cyst excision and Roux-en-Y hepaticojejunostomy has become the golden standard of treating CCC.As the development of electric technology and its use in medical area,laparoscopic technique has been widely used from simple observation to complicate surgery,from adult patients to children even neonates.Farello GA reported the first laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy in 1995,from then,this treatment has become more and more popular.However,the safety of this surgical approach is in controversy.Laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy was not reported in China until 2001 Within two decades,this surgical approach has not been widely accepted and performed with only a few cases being reported.To address the gap in the literature,this study contained two parts:the first part is the summary and analysis of the clinical characteristics of children with CCC who underwent surgery in our center from June,2003 to May,2015.The second part is a meta-analysis of comparing open and laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy among Chinese children according to the present Chinese and English literature.This study aims to evaluate the safety and clinical effect of laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy in treating children with CCC,and to provide detailed conclusion and analysis about this new surgical approach.Method:The first part:We retrospectively analyzed the clinical characteristics and follow-up data of children with CCC who underwent surgery in Department of pediatric surgery in Shandong University affiliated Qilu Hospital from June,2003 to May,2015.All eligible patients were arranged into two groups:open surgery group and laparoscopic group.The operation time,blood loss,time to food intake,length of hospital stay and follow-up data were collected and analyzed.The patients in laparoscopic group were further divided into two subgroups:age less than 3 years old and over than 3 years old.The operation time,blood loss,time to food intake and length of hospital stay were compared between two subgroups.Then we analyzed clinical characteristics of 20 children with CCC who underwent surgery after external drainage in our center from June,2008 to May,2015.Among these patients,6 underwent percutaneous biliary drainage under ultrasound,8 underwent laparoscopic bile duct drainage,and the rest underwent laparoscopic cholecystostomy.Operation time,bile drainage within 24 hours after surgery,drainage time and the time interval between 2 stages of surgeries were compared among these three groups.Laboratory tests on hepatic function(ALT,AST,GGT,TBIL,DBIL included)before external drainage and after surgery,to be specific on the fifth to the seventh day,were also recorded and compared among these three groups.The second part:We searched databases including CNKI,Wanfangdata,Cqvip,PubMed,Embase,theScience Citation Index,and Cochrane Library,to identify all related published studies,comparing the laparoscopic and the open choledochal cyst excision with hepaticojejunostomy for Chinese children with CCC.Relevant information from each eligible article was abstracted such as operation time,blood loss,time to flatus,time to food intake,length of hospital stay and postoperative morbidity.RevMan 5.2 was used to analyze data.Heterogeneity was assessed by using the Q test and 12 statistic.Fixed-effects model or random-effects model was selected according to the result of heterogeneity test for the pooled-analysis.Statistical analysis of dichotomous variables was performed via the odds ratio(OR)and 95%confidence intervals(CI).Continuous variables were analyzed by the weighted mean difference(MD)and CI.Funnel plots were used for detecting outliers.Result:The first part:Our center's data analysis shows that compared with open surgery,laparoscopic surgery is associated with increased operation time but decreased blood loss,time to food intake and length of hospital stay.The comparison between two subgroups divided by 3 years age shows no statistically significant difference in operation time,blood loss and postoperative recovery.All 20 patients in three groups were relieved fiom abdominal pain,fever and jaundice after external drainage,and there is no statistically significant difference in the decrease rate of ALT,AST,GGT.TBIL,DBIL after surgery.The mean operation time of external drainage and radical surgery is 25.00±4.47min and 277.50±29.96min for percutaneous biliary drainage under ultrasound,84.38±24.99min;299.38±36.00 min for laparoscopic bile duct drainage,and 50.83± 13.57min;225.00±33.32 min for laparoscopic cholecystostomy.The second part:8 eligible studies are included in the final analysis,with 4 written in Chinese and other 4 written in English.The meta-analysis shows that compared with open surgery,laparoscopic surgery for CCC children in China is associated with longer operation time(MD=40.12,95%CI=34.55-45.68,P<0.00001),less blood loss(MD=-16.14,95%CI=-17.12--15.16,P<0.00001),shorter time to flatus(MD=-0.91,95%CI=-1.05--0.78,P<0.00001),earlier food intake(MD=-1.10,95%CI=-1.20--1.00,P<0.00001),decreased length of hospital stay(MD=-2.50,95%CI=-2.78--2.23,P<0.00000)and decreased morbidity(OR=0.24,95%CI=0.17-0.35,P<0.00001).Conclusion:1.Laparoscopic choledochal cyst excision with hepaticojejunostomy for children with CCC including infants and neonates is reliable and safe.2.Laparoscopic choledochal cyst excision with hepaticojejunostomy is associated with less blood loss,faster recovery,decreased morbidity and length of hospital stay when comparing with open surgery.3.The primary minimal invasive external drainage could be used in some severe cases with CCC to allow minimal invasive radical surgery and improve the safety.4.As the technique of laparoscope develops and the skills of surgeons improve,laparoscopic surgery could be the prior treatment for children with CCC.