| BackgroundCholedochal cysts, also known as the congenital cystic dilatation of biliary tract, are the kind of disease which is characterized by bile duct dilatation with cholestasis. It occurs in any part of the biliary system, including the intrahepatic and extrahepatic bile duct. It has a preponderance in women and is more popular in Asian countries. The exact etiology and pathogenesis is not yet clear though. One of the most widely accepted theory is anomalous pancreaticobiliary duct union(APBDU) presented by Babbitt. Other doctrines include the theory of the proliferation imbalance of biliary epithelial, sphincter of Oddi dysfunction, neuro dysplasia of the biliary tract and so on.Choledochal cysts are classified into five types, and the most common types are type Ⅰ, which is known as the dilatation of the extrahepatic bile duct, and type Ⅳa, which is known as the dilatation of both intra- and extrahepatic bile duct. The incidence of biliary tract malignancy ranges from 2.5% to 26%, which is much higher than the people without choledochal cysts. So the principle of management of choledochal cysts is early treatment under detection.Roux-en-Y hepaticojejunostomy(RYHJ) bilioenteric reconstruction after choledochal cysts total resection is the preferred surgical approach. The extent of the bile duct be resected ranges from the normal part above the expanded part of the bile duct in the top down to the intrapancreatic bile duct above the junction point of the bile duct and pancreatic duct. Since many patients with choledochal cysts often has a history of cholangitis or pancreatitis, the bile duct may probably adhere with surrounding tissues, especially to the intrapancreatic bile duct. In the process of resecting the intrapancreatic bile duct, it is likely to cause the pancreatic tissue bleeding, or even damage the pancreatic duct. After the resection of the intrapancreatic bile duct, a wound will appear at the upper edge and the rear of the head of the pancreas, and we called it pancreatic wound. If not handled properly, it can easily lead to the occurrence of postoperative complications. Therefore, how to deal with the pancreatic wound reasonably has become the most important issue to the operation of choledochal cysts. ObjectiveThis study aims at doing research on the postoperative complications of choledochal cysts by comparing two different kind of treatment to the pancreatic wound, and discussing how to deal with the pancreas wound reasonably. After this, we can improve the safety of the operation and reduce the postoperative complications. MethodsA retrospective review is developed in the patients who underwent surgical teatment of choledochal cysts directed by in Professor Zhang in Eastern Hepatobiliary Hospital affiliated to the Second Military Medical University from January 2008 to February 2013. The patients include those who receive the operation for the first time and those who have received the operation of this disease before. According to the different treatment of the pancreatic wound, all patients were enrolled into two groups: in one group, we make the pancreatic wound completely opened, make it keep the original shape with the drainage placed around the surgical area; in the other group, we stitched on the surface of the pancreatic wound to close it.Clinical data were collected in the two groups. The preoperative clinical information includes the patients’ basic information, the complete medical history, preoperative imaging findings and preoperative hematological indices. Surgery-related data include the surgical exploration situation, the actual surgical approach, the treatment of distal bile duct, and the treatment of the pancreatic wound. The postoperative clinical information observed includes the postoperative hematological indices, the patients’ basic condition, the condition of the peritoneal drainage, the incidence of postoperative complications and the corresponding measures, and the situation of recovery after treatment.According to the relevant definitions, we made the judgment of postoperative complications. The complications related to our research include pancreatic fistula, abdominal bleeding, abdominal infection and so on. We use the PSM to reduce the differences of the elementary data between the two groups. A PSM was estimated for all patients after Logistic regression analysis. Variables used in the model is the history of biliary tract surgery. Through the logistic regression analysis and comparing the incidence of postoperative complications between the two groups, we can discuss the influence that the two different treatments of pancreatic wound made on the postoperative complications, and do research on the related causes of it. ResultsIn all 149 cases of choledochal cysts patients enrolled in the research, there are 108 cases of which the pancreatic wound were opened, and 41 cases of which the pancreatic wound were closed. Among all of them, surgical complications associated with this study occurred in 36 cases. The morbidity was 24.2%. Among all surgical complications occurred in these ones, 30 were the complication of pancreatic fistula, which account for 20%. In cases who suffered the complication of pancreatic fistula, 19 were Class A and 11 were Class B. There were no Class C cases. In addition, there are 5 cases suffered abdominal infections and 2 cases suffered abdominal bleeding, no deaths and reoperation cases.In pancreatic wound opened group, there were 15 cases suffered the complication of pancreatic fistula, which accounted for 13.9% of the cases of this group. The abdominal infection cases were 3, and the abdominal bleeding cases were 2. No cases suffered two or more complications simultaneously.In pancreatic wound closed group, there were 15 cases suffered the complication of pancreatic fistula, which accounted for 36.6% of the cases of this group. The abdominal infection cases were 2. There were no abdominal bleeding cases. One case suffered the complications of abdominal infection and abdominal bleeding simultaneously. No cases suffered all of the three complications together.After statistical analysis, we find that the incidence of pancreatic fistula in pancreatic wound opened group(13.9%) was significantly lower than that in pancreatic wound closed group(36.6%), and the difference was statistically significant(p <0.05). The incidence of abdominal infection and abdominal bleeding between the two groups had no significant difference.To eliminate the differences in baseline demographics data between the two groups, the PSM analysis was carried out. Logistic regression analysis shows that the factor of closing pancreatic wound was an independent risk factor for postoperative pancreatic fistula. The pancreatic fistula in pancreatic wound opened group(19.5%) was significantly lower than that in pancreatic wound closed group(41.5%), and the difference was statistically significant(p <0.05). Similarly, the incidence of abdominal infection and abdominal bleeding between the two groups had no significant difference. ConclusionsIn the premise of completely hemostasis in the operation of choledochal cysts total resection, making the pancreatic wound opened can reduce the incidence of postoperative pancreatic fistula. But the occurrence of complications of abdominal infection and abdominal bleeding has nothing to do with what kind of treatment used for the pancreatic wound. The reasonable approach for the treatment of pancreatic wound has an important role in reducing the incidence of postoperative complications after choledochal cysts total resection. |
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