The Application Of Enhanced Recovery After Surgery In Pediatric Congenital Choledochal Cyst

Background:Congenital Choledochal Cyst(CCC),also known as Congenital Biliary Dilatation(CBD),is a common.biliary disease in children.It is mainly characterized with cystic or fusiform choledochal dilatation,sometimes it is accompanied by dilatation of the intrahepatic bile ducts.CCC is more common in Asian countries than in western countries,and has a preponderance in women.In 1723 Vater firstly reported a young patient with dilatation of the bile duct.Until the end of the 20th century,Todani classified CCC into 5 main types according to patients' clinical characteristics and their bile duct angiography,Type ?:common type.Type ?a:cystic dilatation of the choledochus;Type ?b:segmental choledochal dilatation;Type ?c:fusiform dilatation of the choledochus.Type ?:diverticulum type in the whole extrahepatic duct.Type ?:prolapse of the choledochal cyst.Type ?a:multiple cysts at the intra-and extrahepatic ducts.Type ?b:multiple cysts at the extrahepatic duct only.Type ?:intrahepatic bile duct cyst(single or multiple).Clinically,Todani type? and type ? are extremely rare among children.Secondly,Todani type ? is completely different from the common CCC in the etiology and treatment.Therefore,scholars are more inclined to the simplified classification of CCC,including the stenotic distal CCC and non-stenotic distal CCC.Currently,choledochal cyst excision with Roux-Y hepaticojejunostomy is the main surgical method for treating CCC.With the continuous development of minimally invasive technology,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 choledochalcyst excision with Roux-Y hepaticojejunostomy in 1995.From then,laparoscopic choledochal cyst excision with Roux-Y hepaticojejunostomy has gained more and more affirmation and support,and has become the golden standard of treating CCC,which is less invasive and quick recovery.However,as a special form of trauma,surgery causes severe stress and psychological pressure in both children and their parents.Furthermore,the conventional perioperative management approaches—including prolonged preoperative fasting,use of surgical drains and tubes,and improper postoperative pain management—cause different levels of stress responses and complications,severe cases require interventional treatment or even secondary surgical intervention,which will delay the postoperative recovery of children and increase the cost of hospitalization.The term "Enhanced Recovery After Surgery(ERAS)" first appeared in a paper by the Danish surgeon Henrik Kehlet in the 1990s,which reported that a group of patients undergoing colorectal surgery received early postoperative oral feeding,early postoperative mobilization without indwelling gastric tube,urinary tube,drainage tube and other measures,and then their postoperative hospital stay was shortened.Subsequently,the perioperative management concept has been rapidly popularized and applied in adult surgery.Various ERAS guidelines have been established for several kinds of adult surgeries.While the application of ERAS in pediatric population remained to be explored.Previous retrospective observational studies have confirmed the applicability of the ERAS concept in the perioperative period of pediatric congenital choledochal cyst,but some measures are still controversial,such as whether the gastric tube and the drainage tube needs to be indwelled and their indications,and the timing of getting out of bed early after surgery and so on.Objective:The purpose of present study was to evaluate the application of ERAS protocol in the perioperative period of pediatric congenital choledochal cyst and prove that ERAS protocol can safely and effectively optimize the outcomes of surgical patients.Methods and materials:A total of 146 patients with congenital choledochal cyst who underwent laparoscopic or open choledochal cyst excision with Roux-Y hepaticojejunostomy in the First Affiliated Hospital of Zhengzhou University from January 2017 to September 2019 were retrospectively analyzed.With the informed consent of patients and approval of the ethical committee,data included patient characteristics(American Society of Anesthesiologists grade,age,sex,weight),CCC Todani classification,CCC shape,CCC diameter,preoperative laboratory data(white blood cell,albumin,alanine aminotransferase,alanine aspartate aminotransferase,y-glutamyl transpeptadase,prothrombin time,total bilirubin),surgical approach,operation time,intraoperative hemorrhage,perioperative interventions,ERAS items,and outcomes(including postoperative complications,time to normal bowel function recovery,time to achieve targeted mobility,postoperative LOS,hospitalization expenses,etc).Complications were defined and graded as Clavien-Dindo ?-? as described by Clavien-Dindo classification and were included if they occurred within 30 days after surgery.Data were censored at 30 days following surgery for patients who remained in the hospital.According to the surgical approach,the patients were divided into open surgery group and laparoscopic surgery group.The patients receiving ERAS protocol were divided into ERAS group,otherwise into the control group.All data were anonymously analyzed.The statistic was performed by statistical software SPSS 22.0.Logistic regression analysis was performed for evaluating the postoperative complications.The significant variables of univariate analysis were included into multivariate analysis to determine the factors that had independent influence on postoperative complications.Results:1.A total of 59 patients who underwent open choledochal cyst excision with Roux-Y hepaticojejunostomy were included in open surgery group,of which 21 were enrolled in ERAS group and 38 in control group.The age(P=0.202),gender(P=0.946),weight(P=0.156),CCC Todani classification(P=0.332),CCC shape(P=1.000),CCC diameter(P=0.542),preoperative laboratory data of the ERAS group showed no significant difference compared with the control group.The operative time was equal between the two groups,258.6±80.4 mins in the ERAS group and 235.2±67 mins in the control group,showing no significant difference(P=0.237).There was no significant difference in the midian intraoperative hemorrhage between the two groups(P=0.848).After surgery,the midian time to first flatus of patients in the ERAS group was 24 hour,significantly shorter than that of the control group(P=0.008).Compared with the control group,postoperative length of hospital stay(LOS)in the ERAS group was also significantly shorter(6.0 days VS.9.5 days;P=0.016).Similarly,patients in ERAS group enjoyed less cost(P=0.003).In the control group,34.2%(13/38)of the patients experienced different degrees of postoperative complications,while the rate in the ERAS group was 24.8%(5/21).The proportion of postoperative complications was higher in the control group than in the ERAS group,although there was no statistical difference(P=0.406).2.A total of 87 patients who underwent laparoscopic choledochal cyst excision with Roux-Y hepaticojejunostomy were included in laparoscopic surgery group,of which 62 were enrolled in ERAS group and 25 in control group.The age(P=0.782),gender(P=0.635),weight(P=0.567),CCC Todani classification(P=0.956),CCC shape(P=0.279),CCC diameter(P=0.266),preoperative laboratory data of the ERAS group showed no significant difference compared with the control group.The operative time was equal between the two groups,228.2±50.1 mins in the ERAS group and 247.6±66.8 mins in the control group,showing no significant difference(P=0.142).No significant differences in the midian intraoperative hemorrhage were found between the ERAS group and the control group(12.5ml VS.10.0ml;P=0.661).After surgery,the midian time to first flatus of patients in the ERAS group(22.0 hours)was significantly shorter than that of the control group(45.0 hours,P<0.001).The midian LOS in the ERAS group was 6.0 days,significantly shorter than that of the control group(8.0 days;P<0.001).Similarly,patients in ERAS group enjoyed less cost(P<0.001).In the control group,20.0%(5/25)of the patients experienced different degrees of postoperative complications,while the rate in the ERAS group was 9.7%(5/62).The proportion of postoperative complications was higher in the control group than in the ERAS group,although there was no statistical difference(P=0.340).3.A total of 29 patients(19.9%)presented with postoperative complications and 20 patients(13.7%)developed Clavien-Dindo Grade ?-? complications.On multivariable analysis(MVA),ERAS protocol(OR 0.345,95%CI 0.176-0.736,P=0.021)can significantly reduce the incidence of Clavien-Dindo Grade ?-?complications,whereas intraoperative hemorrhage was an independent risk factor for Clavien-Dindo Grade ?-? complications(OR 1.011,95%CI 1.000-1.008,P=0.041).Conclusion:1.The application of ERAS protocol can significantly promote the recovery of gastrointestinal function,shorten the postoperative hospitalization time,reduce hospital costs,and accelerate postoperative rehabilitationin in the perioperative period of pediatric congenital choledochal cyst.2.The ERAS protocol can significantly reduce the incidence of postoperative complications in CCC children undergoing open or laparoscopic choledochal cyst excision with Roux-Y hepaticojejunostomy.And the intraoperative hemorrhage is an independent risk factor for postoperative complications.