| BackgroundBiliary dilatation(BD),also known as a choledochal cyst,is a rare form of abnormal biliary development.It includes multiple or isolated cystic changes of bile duct in different locations of liver and extrahepatic.Extrahepatic bile duct dilatation(EHBD)is the most common type in clinic,accounting for more than 90% of BD.BD is associated with a high risk of cancer because the pathological bile duct is repeatedly stimulated by inflammation.The highest canceration rate in adults is 28%.Therefore,early diagnosis and surgical treatment of BD is very important.The principles of surgical treatment of BD are: Complete removal of diseased dilated bile duct,biliopancreatic shunt,elimination of cholestasis,treatment of biliary tract infection and prevention of canceration.Farello first reported laparoscopic choledochal cyst excision plus hepaticojejunostomy in 1995,which pioneered minimally invasive surgery for EHBD.With the continuous improvement of laparoscopic operation technology and the update of laparoscopic equipment,minimally invasive treatment of EHBD has been widely carried out.Minimally invasive surgery for choledochal cyst resection and hepaticojejunostomy is safe and feasible.It has the short-term advantages of minimal trauma,rapid recovery,incision cosmetology and low incidence of complications,and its long-term effect is comparable to that of open surgery.Moreover,the incidence of the disease is higher in children or young women,and these patients often have more demand for minimally invasive treatment.BD involves a variety of pathological types of intrahepatic and extrahepatic bile ducts,and its disease classification has important guiding significance for the choice of surgical treatment.At present,Todani classification is widely used in the world on the basis of the morphology and distribution of the diseased bile ducts,which provides a basis for the clinical diagnosis and surgical treatment of BD.In China,Dong classification is based on the location of the diseased bile ducts involving the bile duct tree and the clinicopathological characteristics,which has guiding significance for the formulation of BD surgical strategy.However,EHBD,which accounts for more than 90% of BD,is only one of the two subtypes.Literature reports and our clinical practice have found that although EHBD with different imaging and morphological characteristics has the same classification,the difficulty and risk of surgery,especially the difficulty and risk of minimally invasive surgery,are quite different.Previous typing methods have no guiding significance for the selection of EHBD surgical methods and the prediction of surgical difficulty.Therefore,it is necessary to establish a new typing method for EHBD to guide its surgical decision-making on the basis of previous typing methods.This research is divided into two parts.In the first part,through retrospective analysis of the imaging characteristics of EHBD,combined with intraoperative exploration of pathological changes in bile duct morphology,a new classification method of EHBD was established on the basis of previous classification.The clinical characteristics of different types of EHBD were analyzed and summarized,and the guiding value of the new classification method for surgical treatment of EHBD was preliminarily discussed.The second part compares the perioperative and follow-up results of different types of EHBD treated by minimally invasive surgery and laparotomy,and explores the guiding significance of the new classification for the minimally invasive treatment of EHBD,so as to provide the basis for the choice of surgical methods.MethodsThe part ?: To analyze the imaging data of 207 EHBD patients admitted to the Institute of Hepatobiliary Surgery,Southwest Hospital,Army Medical University from December 2010 to December 2018,including ultrasonography(Ultrasonography,US),computed tomography(CT)and magnetic resonance cholangiopancreatography(MRCP).A new typing method was established by combining the features of pathological bile duct with the morphological features of pathological bile duct observed during operation.The clinical symptoms,complications,perioperative and follow-up results of different types of EHBD were compared.The part ?: The data of 136 patients with EHBD who underwent minimally invasive surgery and 71 patients with EHBD who underwent laparotomy from December 2010 to December 2018 were retrospectively analyzed.To analyze the general data,perioperative and follow-up results of minimally invasive surgery for different types of EHBD,and to compare the perioperative and follow-up results of minimally invasive and laparotomy for the same type of EHBD.SPSS 20.0 software was used to analyze the measurement data.One-way ANOVA was used to analyze the measurement data.Chi-square test and continuous correction test were used to test the exact probability of Fisher.P < 0.05 had significant difference.According to the new classification,the corresponding diagnosis and treatment strategies were formulated,and the characteristics of minimally invasive treatment of different classification were summarized.ResultThe part?: To analyze the preoperative imaging data of 207 EHBD cases,and to observe the morphological changes of the lesion bile duct during the operation,define a new classification: type A(upper segment type): the confluence of left and right hepatic ducts is involved,and the distal bile duct is near normal.Type B(intermediate type): The diseased bile duct is located in the middle of the common bile duct.The confluence of left and right hepatic ducts and the end of the bile duct are basically normal.Type C(lower segment): The diseased bile duct is mainly located at the end of the bile duct.The confluence of left and right hepatic ducts and the upper segment of the bile duct are basically normal.Type D(whole course): The lesion involves the whole bile duct,and the joint of left and right hepatic ducts and the end of the bile duct are involved.Among 207 cases,68 cases(32.9%)were type A,35 cases(16.9%)were type B,33 cases(15.9%)were type C and 71 cases(34.3%)were type D.Comparing the four types of EHBD,there were significant differences in the incidence of preoperative choledocholithiasis(A vs B vs C vs D:5.9% vs 5.7% vs 24.2% vs 15.5%,P=0.027),acute and chronic cholangitis(A vs B vs C vs D:10.3% vs 2.8% vs 24.2% vs 19.7%,P=0.039).The incidence of type C,D combined with choledocholithiasis and acute and chronic cholangitis was higher than that of type A and B respectively.The four types of operation time were: type A(229.7±92.1min),type B(211.4 ±43.8min),type C(306.5±76.3min)and type D(293.9±91.3min).There were significant differences between the groups(P=0.005).The operation time of type C and D was longer than that of type A and B.The intraoperative blood loss of type A(201.3±97.7ml),type B(189.3±51.0ml),type C(247.1±85.4ml)and type D(297.4±145.1ml),respectively.The incidence of pancreatic leakage after operation of type C and D was significantly higher than that of type A and B(A vs B vs C vs D:5.8% vs 5.7% vs 27.3% vs 35.4%,P=0.024);clinical symptoms: abdominal pain,jaundice,abdominal mass had no significant difference;preoperative cholecystolithiasis,intrahepatic cholelithiasis,acute cholecystitis,acute cholecystitis and acute cholecystitis had no significant difference.There was no significant difference in the incidence of complications such as chronic pancreatitis,biliary leakage,long-term complications(anastomotic obstruction,cholangitis,stones)and reoperation.The part?: 207 EHBD patients were enrolled in the group,and 136 patients in the minimally invasive surgery group(MISG),including 46 cases of type A,20 cases of type B,22 cases of type C and 48 cases of type D.There were 71 cases in the open surgery group(OSG),including 22 cases of type A,15 cases of type B,11 cases of type C and 23 cases of type D.The operation time of four types of EHBD in MISG were: type A(244.7±68.1min),type B(227.1±71.4min),type C(322.5±63.8min)and type D(335.4±101.9min).There was significant difference between the two groups(P=0.000).The operation time of type C and D was significantly longer than that of type A and B.The intraoperative blood loss was: type A(151.8±113.7ml),type B(129.0±72.0ml),type C(170.0±115.1ml),type D(231.3±160.9ml)respectively.The incidence of pancreatic leakage and conversion to laparotomy were significantly higher in type C and D than in type A and B(pancreatic leakage rate,A vs B vs C vs D:4.3% vs 5.0% vs 22.7% vs 22.9%,P=0.024),(transitional rate,A vs B vs C vs D:2.2% vs 5.0% vs 13.6% vs 18.7%,P=0.049).There was no significant difference in the rate of reoperation(P > 0.05).Perioperative results of all types of EHBD in MISG and OSG: The blood loss,eating time and hospitalization time of four types of MISG were lower than those of OSG.type A: MISG vs OSG,blood loss = 151.8±113.7ml vs 238.6±111.2ml,P=0.005,postoperative feeding time=2.8±0.8d vs 4.8±1.2d,P=0.000,hospitalization time after operation=8.2±3.0d vs 10.4±2.9d,P=0.042.type B: MISG vs OSG,blood loss = 129.0±72.0ml vs 223.3±153.4ml,P=0.040,postoperative feeding time = 2.8 ±0.7d vs 5.2±5.8d,P=0.000,postoperative hospitalization time after surgery = 8.8±2.7d vs 12.1±5.8d,P=0.030.type C MISG vs OSG,blood loss = 170.0±115.1ml vs 327.3±173.7ml,P=0.000,postoperative feeding time=3.0±1.0d vs 6.5±1.4d,postoperative hospital stay=8.1±3.0d vs 12.1±2.2d,P=0.001,type D MISG vs OSG,blood loss=231.3±160.9ml vs 343.5±210.1ml,P=0.030,postoperative feeding time=2.9±1.0d vs 5.2±1.2d,P=0.000,postoperative hospitalization time = 9.7±3.5d vs 11.1±2.9d,P=0.024.There was no significant difference between type A and B in MISG and type A and B in OSG.The operation time of type C and D in MISG was significantly longer than that of type C and D in OSG(type C MISG vs OSG,operation time = 322.5±63.8min vs 267.9±70.5min,P=0.045),(type D MISG vs OSG,operation time=335.4 ±101.9min: 263.2±112.8min,P=0.013).There was no significant difference in the incidence of pancreatic leakage and biliary leakage and long-term complications(anastomotic stricture,recurrent bile duct,intrahepatic bile duct stones)between MISG and OSG.Conclusion1.Based on the analysis of imaging and morphological changes of bile ducts in EHBD lesions in large cases,a new classification method of EHBD is proposed for the first time.The clinical characteristics of different types of EHBD are analyzed and summarized,and the guiding value of the new classification method in the surgical treatment of EHBD is preliminarily clarified.2.The new typing has important guiding significance for the choice of surgical methods for EHBD.Minimally invasive treatment of type A and B EHBD has definite advantages and should be the first choice.C and D type EHBD minimally invasive surgery also has the advantages of less intraoperative blood loss and faster recovery after operation.However,there are some problems such as long operation time and high conversion rate to open surgery.Especially in some cases with common bile duct stones and recurrent cholangitis,the operation is difficult and needs to be carefully handled in combination with team experience.3.This subject is a single-center study.Follow-up prospective studies with multi-center and large samples are needed to further verify the guiding value of EHBD typing. |
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