Page 34 - World Journal of Laparoscopic Surgery

Laparoscopic Choledochal Cyst Resection with Biliary Reconstruction
Table 3: Surgical variables and outcomes, with at least 2-year follow-up ICU and resolution of the acute phase), the resection of the cyst is
1
Variable (%), SD performed. In our series of cases, complete resection of the CC and
Average surgery time 147 minutes bilioenteric reconstruction was performed in one surgical time with
(113–195 minutes) a 0% conversion rate and no need of reintervention.
Perhaps the most important aspect of the procedure, besides
Average intraoperative bleeding 15–50 cc an adequate resection of the CC, is an adequate biliary-enteric
Mean hospitality stay 5 days reconstruction where the anastomosis made should allow free
Bile leaks 0 biliary flow into the intestine, avoiding as biliary reflux, which is
Converted to open surgery 0 the most important cause malignancy in these patients. It can
1,3
Oral feeding and adequate tolerance at POP 2 be done with a hepatic-duodenostomy, choledochojejunostomy,
(days) or with a Roux-en-Y hepaticojejunostomy. 1,3,6 Being the first and
Mortality 0 third the most frequent; today there is great controversy regarding
POP, postoperative which of the two most used procedures is the best as it can be
evidenced in the experience of Narayanan et al., who in 2013
published a systematic review in which when comparing 679 cases
Prior to 1980’s, management for common bile duct consisted of patients, 60.7% taken to hepatico-duodenostomy and 39.3%
on drainage; however, reports of cholangiocarcinoma, recurrent to hepaticojejunostomy, respectively, they reported: a hospital
cholangitis, and biliary lithiasis led to a change in the way surgeons stay time of 4.8 days and 6.1 days, the incidence of biliary leakage
3,4
managed this disease. That is why currently, the management of 2.1% and 2.94%, the incidence of cholangitis 2.47% and 2.42%, the
Todani I, II, and IV CC is similar and involve a complete resection of incidence of anastomotic stenosis 1.21% and 1.47%, the incidence of
the defect with posterior bilioenteric reconstruction. 1–3,5,11 biliary reflux 5.88% and 0%, incidence of intestinal obstruction due to
Sastry et al. show the incidence of CC according to the Todani adhesion syndrome 0% and 5.12%, and the need for re-intervention
19
classification, being type I the most frequent (69.8%), followed 1.21% and 2.45%. Most studies demonstrate that there are really
12
by type IV (23.7%), type V (3.1%), type II (2%) and type III (1.4%). no clinically significant differences between the two procedures.
The goal of the surgical management of type IV-A and IV-B CC is However, due to the existing evidence with hepaticoduodenostomy
to stop or at least slow down the progression of liver damage. and the development of gastric cancer secondary to biliary reflux,
The complications of non-operated CC are the result of stasis in in our study, we only performed bilioenteric reconstruction with a
which cholangitis, biliary stone formation, recurrent pancreatitis, Roux-en-Y hepaticojejunostomy. 1,20 In our case series, there was no
cirrhosis, and portal hypertension without mentioning the risk for biliary leakage, no re-intervention were needed; and our hospital
cholangiocarcinoma; for that reason, surgical management in adult stay time was shorter to the one reported in the medical literature.
population is indicated. 13 It is a common factor among the opinion of experts in the world
When complete resection of the cyst is not possible (usually medical literature on this regard that the laparoscopic approach is a
in CC type IV-A) complete resection of the extrahepatic biliary challenging for the surgeon but if performed correctly it is effective
2
tract should be performed in addition to a lobectomy (of the and appropriate. The conversion rate to open approach ranges
compromised portion of the intrahepatic biliary tree) with posterior from 0% to 37%, as described by Palanivelu et al. (2008) in a study
biliary-enteric reconstruction. Incomplete resection of the cyst does published in the Journal of the American College of Surgeons that
not seem to be related to perioperative complications although report a conversion rate of 8.5%. However, in our series there were
3
some argue a persistent risk of malignancy. 14,15 no conversions to open surgery. The age of the patient has been
The usefulness of laparoscopy in the surgical management of shown to be directly related to the need for conversion, is it more
this type of patients has been questioned due to the complexity frequent in pediatric patients than in adults, which is extrapolated
2
of the procedures, the need for precise movements, and the long to our results. On average, the length of hospital stay time in
16
learning curve necessary to obtain adequate results. However, minimally invasive management ranges from 3 days to 4.7 days and
resection with minimally invasive technique with a Roux-en-Y in the open approach from 5 days to 20.5 days and has a mortality
reconstruction has been shown to be safer when compared to of up to 3.3%, as evidenced in our series. 2,3,6
open approach. 16,17 Early postoperative complications include pancreatitis, enteric
Some of the advantages of laparoscopic management in or biliary leakage from the anastomosis, bleeding, SSI, and pancreatic
these cases are the better visualization of structures, more or biliary fistulas. The most frequent delayed complications (after
precise dissections due to the magnification of structures, less 30 days postoperative) are intrahepatic or extrahepatic bile duct
postoperative pain, shorter hospital stay time, better esthetic stenosis, lithiasis, malignancy, intestinal obstruction, recurrent
results, decreased bleeding, lower risk SSI and lower incidence of pancreatitis, hepatic cirrhosis, and cholangitis. 1,4,8 Postoperative
postoperative ileus; being the only negative aspect a prolonged complications in children are rare; however, in adults, they occur
1
surgical time. 6,18 However, some authors have described an between 17% and 40% of cases. the most frequent complication
association between the laparoscopic approach and an augmented with an incidence of 0% to 20% of cases is an anastomotic leakage;
risk of malignancy due to incomplete CC resections that lead to however, in our study, there were no postoperative complications. 3
chronic inflammatory process; they argue that open approach Studies that support the use of robots for the surgical
should not be fully abandoned since it is possible to better identify management of CC, such as the one reported by Wang et al. who
structures even in cases of severe local inflammatory processes and reported their experience in 2016 with a 26-year-old patient who
anatomical distortion. 3,11 was diagnosed with a type I CC and decided to take him to a
Some patients benefit from a two-stage surgical procedure, robotic Roux-en-Y hepaticojejunostomy with the alimentary and
where during the first surgical time the CC is drained. During the bilioenteric loops in a retrocolic position with satisfactory results
second operative time (after physiological resuscitation in the in terms of incidence, early or late complications, esthetic results

80 World Journal of Laparoscopic Surgery, Volume 12 Issue 2 (May–August 2019)