Page 35 - World Journal of Laparoscopic Surgery

Laparoscopic Choledochal Cyst Resection with Biliary Reconstruction
and SSI, with a surgical time of 480 minutes (longer when compared it is an observational retrospective study without randomization
with our surgical time) and a bleeding of 100 cc (also greater than and no control group. It is therefore subject to selection bias. In
10
the one reported in our series). The evidence on robotic surgery addition, the population size of our study may be too small to draw
in these cases is very limited; however, some authors consider that statistically relevant conclusion, even if it is an infrequent disease
aspects such as the magnified three-dimensional image, along in Latin America.
with more precise movements could represent the difference in
the prognosis of the patients. 1,10 conclusIon
As it was said before, some authors have reported that
cholangiocarcinoma may be a secondary to unresected portions Adult CC are a group of rare entities that lead to high mortality and
26
CC, with an incidence of up to 30% in the adult population. risk of developing cancer, these make their management critical and
The global incidence reported in the word medical literature for necessary. Complete resection of the CC and laparoscopic Roux-
cholangiocarcinoma is 0.95 per 100,000, being more frequent in en-Y bilioenteric reconstruction is an effective and safe method,
patients with CC. 21,22 The risk of malignancy reported for these although complex and challenging for the surgeon. This simplified
patients is 0.7% to 28%, this risk increases over time. 2,5,6,8,23 Sastry laparoscopic approach to bile duct reconstruction with Roux-en-Y
et al., in one of their studies with a population of 7,880 patients anastomosis seems to be an effective and safe alternative for the
(1,914 under 18 years of age and 3,866 adults), from which 4.59% management of this pathology. Additional research is warranted
had histopathological studies revealing malignancy, 70.4% of these to assess long-term results in a larger series.
patients had cholangiocarcinoma, 23.5% gallbladder carcinoma, AcknowledgMents
and 6.1% other malignancies. The incidence of cholangiocarcinoma
21
in type I CC is 68%; and in type IV CC it is of 21%. The risk of The authors are pleased to acknowledge Dr Ximena Alvira who
malignancy is high, and it is associated with a global survival of provided clinical feedback and assistance in preparing the
6 to 21 years. Incidence of malignancy referred by Amid et al., in manuscript for submission. Dr Ernest Njeru provided quality English
type IV CC was of 9.2%, type I 7.6%, type II 4.3%, type III 4%, and translation.
12
type V 2.5%. For this reason, it is imperative to make a complete
resection of CC and to make a strict postoperative follow-up. references
There is still some controversy regarding abandoned CC parts 1. Soares KC, Arnaoutakis DJ, Kamel I, et al. Choledochal cysts:
and their risk of malignancy; however, some of the studies on this presentation, clinical differentiation, and management. J Am Coll
regard seem to indicate that a complete resection is superior to a Surg 2014;219(6):1167–1180. DOI: 10.1016/j.jamcollsurg.2014.04.023.
partial resection in terms of reducing the risk of malignancy as it 2. Hasan A, Nuha Y, Basil A. Laparoscopic resection of type I choledochal
is shown by Ten Hove et al. in a meta-analysis published in 2018, cyst in an adult and Roux-en-Y hepaticojejunostomy: a case
where they compare a total of 80 studies and 2,904 patients, with report and literature review. Surg Laparosc Endosc Percutan Tech
an incidence of 10.7% of cholangiocarcinoma, with an increased 2006;16(6):439–444. DOI: 10.1097/01.sle.0000213768.70923.99.
risk for patients with type I and IV CC with a statistically significant 3. Palanivelu C, Rangarajan M, Parthasarathi R, et al. Laparoscopic
management of choledochal cysts: technique and outcomes – a
p of 0.016, and with an increased risk for cholangiocarcinoma for retrospective study of 35 patients from a tertiary center. J Am Coll
patients taken to CC drainage and partial resection with an OR Surg 2008;207(6):839–846. DOI: 10.1016/j.jamcollsurg.2008.08.004.
of 3.97, almost four times more than patients taken to complete 4. Edil BH, Olino K, Cameron JL. The current management of choledochal
resection (as it was performed in our series). 1,2,24,25 Mutations in K-ras cysts. Adv Surg 2009;43:221–232. DOI: 10.1016/j.yasu.2009.02.007.
and p53 genes have been associated with cholangiocarcinoma and 5. Tadokoro H, Takase M. Recent advances in choledochal cysts. OJ Gas
a history of common bile duct disease. 1,4,8 Nevertheless, no tumor 2012;2(4):145–154. DOI: 10.4236/ojgas.2012.24029.
markers show direct relationship between their serum levels and 6. Ahmed B, Sharma P, Leaphart CL. Laparoscopic resection of
the presence of cholangiocarcinoma. 26 choledochal cyst with Roux-en-Y hepaticojejunostomy: a case report
Nicholl et al. revealed a direct correlation between patient and review of the literature. Surg Endosc 2017;31(8):3370–3375. DOI:
10.1007/s00464-016-5346-3.
age and cancer risk: from 0 year to 30 years (0%), from 31 years 7. Crespo G, Garcia M, Marqués E, et al. Lesiones quísticas del conducto
27
to 50 years (19%), and from 51 years to 70 years (50%). Surgical cístico (lesiones tipo VI). Rev Esp Enferm Dig 2017;109(5):373.
management of CC with complete surgical excision during 8. Soares KC, Goldstein SD, Ghaseb MA, et al. Pediatric choledochal
early life tends to decrease the probability of developing cancer cysts: diagnosis and current management. Pediatr Surg Int 2017;33(6):
cholangiocarcinoma later in life especially in the group of patients 637–650. DOI: 10.1007/s00383-017-4083-6.
with type I CC. 28,29 One study of 56 patients with a previous history 9. Manoj Kumar GP, Rajagopalan B. Choledochal cyst. Med J Armed
of resection three patients progressed to cholangiocarcinoma Forces India 2012;68(3):296–298. DOI: 10.1016/j.mjafi.2012.04.011.
with a range of 2–19 years after the procedure, showing that a 10. Wang S-E, Chen S-C, Shyr B-U, et al. Robotic assisted excision of
type I choledochal cyst with Roux-en-Y hepaticojejunostomy
strict follow-up is necessary after the procedure and during a long reconstruction. Hepatobiliary Surg Nutr 2017;6(6):397–400. DOI:
period of time to ensure an early diagnosis and improve long-term 10.21037/hbsn.2017.01.15.
30
outcomes even in malignant positive patients. Other study that 11. Stringer M. Laparoscopic management of choledochal cysts: is a
supports this shows that 15 patients out of 214 cases reported keyhole view missing the big picture? Pediatr Serg Int 2017;33(6):
were associated with malignancy of the biliary tree; their survival 651–655. DOI: 10.1007/s00383-017-4089-0.
was of 6–21 months after being diagnosed, poor prognosis was 12. Sastry AV, Abbadessa B, Wayne MG, et al. What is the incidence of
31
associated with late Lee et al. in a study of 40 patients diagnosed biliary carcinoma in choledochal cysts, when do they develop, and
with cholangiocarcinoma during early stages and had a better how should it affect management? World J Surg 2015;39(2):487–492.
DOI: 10.1007/s00268-014-2831-5.
prognosis; specifically, the 5-year survival rates of patients with 13. Chaturvedi A, Singh J, Rastogi V. Case report: cholangiocarcinoma in
stages Ia, Ib, and IIa cholangiocarcinoma reached 90.4%, 40.0%, a choledochal cyst. Indian J Radiology & Imaging 2008;18(3):236–238.
32
and 25.1%, respectively. The main limitation of this study is that DOI: 10.4103/0971-3026.41836.
World Journal of Laparoscopic Surgery, Volume 12 Issue 2 (May–August 2019) 81