Mei Diao

Timing of surgery for prenatally diagnosed asymptomatic choledochal cysts: a prospective randomized study.

BACKGROUND/PURPOSE Choledochal cysts (CDCs) are increasingly being diagnosed antenatally. The timing of surgery in this group of patients is unclear. We undertook a prospective randomized trial to establish the optimal timing of surgery for prenatally diagnosed asymptomatic CDCs. METHODS Between 2003 and 2011, 68 fetuses with ultrasound-detected subhepatic cysts (ie, potential CDC) were randomized into 2 groups: (1) early (≤1 month) operation group (n = 34) and (2) late (>1 month) operation group (LO; n = 34). Operative time, postoperative hospital stay, drainage duration, postoperative complications, and perioperative ultrasonographic and laboratory results were analyzed. RESULTS During the first month of life, 32 infants became symptomatic (eg, became jaundiced) and were excluded from the trial. This left 36 neonates who were asymptomatic (early operation, n = 16; LO, n = 20) and constituted the study group. It is noteworthy that a further 9 infants in the LO group then became symptomatic after 1 month of age. Grades III and IV hepatic fibroses were significantly more common in the LO group and in patients who were diagnosed during early pregnancy. Interestingly, liver functions in patients diagnosed at early fetal stage were only moderately deranged. Median follow-up period was 36 months. Neither mortality nor complications of bile leak or anastomotic stricture were encountered. However, complete liver function normalization was significantly delayed in the LO group and in patients with high-grade hepatic fibrosis. CONCLUSION Prenatally diagnosed CDC is a distinct group with a tendency of developing liver fibrosis immediately after birth. Early surgical intervention is warranted in the neonatal period.

A shorter loop in Roux-Y hepatojejunostomy reconstruction for choledochal cysts is equally effective: preliminary results of a prospective randomized study

BACKGROUND Conventionally, an adults standard of a 40-cm loop is adopted in Roux-Y hepatojejunostomy (RYHJ) in choledochal cyst (CDC) in children, irrespective of patient size. The redundant length of the jejunal limb may lead to complications. We compared the outcome of an individualized short Roux loop with the standard loop length in RYHJ in children with CDC. METHODS Two hundred eighteen children with CDC undergoing laparoscopic RYHJ were prospectively randomized into 2 groups: (1) conventional group (CG; n = 108) where a standard 35-40 cm Roux-loop length was used regardless of the childs size and (2) short loop group (SLG; n = 110) in which the Roux-loop length was based on the distance between hepatic hilum and umbilicus. Ultrasonography, upper gastrointestinal contrast studies, and laboratory tests were conducted during the follow-up period. RESULTS The mean Roux-loop length of SLG was significantly shorter than that of CG (Student t test, P < .05). There was no significant difference between the 2 groups in age, operative blood loss, operative time, postoperative hospital stay, and duration of drainage. In CG, 2 of (1.8%) 108 patients developed Roux-loop obstruction, whereas none was detected in SLG (0%). Mild reflux was detected in 2 CG patients and 1 SLG patient 1 month postoperatively, all of which subsided 6 months later. No episodes of cholangitis were observed in either group. CONCLUSIONS An individualized short Roux-loop length in RYHJ is as effective as the conventional Roux-loop length.

Role of laparoscopy in treatment of choledochal cysts in children

Laparoscopy enables surgeons to approach the surgical conditions from a new perspective. Laparoscopic surgery has revolutionized the treatment of choledochal cysts (CDC). Yet, this new technique requires objective evaluations. We have examined the controversies about the CDC dissection, distal common bile duct ligation, ductoplasty for hepatic duct stenosis, intrahepatic duct and common channel protein plug clearance, timing of surgery for antenatally diagnosed CDC, and the Roux loop length in CDC children. In the hands of experts, laparoscopic excision of the cyst and Roux-en-Y hepaticojejunostomy is a safe and effective approach. We provide our opinions on these issues based on our experience and publications. We conclude that the main outcomes comparable to those of the open surgery. The better wound cosmesis and reduction of surgical trauma are the advantages.

Long term outcomes of laparoscopic-assisted anorectoplasty: A comparison study with posterior sagittal anorectoplasty

PURPOSE The aim of this study is to compare the long term outcomes between laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) for children with rectobladderneck and rectoprostatic fistula anorectal malformations (ARM). METHODS Thirty-two ARM children with rectobladderneck and rectoprostatic fistula who underwent LAARP between October 2001 and March 2012 were reviewed. The outcomes were compared with those of 34 ARM children who underwent PSARP between August 1992 and September 2001. The sacral ratio (SR), age at operation, operative time, postoperative hospital stay and complications were evaluated. Bowel functions were assessed using the Krickenbeck classification. RESULTS The mean operative time of the LAARP was significantly shorter than that of PSARP group (1.62 ± 0.40 vs 2.13 ± 0.30 h). The postoperative hospital stay was significantly shorter in the LAARP group (5.8 ± 0.65 vs 8.4 ± 0.67 h). The wound infections (11.8% vs 0%) and recurrent fistula (11.8% vs 0%) were more common in PSARP patients. Th e overall morbidity rate of PSARP group was significantly higher than that of the LAARP group (35.3% vs 12.5%, p<0.05). However, 7.5% of the LAARP patients developed rectal prolapse. Twenty-four of 32 patients were followed up for more than 3 years in LAARP group. The median follow up period was 7.5 years (range 4-11) in LAARP patients and 15.5 years (range 11-20) in PSARP patients. The rates of voluntary bowel movement, soiling (grade 1, 2 & 3) were similar in both groups. More patients from PSARP group developed grade 2 or 3 constipation (22.5% vs 0%, P<0.01). CONCLUSIONS Compared to PSARP, LAARP is a less invasive procedure. The long term functional outcomes after LAARP were equivalent if not better than those of PSARP.

Laparoscopic cholecystocolostomy: a novel surgical approach for the treatment of progressive familial intrahepatic cholestasis.

Objective: Conventionally, liver transplantation, ileoileal bypass, and partial external or internal biliary diversion are used in the treatment of progressive familial intrahepatic cholestasis (PFIC). However, postoperative recurrence, chronic diarrhea, and permanent stoma are the major concerns. We present a novel approach of laparoscopic cholecystocolostomy with antireflux Y-loop for the management of children with PFIC. Methods: Between August 2003 and April 2011, 20 children with PFIC (median age: 1.47 years; range: 10.8 months to 5.11 years) successfully underwent laparoscopic cholecystocolostomies for bile diversions. Gallbladder was incised longitudinally for cholecystocolostomy. Transverse colon was divided proximal to splenic flexure. End-to-side anastomosis was established between distal transverse colon and mid-descending colon. The mobilized splenic flexure and proximal descending colon, that is, the stem of the Y-loop, was anastomosed to the gallbladder. Results: The mean operative time was 2.02 ± 0.18 hours (range: 2–2.5 hours). The mean postoperative hospital stay was 8 days (range: 5–10 days). Average time for full resumption of diet was 3 days (range: 2–4 days). Average Y-loop length was 17.65 cm (range: 15–20 cm). The median follow-up period was 54 months (range: 12–104 months). All patients were jaundice free after 7 to 20 days and pruritus subsided in 3 to 14 days. Liver function parameters significantly improved postoperatively. Success rate (normalization of serum bile acids at postoperative 12 months) was 85%. No mortality or morbidities associated with diarrhea, cholangitis, or intrahepatic reflux were observed. Conclusions: The novel approach of laparoscopic cholecystocolostomy offers a safe and effective treatment option for PFIC in children with good success rates and minimal morbidity.

Gastroportal shunt for portal hypertension in children

PURPOSE Extrahepatic portal venous obstruction is the most common cause of portal hypertension in children. The Rex shunt has been used successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of internal jugular vein. The authors describe a novel adaptation of gastroportal shunt, successfully carried out in 8 children with extrahepatic portal hypertension. METHODS The mean age of the 8 patients (6 boys and 2 girls) was 66.6 months at the time of operation. All children had portal hypertension. Seven had a history of upper gastrointestinal bleeding, and 4 had splenomegaly and hypersplenism. Gastroportal shunt was performed in all patients. The left gastric vein was mobilized and anastomosed to left portal vein. In 1 patient, the left gastric vein was not of adequate length and required a venous graft (the inferior mesenteric vein). All patients were followed up for 3 to 20 months (median, 9 months). RESULTS The gastroportal shunt was successfully performed in all patients. The median operative time was 265 minutes (range, 205-360 minutes). Operative blood loss was 21 ± 7.4 mL, and the length of hospital stay varied from 9 to 19 days (median, 15 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized, and the biochemistry tests were within reference range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the gastroportal shunt in each patient. The size of spleen decreased. There was no recurrence of variceal bleeding. CONCLUSIONS The gastroportal shunt is an effective treatment of extrahepatic portal hypertension.

A prospective study comparing laparoscopic and conventional Kasai portoenterostomy in children with biliary atresia

OBJECTIVE The objective of the study is to evaluate the outcome of laparoscopic Kasai portoenterostomy for type III biliary atresia in children. METHODS A total of 95 type III biliary atresia patients were treated at the Capital Institute of Pediatrics between September 2009 and August 2011. The patients were randomized into 2 groups preoperatively: the laparoscopic group (LP group, n=48) and the open group (OP group, n=47). In the LP group, 4 patients were converted to open operations, whereas the remaining 44 patients in the LP group and 47 patients in the OP group were included in the study. RESULTS The gender distribution and age of the LP group did not differ from those of the OP group (LP group F/M 21/23, median age 61.5days, OP group F/M 24/23, median age 67days, P=0.75 and 0.11). The operation time in the LP group was significantly longer than that in the OP group (median 169.5min vs 146min, P<0.01). Intraoperative blood loss in the LP group was significantly lower than in the OP group (median 10ml vs 15ml, P<0.01). The resumption oral intake was significantly faster in the LP group than in the OP group (median 3days vs 3days, P<0.01). There were no significant differences between the postoperative hospital stay in the two groups (median 12.5days vs 13days, P=0.21). The median follow-up period was 16months in the LP group and 17months in the OP group. There was no statistically significant difference in the jaundice clearance rate at the end of the third postoperative month or in the incidence of cholangitis, native liver survival rate, and liver function recovery between the 2 groups. CONCLUSIONS The short-term and mid-term results are comparable between the laparoscopic and open Kasai portoenterostomy groups. The laparoscopic Kasai procedure does not improve the prognosis of biliary atresia.

Congenital biliary dilatation may consist of 2 disease entities

BACKGROUND/PURPOSE This study aims to establish the possible mechanisms of pathogenesis of congenital biliary dilatation and to classify the disease accordingly. METHODS Radiologic features of congenital biliary dilatation and pancreaticobiliary malunion in 107 affected children were examined and correlated with laboratory results. Relative lengths/diameters were calculated to provide comparison between children of different ages. Intraluminal pressures of common bile duct (CBD) were measured intraoperatively. RESULTS The minimal relative diameters of distal CBD negatively correlated with the maximal relative diameters/lengths of dilated CBD, the maximal relative diameters of common hepatic duct, and left/right hepatic ducts. The intraluminal pressure in patients with a stenotic distal CBD (stenotic group) was significantly higher than that in patients with a nonstenotic distal CBD (nonstenotic group). The narrower the distal CBD, the more deranged the liver function. Conversely, serum/bile amylase levels were more elevated in the nonstenotic group. Common channel protein plugs were only found in the nonstenotic group, whereas common hepatic duct strictures, intrahepatic duct dilatations, and calculi were detected more frequently in the stenotic group. CONCLUSION We propose to categorize congenital biliary dilatation into 2 subgroups: (1) cystic type with stenotic distal CBD associated with deranged liver function and common hepatic duct stricture and (2) fusiform type with nonstenotic distal CBD associated with pancreatitis and common channel protein plugs. Different underlying pathologies of each group require different operative strategies.

To drain or not to drain in Roux-en-Y hepatojejunostomy for children with choledochal cysts in the laparoscopic era: a prospective randomized study

BACKGROUND/PURPOSE Routine drain placement after choledochal cyst (CDC) excision and Roux-en-Y hepatojejunostomy (RYHJ) is commonly practiced to predict and prevent bile/pancreatic leaks and hemorrhage. Recently, laparoscopic excision of CDC has decreased postoperative morbidity. The necessity of drainage has been questioned. We undertook a prospective randomized trial to assess the need for drainage. METHOD Between 2009 and 2011, 121 CDC children were randomized into 2 groups before the laparoscopic RYHJ: drainage group (n = 61) and nondrainage group (n = 60). Patients without severe cyst inflammation, perforated bile peritonitis, common/left/right hepatic duct strictures requiring ductoplasty, or distal cyst deeply embedded in pancreas were included. Normal activity resumption, postoperative hospital stay, complications, and pain scores were analyzed. RESULTS One hundred patients were recruited according to the selection criteria (drainage/nondrainage, 50/50). Normal activity resumption was significantly faster and the postoperative hospital stay was significantly shorter in the nondrainage group. The pain score in the drainage group was significantly higher. On postoperative days 2 and 3, 14% and 38% of the nondrainage group patients were pain free, whereas all the drainage group patients still suffered from pain (P < .01 and P < .001, respectively). The median follow-up period was 12.5 months in the drainage group and 12 months in the nondrainage group. None of the patients developed bile/pancreatic/intestinal leaks. CONCLUSION With the laparoscopic approach, no drainage is needed after RYHJ for the majority of CDC children in expert hands. It minimizes postoperative pain and complications, and facilitates recovery.

Laparoscopic-assisted clearance of protein plugs in the common channel in children with choledochal cysts

BACKGROUND The purpose of the study was to assess the efficacy of laparoscopic-assisted removal of protein plugs from the common channel in choledochal cysts. METHODS Between 2001 and 2009, 34 patients with choledochal cysts (mean age, 4.98 years) with protein plugs in the common channel successfully underwent laparoscopic cyst excision and Roux-en-Y hepatojejunostomy. Under direct vision during laparoscopy, urethroscopes or catheters were inserted into the common channel to irrigate and remove the protein plugs. Complete clearance was confirmed by either direct urethroscopic visualization or cholangiogram that demonstrated (1) no filling defects in the common channel, (2) significant reduction of common channel diameter, (3) free passage of contrast agent into the duodenum, and (4) no pancreatic duct reflux. Operative time and blood loss, postoperative hospital stay, duration of drainage, postoperative complications, perioperative ultrasonographic findings, and laboratory results were reviewed. RESULTS Protein plugs were completely removed in all the patients. The mean operative time, postoperative hospital stay, and drainage duration were 3.51 hours, 7.08 days, and 3.41 days, respectively. The median follow-up period was 32 months. Neither mortality nor complications of pancreatic juice leak, pancreatitis, or stone formation were observed. Liver function parameters and serum amylase levels returned to normal postoperatively. CONCLUSIONS Laparoscopic-assisted clearance of the protein plugs in the common channel in choledochal cyst is effective, with good medium-term results observed.