Laparoscopic-assisted cyst excision and ductoplasty plus widened portoenterostomy for choledochal cysts with a narrow portal bile duct

Abstract

Background: Complete cyst excision with Roux-en-Y hepaticojejunostomy is the standard procedure for choledochal cysts (CCs). In recent years, neonates have been increasingly diagnosed with CCs prenatally. Earlier treatment has been recommended to avoid complications. For type IVa malformation without extensive intrahepatic bile duct dilatation, laparoscopic hepaticojejunostomy is technically challenging, and anastomotic stricture is a concern. Therefore, we propose laparoscopic synthetical techniques-laparoscopic excision of cyst and ductoplasty plus widened portoenterostomy to avoid stricture in CCs with a narrow hilar duct.

Methods: An anastomosis was created around the transected end of the common bile duct in 12 minipigs (Group A), and another 12 minipigs (Group B) received conventional cholangiojejunostomy. Anastomotic diameter measurements and cholangiography were conducted at different times. Histological findings of inflammation and scarring were compared. The expression levels of TGF-β1 and type I collagen were detected by real-time quantitative PCR. Between January 2012 and January 2016, laparoscopic excision of cyst and ductoplasty plus widened portoenterostomy were performed on 29 children with confirmed CCs with a narrow portal bile duct who were followed up for 12-48 months.

Results: Group A survived well without obstruction. Slight inflammation and fibrotic tissue were confined to the bile duct periphery. In Group B, five pigs developed stricture. Severe inflammation and diffuse fibrosis affected the whole layer of the anastomosis. Fibrotic biomarkers were significantly higher postoperatively in Group B. Clinically, 29 patients exhibited satisfactory outcomes. No anastomotic stricture has been observed to date.

Conclusions: Laparoscopic synthetical techniques may be a superior option to prevent anastomotic stricture in treating CCs with a narrow portal bile duct.

Keywords: Anastomotic stricture; Choledochal cyst; Laparoscopy; Wide hepaticojejunostomy.

Fig. 1

Schematic illustration of two different anastomotic methods in Group A and B: A The seromuscular layer of the common bile duct was sutured interruptedly to the whole layer of the jejunum (arrows), simulating the scarring condition of an anastomosis around the transected end of the portal bile duct; B The whole layer of the common bile duct was sutured to the whole layer of the jejunum interruptedly (arrows), simulating the scarring condition of the hepaticojejunostomy

Fig. 2

Completed appearance (A) and schematic illustration of a laparoscopically widened portoenterostomy (B)

Fig. 3

Comparison of the gross and histological findings at 3 months after the operation. A Intrahepatic bile ducts and common bile ducts exhibited normal morphology and patency in Group A; B Common bile ducts and intrahepatic bile ducts were obviously dilated (arrow) in Group B (4 of 12 pigs); C A wider anastomotic stoma (5.58 ± 0.49 mm) in Group A; D Anastomotic stenosis (3.00 ± 2.28 mm) in Group B; E Anastomotic mucosae healed with slight inflammation in Group A; F Severe inflammatory infiltration into the whole layer of the anastomosis was observed in Group B; G Thin scar fibers were arranged neatly around the bile duct in Group A (arrow); H Coarse mucosae and disordered scar tissue surrounding the whole layer of the anastomosis (arrow) were observed in Group B

Fig. 4

Relative mRNA expression levels of TGF-β1 and type I collagen preoperatively and 1 week, 1 month and 3 months postoperatively

Fig. 5

Intraoperative pictures of robotic-assisted laparoscopic synthetical techniques: A Complete excision of the cyst; B Widening of the opening created by splitting along the bilateral hepatic ducts; C Anastomosis around the transected end of the portal bile duct; D Completed appearance

Fig. 6

Schematic illustration demonstrating that full layer cicatricial anastomosis after cholangiojejunostomy is more likely to result in stenosis than is anastomosis around the common bile duct stump