Laparoscopic excision of the choledochal cyst in adult patients: An experience.

BACKGROUND: Laparoscopic choledochal cyst excision (LCCE) in adult patients is not common. AIMS: The aim is to report our experience of LCCE in adult patients. PATIENTS AND METHODS: This study includes a retrospective review of twenty adult patients (age >18 years) with choledochal cyst (CC) who underwent LCCE by a single surgical team from February 2011 to April 2016.
RESULTS: The mean age was 45.5 years. Nineteen (95%) patients had Type-I CC, and one patient (5%) had Type-IV CC (Todani's classification). Fifteen patients (75%) presented with pain in the abdomen, and five patients (25%) presented with jaundice and/or cholangitis. LCCE was successful in 16 (80%) patients, whereas four patients (20%) required conversion to open method. The reason for conversion was technical difficulty due to the initial learning curve, adhesion and inflammation. The mean blood loss, operation time and post-operative stay were 117.5 ml, 299.5 min and 8.15 days, respectively. Bilioenteric anastomosis leak and formation of pseudoaneurysm occurred in one patient (5%); this patient later died due to uncontrolled intra-abdominal haemorrhage. There were no remote complications during a mean follow-up of 17.2 months.
CONCLUSION: LCCE in adult patients is safe and feasible, but bilioenteric anastomosis leak may have fatal consequences.

INTRODUCTION

Choledochal cyst (CC) is characterised by cystic dilatation of extra- and/or intra-hepatic bile ducts. Aetiology of CC is not clearly understood, but its association with an abnormal pancreaticobiliary duct junction (APBDJ) is well established.[1] The majority of patients with CDC presents in childhood, but 20% of patients may present at an adult age.[2] Symptoms of CC in adult patients usually mimic to gallstone disease, likewise most of the complications of a longstanding CC are also similar.[23] Biliary tract cancer and secondary biliary cirrhosis are two lethal complications of CC and because of this surgical excision of CC is recommended even in an asymptomatic patient.[45]

Initially, Alonso-Lej et al. classified CC in three types, but later on Todani et al. modified this classification and described total five types of CC, and they also suggested treatment for all the five types of CC.[67] Type-I and IV CC are commonly encountered variants of CC, and both these types necessitate surgical excision of extrahepatic part of CC and bilioenteric bypass procedure.[7] Laparoscopic treatment is gradually replacing open surgical treatment of CC in paediatric patients.[89] In contrast, laparoscopic CC excision (LCCE) in adult patients is technically difficult and associated with a high complication and conversion rate; however, a few authors have reported results similar to paediatric population.[510] We attempted LCCE in twenty adult patients with CC and hereby report our experience.

PATIENTS AND METHODS

This retrospective study was conducted at a tertiary care referral centre in North India from February 2011 to April 2016. A total of twenty adult female patients with CC were considered for LCCE during the study period. Informed consent was obtained from all the patients. As per prevailing guidelines, the permission from the institutional committee of ethics was not necessary. Blood investigations included complete blood counts, liver function tests, renal function tests, international normalised ratio and serum markers for hepatitis B and C. Radiological investigations included ultrasound of the abdomen, magnetic resonance cholangiopancreaticography (MRCP) and a chest X-ray [Figure 1]. Endoscopic retrograde cholangiopancreaticography (ERCP) was advised in patients with cholangitis and suspected diagnosis of common bile duct stone instead of CC. Endobiliary stent was inserted in patients with cholangitis and/or failed clearance of stone on ERCP. Intraoperative cholangiogram was performed wherever indicated. Todani et al.'s classification system was used for disease stratification.[7]

Figure 1

Magnetic resonance cholangiopancreaticogram of a patient with Type-I choledochal cyst

Technique

Patients were placed in reverse Trendelenburg's position, and operating surgeon was on the left side of the patient. Total four laparoscopic access ports were used. Dissection of hepatocystic triangle and division of cystic artery and cystic duct preceded dissection of cyst so that gallbladder (GB) can be used for hepatic retraction [Figure 2a]. In patients with prior cholecystectomy, falciform ligament was used for hepatic retraction. Supraduodenal part of CC was mobilised and encircled in loop for retraction during further dissection [Figure 2b]. Intrapancreatic part of the cyst was dissected carefully to avoid injury to pancreatic duct, and an Endo GIA™ stapler (white cartridge, 35/45 mm, Ethicon Endo-Surgery, Cincinnati, USA) was used to divide intrapancreatic part of CC [Figure 2c]. Cephalic part of CC was dissected and divided just below the formation of biliary confluence [Figure 2d]. Both right and left hepatic ducts were flushed with normal saline to clear intrahepatic bile duct stones and/or sludge.

Figure 2

(a) Dissection of calots completed and gallbladder used for hepatic retraction, (b) dissection of supraduodenal part of the cyst, (c) division of intrapancreatic part of choledochal cyst, (d) division of cephalic (infrahilar part) of choledochal cyst

Approximately 15 cm distal to duodenojejunal junction, a window was created in the jejunal mesentery and an Endo GIA™ stapler (35/45 mm blue cartridge, Ethicon Endo-Surgery, Cincinnati, USA) was used to divide the jejunum [Figure 3a with inset]. Divided distal end of jejunum was brought up to supracolic compartment through a window in the transverse mosocoln [Figure 3b]. An enterotomy was made over the jejunum to fashion a bilioenteric anastomosis with interrupted polyglactin (Ethicon, Aurangabad, India) sutures [Figure 3c with inset]. In some patients, the left hepatic duct was laid open to provide adequate size bilioenteric anastomosis (>20 mm). A dry gauge was used to check for the leak from bilioenteric anastomosis, and any area of leak was reinforced with sutures. Jejunojejunostomy was performed 70 cm distal to bilioenteric anastomotic site and Endo GI stapler (35 mm, blue cartridge, Ethicon, Endo-Surgery, USA) was used for this purpose [Figure 3d]. Enterotomy sites were approximated with each other using interrupted silk sutures (3-0, Ethicon, Aurangabad, India) [Figure 3d inset]. GB was separated from the liver bed and delivered out. Both the anastomotic sites were reinspected, and port sites abdomen was closed after placement of an abdominal drain (24 French) in the right subhepatic space.

Figure 3

(a) A window in jejunal mesentery to pass an endostapler with inset showing division of jejunum, (b) passage of distal end of jejunum through transverse mesocolon, (c) bilioenteric anastomosis with inset showing completed bilioenteric anastomosis, (d) stapled jejunojejunostomy with inset showing closed enterotomy

Statistical methods

Statistical package SPSS version 22 for Windows (IBM, Chicago, IL, USA) was used for the analysis of the data. Parametric numerical data were represented as mean ± standard deviation, non-parametric numerical data were represented as median (range), and categorical data were represented as percentages.

RESULTS

All twenty patients were females with the mean age of 45.5 ± 11.4 years. Nineteen (95%) patients had Type-I CC, whereas one (5%) patient had Type-IV CC. Chief presenting complaint was pain in abdomen in 15 patients (75%), whereas five patients (25%) presented with jaundice and/or cholangitis [Table 1]. Ten (50%) patients were suspected to have CC on ultrasound examination, and 18 (90%) patients were diagnosed by MRCP. Cystolithiasis was present in six patients (30%), and cholelithiasis was present in five patients (25%). LCCE could be completed in 16 patients (80%), whereas four patients (20%) required conversion to open method. The main reason for conversion was technical difficulty due to the initial learning curve, presence of adhesions, and inflammation of the cyst/duct wall [Tables 1 and 2].

Table 1

Demographic and clinical characteristics

Table 2

Operative and postoperative details

The mean duration of surgery was 299.5 ± 98.3 min, mean blood loss was 117.5 ± 81.6 and mean hospital stay was 8.15 ± 3.6 days [Table 2]. One patient (5%) detected to have gallbladder cancer on intraoperative frozen biopsy of a suspicious mucosal lesion (on inspection of GB specimen); this patient finally underwent radical cholecystectomy and CC excision with Roux-en-Y hepaticojejunostomy. One (5%) patient had thin, inflamed and friable duct wall which was not holding suture properly, and hence bilioenteric anastomosis was revised by open method. This particular patient developed bile leak and intra-abdominal collection and was initially managed with ultrasound-guided percutaneous catheter drainage and parenteral antibiotics. Later on, this patient developed spontaneous haemorrhage due to rupture of a pseudoeneurysm and required exploratory laparotomy but unfortunately died on a post-operative day 21. There was no other mortality, and all surviving 19 (95%) patients were doing fine during a mean follow of 17.2 ± 14.6 months [Table 2].

DISCUSSION

Farello et al. performed the first LCCE in a paediatric patient, and since then LCCE has been increasingly used in paediatric patients.[11] Liem et al. have reported LCCE in 400 paediatric patients with a very low conversion and complication rate.[8] Watanabe et al. reported the first LCCE in an adult patient and Jang et al. reported the largest series of 82 patients with LCCE in adults.[1213] Until now, more than 300 adult patients have been managed with laparoscopic approach, but this practice is limited to the centres with a good experience in both laparoscopic and hepatobiliary surgeries.[12131415] In this series, mean age of the patients was higher, but other parameters such as operation time, blood loss and hospital stay were comparable to the literature.[12131415] Relatively high rate of conversion in this series was due to initial learning curve and inclusion of patients with more complicated disease.[1012131415] First three cases in this series required conversion due to technical difficulty in performance of bilioenteric anastomosis and in rest 17 cases, only one patient required conversion.

Incidence of gallbladder stone, cystolithiasis, APBDJ and malignancy in this study was comparable to the literature.[1234516] The presence of inflammation, thin cyst wall and friability was associated with bilioenteric anastomosis leak and consequently increased mortality in the study. The reported hospital mortality after LCCE is 1.8% and that of open CC excision it is 3%–4%.[210] Altered anatomy, presence of adhesion and lack of palpatory sensation in LCCE make LCCE technically difficult and increase the risk of injury to surrounding structure. Therefore, gentle tissue dissection and a low threshold for conversion are necessary to avoid iatrogenic complications. Thorough pre-operative workup is necessary to exclude patients with biliary tract malignancy. All resected samples should be inspected in operation theatre and wherever necessary radical surgery for an incidental biliary tract malignancy should be done at same sitting. Drawback of this study was small sample size, selection of patient with mainly Type-1 CC and inclusion of patient with complicated disease (chronic pancreatitis).

CONCLUSION

LCCE in an adult patient is a safe and feasible; however, bilioenteric anastomosis failure may have fatal consequences.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.