Laparoscopic Hepaticoduodenostomy Versus Open Hepaticoduodenostomy for Reconstruction After Resection of Choledochal Cyst

Introduction

The incidence of choledochal cysts in childhood has remained relatively stable over the last 20 years.^1–3 Currently, the most common treatment is cyst excision with Roux-en-Y hepaticojejunostomy reconstruction through a subcostal incision. However, as minimally invasive surgical techniques have become more refined, complex laparoscopic surgery is being increasingly practiced for this condition.^4–10 Several centers have described cyst resection with laparoscopic hepaticojejunostomy; however, only a few have described hepaticoduodenostomy as an alternative method of reconstruction.^6,10–12 Initially thought to incur increased risk of postoperative cholangitis, pancreatitis, and anastomotic complications, several reports now indicate that hepaticoduodenostomy is both safe and reliable for biliary-enteric reconstruction.^6,10–11 We recently compared our results with open hepaticojejunostomy and hepaticoduodenostomy and found no difference in biliary complications between the two procedures. ¹³ The hepaticoduodenal anastomosis may confer additional benefits over hepaticojejunostomy in the setting of a laparoscopic approach. The creation of a single anastomosis can decrease operative time and anesthetic exposure, minimize bowel handling, and decrease spillage of intestinal contents. In addition, the avoidance of a Roux limb permits easy enteral access to the biliary-enteric anastomosis for potential surveillance or intervention.

We report the technique and outcomes of our initial 12 months experience with laparoscopic choledochal cyst excision and hepaticoduodenostomy. We compare this group to a historical cohort of patients who underwent open hepaticoduodenostomy (OHD) reconstruction at our institution.

Methods

Between October 2008 and May 2009, 6 patients underwent laparoscopic choledochal cyst resection with hepaticoduodenostomy. One patient underwent operative conversion to an open procedure. Data were collected through the electronic medical record by 2 independent reviewers and compared for consistency. The following data were obtained: presenting symptoms, complications of the disease, diagnostic modality, size, cyst classification, operative time, blood loss, operative complications, duration of procedure, return to full enteral diet, presence of postoperative leak, and cholangitis. For descriptive analysis, median and interquartile range were calculated for each variable. For summary statistics, an independent t-test was used to compare continuous data from the OHD and laparoscopic hepaticoduodenostomy (LHD) groups. The level of significance (α level) was set at 0.05. A chi-square test was used for any binary data with the α level set at 0.05.

Results

From August 2005 to May 2009, 21 patients underwent choledochal cyst excision with hepaticoduodenostomy reconstruction. Of the 21 patients, 6 underwent LHD and 15 underwent OHD. One surgeon (A.W.F.) performed 19 (90.4%) of the operations, including 5 of the 6 LHDs. There were no significant differences in age or gender between the LHD and OHD groups. The majority of the choledochal cysts in both groups were characterized by a fusiform dilation of the extrahepatic bile duct (Table 1). Patients most commonly presented with abdominal pain or chemical pancreatitis. Prenatal diagnosis of a choledochal cyst was made in 3 patients. There were no significant differences in preoperative liver function tests or choledochal cyst size (Table 1). There were no significant differences in operative time, operative blood loss, days to full enteral nutrition, or length of stay (Table 2). However, the LHD group trended toward earlier enteral nutrition and a shorter hospital stay (Table 2). One older patient from the LHD group was converted to the open technique when it was thought to be too much tension on the hepaticoduodenostomy anastomosis. Conversion was undertaken to ensure a tension-free hepatobiliary anastomosis. One patient from the LHD group and 2 from the OHD group were readmitted for abdominal pain with no long-term sequelae. The follow-up period ranged from 1 to 4.5 years (mean: 2.8 years) for the OHD patients and 12–20 months (mean: 16 months) for the LHD patients. There were no postoperative infections in the LHD group, but one superficial wound infection occurred in the OHD group.

Conclusion

Choledochal cyst is a cystic dilation of the biliary tree, which can confer significant morbidity in childhood and lead to potential malignant degeneration in adulthood. In infancy, it may mimic biliary atresia, with jaundice being the primary presenting symptom, whereas older children may present with pancreatitis or ascending cholangitis. Chronic obstruction can progress to biliary cirrhosis and end-stage liver failure.

The treatment of choledochal cysts involves excision of the cyst followed by biliary-enteric reconstruction. ¹⁴ Total cyst excision via an open laparotomy with Roux-en-Y hepaticojejunostomy has become the standard procedure. Recently, many centers have adopted a laparoscopic approach to cyst resection with hepaticojejunostomy reconstruction and have had similar outcomes compared with the open technique.^{4–5,7,11,15} Proponents of hepaticoduodenostomy describe it as providing a more physiologic anatomic arrangement, while being technically simpler to perform. Successful laparoscopic cyst excision with hepaticoduodenostomy reconstruction was first described by Tan et al. ¹² Subsequently, Liem et al. reported their experience with 74 laparoscopic choledochal cyst excisions and hepaticoduodenostomy reconstruction, demonstrating that this method is feasible and safe in a large series. ⁶ Most recently, Thanh et al. reported the largest series of laparoscopic resection followed by hepaticojejunostomy or hepaticoduodenostomy. They reported similar operative times, biliary leak rates, and stricture development between the two methods of reconstruction, but reported cholangitis and bile reflux only within the hepaticoduodenostomy group. ¹¹ The data we report from our first year of performing LHD are consistent with these prior reports. In the operations performed at our center, the two techniques were equivalent. There were no significant differences in the presenting signs, symptoms, and laboratory values of the 2 groups of patients. The laparoscopic approach had a trend toward a longer operative time, but was associated with less blood loss than the open approach, although neither difference was statistically significant. Data on follow-up for both groups were available for at least 30 days after surgery. There were no significant differences in leak rate, reoperation, readmission, time to full enteral diet, and length of stay between the open and laparoscopic groups. Our short follow-up time may have limited our ability to identify cholangitis and bile reflux as longer-term complications. Further comparisons between the two operative techniques at our center will require ongoing and longer-term data analysis to monitor for these potentially significant complications.

In our view, an important advantage of LHD reconstruction is the ability to more easily perform endoscopic procedures of the biliary tree for both diagnostic and therapeutic reasons if necessary. To assess the biliary tree after Roux-en-Y reconstruction, various techniques including the use of single- or double-balloon enteroscopes, endoscopic retrograde cholangiopancreatography (ERCP) via a surgical gastrostomy, and interventional radiology techniques such as percutaneous retrograde transjejunal cholangiography have been applied with variable degrees of success.^16–21 Easier endoscopic access to the biliary tree may permit earlier diagnosis and subsequent treatment of biliary pathology including cholangiocarcinoma in a select group of patients. It may also confer advantages to the management of postoperative stricture and leak.