|Year : 2016 | Volume
| Issue : 2 | Page : 93-97
Combination of laparoscopy and endoscopy for fusiform choledochal cysts
Zhang Jun1, Liu Shuli1, Chen Zhen1, Zhang Zhen1, Li Long1, Cheng Wei2
1 Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
2 Department of Surgery, Beijing United Family Hospital, Beijing, People's Republic of China
|Date of Submission||10-Nov-2014|
|Date of Acceptance||18-Feb-2015|
|Date of Web Publication||11-Mar-2016|
Yabao Road, Chaoyang, Beijing - 100 021
People's Republic of China
Source of Support: None, Conflict of Interest: None
Objective: The purpose of the study was to elucidate the efficacy of laparoscopy and endoscopy in the treatment of fusiform choledochal cysts (CDC).Materials and Methods: Between June 2006 and June 2012, 18 patients with fusiform CDC were treated in our hospital. All the 18 patients presented abdominal pain, and 13 presented jaundice. 18 patients presented elevated serum and urinary amylase, when abdominal pain appeared. All the patients underwent laparoscopic and endoscopic surgery successfully. The clinical presentation, radiological features and surgical treatment were analyzed. The postoperative symptoms, laboratory examination and bile duct changes were evaluated during follow-up term. Results: Intraoperative cholangiography showed filling defect, dilatation of the common channel and pancreatic ducts visualization in 18 patients, including 9 patients of pancreatic duct dilatation. The protein plugs and/or stones were removed completely under laparoscopy and endoscopy in 18 patients. Patients were followed-up for 3 months to 6 years. The biochemical and ultrasound examination showed no increase in pancreatic amylase and recurrence of the stones in the common channel and pancreatic duct. Conclusions: The children with congenital fusiform biliary dilatation presented abdominal pain. Patients presented elevated serum and urinary amylase, when abdominal pain occurred. Filling defect and dilatation of the common channel showed by cholangiography. Laparoscopy and endoscopy clearance of the protein plugs and/or stones in the common channel in congenital fusiform biliary dilatation is effective, and the long-term result is good.
Keywords: Congenital fusiform biliary dilatation, endoscopy, laparoscopy, surgery
|How to cite this article:|
Jun Z, Shuli L, Zhen C, Zhen Z, Long L, Wei C. Combination of laparoscopy and endoscopy for fusiform choledochal cysts. J Min Access Surg 2016;12:93-7
| ¤ Introduction|| |
Choledochal cysts (CDC) is a common biliary disease in children, which is related to the anomalous junction of pancreaticobiliary duct, biliary wall weak and distal choledochal duct obstruction.,,, The incidence of CDC shows significant geographic variation, being higher in the Asian population and reaching up to 1 in 1000. The pathological changes include biliary dilation, anomalous junction of pancreaticobiliary duct, ectopia of the distal opening of duodenum papilla, pancreatic tube malformation and so on. Complicating with the formation of the protein plugs and/or stones which is the direct cause of biliary obstruction and pancreatitis is one of the most important pathological features.,,, Before 1979, Roux-en-Y cystojejunostomy was used for the treatment of CDC. Then cystectomy and hepaticojejunostomy or hepatico-jejuno-duodenostomy has been carried out in clinical practice. Laparoscopic surgery was started in 2006 and nowadays becomes a routine procedure for the treatment of CDC.,,,, However, laparoscopic clearance of the obstruction in the common channel in fusiform CDC has always been a difficulty. This study was to assess the plausibility of combining laparoscopy and endoscopy for the obstruction of common channel in congenital fusiform biliary dilatation.
| ¤ Materials and Methods|| |
Between June 2006 and June 2012, 18 patients with congenital fusiform CDC were analyzed. The group comprised 10 females and 8 males with a median age of 6.5 years (range, 1-year 8 months-14 years) at the time of cyst excision. The main clinical symptoms included abdominal pain (n = 18), vomit (n = 15), jaundice (n = 13) and acholic stool. The protocol of the present study was approved by the Institutional Review Board of Capital Institute of Pediatrics.
Of the 18 patients, all the 18 patients with abdominal pain occurred elevated serum and urinary amylase and hyperbilirubinemia was found in 13 patients. All the included 18 patients was showed fusiform biliary cysts and doubtful sediments of the distal biliary system by preoperative ultrasonography and computed tomography (CT) of the abdominal cavity. Nine patients was found filling defect of the common channel and suspected the existence of stones by magnetic resonance-cholangiopancreatography (MRCP) [Figure 1].
|Figure 1: Magnetic resonance-cholangiopancreatography demonstrates fusiform CC (D), filling defect (F), and pancreaticobiliary reflux (P)|
Click here to view
- Intubating stomach tube and catheter before operation.
- The patients all took recumbent head high supine position, and monitor was located in the side of the head.
- Firstly, a 5 mm longitudinal incision was created in the navel on abdominal wall, and a 5 mm Trocar were inserted with open stylel. CO2 pneumoperitoneum was created at the pressure of 10-12 mmHg. Then three additional 5 mm trocars was inserted respectively at subcostal region at the right midclavicular line, 4-10 cm below the above port and left subcostal region.
- Cholangiography: The gall bladder was exteriorized through the right subcostal port site, incised, and inserted catheter into gall bladder for sampling of the bile and cholangiography. 38% meglumine diatrizoate was injected into gallbladder through the catheter to determine the anatomy of the biliary and the pancreatic duct system, and confirmed the shape of the cyst, filling defect of the common channel and visualization of the pancreatic duct [Figure 2]. 18 patients showed filling defect and dilatation of the common channel by intraoperative cholangiography. Of the patients, 13 presented simple common channel dilatation, and 9 showed above image associated with pancreatic duct dilatation. 14 patients common channel openings located in the junction of the second and third portion of the duodenum [Figure 2], four located in the third portion of the duodenum, and all shared the same image the long common channel. Complete obstruction in the common channel exsist in 1 case, and intrahepatic small capillary biliary duct showed clear development [Figure 2].
|Figure 2: Intraoperative cholangiogram demonstrates fusiform CC (D), filling defect, the common channel dilatation, pancreaticobiliary reflux (P), intrahepatic bile duct (B)|
Click here to view
- Under the laparoscopic monitoring, we dissociated the full-layer of the cyst till the till the distal duct of choledocho. Then we made an lateral incision in the front wall of the cyst. Through the incision we inserted choledochoscope or urethrascope [Figure 3]a into the far end of the common channel. Laparoscopy combined with endoscopy for biliary exploration, rinsing and stones removing and crushing [Figure 3]b and[Figure 4], till thorough clearance of protein plugs and/or stones in the common channel [Figure 5], then choledochoscopy and urethroscopy can smoothly enter duodenum through the duodenal papilla [Figure 6]. Ligating at the junction of choledochal duct and pancreatic duct, and then removed the cyst completely.
|Figure 3: (a) an urethrascope inserted into chongchannel (vertical arrow). (b) Stons in common channel found by endoscope (horizontal arrow)|
Click here to view
|Figure 6: Endoscopy can smoothly enter duodenum through the duodenal papilla|
Click here to view
- Laparoscopic hepatic duct jejunum Roux — Y anastomosis according to the method of our previous reports. Roux-Y jejunojejunostomy was performed extracorporeally through umbilical incision (2 cm), and an end to side anastomosis was carried out intracorporeally.
The follow-up time after operation for fusiform CDC ranged from 3 months to 6 years. Their clinical symptoms, laboratory investigations and imaging investigations were analyzed retrospectively.
| ¤ Results|| |
A total of 18 patients with congenital fusiform CDC underwent laparoscopic and endoscopic procedures successfully. Laparoscopic cyst excision and hepatojejunostomy was performed. Obstruction of the distal common channel was relieved. The symptoms of abdominal pain and vomit disappeared after operations. Jaundice gradually decreased for about 3-8 weeks (median 5 weeks) postoperatively. Postoperative biochemical examination showed that amylase recovered to normal level for about 4-9 days (median 4.5 days) and transaminase for about 2-5 months (median 3.3 months). The postoperative ultrasound, CT and magnetic resonance imaging examinations of all patients showed that there was no biliary dilatation and sentiments in the distal biliary system, no filling defect in the common channel. During the period of follow-up, there was no cholestasis, biliary duct stones, cholangitis, protein plugs and/or stones in common channel and pancreatitis.
| ¤ Discussion|| |
Many authors reported protein plugs and/or stones in the common channel in children with congenital fusiform biliary dilatation, which resulted in common biliary obstruction and caused clinical symptoms., The abdominal pain is a main symptom of our 18 patients. Of the patients, elevated serum and urinary amylase occured in 13 patients when abdominal pain appeared. These findings are in accordance with the reports of Ando et al. On the other hand, we speculate that the protein plugs and/or stones in the common channel may have some correlation with the level of serum and urinary amylase, because the serum and urinary amylase increased when abdominal pain appeared. This also suggested that the abdominal pain and the increase of serum and urinary amylase have an important clinical significance in the diagnosis of protein plugs and stones in the common channel.
Preoperative ultrasound examinations and CT examinations indicated fusiform CDC and doubtful sentiments in the distal biliary system. Among 14 patients undergoing MRCP examinations, 9 patients showed filling defect in the common channel and were suspected the existence of stones. Intraoperative cholangiography presented filling defect and dilatation of the common channel in 18 patients, which showed that intraoperative cholangiography is a reliable means in diagnosis of protein plugs and/or stones in the common channel. Through laparoscopic and endoscopic exploration, the shape of protein plugs and/or stones in the common channel could be clearly seen and could be cleared thoroughly. Consequently, laparoscopic and endoscopic exploration is the direct evidence of diagnose protein plugs and/or stones in the common channel. Furthermore, preoperative and intraoperative radiographic examinations are also important, and intraoperative cholangiography is a necessary means to avoid misdiagnosis.
Protein plugs and/or stones in the common channel can cause obstruction in the biliary and pancreatic ducts, intrahepatic cholestasis and pancreatitis. Secondary cirrhosis which occurred in the later period is the main reason of CDC combined with liver damage. Biliary cirrhosis caused by CDC, to some extent, is reversible. Indicators of liver function can recover to normal level, when obstruction was relieved after operation. Therefore, the clearance of protein plugs and/or stones in the common channel can release obstruction of biliary and pancreatic ducts, and the lesions that lead to liver damage. The follow-up showed that after the clearance of protein plugs and/or stones in the common channel, no cholestasis, biliary duct stones, cholangitis, protein plugs and/or stones in the common channel and pancreatitis recurred. The long-term prognosis of our study was satisfactory.
Ando et al. reported that protein plugs and/or stones in the common channel can be cleared successfully by saline rinse., Our center also reported clearance of protein plugs and/or stones in the common channel and biliary ducts by laparoscopic intubation., However, we supposed that there are several limitations in this technology, which was listed as follows. Firstly, it's easy to rinse fragile protein plugs, whereas to rinse and remove stones may be much more difficult. Secondly, without direct vision we can't assess the patency of common channel directly. Thirdly, intraoperative cholangiography is needed again after rinsing. So, we recommend the use of laparoscopy combined with endoscopy for biliary exploration, rinsing and removing stones unless it's subjected to limited conditions (there's no choledochoscopy and urethroscopy). Previous studies said that the use of laparoscopy and endoscopy for stone removing in adult surgery., This technique in pediatric surgery is strictly subjected to the age of patients, because the diameter urethroscopy is thick.
We adopted laparoscopy combined with endoscopy for biliary exploration. Under direct vision, protein plugs and/or stones in the common channel was removed thoroughly. Then choledochoscopy and urethroscopy can smoothly enter duodenum through the duodenal papilla. The protein plugs and/or stones in the common channel can be clearly seen under the scope, and we can clarify the diagnosis easily. We can adopt this technique for biliary rinsing, stones crushing and removing under direct vision. In addition, it is a direct and reliable means for clearance of protein plugs and/or stones, and that avoided intraoperative cholangiography once more. All patients were followed-up at least 3 months postoperatively, and no patients presented abdominal pain, elevated of amylase and reoccurrence of protein plugs and/or stones in the common channel and pancreatic ducts, which suggested this technique was safe and effective to release of obstruction in the common channel, and long-term efficiency was satisfactory.
This research presents that obstruction (protein plugs and/or stones) of the common channel might exsist in children with congenital fusiform CDC. Patients mainly presented abdominal pain, elevated serum and urinary amylase when abdominal pain appeared. Radiographic examination indicated filling defect and dilatation of the common channel. Intraoperative cholangiography can further define the obstruction in the common channel. The combination of laparoscopy and endoscopy can release the obstruction in the common channel completely. The long-term results were satisfactory.
| ¤ Acknowledgments|| |
We thank those authors who provided us with the full-text and those patients who support our work.
| ¤ References|| |
Babbitt DP, Starshak RJ, Clemett AR. Choledochal cyst: A concept of etiology. Am J Roentgenol Radium Ther Nucl Med 1973;119:57-62.
Glenn F, McSherry CK. Congenital segmental cystic dilatation of the biliary ductal system. Ann Surg 1973;177:705-13.
Anand U, Priyadarshi RN, Kumar B, Khandelwal C. Diagnosis and management of giant choledochal cysts: Complexities compared to smaller cysts. Indian J Gastroenterol 2013;32:262-7.
Khandelwal C, Anand U, Kumar B, Priyadarshi RN. Diagnosis and management of choledochal cysts. Indian J Surg 2012;74:401-6.
Hung MH, Lin LH, Chen DF, Huang CS. Choledochal cysts in infants and children: Experiences over a 20-year period at a single institution. Eur J Pediatr 2011;170:1179-85.
Kaneko K, Ando H, Ito T, Watanabe Y, Seo T, Harada T, et al.
Protein plugs cause symptoms in patients with choledochal cysts. Am J Gastroenterol 1997;92:1018-21.
Noda A, Ibuki E, Murayama H, Hase S. Bromhexine hydrochloride eliminates protein plugs and relieves attacks of pancreatitis. Pancreas 1997;15:209-11.
Koshinaga T, Hoshino M, Inoue M, Gotoh H, Sugito K, Ikeda T, et al.
Pancreatitis complicated with dilated choledochal remnant after congenital choledochal cyst excision. Pediatr Surg Int 2005;21:936-8.
Fujishiro J, Masumoto K, Urita Y, Shinkai T, Gotoh C. Pancreatic complications in pediatric choledochal cysts. J Pediatr Surg 2013;48:1897-902.
Farello GA, Cerofolini A, Rebonato M, Bergamaschi G, Ferrari C, Chiappetta A. Congenital choledochal cyst: Video-guided laparoscopic treatment. Surg Laparosc Endosc 1995;5:354-8.
Romanelli JR, Mark L, Omotosho PA Single port laparoscopic cholecystectomy with the TriPort system: A case report. Surg Innov 2008;15:223-8.
Li L, Feng W, Jing-Bo F, Qi-Zhi Y, Gang L, Liu-Ming H, et al
. Laparoscopic-assisted total cyst excision of choledochal cyst and Roux-en-Y hepatoenterostomy. J Pediatr Surg. 2004;39:1663-6.
Liem NT. Laparoscopic surgery for choledochal cysts. J Hepatobiliary Pancreat Sci 2013;20:487-91.
Kaneko K, Ono Y, Tainaka T, Sumida W, Ando H. Acidic and basic solutions dissolve protein plugs made of lithostathine complicating choledochal cyst/pancreaticobiliary maljunction. Dig Dis Sci 2009;54:1475-80.
Diao M, Li L, Cheng W. Is it necessary to ligate distal common bile duct stumps after excising choledochal cysts? Pediatr Surg Int 2011;27: 829-32.
Ando H, Kaneko K, Ito F, Seo T, Harada T, Watanabe Y, et al.
Surgical removal of protein plugs complicating choledochal cysts: Primary repair after adequate opening of the pancreatic duct. J Pediatr Surg 1998;33:1265-7.
Liu Hu, Xu Bin, Li Weisong, et al
. Clinical and pathological analysis in children with congenital choledochal cyst combined with liver damage. Anhui Med J 2010;08;882-6.
Li L, Feng W, Jing-Bo F, Qi-Zhi Y, Gang L, Liu-Ming H, et al.
Laparoscopic-assisted total cyst excision of choledochal cyst and Roux-en-Y hepatoenterostomy. J Pediatr Surg 2004;39:1663-6.
Diao M, Li L, Zhang JS, Cheng W. Laparoscopic-assisted clearance of protein plugs in the common channel in children with choledochal cysts. J Pediatr Surg 2010;45:2099-102.
Yi SY. Recurrence of biliary symptoms after endoscopic sphincterotomy for choledocholithiasis in patients with gall bladder stones. J Gastroenterol Hepatol 2000;15:661-4.
Yu M, Jing-li W. Squential treatment of extrahepatic bile duct calculus using the technique of three-endoscope-combination in one anesthetic session. Chin J Pract Surg 2011;17:648-51.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]