Hội phẫu thuật nhi Việt Nam

Is the Laparoscopic Operation as Safe as Open Operation for Choledochal Cyst in Children?

Nguyen T. Liem, MD, PhD, Hien D. Pham, MD, and Hoan M. Vu, MD

Abstract

Aim: The aim of this study was  to compare the safety  of laparoscopic operation with  open  

surgery for chole- dochal  cyst in children.

 

Methods: Early  outcomes of open  surgery from  January  2001 to  December  2006 were  compared 

with  early outcomes of laparoscopic operations from January  2007 to July 2010. The main outcome 

variables  included intra- and early postoperative complications, operative time, rate of 

reintervention, and duration of postoperative stay. Results:  There  were  307 patients in the  

open  operation group and  309 patients in the  laparoscopic operation group. There was no 

significant  difference  in cyst diameter between the 2 groups. The operative time was longer in  

the  laparoscopic operation group. The  number of patients requiring blood  transfusion was  lower  

in  the laparoscopic operation group.  Intraoperative complications were  low  in  both  groups and 

 not  significantly different.  The rate  of postoperative complications was  lower  in the  

laparoscopic operation group but  not  sig- nificantly.  The rate  of reintervention was  

significantly lower  in the laparoscopic operation group. The postop- erative  stay  was  

significantly shorter  in the laparoscopic operation group.

Conclusion: Laparoscopic operation is as safe as open operation for choledochal cyst. The 

postoperative stay was significantly shorter  in the laparoscopic operation group.

Introduction

Cystectomy and  bilio-digestive  anastomosis has  be- come  a  standard  procedure in  the  

management  of choledochal  cyst.1    The  first  laparoscopic cystectomy and Roux-en-Y 

hepaticojejunostomy was carried out in 1995.2 This approach has been accepted in many centers.3–19 

However, its safety remains a major concern. So far there has been no study published comparing the 

 safety  of  laparoscopic operation with  open operation.

The aim of this study was  to compare the safety  of lapa- roscopic operation with the open 

approach, based on the rate of intraoperative and early postoperative complications.

Materials  and Methods

Criteria for inclusion

Open operation group.   Patients   with  choledochal  cyst with  type  I or IV according to the  

Todani  classification  un- derwent operations from January  2001 to December  2006 at the National 

Hospital of Pediatrics,  Hanoi,  Vietnam.

Laparoscopic operation group.   Patients  with choledochal cyst  with  type  I or IV underwent 

operations from  January

2007 to July 2010 at the same hospital.

Criteria for exclusion

Patients  with a perforated cyst in the open operation group (15 patients) were  excluded. 

Laparoscopic operation is not indicated for perforated cysts.

The open operations were performed by one of four senior hepatobiliary surgeons. Two surgical 

techniques were used in the open  operation group:  cystectomy and  Roux-en-Y hepa- 

ticojejunostomy,1 and cystectomy and jejunal interposition hepaticoduodenostomy.20

The laparoscopic cystectomy was performed by one of four senior laparoscopic surgeons. The 

hepaticoduodenostomy or Roux-en-Y hepaticojejunostomy was performed by the same senior  surgeon. 

The laparoscopic techniques have  been  de- scribed  in two previous reports.21,22

Oral   feeding   was   initiated  on  the   third   postoperative day  after fluid from a gastric  

tube  was clear.

)

The abdominal drain  was  removed on the  fifth day  if there  was  no biliary leakage.

The main outcome variables  were intraoperative and early postoperative complications, including 

injury  to portal  vein, hepatic  arteries,  or hepatic  ducts;  bilio-digestive anastomotic leakage; abdominal abscess; intestinal obstruction; abdominal wound dehiscence; need for reintervention; and mortality. We also compared operative time and  duration of postoperative stay.

Sample size.   Using the rate of early complications in open operation (9.3%)23 and the expected 

rate of early complications in laparoscopic operation (18.6%) with  a significance  level of

5%, and 90% power,  at least 290 patients were needed in each treatment arm to provide a reasonable 

likelihood of statistical significance.

Analysis

Data  were  analyzed using  SPSS 15.0. The chi-square test was  used  for categorical  variables  

and  Student’s  t test  was used  for continuous variables. A P value  of  < .05 was  con- sidered 

statistically significant.

Results

Totally, 616 patients were included in the study.  Three hundred  nine  patients  underwent  

laparoscopic operation from January  1, 2007 to July 13, 2010, including 192 patients with   cyst  

excision  and   hepaticoduodenostomy,  115  with Roux-en-Y hepaticojejunostomy, and 2 patients 

requiring conversion to open surgery. The open operation group in- cluded  307 patients from  

January  1, 2001 to  December  30,

2006. Two hundred sixty-one  patients underwent cyst exci- sion and Roux-en-Y hepaticojejunostomy 

and 46 patients underwent a jejunal interposition hepaticoduodenostomy.

Clinical characteristics of these 616 patients are presented in

Table 1.

The mean  age of patients was younger in the laparoscopic operation group than  in the open  

operation group (48.7 – 2.3 months versus  63.5 – 2.9 months, P = .001).

Mean choledochal cyst diameter was not significantly  dif- ferent between the 2 groups (47.8 – 1.5 

cm versus 47.6 – 1.5 cm, P = .89).

The rate of associated dilatation of the intrahepatic biliary tract  was  not  significantly   

different  between the  2 groups (40.4% versus  41.7%, P = .7).

Mean operative time was significantly  longer  in the Roux- en-Y laparoscopic operation group in 

comparison with  the open   Roux-en-Y  hepaticojejunostomy group  (211  minutes versus  145 

minutes, P < .001). Mean operative time according to surgical  technique is presented in Table 2.

Ten patients (3.2%) in the laparoscopic group required in- traoperative blood  transfusion versus  

34 patients (11.1%) in the open  operation group. The difference  is statistically sig- nificant (P 

= .001).

Two patients in the laparoscopic operation group had  in- traoperative complications (1 patient  

had  injury  to the right portal vein and 1 patient  had injury to the right hepatic duct). The 

small  perforations of portal  vein and  hepatic  duct  were laparoscopically closed successfully.  

One patient  in the open operation group had injury to the right hepatic  artery.

Postoperative evolution was more favorable in the lapa- roscopic operation group (Table 3).

Twelve patients (3.9%) in the complete  laparoscopic oper- ation  group had  postoperative 

complications, whereas 17 patients (5.5%) in the open operation group had postoperative 

complications (Table 4). The difference  is not statistically significant   (P = .3). Seven  

patients in  the  complete   laparo- scopic operation group had bile leakage: 3 patients in 2007, 2 

patients in 2008, 1 patient  in 2009, and  1 patient  in 2010. Six patients in the  open  operation 

group had  bile leakage.  The rate  of bile leakage  between different  operative techniques was  

not significantly  different.  Only 1 patient  in the laparo- scopic group had postoperative 

bleeding,  whereas 5 patients in  the  open   operation group  had   postoperative  bleeding (Table 

4).

One patient  (0.3%) in the complete  laparoscopic operation group required reintervention versus 11 

patients (3.6%) in the open  operation group. The difference  is statistically signifi- cant (P < 

.01).

Mean postoperative stay was 7.0 – 0.2 days  for the laparo- scopic  group versus   9.1 – 0.2  days  

 in  the  open   operation group. The difference  is statistically significant  (P = .001).

The  intraoperative and  postoperative complication rates were   not  significantly   different   

between  the  laparoscopic Roux-en-Y  hepaticojejunostomy group and  the  open  Roux- en-Y 

hepaticojejunostomy group. However, the reintervention rate was significantly lower in the 

laparoscopic Roux-en-Y hepaticojejunostomy group (Table 5).

There were no deaths in either group.

groups (0.22% versus  0.20%). Anastomotic leakage  in the laparoscopic group decreased with 

learning  curve. The rate of bile leakage  in 2009 and 2010 was very low.

Reintervention was  significantly  less frequent in the lapa- roscopic  operation group. Only 1 

patient  in the laparoscopic group required reintervention because  of bile leakage.  The main 

reasons  for reintervention in the open  operation group were abdominal abscess and bleeding.

Total  early  complications and  mortality rate  in our  lapa- roscopic operation group were 

significantly  lower than in the open operation series reported by Li et al. (Table 6).

The  rate  of early  postoperative  complications in  laparo- scopic operation for choledochal cyst 

was  also low in other

3–8,11,15

Discussion

Abdominal wound dehiscence has occurred in

Our study revealed that intraoperative complications were not  significantly   different  between 

laparoscopic operations and  open  operations. However, the  number of patients re- quiring  blood  

transfusion during operation was significantly lower in the laparoscopic operation group.

Injury  to portal  vein and  hepatic  arteries  is the main  con- cern  during cystectomy, 

especially  in  laparoscopic  cystect- omy. These complications happened in only 1 patient  in our 

laparoscopic group, because  of severe  adhesions. Dissection close to the cyst wall is mandatory 

to avoid this complication. Total  early  complications were  not  significantly  different between 

the  2 groups. Postoperative bleeding was  less fre- quent  in the laparoscopic group, although 

expected  frequen- cies are too small for reliable statistical  analysis.  Recognition of bleeding 

and  subsequent hemostasis seems  to be a better

option,  using magnification with the laparoscope.

The rate of bilio-digestive anastomotic leakage is a common complication of surgery for choledochal 

cyst, with  rates  re- ported from 5.8% to 7.3% in open operation.23,24 In our study, bile  leakage 

 was  not  significantly   different   between the  2

open operations but has not been encountered in laparoscopic

operations.4,5,10,11,23

Our overall mean operative time was significantly longer in the laparoscopic group. The mean  

operative time  of laparo- scopic cyst excision and Roux-en-Y hepaticojejunostomy was

66 minutes longer  in the laparoscopic operation. However, it was only 21 minutes longer in 

laparoscopic cyst excision and hepaticoduodenostomy in comparison with  open  Roux-en-Y 

hepaticojejunostomy (Table 2).

Postoperative recovery  was  more  favorable in the laparo- scopic group, with  significantly  

shorter  duration of postop- erative   infusion,   shorter   duration  from   the   operation  to 

occurrence of flatus, and shorter  duration of drain placement. The mean  postoperative stay  was  

significantly  shorter  in the laparoscopic operation group than  in the open  operation

group.

There were  no significant  differences  between the laparo- scopic  Roux-en-Y  hepaticojejunostomy 

group and  the  open Roux-en-Y hepaticojejunostomy patients in terms  of in- traoperative blood  

transfusion, intraoperative complications, and postoperative complications. However, the 

reintervention

 

rate   was   significantly  lower   in   the   laparoscopic group

(Table 5).

Our study allows us to conclude  that the laparoscopic op- eration  is as safe as open operation 

for choledochal cyst. Moreover,  recovery  and  hospital stay  were  shorter  and  the cosmetic 

result  is superior.

Acknowledgment

The authors thank  Dr. John Taylor, Clinical Associate Professor,  Department of Pediatrics,  

School of Medicine, University of Washington, for his careful  reading and  valu- able comments on 

the manuscript.

Disclosure Statement

No competing financial interests  exist.

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Address  correspondence  to: Nguyen T. Liem, MD, PhD Department of Surgery National Hospital of 

Pediatrics

18/879 La Thanh Road, Dong Da District

Hanoi, Vietnam

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