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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