Efficacy of Robot-assisted Hepaticojejunostomy and Laparoscopic-assisted Hepaticojejunostomy in Pediatric Congenital Choledochal Dilatation ： A System Review and Meta-analysis

doi:10.21203/rs.3.rs-2089116/v1

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Efficacy of Robot-assisted Hepaticojejunostomy and Laparoscopic-assisted Hepaticojejunostomy in Pediatric Congenital Choledochal Dilatation ： A System Review and Meta-analysis

https://doi.org/10.21203/rs.3.rs-2089116/v1

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Purpose: The efficacy of Robot-assisted hepaticojejunostomy (RAHJ) and Laparoscopic-assisted hepaticojejunostomy (LAHJ) in children with congenital choledochal dilatation has been a topic of much debate and controversy. The purpose of this study was to evaluate the role of RAHJ and LAHJ in pediatric congenital choledochal dilatation.

Method: The review program has been prospectively registered (PROSPEROID: CRD42022306868). We searched the PubMed, Embase, Cochrane, CBM, VIP, Web of Science, CNKI databases and Wanfang databases from March 2021. The Mantel–Haenszel method and a random effects model were used to figure out the hazard ratio (95% CI).

Results: Ten studies evaluated 869 subjects (332 in the robotic group and 537 in the laparoscopic group), meeting all inclusion criteria. Compared with the laparoscopic group, robotic group demonstrated fewer postoperative complications [p = 0.0009; OR = 0.34 (95% CI, 0.18-0.64); I²= 3%], shorter postoperative hospital stay [p < 00001; MD = -2.05 (95% CI, -2.40-1.70); I² = 0%] and less intraoperative bleeding [p < 0.008; MD = -10.08 (95% CI, -18.80--2.81); I² = 99%]. There was no significant difference in operative time between the two groups [p = 0.10; MD = 24.53 (95% CI, -5.11-54.17); I² = 99%]. The same situation happened in short-term complication outcomes [p = 0.06; RR = 0.45 (95% CI, 0.19-1.04); I² = 0%]. However, children in the RAHJ group had significantly lower levels of long-term complications [p = 0.04; OR = 0.41 (95% CI, 0.17-0.96); I² = 0%]. Hospitalization costs were significantly higher in the RAHJ group [p < 0.00001; OR = 27113.86 (95% CI, 26307.24-27920.48); I² = 0%]. For overall complications, subgroup analysis of literature published after 2020 and of literature with high quality scores showed a significant decrease in the RAHJ group.

Conclusion: In children with congenital choledochal dilatation, RAHJ is associated with reduced intraoperative bleeding, postoperative complications and length of stay. Robotic surgery has a bright future in the treatment of pediatric common hepatic duct cysts and deserves to be promoted and popularized.

robot-assisted hepaticojejunostomy

laparoscopic-assisted hepaticojejunostomy

congenital choledochal dilatation

meta-analysis

Congenital choledochal dilatation is a congenital malformation involving both local dilatation of the extrahepatic bile duct, including the common bile duct, and pancreaticobiliary maljunction. However, cases associated with intrahepatic bile duct dilatation can be included in this entity(1). Congenital choledochal dilatation are uncommon congenital anomalies of bile ducts with an incidence of 1 in 100,000–150,000 live births in the western population(2–4), but reported to be as high as 1 in 13,500 live births in the United States and 1 in 15,000 in Australia(5). The incidence is higher in Asian population with an incidence of 1 in 1000(6), of which about two-third cases are reported from Japan(7). Holistic examination of the data regarding robotic congenital choledochal dilatation excision in children makes it clear that more research is needed to examine the utility of this approach. The most recent and larger studies do show acceptable complication rates, and robotic congenital choledochal dilatation excision does not appear inferior with regards to complications if performed by experienced surgeons. On the other hand, concerns regarding the long operative times may be reinforced if forthcoming data shows similar trends; additionally, cost-effectiveness information should be reported given known expense of robotic platforms(8).

The current investigation is an updated meta-analysis of postoperative complications and postoperative length of stay for RAHJ and LAHJ for pediatric congenital choledochal dilatation. More specifically, a systematic evaluation and meta-analysis was performed to determine the impact of RAHJ and LAHJ on postoperative complications and postoperative length of stay.

Search Strategy

The review protocol was prospectively registered (PROSPEROID: CRD42022306868). A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline(9). The search was conducted in the major electronic databases of PubMed, Embase, Cochrane, CBM, VIP, Web of Science, CNKI databases and Wanfang databases.

Giving an example, we search terms such as choledochal cyst, robotic surgery and literature types, as well as all related MeSH terms. The keyword of the search was recoded in the appendix section.

When several studies reported findings for the same patients, the most recent or most complete study was chosen.

Inclusion Criteria

Studies were included according to the following criteria. Case inclusion criteria: 1. congenital choledochal dilatation diagnosed by magnetic resonance cholangiopancreatography; 2. children undergoing da Vinci robotic surgery or conventional laparoscopic surgery (including intraoperative conversion to open surgery); 3. surgery time, intraoperative bleeding, postoperative complications and hospital stay were recorded.

We excluded articles that included in the study those who presented with choledochal cyst-related acute abdomen necessitating emergency surgery. Studies were excluded if the type of article was a case report or a review. A small number of studies were conference literature, where the original article could not be found, and were also excluded. (Fig. 1).

Definitions

In this post, we foucus on patients who underwent RAHJ and LAHJ. "RAHJ" stands for robot-assisted hepatic tunnel-jejunostomy and "LAHJ" stands for laparoscopic hepatic tunnel-jejunostomy.

Data Extraction

We reviewed all titles and abstracts to determine eligibility and retrieve articles. The following information was extracted according to a fixed protocol: study design, geographical location, stage, sample size, group number, number of complications (Table 1).

Validity Assessment

The quality of included studies was accessed independently by using the Newcastle–Ottawa Quality Assessment Scale. The scale was comprised of three factors: patient selection, comparability of the study groups, and assessment of outcome. A score of 1 was awarded for each item if the standard was completely met, a score of 0.5 was awarded if the standard was partially met, and a score of 0 was awarded if it was not met or if it was unclear whether it was met. The total score for each study was then calculated, a score of > 6 indicated a high-quality study, a score of ≥ 3 and ≤ 6 indicated a median-quality study, while a score of ≥ 0 and ≤ 2 indicated a low-quality study (10).

None of the 10 included studies stated that operational selection was randomized (selection bias). The type of topic of our study dictates that confidentiality of participants and personnel is not possible (performance bias). The same happens with the confidentiality of the assessment of the results (test bias). After careful assessment of reports of Koga et al.(11), Cai et al.(12), Xie et al.(13), a brief description of follow-up durations could not be observed, and it was rated as unclear of bias. In reports of Cai et al.(14), Xiao et al.(15), some postoperative complications were not introduced clearly, and it was also rated as unclear of bias (attrition bias). These cases are summarized in Fig. 2.

Statistical Analysis

Statistical analysis was conducted by Review Manager version 5.4. The significance of pooled OR/MD was assessed by Z-test, and a P-value < 0.05 was considered significant. Statistical heterogeneity between studies was assessed by I² and Q statistics. The I² statistic was used to test for heterogeneity. More than 50% of I² was considered to be highly heterogeneous and the results were aggregated using random effects models. However, I² < 50% is considered to be low heterogenous, so fixed-effect models can be used, and subgroup analysis was used to explore potential causes of heterogeneity(16).To assess the risk of Publication bias, funnel plots Funnel plots were used to assess publication bias (17). P-values < 0.05 were considered significant for heterogeneity.

Ten studies evaluating 869 subjects (537 in the laparoscopic group and 332 in the robotic group). Sample sizes ranged from 2 to 172 (Table 1). The literatures were published in 2019 or later. Validity scores could be obtained in Table 2. 6 articles were of high quality, 4 articles were of moderate quality, and low-quality articles were not being continued research. Xie et al. (13, 18) additionally documented surgical conditions, complications and postoperative length of stay in open surgery patients.

Results of the Meta-analysis

Robotic surgery showed a trend toward reduced intraoperative bleeding and shorter postoperative hospital stay. There was no obvious distinction in operative time between the two groups. Robotic surgery group significantly improved the postoperative complication profile of patients. Children in the RAHJ group had significantly lower levels of long-term complications. However, short-term complication outcomes didn’t change obviously. RAHJ group was proved to be more expensive, as expected. For overall complications, subgroup analysis of literature published after 2020 and of literature with high quality scores showed a significant decrease in the RAHJ group.

Intraoperative Bleeding

Six studies provided data including 781 patients with congenital congenital choledochal dilatation (295 in the RAHJ group and 486 in the LAHJ group). Heterogeneity between studies was also significant (I²= 99%, P < 0.00001). Therefore, a random-effects model was applied. Of the 6 studies included in the review, 5 studies reported less intraoperative bleeding in the RAHJ group. There was less intraoperative bleeding in the RAHJ group ([p = 0.008; MD = -10.08 (95% CI, -18.80-2.81); I² = 99%] (Figure 3).

Time to Surgery

Eight studies (12, 13, 18-23) provided data including 862 patients with congenital choledochal dilatation (330 in the RAHJ group and 532 in the LAHJ group). Heterogeneity between studies was significant [I²= 99%, P < 0.00001], and a random effects model was subsequently applied. Of the included articles reviewed, five studies by Cai et al. (12), Chi et al. (19, 23), Dong et al. (20), and Lin et al. (22) reported less operative time in the LAHJ group. However, no obvious distinction happened on this indicators [p = 0.10; MD = 24.53 (95% CI, -5.11-54.17); I² = 99%] (Figure 4).

Post-operative Hospital Stay

In the current meta-analysis, a total of 457 cases were included in the 4 studies to study the issue of postoperative length of stay, and after sensitivity analysis, the article by Chi et al. was finally removed. A total of 3 articles were finally included, including 131 cases in the RAHJ group and 186 cases in the LAHJ group. All of which showed a significantly lower postoperative length of stay in the RAHJ group compared to the LAHJ group [I²= 0%, P = 0.55]. RAHJ group was able to significantly reduce the postoperative hospital stay [p < 0.00001; OR = -2.05 (95% CI, -2.40-1.70); I²= 0%] (Figure 5).

Postoperative Complications

Total Complications

A total of 818 cases were included in the final nine papers, 308 in the RAHJ group and 510 in the LAHJ group [I²= 3%, P = 0.40]. RAHJ was associated with a reduction in complications, possibly because of the reduced bleeding and operative time in the surgery [p = 0.0009; MD = 0.34 (95% CI, 0.18-0.64); I² = 3%] (Figure 6).

Short-term Complications

Short-term complications were defined as those that occurred within 30 days after surgery. Short-term complications were documented in 8 of the 10 publications, with a cumulative total of 862 cases included (330 in the RAHJ group and 532 in the LAHJ group). The overall heterogeneity was low [I²= 0%, P = 0.58]. The two surgical procedures did not produce obvious changes in this metric [p = 0.06; RR = 0.45 (95% CI, 0.19-1.04); I² = 0%] (Figure 7).

Long-term Complications

Long-term complications were defined as those that occurred more than 30 days after surgery. Long-term complications were documented in 5 of the 10 publications, with a cumulative total of 678 cases included (274 in the RAHJ group and 404 in the LAHJ group). The overall heterogeneity was low [I²= 0%, P = 0.95]. RAHJ group had significantly lower levels of long-term complications [p = 0.04; OR = 0.41 (95% CI, 0.17-0.96); I² = 0%] (Figure 8).

Hospitalization Costs

The cost of robotic surgery is undoubtedly higher than that of laparoscopic surgery. In order to discuss the difference in the total cost of the two treatment modalities when accounting for postoperative hospitalization costs, a further analysis was performed. Among them, the cost data recorded in the Cai et al.(12) article were recorded with interquartile spacing and were skewed [RAHJ: 11250 (10950 ~ 12900) $, LAHJ: 4800 (4050 ~ 5400) $], so they are only statistically described here and not included in the combined analysis. The overall heterogeneity was low [I²= 0%, P = 0.63]. As expected, RAHJ group showed an expensive price [p < 0.00001; OR = 27113.86 (95% CI, 26307.24-27920.48); I² = 0%] (Figure 9).

Subgroup Analysis

We performed subgroup analysis of total complications, short-term complications and long-term complications of cases according to the year of publication (<2020, >2020) and quality score (high or medium; Table 3). Of the literature reporting long-term complications, the number of publications before 2020 was only 1 and could not be included in the combined analysis. There were no significant differences in levels in each subgroup, whether for long-term or short-term complications. For overall complications, subgroup analysis of literature published after 2020 and of literature with high quality scores showed a significant decrease in the RAHJ group, while subgroup analysis of literature published before 2020 and of literature with moderate quality scores showed no obvious distinction(Figure 10).

Publication Bias

In the funnel plots comparing postoperative complications (Supplementary Figure 1), postoperative length of stay (Supplementary Figure 2), intraoperative bleeding (Supplementary Figure 3) and operative time (Supplementary Figure 4) between the RAHJ and LAHJ groups, studies grouped at the top of the plot suggest that larger studies with larger numbers of patients are more likely to be included. The lack of studies at the bottom of the graph suggests that publications with smaller sample sizes are rare.

Robotic surgical system has been utilized in the treatment of choledochal cysts since 2006. Its advantages include three-dimensional visualization through a stereoendoscope, tremor reduction, motion scaling, and the additional degrees of freedom compared to the standard laparoscopic instruments. However, at present, it is not widely accepted yet because of the size of current robotic hardware in relation to child’s body size, the loss of hepatic feedback, special training requirement, and expensive hardware and maintenance of the robotic system. With the technical improvement, the refined robotic system will provide an optimal alternative to achieve the advanced goal of minimal invasive surgery, scarlessness, minimal surgical trauma, and steep learning curve(24). More recent studies have shown improved outcomes compared to the early era of robotic choledochal dilatation excision(8). The purpose of this study was to evaluate the role of robot-assisted and laparoscopic-assisted surgery in the management of children with congenital choledochal dilatation.

Learning Curve and Cyst Typing

Wen et al.(25) reported a learning curve of 37 units for laparoscopic-assisted hepaticojejunostomy of congenital choledochal dilatation. The learning curve for laparoscopic surgery is steep. Meanwhile, whether the robotic surgical operator completes the appropriate learning curve is one of the important influencing factors for surgical outcome. If the learning curve is not completed, the corresponding intraoperative bleeding, postoperative complications and other indicators will increase. All of the literature included in this study refers to the issue of the learning curve of the surgical operator. This undoubtedly affects the credibility of the statistical results.

Only a single type of cyst was recorded in the reports of Cai et al.(12), Cai et al.(14), Dong et al.(20) and Xiao et al.(15). The type of cyst in the child was not recorded in the report of Koga et al.(11). Other than that other literature documented more than 2 types of cysts.

Age of Surgery

The age at which the surgery is performed is critical to the outcome of the child. In general, if the surgery is performed early in life, the possibility of surgical site adhesions is low and the surgery time is short; however, if the surgery is performed at an older age, the possibility of surgical site adhesions increases accordingly and the surgery time is prolonged. This will undoubtedly affect the subsequent combined analysis of the relevant indicators. The number of cases recorded in the Xiao et al.(15) article was only one case in the RAHJ group, which was older, at 9 years, and only one case in the LAHJ group, also at a much younger age of 3 years and 2 months. This implies that patients in this literature with robotic surgery have a higher likelihood of increased adhesions at the surgical site. The same occurred in the literature of Koga et al.(11) with an age of 5.6 ± 3.4 years in the RAHJ group and 5.2 ± 3.8 years in the LAHJ group. In the report by Cai et al.(12), the age at surgery for children in the RAHJ group was also among the older children operated on, at 52.2 ± 47.5 months, much higher than in the LAHJ group (26.9 ± 23.2 months). This situation can seriously affect the subsequent combined analysis. On the other hand, the abdominal volume of children with a small surgical age is also small, and the relatively large diameter of the surgical robot's instruments clearly limits the performance of the surgical robot.

Cai et al.(12) concluded that the da Vinci robot does not have significant advantages in the management of large cysts in older children, where the hyperplastic vessels are too thick and too many, resulting in frequent bleeding during dissection of the cyst wall, and the hemostatic function of the da Vinci robot does not have significant advantages over traditional instruments. The da Vinci special ultrasonic knife lacks the function of multi-angle rotation of the manipulator. Combined with the fact that the cost of da Vinci surgery is much higher than that of laparoscopic surgery and the relatively low acceptance of parents for intermediate open surgery, operators, especially beginners, are advised to avoid patients of older age with large cysts when selecting cases.

Intraoperative Bleeding, Time to Surgery and Post-operative Hospital Stay

The meta-analysis by Yin et al. in terms of intraoperative bleeding included 4 studies including 391 patients with choledochal dilatation (145 in the RAHJ group and 246 in the LAHJ group), where overall there was no significant difference in intraoperative bleeding between the RAHJ and LAHJ groups, subgroup analysis showed no significant difference between the two groups in pediatric patients, while adult patients showed lower bleeding(26). Compared to the meta-analysis by Yin et al., this paper focuses on pediatric patients themselves rather than all age groups, includes a newer and more complete literature, and draws conclusions with improved reliability.

In Koga's report, the mean operative times in the 2 groups were 618 and 654 minutes, significantly longer than in the other 7 groups. Similar to the meta-analysis on intraoperative bleeding, the heterogeneity of this part of the meta-analysis was very high. The clinical value of the conclusions drawn from it was low. The meta-analysis by Yin et al. in terms of surgery time included 6 studies including 484 patients with choledochal dilatation (177 in the RAHJ group and 307 in the LAHJ group), where overall there was no significant difference in surgery time between the RAHJ and LAHJ groups, subgroup analysis showed no significant difference between the two groups in pediatric patients, while adult patients showed significant shorter operative time(26). This is consistent with the conclusion reached in this paper.

It is worth noting that patients' postoperative medications differed in different studies, which to some extent affects the accuracy of the conclusions on postoperative length of stay. The meta-analysis by Yin et al. on length of stay included 6 studies including 484 patients with biliary dilatation (177 in the RAHJ group and 307 in the LAHJ group), in which overall there was no significant difference in length of stay between the RAHJ and LAHJ groups, and subgroup analysis showed no significant differences between the two groups in pediatric and adult patients(26). This is inconsistent with the conclusion reached in this paper. This may be related to the small number of pediatric patient cases included in this literature.

Postoperative Complications

Total Complications

In the present analysis, 10 reports described intraoperative and postoperative complications. Unexpectedly, Cai et al. (12, 14), Dong et al. (20), Xiao et al. (15), Xie et al. (13, 18), Chi et al. (19), Kim et al. (27) and Lin et al. (22) reported that complications were not related to the extent of resection. After sensitivity analysis, the article by lin et al. was excluded.

Short-term Complications

A total of 6 (1.8%) patients in the RAHJ group were identified as having short-term complications, compared to a total of 30 (5.6%) in the LAHJ group. The most common short-term complication in the RAHJ group was anastomotic bleeding(n = 3, 50.0%), and the most common complication in the LAHJ group was wound infection(n = 8, 26.7%). In addition, 4 patients in the RAHJ group had umbilical incision infection with abscess (n = 1, 16.7%), intra-abdominal bleeding (n = 1, 16.7%), upper respiratory tract infection (n = 1, 16.7%), and peritoneal effusion (n = 1, 16.7%). 22 patients in the LAHJ group had biliary fistula (n = 11, 36.7%), anastomotic bleeding (n = 6, 20.0%), peritoneal effusion (n = 1, 3.3%), pancreatic fistula (n = 1, 3.3%), anastomotic fistula (n = 1, 3.3%), and upper respiratory tract infection (n = 3, 10.0%). In the report by Yin et al.(26), no significant differences in short-term complications were shown between RAHJ-treated and LAHJ-treated patients. The results of the subgroup analysis remained the same for the pediatric group as well as the adult group.

Long-term Complications

A total of 7 (2.6%) patients in the RAHJ group were identified as having short-term complications, compared to a total of 25 (6.2%) in the LAHJ group. The most common complication in the RAHJ group was cholangitis (n = 3, 42.9%), and the most common complication in the LAHJ group was anastomotic stricture (n = 10, 40.0%). Other long-term complications in the RAHJ group included anastomotic strictures (n = 1, 14.3%), distal stones (n = 1, 14.3%), and intestinal obstruction (n = 2, 28.6%). Other long-term complications in the LAHJ group included residual abscesses (n = 4, 16.0%), distal stones (n = 4, 16.0%), cholangitis (n = 3, 12.0%), gallstones (n = 2, 8.0%), and intestinal obstruction (n = 2, 8.0%).In the report by Yin et al.(26), there was no significant difference in the long-term between the RAHJ and LAHJ groups in terms of the level of complications, and the same was true for the results of the pediatric and adult groups in the subgroup analysis.

Secondary Surgery and Hospitalization Costs and Follow-up Time

Among the 10 publications, only the report of Xie et al.(18) clearly documented the secondary surgery, one case in the RAHJ group and five cases in the LAHJ group. In RAHJ group, one patient with bleeding at the hepaticojejunostomy received a reoperation with laparotomy. In LAHJ group, one patient with bleeding at the hepaticojejunostomy received an exploratory laparotomy, one patient with biliary stone received choledochojejunotomy and lithotomy, three patients with stricture of the hepaticojejunostomy received a reoperation of choledochojejunostomy.

The analysis result of hospitalization costs is also in line with expectations. However, only 2 Chinese studies were included in this price comparison. Koga et al.(11) reported that the Japanese national health insurance system does not cover the use of robotic surgery, resulting in an average procedure cost of approximately $15,000. There are few statistical studies related to congenital choledochal dilatation abroad, and the cost issue lacks supporting literature. Therefore, the conclusions are limited for foreign children.

Seven articles mentioned the issue of follow-up time. Among them, the mean of the follow-up time exceeded 24 months in both the RAHJ and LAHJ groups as reported by S. Q. Chi et al.(23), Chi et al.(19) and Lin et al.(22).

Subgroup Analysis

We believe the outcome is due to the increasing popularity of the surgical da Vinci robot over time, as well as the increasing experience and proficiency of robotic surgical operators through continuous practice and training, which undoubtedly contributes to the improvement of robotic surgical outcomes. At the same time, articles with high quality scores imply less bias and higher reliability of the conclusions drawn. The relevant information is summarized in Fig. 10.

Limitations

This meta-analysis has some limitations. Firstly, A more precise analysis would have been possible if data from individual patients had been available and could have been adjusted for age, sex, race, and geographic location. Secondly, the included literature does not meticulously describe the patient's preoperative infection and preoperative bile drainage. Thirdly, different study sites use different perioperative therapeutic agents for patients; there is no uniformity in the evaluation of surgical tolerance, and biological heterogeneity affects clinical outcomes. Fourthly, congenital choledochal dilation has a distinct presentation in the Eastern population yet shares some commonality with Western patients. However, some reported differences in presentation, malignancy risk, and patient demographics between Western and Eastern populations should spur further investigation into congenital choledochal dilation in Western patients to understand this disease and tailor management guidelines to Western populations(28). Most of the literature data included in this meta-analysis were from Asian countries, and their reference value for children with choledochal cysts in Western countries is questionable. Lastly, the annual surgical volume of units published in the literature also influenced the results of our subgroup analysis. If the annual surgical volumes of the corresponding hospitals included in the study were comparable, it would be easier to compare the advantages and disadvantages of the two surgical approaches in different years.

Prospect

The advantages of robotic surgery include the following: 1. robotic surgery has more technical advantages(29), including 3D imaging, tremor filters and articulated instruments(30), three-dimensional vision can be magnified 10–15 times; 2. greater rotation angle of the robotic arm; 3. reduced hand tremors on the surgery; 4. no need to hold the mirror, optimizing the experience of the surgical operator.

However, robotic surgery also has some disadvantages: 1. the surgery is expensive; 2. the system lacks haptic feedback, so the operator cannot perceive force feedback when performing separations, sutures, and knots, however, as the learning curve increases, the visual feedback of hand-eye coordination can compensate for the mechanical sensation of tactile feedback; 3. the installation time is long; 4. it is not possible to change the position of instruments and operators during the procedure as needed; 5. the aesthetics of the surgical incision is not as good as that of laparoscopic surgery.

Robotic surgery has a bright future in the treatment of congenital choledochal dilatation and deserves to be promoted and popularized. The robot, which has larger diameter operating instruments, shows its operational limitations in younger children, but its advantage is that the operating arm is flexible and can be operated at various angles. As robotic surgical systems continue to improve, it is likely that in the future their design direction will tend to accommodate smaller volume surgical objects. The effectiveness of different types of cysts for different surgical procedures is also an issue that needs to be taken into account. This requires more cases and classification by cyst type for comparative studies.

Data Availability Statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author/s.

Author Contributions

RZ, SL and TL contributed to the conception, design of the study, and drafting of the article. JZ contributed to revising the article critically for important intellectual content and contributed to the final approval of the version to be submitted. All authors contributed to the article and approved the submitted version.

Funding

This study was funded by the Natural Science Foundation of Xinjiang Uygur Autonomous Region (grant number: 2021D01A38).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Chan EKW, Lee KH, Wong VHY, Tsui BSY, Wong SYS, Pang KKY, et al. Laparoscopic management of choledochal cysts in infants and children: A review of current practice. Surgical Practice. 2018;22:131-137. https://doi.org/ 10.1111/1744-1633.12310
Lin S, Chen J, Tang K, et al. Trans-umbilical single-site plus one robotic assisted surgery for choledochal cyst in children, a comparing to laparoscope-assisted procedure. Front Pediatr. 2022;10:806919. https://doi.org/ 10.3389/fped.2022.806919
Chi SQ, Xu YH, Tang ST, et al. Comparison between robot-assisted and traditional laparoscopic surgery on choledochal cyst excision and hepaticojejunostomy in children [J]. Chinese Journal of Robotic Surgery. 2021, 2:248-254. https://doi.org/10.12180/j.issn.2096-7721.2021.04.002
Diao M, Li L, Cheng W. Role of laparoscopy in treatment of choledochal cysts in children. Pediatr Surg Int. 2013;29:317-326. https://doi.org/ 10.1007/s00383-013-3266-z
Wen Z, Liang H, Liang J, et al. Evaluation of the learning curve of laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy in children: CUSUM analysis of a single surgeon's experience. Surg Endosc. 2017;31:778-787. https://doi.org/10.1007/s00464-016-5032-5
Yin T, Chen S, Li Q, et al. Comparison of outcomes and safety of laparoscopic and robotic-assisted cyst excision and hepaticojejunostomy for choledochal cysts: A systematic review and meta-analysis. Annals of Medicine and Surgery. 2022;75:103412. https://doi.org/ 10.1016/j.amsu.2022.103412
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Table 1

Summary of All Incorporated Literature

Reference	Country	Typing	Sample size	Group Number	No. of complication
Cai et al. 2022	China	I:44	44	RAHJ:25 LAHJ:19	RAHJ:2 LAHJ:1
Cai et al. 2021	China	Ⅱ:5	5	RAHJ:1 LAHJ:4	No complications
S．Q．Chi et al. 2021	China	Ia:111 Ⅱb:3 Ⅲc:46 Ⅳa:8 Ⅳb:2	170	RAHJ:85 LAHJ: 85	RAHJ:4 LAHJ:12
Dong et al.2021	China	I:87 Others:16	103	RAHJ:21 LAHJ:82	RAHJ:1 LAHJ:5
Xiao et al.2019	China	V:2	2	RAHJ:1 LAHJ:1	No complications
Xie et al.2021	China	I:341 Ⅱ:1 Ⅳ:59	401(172)	RAHJ:54 LAHJ:118 OS:229	OS:7 LAHJ:9 RAHJ:2
Chi et al. 2021	China	Ia：87 Ib：3 Ic：40 Ⅳa：8 Ⅳb：2	140	RAHJ:70 LAHJ:70	RAHJ:3 LAHJ:21
Koga et al.2019	Japan	NA	37	RAHJ:10 LAHJ:27	LAHJ:1
Lin et al.2022	China	Ia:29 Ib:3 Ic:11 IVa:7 IVb:1	51	RAHJ:24 LAHJ:27	RAHJ:2 LAHJ:23
Xie et al.2020	China	Ⅰ：312 Ⅱ：1 Ⅳ：58	371(145)	RAHJ:41 LAHJ:104 OS：226	RAHJ:2 LAHJ:9 OS：7

Table 2

Literature Quality Score

References	Selection	Comparability	Outcome	Total
Cai et al. 2022	3.5	0	1.5	5
Cai et al. 2021	3.5	1	2.5	7
S．Q．Chi et al. 2021	3.5	0	1.5	5
Dong et al.2021	3.5	1	2.5	7
Xiao et al.2019	3	0	2	5
Xie et al.2021	3	1	2	6
Chi et al. 2021	3.5	2	2.5	8
Koga et al.2019	3.5	2	2.5	8
Lin et al.2022	3.5	2	2.5	8
Xie et al.2020	3.5	1	2.5	7

Table 3

Summary of Subgroup Analysis Results TC: Total Complications SC: Short-term Complications LC: Long-term Complications

Subgroups

TC:

RAHJ vs. LAHJ

SC:

RAHJvs.LAHJ

LC:

RAHJvs.LAHJ

Years

<2020

OR=0.59[0.14,2.44]

I²=0%

P=0.46

RR=0.85[0.14,5.21]

I²=0%

P=0.86

>2020

OR=0.32[0.14,0.74]

I²=26%

P=0.008

RR=0.43[0.15,1.22]

I²=4%

P=0.11

OR=0.28[0.07,1.13]

I²=0%

P=0.07

Quality

Moderate

OR=0.42[0.18,1.02]

I²=0%

P=0.06

RR=0.56[0.12,2.71]

I²=20%

P=0.47

OR=0.49[0.16,1.46]

I²=0%

P=0.20

High

OR=0.31[0.10,0.95]

I²=30%

P=0.04

RR=0.39[0.13,1.11]

I²=0%

P=0.08

OR=0.30[0.07,1.20]

I²=0%

P=0.09

No competing interests reported.

ZhanSupplementaryFigure1.tif.tif
Supplementary Fig. 1 Funnel Diagram on Postoperative Complications
ZhanSupplementaryFigure2.tif.tif
Supplementary Fig. 2 Funnel Chart on Postoperative Hospital Stay
ZhanSupplementaryFigure3.tif.tif
Supplementary Fig. 3 Funnel Plot on Intraoperative Bleeding Volume
ZhanSupplementaryFigure4.tif.tif
Supplementary Fig. 4 Funnel Diagram on Surgery Time
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Editorial decision: Major revision
16 Oct, 2022
Reviews received at journal
14 Oct, 2022
Reviewers agreed at journal
04 Oct, 2022
Reviewers invited by journal
01 Oct, 2022
Editor assigned by journal
26 Sep, 2022
Submission checks completed at journal
26 Sep, 2022
First submitted to journal
21 Sep, 2022

You are reading this latest preprint version

Efficacy of Robot-assisted Hepaticojejunostomy and Laparoscopic-assisted Hepaticojejunostomy in Pediatric Congenital Choledochal Dilatation ： A System Review and Meta-analysis

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Abstract

Figures

Introduction

Materials And Methods

Search Strategy

Inclusion Criteria

Definitions

Data Extraction

Validity Assessment

Statistical Analysis

Results

Results of the Meta-analysis

Intraoperative Bleeding

Time to Surgery

Post-operative Hospital Stay

Postoperative Complications

Total Complications

Short-term Complications

Long-term Complications

Hospitalization Costs

Subgroup Analysis

Publication Bias

Discussion

Learning Curve and Cyst Typing

Age of Surgery

Intraoperative Bleeding, Time to Surgery and Post-operative Hospital Stay

Postoperative Complications

Total Complications

Short-term Complications

Long-term Complications

Secondary Surgery and Hospitalization Costs and Follow-up Time

Subgroup Analysis

Limitations

Prospect

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1