Does bile exposure during surgery affect the postoperative recovery and complications of pediatric patients with choledochal cysts treated by laparoscopic surgery?

doi:10.21203/rs.3.rs-4720675/v1

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Does bile exposure during surgery affect the postoperative recovery and complications of pediatric patients with choledochal cysts treated by laparoscopic surgery?

https://doi.org/10.21203/rs.3.rs-4720675/v1

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Purpose

We aimed to investigate the impact of intraoperative bile exposure (BE) on postoperative recovery and complications in pediatric patients with choledochal cysts (CCs).

Methods

We reviewed the medical records of CC patients who underwent laparoscopic surgery at our institutions between 2016 and 2024. The patients were divided into two groups according to the presence (BE group) or absence (control group) of intraoperative BE.

Results

Forty patients were enrolled (control group, n = 29; BE group, n = 11). The clinical data were compared between the two groups. The patients’ background characteristics, operative data, intraoperative adverse events, and postoperative complications during hospitalization did not significantly differ between the two groups. The incidence of postoperative cholangitis in the long-term postoperative period was significantly higher in the BE group than in the control group (2(6.9%) vs. 4(36.4%), p = 0.03). However, they did not have stenosis at the anastomotic site or intrahepatic stones.

Conclusion

intraoperative BE did not affect the postoperative recovery of patients with CC treated by laparoscopic surgery. However, it did affect the rate of occurrence of cholangitis in the postoperative chronic period. Further investigations are necessary to clarify the mechanism underlying the development of postoperative cholangitis in pediatric patients with CC.

choledochal cyst

laparoscopic surgery

bile exposure

postoperative recovery

complications

In hepatobiliary surgery, uncontrolled postoperative bile leakage due to common bile duct injury or anastomotic leakage may result in loculated collection, abscess formation, biliary ascites, or bile peritonitis. However, the impact of intraoperative bile exposure (BE) in patients undergoing surgery for bile duct injury or hepaticojejunostomy procedures is unknown. Even for laparoscopic hepaticojejunostomy in pediatric patients with choledochal cysts (CC), we sometimes experience BE during surgery. It is similar to the postoperative bile leakage situation; BE during surgery causes inflammation and affects postoperative recovery; therefore, it is important to investigate the effects of BE during surgery among pediatric patients with CC.

In 2016, we switched from an open approach to a laparoscopic approach for cyst excision and hepaticojejunostomy with Roux-en-Y intestinal reconstruction in patients with CC. Laparoscopic procedures were performed by a single surgeon at our institution and associated institutions [1]. The procedures changed from the early period to the recent period. During the early period, patients received cyst excision and bile duct transection for hepaticojejunostomy before Roux-en-Y small intestine anastomosis. In the recent period, the procedure was changed to cyst excision and bile duct transection for hepaticojejunostomy after Roux-en-Y small intestine anastomosis. In the early period procedure, patients often experienced BE because of the remaining transected bile duct. However, in the recent period, the period of BE was extremely short in comparison to the early period.

In this study, we aimed to investigate the impact of BE during surgery for CC on postoperative recovery and complications in pediatric patients.

Study design

We retrospectively reviewed all patients who underwent laparoscopic cyst excision, bile duct transection, and hepaticojejunostomy for CC at our institution and associated institutions between April 2016 and April 2024. All procedures were supervised by a single experienced surgeon employed by our institution, and all intraoperative cholangiography and choledochoscopy were performed in every case. The patients were divided into two groups: the within-group (control group) and the BE group. We compared patient characteristics, operative outcomes, and postoperative complications between the two groups retrospectively. To define the demographics and characteristics of the patients, we analyzed the following data: patient age, sex, body weight, type and choledochal cyst size, and history of preoperative cholangitis. The quality of the operation was defined by operative time, volume of blood loss, intraoperative adverse events, postoperative time to the start of oral intake, postoperative time to drain tube removal, and length of hospital stay. To define the outcome of the operation, biliary leakage, cholangitis, pancreatic fistula, wound infection, and redo surgery were evaluated as complications during hospitalization. Stenosis of the anastomotic site, intrahepatic stones, cholangitis, and ileus were evaluated as long-term postoperative complications.

Statistical analyses

Continuous variables were described as the mean and standard deviation (SD). Nominal variables are presented as numbers and percentages. For the quantitative results, t-tests were performed for univariate analyses. Categorical data and complication rates were analyzed using the chi-square test. P values of < 0.05 were considered to indicate statistical significance.

All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a modified version of R commander (The R Foundation for Statistical Computing, Vienna, Austria) designed to add statistical functions that are frequently used in biostatistics [2].

Ethical approval

This study was performed in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects by the Ministry of Health, Labor and Welfare of Japan in 2014 and in compliance with the 1964 Declaration of Helsinki (revised in 2013). Patient data were collected by blinding personal information and registering patients using consecutive patient numbers. This study was approved by the local ethics committee of our institution (registration number: 27-119). Informed consent for publication was obtained from the patients’ parents.

Background characteristics

A total of 40 patients with CC were enrolled this study. They were divided into the BE group (n=11) and the control group (n=29) according to the presence or absence of BE. The background characteristics of the patients in the two groups are presented in Table 1. There were no significant differences between the two groups (control group vs. BE group): age , 83.0 ± 77.0 vs. 68.1 ± 83.0 months (p = 0.60); sex (male: female), 7 : 22 vs. 4:7 (p = 0.46); body weight, 24.4 ± 17.3 vs. 19.4 ± 16.5 kg (p = 0.41); diameter of the dilated common bile duct, 2.8 ± 2.2 vs. 3.7 ± 2.8 cm (p = 0.26); type of choledochal cyst [3] (Ia: Ic: IVa ), 9 : 5 : 15 vs. 2 : 0 : 9 (p = 0.24); and history of preoperative cholangitis (n, %), 19 (65.5%) vs. 7(63.6%) (p = 1.00).

Operative results and perioperative outcomes

The operative results and perioperative outcomes are compared in Table 2. There were no significant differences between the two groups (control group vs. BE group): operative time, 539 .7 ± 100.9 vs. 516.5 ± 81.4 min (p = 0.50); blood loss volume, 86.1 ± 112.1 vs. 48.0 ± 68.3 mL (p = 0.30); time to the initiation of water intake, 4.1 ± 1.6 vs. 4.0 ± 1.5 POD (p = 0.90); time taken to the initiation of meal intake, 5.5 ± 1.8 vs. 5.1 ± 1.6 POD (p = 0.46); time taken to the removal of the drain tube, 9.7 ± 7.6 vs. 7.2 ± 3.4 POD (p = 0.30); and length of hospital stay, 15.6 ± 9.8 vs. 13.2 ± 5.5 days (p = 0.46).

Postoperative complications during hospitalization

Postoperative complications during hospitalization are shown in Table 3. There were no significant differences in the incidence of postoperative complications during hospitalization between the two groups (control group vs. BE group): biliary leakage, n = 3 (10.3%) vs. n = 0 (p = 0.55); cholangitis, n = 0 vs. n = 0; pancreatic fistula, n = 0 vs. n = 0; wound infection, n = 0 vs. n = 0; redo surgery, n = 1 (3.4%) vs. n = 0 (p = 1.00).

Late postoperative complications

The late postoperative complications are compared in Table 4. The mean follow-up period (control group vs. BE group) was 51.0 ± 25.2 vs. 60.7 ± 26.7 months (p = 0.29). The incidence of late postoperative complications was as follows (control group vs. BE group): stenosis at the anastomotic site, n = 3 (10.3%) vs. n = 2 (18.2%) (p = 0.60); intrahepatic stone, n = 0 vs. n = 1 (9.1%) (p = 0.28); cholangitis, n = 2 (6.9%) vs. n = 4 (36.4%) (p = 0.03); ileus, n = 0 vs. n = 0. The incidence of chronic cholangitis was significantly higher in the BE group.

In hepatobiliary surgery, uncontrolled bile leakage is thought to cause postoperative complications and a slow recovery. In the past, there was a temporary increase in bile leakage due to bile duct injury during laparoscopic cholecystectomy in comparison to open surgery. However, due to recent progress in laparoscopic surgical techniques, bile duct injury has become less common [4-6]. Surgical techniques in laparoscopic hepaticojejunostomy have also progressed and have been performed in many institutions in recent years [7]. However, laparoscopic hepaticojejunostomy remains challenging for pediatric surgeons in our country [1]. An analysis of the relationship between surgical techniques and operative outcomes is important. In the present study, we investigated whether BE during surgery affects postoperative recovery and complications in pediatric patients with CC.

For these patients, postoperative cholangitis is thought to be caused by an ascending bile reflux into the bile duct due to stenosis of the anastomotic site or the presence of intrahepatic stones, which can appear long after surgery [8]. Previous reports also suggested the effect of spurt valves in preventing cholangitis [9]. A previous study reported that long-term occurred at more than 5 years after surgery in 113 patients who underwent open cyst excision and hepaticojejunostomy with Roux-en-Y anastomosis at a single institution [10]. According to this report, there were cases in which cholangitis due to anastomotic stricture occurred at 23 and 24 years after surgery. There was also a case in which pancreatic stones and pseudocysts occurred 14 years after surgery and in which repeated pancreatitis was observed without bile duct cancer. In contrast, in the present study, patients with BE had a significantly higher rate of cholangitis in the long-term postoperative period, regardless of whether they had stone stenosis. The operative results were also not significantly different between the two groups; therefore, cholangitis was not related to the surgical procedure.

Anastomotic stenosis complicated by intrahepatic stones or non-complicated stones may occur in the long term after radical surgery, and this complication requires long-term follow-up, even after adulthood [11]. A meta-analysis of postoperative anastomotic stenosis has been reported [12]. In a meta-analysis that included 206 patients with choledochal cysts, postoperative anastomotic stenosis occurred in 2.1% of cases. The incidence in patients with type IVa cysts (10.4%) was significantly higher than that in patients with type I cysts (2.0%). There was no significant difference in the frequency of anastomotic stenosis between laparoscopic and open surgery [13]. These reports suggest that cholangitis due to stenosis or stone formation is a long-term problem. However, it is unclear how BE during surgery affects them. Further long-term studies are required to analyze the effects of BE on postoperative cholangitis.

The other impact of BE is a potential risk factor for peritoneal metastasis in choledochal cancer. It has been reported that 4.1% of CC patients are diagnosed with premalignant/malignant histopathology (PMMH) [14]. This suggests that the risk of developing cancer exists from an early age and that it is important to recognize the risk of peritoneal metastasis when patients have BE during surgery. In the present study, there were no patients with PMMH (irrespective of the presence or absence of BE); however, our follow-up period was too short to diagnose choledochal cancer.

Limitations

The present study was associated with several limitations, including its retrospective design, and the analysis of results derived from the work of a single experienced surgeon. Furthermore, the study population was relatively small. As such, it was exposed to the well-described biases associated with these types of studies.

In conclusion, BE during surgery did not affect the postoperative recovery of pediatric patients with CC who were treated by laparoscopic surgery, but it did affect the incidence of cholangitis in the postoperative chronic period. Further investigations are required to clarify the mechanism underlying the development of postoperative cholangitis in pediatric patients with CC.

Acknowledgments: We thank Mr. Brain Quinn for his comments and help with the manuscript.

Disclosure statement: No competing financial interests exist.

Funding statement: No external or internal sources of funding were used to support this work.

Conflict of interest: The authors declare no conflicts of interest in association with the present study.

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Tables 1 to 4 are available in the Supplementary Files section.

No competing interests reported.

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Version 1

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You are reading this latest preprint version

Does bile exposure during surgery affect the postoperative recovery and complications of pediatric patients with choledochal cysts treated by laparoscopic surgery?

Status:

Version 1

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Materials and Methods

Study design

Statistical analyses

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1