Evaluation of results of laparoscopic choledochocystectomy in adults patients

T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 182 EVALUATION OF RESULTS OF LAPAROSCOPIC CHOLEDOCHOCYSTECTOMY IN ADULTS PATIENTS Nguyen Hai Dang1, Bui Tuan Anh2, Nguyen Quang Nghia3 SUMMARY Objectives: To evaluate the results of laparoscopic choledochocystectomy in adults patients. Subjects and methods: Between 01/2015 and 12/2019, we performed a choledochal cyst excision procedure on 68 adults patients. There were 8 cases of open conversion due to bleeding, severe inflammation, disruption of the distal choledochal and liver stones. For the rest cases, excision of the cyst and hepaticojejunostomy were managed laparoscopically using a four-hole method. There were a total of 30 laparoscopic cases (jejunojejunostomy was performed laparoscopically). Results: The conversion rate was 11.8%. The mean operation time was 247 ± 52 min. The estimated blood loss was 175 ± 267 mL. The average hospital stay was 9.08 ± 4.46 days. Postoperative complications was 20.0%, including bile leakage (15.0%), abdominal fluid accumulation (1.7%), pancreatitis (1.7%) and pancreatic fistula (1.7%). Reoperation was necessary for 1 patient (1.7%) due to bile leakage. No deaths were recorded. Conclusions: Laparoscopic excision of a choledochal cyst in adult patients can be a first-line treatment, which is an effective and safe method, ensuring good cosmetic results and people’s safety. * Keywords: Choledochal cyst; Laparoscopic excision; Choledochocystectomy. INTRODUCTION Choledochal cyst is a relatively rare disease, especially in Western countries. However, the number of adults diagnosed with choledochal cyst has been on the increase thanks to the development of non-invasive hepatobiliaric imaging and the impact of regular health screenings [3]. Although it is a benign disease, the choledochal cyst need to be removed due to the high risk of biliary cancer and late complications such as choledocholithiasis. Choledochal cyst is a disease commonly seen in young and female patients. In these patients, the cosmetic requirement is just as important as the effectiveness. Therefore, we have implemented laparoscopic surgery to remove the choledochal cyst with 4 trocars instead of the conventional open surgery. This technique are routinely carried out in all adult patients diagnosed with choledochal cyst without suspected biliary malignancy. The objective of this study was: To evaluate the early outcome of laparoscopic choledochocystectomy in adults. 1Pham Ngoc Thach Medical University, Ho Chi Minh City 2Vietnam Military Medical University 3Viet Duc Hospital Corresponding author: Nguyen Hai Dang (drhaidang@gmail.com) Date received: 23/8/2020; Date accepted: 30/9/2020 T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 183 SUBJECTS AND METHODS 1. Subjects * Selection criteria: - Adult patients: 16 - 60 years old. - Diagnosed with choledochal cyst using CTscan, MRCP or ERCP. - Diagnosed with type I, type II and type IV choledochal cyst. * Exclusion criteria: - Patients with ASA > 3. - Patients with hypergastric surgical scar. - Being pregnant. - Patients with serious comorbidities contraindicated for laparoscopy. 2. Methods - Research design: Prosspective, case series. - Time and location: From January 2015 to November 2019 at Binh Dan Hospital in Ho Chi Minh City. * Data collection, analysis and processing: All data are encrypted, recorded and calculated using SPSS 22.0 software for Windows. The test-t, Chi squared, Kendall's and Fisher were used. The difference was statistically significant when p < 0.05. * Surgery technique: Exposing the operation field, dissection of the cyst and the distal side of common bile duct (CBD). Then, the distal end of the CBD is ligated. The dissection progress is continued until reaching the common hepatic duct or the right and left hepatic duct. Previously, we extended the incision at the umbilical trocar position about 2 cm, bringing the jejunum out and perform the jejunojejunal anastomosis. In recent cases, we performed the jejunojejunal anastomosis completely laparoscopically using laparoscopic Stappler. We performed the choledochojejunostomy with Roux- en - Y technique in front of the tranverse colon. In some cases, in order to reduce the tension of the anastomosis, we had to carry out choledochojejunostomy through a small artificial perforation of the transverse colon mesentery. Years ago, the anastomosis was sewn with Vicryl, running suture on the posterior site and interrupted suture on the anterior site. However, recently, running pattern with V-lock suture was applied when the diameter of the anastomosis was larger than 10 mm; on the other hand, continuous pattern on the posterior site and discontinuous pattern on the anterior site using PDS sutre was done when the diameter of the anastomosis was smaller than 10mm. RESULTS 1. Operative outcome From January 2015 to December 2019, we performed totally 68 choledochal cystectomy cases. A total of 8 cases were carried out with open surgery: two of which were due to bleeding; 4 other cases had excessive inflammation around the cyst; 1 case had a disrupted distal end of the narrow choledochal cyst during the dissection of the intrapancreatic portion; 1 other case had many stones in the liver which could only be handled with open method and cholangioscopy combined with electro-hydraulic lithotripsy. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 184 * Characteristics of the study subjects: Male/female ratio: 6/62; mean age: 38.03 ± 11.91 years (18 - 60 years); BMI: 21.4 ± 1.5; Todani’s classification Ia: 39 (57.4%), Ib: 1 (1.5%), Ic: 16 (23.5%), IV: 12 (17.6%); Operation time: 247 ± 52 minutes (145 - 410 minutes); mean blood loss volumme: 175 ± 267 mL (10 - 1,500 mL); Post-operative hospital stay: 9.08 ± 4.46 days (6 - 29 days). Table 1: Postoperative complications (60 cases of successful laparoscopic surgery). Complications Number of patients Percentage (%) Bile leakage 9 15.0 Abdominal fluid accumulation 1 1.7 Pancreatic fistula 1 1.7 Pancreatitis 1 1.7 Total 12 20.0 Table 2: Complication rate according to Clavien - Dindo‘s classification (2004). Classification Number of patients Percentage (%) I 3 5.4 II 3 5.4 IIIa 0 0.0 IIIb 1 1.8 IV 0 0.0 V 0 0.0 Total 7 12.5 Most of complications were treated effectively with conservative management. Only 1 case had to be re-operated due to bile leakage and ineffective drainage, leading to general biliary peritonitis. No mortality was recorded in this study. Previously, the jejunojejunal anastomosis was performed extrabdominally by expanding the umbilical trocar incision. However, that technique was done totally laparoscopically in later 30 cases. After open conversion were excluded, we compare the outcome between the two groups: open and laparoscopic performing jejunojejunal anastomosis. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 185 Table 3: Comparison of open and laparoscopic jejunojejunal anastomosis. Laparoscopic jejunojejunal anastomosis 0pen jejunojejunal anastomosis p Total (n) 30 30 Operation time (min) 242 ± 50 253 ± 54 0.416 Jejunojejunal anastomosis time (min) 63 ± 11 40 ± 8 0.000 Blood loss (mL) 101 ± 83 248 ± 357 0.035 Passing gas (day) 2.80 ± 1.27 3.45 ± 1.12 (n = 29) 0.044 Post-operative hospital stay (day) 7.70 ± 1.54 10.47 ± 5.84 0.017 Postoperative complications 4 8 0.333 Re-operation 0 1 1 Mortality 0 0 1 Laparoscopic jejunojejunal anastomosis had better result than open jejunojejunal anastomosis about blood loss, passing gas, post-operative hospital stay. The results suggest that there is not statistically significant difference between the two groups about operation time, postoperative complications, re-operation and mortality. Figure 1: Laparoscopic jejunojejunal anastomosis. (Using laparoscopic Stappler with the reinforcement of V-lock suturing) T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 186 Figure 2: Laparoscopic choledochojejunostomy. - Follow-up: All patients were scheduled for periodically physical examination follow-up at the timepoints of 2 weeks, 3 months, 12 months. The results showed that no cases were detected biliary stenosis or appearance of malignancy after surgery. However, we need to follow up for a longer time to get accurate results. DISCUSSION 1. Epidemiology Choledochal cyst is a more common disease in Asian countries than Europe [2]. The common age group is below 45 years old, the higher the age, the less likely it gets [5, 6, 7]. In our study, the average age was 41 years, the youngest was 20 years and the oldest was 83 years, similar Nguyen Cao Cuong’s study in Vietnam [8]. In our study, the proportion of female patients was 10.3 times higher than male. Similarly, all studies have reported that the choledochal cyst is frequently encountered in females but its reasons has been unknown [5, 6, 7, 8]. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 187 2. Classification of choledochal cyst Through imaging results (MRCP, CTscan and ERCP) and intraoperative identification, there were 56 cases of type I cysts (82.4%), and 12 cases of type IV (17.6%). Our research shows that type I cyst had a high proportion similar to other studies [5]. 3. Surgery technique In 1995, Dr. Farello performed the first technique of laparoscopic cystectomy, so far, there have been many reports abroad about this technique [9, 10]. The technique of laparoscopic choledochocystectomy has gradually been extensively applied and become conventional instead of traditional open surgery. In Vietnam, the technique is widely used in pediatric patients [9], the number of elderly patients undergoing laparoscopic treament is also increasing [2]. However, the operative technique may vary due to the position of the patient and the surgeon, the number of operating trocars, cystic anatomy, choledochojejunostomy... depending on the surgeons. Previously, we extend the incision at the umbilical trocar position about 2 cm, bringing the jejunum out and perform the jejunojejunal anastomosis. In recent cases, we performed the jejunojejunal anastomosis completely laparoscopically using laparoscopic Stappler. This method has the advantage of a more cosmetic surgical scar and less postoperative pain than the conventional method. In the first cases, the surgery time is longer than the old method because we have not fully mastered this technique. In the later cases, the surgery time of both groups was statistically similar. Regarding surgical instruments improvement, the anastomosis was previously sewn with Vicryl, running suture on the posterior site and interrupted suture on the anterior site when the diameter of the anastomosis was larger than 10 mm. Or using the interrupted suture for all the anastomosis when the diameter was smaller than 10 mm. Recently, running pattern with V-lock suture was applied when the diameter of the anastomosis was larger than 10 mm; on the other hand, continuous pattern on the posterior site and discontinuous pattern on the anterior site using PDS sutre was done. V-lock suturing makes laparoscopic manipulation easier and increases the safety of the anastomosis. Moreover, we also use ultrasonic knives Harmonic or Ligasure in surgery, which helps shorten the time and increase the safety of surgery. 4. Surgical time Two phases of the surgery, which take a long time, are cystectomy and the choledochojejunostomy because they require meticulousness. The length of surgery depends on the type of cyst, whether the cyst has any previous complications, the age of the patient and the skills of the surgical team. It is clear that for elderly patients, the long-term course of the disease makes the inflammation around the cysts heavy, difficult for surgery, as a result, increase the surgery time. In addition, the surgical team must be well-trained, from the camera assistant, surgeon assistant, the coordination must be good so the surgery time will be improved. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 188 In our study, surgery time averaged 247 minutes. The time of surgery in the first surgery case in Jang J.Y's study [8] was 330 minutes, but with the accumulated experience, the time was shortened to an average of 228 minutes. In the last 10 cases, the surgery time was less than 200 minutes, however, this study was done for both pediatric patients and elderly patients [8]. The average surgical time in Lu SH.CH's research [7] was 280 minutes, in Hwang D.W’s [4] was 395.8 minutes. The surgical time for open cystectomy in Nguyen Cao Cuong's study was 120 - 180 minutes [1], in Do Huu Liet [2], who performed the open incision under the right flank or the supporting hand was 253 minutes with an average horizontal diameter of 46.9 mm. Some studies show that the time for laparoscopic choledochocystectomy is longer than open method. However, the time for surgery decreases with the training curve. This shows that the laparoscopic choledochocystectomy is a complicated surgery that requires a lot of skills, meticulousness and sophistication of the surgeon. 5. Complications management According to a study by Jang JY and CS in South Korea, 82 patients underwent laparoscopic choledochocystectomy [8], intraoperative complications that failed to perform laparoscopic surgery, which must be converted to open procedure, including: laceration of the distal end of the common bile duct, excessive bleeding due to coagulation disorders in cirrhotic patients and inflamed adhesion condition of the cyst into the portal vein. In this study, 1 patient was converted to open surgery due to the presence of intrahepatic biliary stones which needed electro-hydraulic lithotrypsy. Due to the low economic situation, our patients can’t afford to have regular check-up and come for physical examination for late complications. The author also pointed out the early post-operative complications leading to re-operation including mesenteric bleeding, stenosis of the choledochojejunal anastomosis and major pancreatic duct damage due to excessive dissection and adhesive bowel obstruction. Some authors recommend using laparoscopic Stappler or Ligasure scapel to ligate the mesenteric vessels instead of the ultrasonic knife [8]. We ligate the mesenteric vessels by using an ultrasonic knife combined with a metal clip or hemolock to reduce hospital fee for patients. The rate of early complications in our study was 20.0%, including: bile leakage (15.0%), abdominal fluid accumulation (1.7%), pancreatitis (1.7%) and pancreatic fistula (1.7%). Most of the complication were mild, treated conservatively, only one of them had to be re-operated due to bile leakage and ineffective drainage. No mortality was recorded. This method proves to be safe. We strive to perfect this technique to ensure cosmetics and patient’s safety. However, the long-term results of the technique are not guaranteed, due to short follow-up. Further studies need to be conducted with longer follow-up. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 189 CONCLUSION Choledochal cyst is common among young women, who are especially interested in cosmetics. Laparoscopic management of choledochal cyst may be a mainstay treatment for surgeons who have experience in laparoscopy and hepatobiliary surgery, espcially in the management of choledochal cyst disease in adults. REFFERENCES 1. Nguyễn Cao Cương. Chẩn đoán và kết quả phẫu thuật cắt nang đường mật ở người lớn. Luận án Tiến sĩ Y học. Đại Học Y Dược TP Hồ Chí Minh 2005. 2. Đỗ Hữu Liệt, Bùi An Thọ, Đoàn Tiến Mỹ, Cường Nguyễn Tấn. Kết quả bước đầu phẫu thuật nội soi cắt nang đường mật ở trẻ lớn và người lớn. Ngoại Khoa 2010; 4-5-6(60):13-21. 3. Lee SE, Jang JY, Lee YJ, Choi DW, Lee WJ, Cho BH, Kim SW, Korean Pancreas Surgery Club. 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