Hepaticoduodenostomy vs hepaticojejunostomy for reconstruction after resection of choledochal cyst

Journal of Pediatric Surgery (2011) 46, 209–213

www.elsevier.com/locate/jpedsurg

Hepaticoduodenostomy vs hepaticojejunostomy for reconstruction after resection of choledochal cyst Matthew T. Santore, Brittany J. Behar, Thane A. Blinman, Edward J. Doolin, Holly L. Hedrick, Peter Mattei, Michael L. Nance, N. Scott Adzick, Alan W. Flake ⁎ The Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA Received 27 September 2010; accepted 30 September 2010

Key words: Choledochal cysts; Hepaticojejunostomy; Hepaticoduodenostomy

Abstract Purpose: Roux-en-Y hepaticojejunostomy (HJ) is currently the favored reconstructive procedure after resection of choledochal cysts. Hepaticoduodenostomy (HD) has been argued to be more physiologically and technically easier but is feared to have associated complications. Here we compare outcomes of the 2 procedures. Methods: A retrospective chart review identified 59 patients who underwent choledochal cyst resection within our institution from 1999 to 2009. Demographic and outcome data were compared using t tests, Mann-Whitney U tests, and Pearson χ2 tests. Results: Fifty-nine patients underwent repair of choledochal cyst. Biliary continuity was restored by HD in 39 (66%) and by HJ in 20 (34%). Open HD patients required less total operative time than HJ patients (3.9 vs 5.1 hours, P = .013), tolerated a diet faster (4.8 days compared with 6.1 days, P = .08), and had a shorter hospital stay (7.05 days for HD vs 9.05 days for HJ, P = .12). Complications were more common in HJ (HD = 7.6%, HJ = 20%, P = .21). Three patients required reoperation after HJ, but only one patient required reoperation after HD for a stricture (HD = 2.5%, HJ = 20%, P = .037). Conclusions: In this series, HD required less operative time, allowed faster recovery of bowel function, and produced fewer complications requiring reoperation. © 2011 Elsevier Inc. All rights reserved.

The term choledochal cyst (CDC) describes cystic dilation of various parts of the biliary tree that have in common the potential for obstructive complications of the common bile duct, pancreatic duct, and ultimately malignant degeneration. In infancy, painless jaundice is the most common presentation, whereas older children may present with intermittent abdominal pain related to obstruction from stones or sludge, with or without associated jaundice, ⁎ Corresponding author. Department of Surgery, Abramson Research Center, Philadelphia, PA 19104-4318, USA. Tel.: +1 215 590 3671; fax: +1 215 590 3324. E-mail address: [email protected] (A.W. Flake). 0022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.09.092

pancreatitis, or cholangitis [1-4]. Choledochal cyst can be diagnosed prenatally by ultrasound or magnetic resonance imaging allowing early resection [5-9]. The treatment of CDCs has evolved from drainage procedures to the current standard of complete excision of the cyst with biliary reconstruction [10-13]. A variety of creative surgical reconstructive procedures have been described, but the 2 most common are reconstruction by Roux-en-Y hepaticojejunostomy (HJ) or by hepaticoduodenostomy (HD). The HJ reconstruction seems favored by most surgeons; however, there is minimal support in the literature for this preference. The concerns related to HD include the potential for cholangitis and bile gastritis, which

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are theoretically addressed by HJ. However, reconstruction by HD is technically easier, particularly in the context of laparoscopic CDC resection, may be more physiologic, avoids complications associated with the Roux-en-Y, and allows postoperative endoscopic access to the anastomosis if strictures or stones occur [14]. In view of these significant potential advantages, and the minimal data supporting HJ over HD in the literature, we decided to compare the results of HD and HJ in our series of CDC resections.

1. Methods A retrospective study was performed on all patients who underwent excision of a CDC from August 1999 to July 2009 at the Children's Hospital of Philadelphia after obtaining institutional review board approval. The data were collected through retrospective review of the inpatient and outpatient electronic medical record by 2 independent reviewers and compared for consistency. The following data were collected: presenting symptoms, complications of the disease, diagnostic modality, size and type of the cyst, operative time, blood loss, operative complications, duration of procedure, return to regular diet, and postoperative complications. For descriptive analysis, median and standard deviation were calculated for each variable. For summary statistics, independent t tests, Mann-Whitney U tests, and Pearson χ2 tests were used to Table 1

compare data from HD and HJ groups. The level of significance (α level) was set at .05. A χ2 test was used for any binary data with the α level set at .05.

2. Results Of 59 total patients undergoing resection of CDC, Rouxen-Y HJ was performed on 20 (34%) patients and the remaining 39 (66%) underwent HD. The choice of performing an HJ or HD was by surgeon preference. Most of the operative procedures were performed by a single surgeon (AWF) who performed both operative techniques. The choice of operative technique evolved toward HD over the duration of the series, and it was largely based on the ease of approximation of the duodenum to the hepatic confluence after performance of an extensive Kocher maneuver (ie, when the anatomy allowed a tension-free HD anastomosis, an HD was performed). There were no significant differences in the male-to-female ratio, the median age at diagnosis, or the median age at surgery in the HJ vs HD groups, respectively (Table 1). Similar percentages of HJ and HD patients were prenatally diagnosed (25% vs 21%). Patients who were symptomatic before diagnosis presented with pain, nausea/ vomiting, fever, jaundice, acholic stools, pancreatitis, and/or diarrhea. Hepaticojejunostomy patients had higher presenting total bilirubin levels and had a higher incidence of

Demographic data for HJ and HD patients

Ethnicity White African American Asian Hispanic Other Sex Male Female Type of cyst I II III IV V Median age at diagnosis Median age at surgery Diagnosed in utero Symptomatic before diagnosis Preoperative cholangitis Average preoperative total bilirubin (mg/dL) Previous operations IQR indicates interquartile range.

HJ Roux-En-Y

HD

Total

15 (75%) 4 (20%)

23 (59%) 9 (23%)

38 (64%) 13 (22%)

0 (0%) 1 (5%) 0 (0%)

4 (10%) 1 (3%) 2 (5%)

4 (7%) 2 (3%) 2 (3%)

4 (20%) 16 (80%)

13 (33%) 26 (67%)

17 (29%) 42 (71%)

17 (85%) 1 (5%) 0 (0%) 2 (10%) 0 (0%) 3 (IQR 0.3-4.0) 4 (IQR 1.1-4.0) 5 (25%) 14 (70%) 3 (15%) 3.71 ± 5.46

34 (87%) 2 (5%) 1 (3%) 2 (5%) 0 (0%) 5.5 (IQR 1.1-11.0) 5.5 (IQR 1.1-11.0) 8 (21%) 26 (67%) 1 (3%) 1.75 ± 2.45

51 (86%) 3 (5%) 1 (1.6%) 4 (6.7%) 0 (0%) P = .243 P = .129 P = .563 P = .795 P = .072 P = .618

4 (20%)

7 (18%)

P = .848

HD vs HJ reconstruction after resection of choledochal cyst preoperative cholangitis than HD patients, but these differences were not statistically significant (Table 1). The followup period ranged from 3 months to 6 years (mean, 2.3 years) for the HD patients and 4 months to 9 years (mean, 3.5 years) for the HJ patients. Type I CDC, a cystic dilation involving the hepatic duct and common bile duct, was the most common type of cyst in both HD and HJ groups (85% vs 87%). The size of the cysts in each group was similar with an average size of 3.2 and 2.2 cm for the HD and HJ groups, respectively (P = .154). The HJ patients had a significantly longer operative time when compared to the entire HD group (5.12 vs 4.15 hours, P = .038). However, the HD group includes 6 laparoscopic procedures that required significantly longer times to complete than open HD (Table 2). If the laparoscopic HD procedures are excluded from the analysis, there is a larger significant difference in operative time between the 2 open procedures. Operative blood loss was not significantly different between HJ and HD groups. Postoperatively, there was a trend toward earlier discharge in the HD patients excluding patients who developed complications. There was no difference between the 2 groups in duration of epidural pain control. Importantly, the HD group had a trend toward shorter time to resumption of a regular diet than the HJ patients (HD = 4.8 days vs HJ = 6.1 days; P = .08), but this was not significant and both groups had similar intervals of nasogastric decompression. When comparing postoperative complications, there were no significant differences in the rates of postoperative leak, infection, reoperations, and cholangitis between the 2 groups. There were 3 (7.7%) of 39 compared to 4 (20%) of 20 patients who developed complications in the HD vs HJ groups, respectively. However, the HJ group had a significantly greater rate of complications requiring reoperations compared to the HD group (HJ 20% vs HD 2.5%, P = .037). Rates of postoperative stricture in the 2 groups were not significantly different. There was only one patient within the entire study who developed cholangitis and that patient underwent HJ (Table 3).

Table 2

Perioperative characteristics

Median size of cyst (cm) Average operative time total HD cases vs HJ (min) Average operative time open HD vs HJ (min) Average blood loss (mL)

211 Table 3

Postoperative findings HJ HD Roux-En-Y

Average length of stay (d) Average postoperative epidural duration (d) Average postoperative NG tube duration (d) Average time to regular diet (d) Postoperative leak Postoperative stricture Postoperative cholangitis Reoperation

Significance

9.05 ± 5.8

7.05 ± 6.0 P = .12

2.5 ± 0.9

2.59 ± 1.2 P = .745

3.5 ± 2.5

3.5 ± 1.9

P = .923

6.1 ± 3.6

4.8 ± 5.6

P = .08

2 (10%) 1 (5%) 1 (5%)

2 (5%) 1 (2.6%) 0 (0%)

P = .31 P = .45 P = .33

4 (20%)

1 (2.5%)

P = .037

NG, Nasogastric.

The complications within the HD group included a superficial wound infection that resolved with antibiotics, a biliary leak diagnosed by Hepatobiliary iminodiacetic acid (HIDA) scan that was successfully managed nonoperatively, and a stricture and leak within one patient that required reoperation. This patient developed biliary peritonitis requiring an exploratory laparotomy on postoperative day 15 after nonoperative management failed. During the reoperation, the anastomosis was intact, but the hepatic biliary duct showed a small leak treated with fibrin seal and abdominal drainage. This patient subsequently did well after an Endoscopic Retrograde Cholangiopancreatography (ERCP) dilatation of a minimal stricture of the distal hepatic bile duct. The HJ group required 4 reoperative procedures because of complications of the initial surgery. Two of the reoperations were not related to the biliary anastomosis. One of these patients required a repair of an incisional hernia along the subcostal incision and the other patient, who had a history of gastroschisis repair and a Ladd procedure, developed an early postoperative bowel obstruction and required an exploratory laparotomy with lysis of adhesions and detorsion of a segmental volvulus. Of the 2 patients requiring revision of the biliary anastomosis, one developed cholangitis from a high-grade obstructive stricture and ultimately required 2 operative revisions of the HJ because of several episodes of cholangitis. The other patient developed a biliary leak with peritonitis on the fifth postoperative day and at exploration was found to have a leak from a point on the left hepatic duct 1 cm proximal to the HJ anastomosis. This was patched with adventitial tissue and omentum and drained with resolution of the leak.

HJ Roux-En-Y

HD

Significance

2.2 cm (range, 0.8-0.6 cm) 307

3.2 cm (range, 0.4-12 cm) 249

P = .154

307

235

P = .013

3. Discussion

31.8 ± 14.7

25.7 ± 12.7

P = .080

The debate surrounding biliary reconstruction by HJ vs HD centers on the opinion that the HD reconstruction is more frequently complicated by bile gastritis, cholangitis, and is

P = .038

212 associated with a higher ongoing risk of cholangiocarcinoma [15-17]. A review of the literature, however, finds surprisingly little data supporting these concerns and there have been relatively few studies published comparing HD to HJ. In an early report, Todani et al compared 19 patients undergoing HD and 11 undergoing HJ and found no significant difference in biliary complications between the 2 procedures and advocated the HD procedure because of its “more physiologic state” and fewer postoperative intestinal complications [18]. Perhaps the most influential publication is by Shimotakahara et al [19], which compared 28 patients reconstructed by HJ with 12 patients reconstructed by HD after CDC resection. They observed complications of bile gastritis in 4 of 12 HD patients compared with 0 of 28 HJ patients and had 2 postoperative adhesion-related bowel obstructions in the HJ group with none in the HD group. They concluded that HJ was the surgical reconstruction of choice because of the high incidence of duodenogastric reflux after HD [19]. Supporting their contention is a study by Takada et al [20] in which 3 patients who underwent HD reconstruction and 5 who underwent HJ reconstruction were compared by monitoring with a Bilitec probe (Medtronic, Minneapolis, MN) and were endoscoped to assess the presence and severity of duodenogastric reflux. Although none of the patients were symptomatic, all 3 of the HD patients and none of the HJ patients had chemical and endoscopic evidence of duodenogastric reflux. However, biopsies showed only superficial gastritis in both groups. Finally, a report by Todani et al [21] of hilar cholangiocarcinoma 19 years after CDC excision and HD reconstruction has been influential in favoring HJ over HD. Our results differ from those of Shimotakahara et al as we observed no incidence of symptomatic bile gastritis. The reasons for this difference are unclear as is the reason that patients undergoing an HD reconstruction should have greater amounts of bile gastritis than healthy patients. Our construction of the HD anastomosis is at the junction of the first and second portions of the duodenum performed after an extensive Kocher maneuver to prevent any tension on the anastomosis. This is well distal to the pylorus and should not impact pyloric function or gastric emptying significantly. Although we have not routinely endoscoped patients to monitor for bile gastritis, it has not been a clinical issue in this series. Similarly, we have not seen cholangitis in the absence of stricture formation with either procedure. This is in agreement with all large published series of CDC excision. In circumstances where there is free bile drainage, the incidence of cholangitis should be minimal with either reconstruction. Finally, the question of whether HD entails an increased ongoing risk of cholangiocarcinoma at the hepatic duct confluence or of the intrahepatic ducts is more difficult to address without very long-term follow-up. However, most reports of intrahepatic carcinoma after complete excision of CDC are associated with intrahepatic ductal dilation, stones, strictures, and/or recurrent cholangitis despite a Roux-en-Y HJ reconstruction in several cases [22].

M.T. Santore et al. Of particular relevance to this discussion is the report of a patient by Goto et al who underwent resection of a type Ia cyst (no intrahepatic dilation) with development 10 years later of an intrahepatic cholangiocarcinoma. She had a Rouxen-Y HJ reconstruction [23]. Thus, there may be a field risk of carcinoma of intrahepatic ducts in patients with anomalous pancreaticobiliary junctions irrespective of the type of reconstructive procedure that they undergo. In this series we found few significant differences between our outcomes with HD compared to HJ. It is clear that HD reconstruction requires less operative time and is a simpler procedure to perform than HJ. This is particularly true of the laparoscopic procedure where the construction of the Roux-en-Y can add significant difficulty to the procedure and is often performed extracorporeally. There was also a trend toward shorter times to enteral feeds and length of stay after HD. Although these findings were not statistically significant, they are likely to be real given the reduced bowel manipulation required in the HD procedure. Importantly, there did not appear to be an increased rate of bile leak, stricture formation, or cholangitis in the HD group. However, one of the bile leak patients who underwent an HD illustrates one of the clear advantages of HD over HJ, which is endoscopic accessibility of the anastomosis. If an HD reconstruction is performed, the ability to endoscopically place stents or dilate the HD can avoid the need for reoperation when a leak or stricture occurs. Finally, our HJ patients had a higher rate of reoperation than the HD group. One of these was related to intestinal obstruction as has been observed in other comparative series. The complications related to Roux-en-Y conduits are well documented in the literature and, aside from mechanical or adhesion-related complications, include reports of fat malabsorption and duodenal ulcers supporting the concept that HD drainage is more physiologic and suggesting that a Roux-en-Y should be avoided if there is an equally effective alternative [16,24]. Our results support HD as the preferred procedure for biliary reconstruction after resection of CDC. In our view, the advantages of relative simplicity, particularly with the laparoscopic approach, avoidance of complications related to the Roux-en-Y conduit, postoperative endoscopic accessibility of the anastomosis, and restoration of relatively physiologic bile drainage outweigh the potential disadvantages of this approach, which for the most part remain unproven.

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Discussion John Raffensperger, MD (Sanibel, Fla) Dr Raffensperger, MD: Stricture, leak, and cholangitis. It seems to me that is a lot of complications. Did you do frozen sections at the proximal end of the resection to see that you had normal mucosa? Sometimes you have to go back all the way to the junction of the right and left hepatic ducts. And in other areas of the body such as the ureterovesical junction and the esophagogastric junction it does not pay to ignore the body's natural sphincters, the natural valves that prevent reflux. First of all, the draining bile way down in the jejunum is not physiologic. Draining bile into the duodenum without a valve is not physiologic. It seems to me that there is a third alternative and that is to take an isolated segment of jejunum with a little intussuscepted valve and then you protect your system from cholangitis if you make sure you have normal mucosa at the proximal end you won't have strictural leak. Your follow-up is very brief. Three years isn't very much when these patients have a life expectancy of 70, maybe even 80 years, like me. Dr Santore (response): As far as some of our complications, as far as biliary gastritis, we do an extensive Kocher maneuver of the duodenum and do an anastomosis fairly far down on the duodenum. I appreciate your comments as far as alternatives for different types of operations. Unidentified Speaker: I have one quick question. In your abstract you eliminated the laparoscopic hepaticoduodenostomies from your op time and talked about whether or not it was shorter. Do you do the same thing for your feeding time? Did you break out the … Dr Santore: I did. Speaker: So that feeding time is actually all the opens?0 Dr Santore: Yes, correct.