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Single-stage operation for perforated choledochal cyst
Journal of Pediatric Surgery 53 (2018) 653–655
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Single-stage operation for perforated choledochal cyst Go Ohba a,⁎, Hiroshi Yamamoto a, Masato Nakayama a, Shohei Honda b, Akinobu Taketomi b a b
Department of Surgery, Tenshi Hospital, North 12 East 3-1-1, Higashi-ku, Sapporo 065-8611, Japan Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo 060-8638, Japan
a r t i c l e
i n f o
Article history: Received 14 March 2017 Received in revised form 14 June 2017 Accepted 15 July 2017 Key words: Choledochal cyst Perforation
a b s t r a c t Background: The option of either single- or two-staged cyst excision has been proposed for perforated choledochal cysts (CCs), but which of the two methods is more effective remains controversial. We examined the complications and short-term outcomes of single-stage excision of perforated and non-perforated CCs. Methods: The medical records of patients treated for CCs from 2003 to 2016 were retrospectively reviewed. Outcomes were compared between patients with perforated CCs (Group A) and non-perforated CCs (Group B). The operative time, intraoperative bleeding, length of stay, and postoperative complications were analyzed. Results: Group A comprised 6 patients (2 males, 4 females; mean age, 29 months), and Group B comprised 26 patients (2 males, 24 females; mean age, 41 months). All patients underwent single-stage complete excision with Roux-en-Y hepaticojejunostomy. There were no significant differences in the operative time, bleeding, and/or length of stay. There were no operative deaths or complications such as anastomosis leakage or postoperative cholangitis, but a pancreatic fistula developed in one patient in Group A and two in Group B. Conclusion: Single-stage excision for a perforated CC is feasible if the patient's condition is stable. Levels of evidence: Treatment Study, LEVELIII. © 2017 Elsevier Inc. All rights reserved.
Perforation of a choledochal cyst (CC) is extremely rare, with a reported frequency ranging from 1.8% to 2.8% [1,2]. The pathogenesis of spontaneous perforation has not been established, but proposed mechanisms include reflux of pancreatic secretions [3], increased intraluminal pressure due to protein plugs [4], and viral infection [5]. The option of either single- or two-staged cyst excision has been proposed for perforated CCs, but the more effective method of the two remains controversial [4,6,7]. In this study, we evaluated the complications and short-term outcomes of single-stage excision of CCs, including perforated CCs, to determine the best approach to treating perforated CCs.
1. Materials and methods The medical records of patients treated for CCs from 2003 to 2016 were retrospectively reviewed. We covered all cases from 2003, when we began to perform pediatric surgery in our hospital, up to 2016. The children comprising the study group were those who had presented with either a plain CC or a perforated CC that was treated during the study period, with no exclusions. The following outcomes were Abbreviation: CC, choledochal cyst. ⁎ Corresponding author. Tel.: +81 11 711 0101; fax: +81 11 751 1708. E-mail addresses: [email protected] (G. Ohba), [email protected] (H. Yamamoto), [email protected] (M. Nakayama), [email protected] (S. Honda). http://dx.doi.org/10.1016/j.jpedsurg.2017.07.014 0022-3468/© 2017 Elsevier Inc. All rights reserved.
compared between patients with perforated CCs (Group A) and those with non-perforated CCs (Group B): operative time, intraoperative bleeding, length of hospital stay, full feeding day (i.e., the postoperative day on which the patients returned to their normal diet), and postoperative complications. All operations were performed in the same institution, and the surgeons had N10 years of clinical experience. SPSS version 19.0 for Windows was used to create a database and perform statistical analyses. Data were analyzed using Student's t test. P b .01 was considered statistically significant. 2. Results Group A comprised 6 patients (2 males, 4 females; mean age, 29 months; median age, 23.5 months). Group B comprised 26 patients (2 males, 24 females; mean age, 41 months; median age, 31.5 months). In Group A, three patients were diagnosed with a perforated CC preoperatively based on the presence of a massive fluid collection in the abdomen viewed on computed tomography (CT). Intraoperative findings included bile ascites and perforation of the anterior or right wall. Two patients had perforation of the posterior wall, with biliary edema in the retroperitoneum that was revealed during surgery. Preoperative CT showed that the retroperitoneum was edematous. One patient presented with sharp abdominal pain on the day of the scheduled surgery. Surgery revealed a perforated anterior wall and bile ascites. Only one patient had pan-peritonitis. No patients were in shock (which was defined as a decline in blood pressure due to
654
G. Ohba et al. / Journal of Pediatric Surgery 53 (2018) 653–655
Table 1 Patients' background characteristics.
Age (months) Male:female Comorbidities Prenatal diagnosis Todani classification [16] Preoperative white blood cell count (/μl) Preoperative C-reactive protein (mg/dl) Preoperative serum amylase (IU/l)
Group A (perforated) (n = 6)
Group B (non-perforated) (n = 26)
P value
29 (13–61) (median, 23.5) 2:4 0 0 Type I (n = 4) Type IVa (n = 2) 11,618 (6830–19,380) 3.50 (0.12–7.28) 166 (34–275)
41 (0–131) (median, 31.5) 2:24 0 2 Type I (n = 18) Type IVa (n = 8) 9357 (4310–15,220) 0.31 (0.01–2.60) 326 (7–1358)
.21
.09 .00* .17
Data are presented as mean (range), median or the number of patients. *P b .01.
circulatory failure). All patients underwent single-stage complete excision with Roux-en-Y hepaticojejunostomy. The patients' characteristics are summarized in Table 1. No significant differences in background characteristics were noted between the two groups except for the C-reactive protein concentration, which was significantly elevated in both groups (Group A: 3.50 mg/dl; Group B: 0.31 mg/dl). Table 2 shows the outcome data for the two groups. The mean operation time was 268 min in Group A and 249 min in Group B, without a significant difference. There were also no significant differences in bleeding, full feeding day, the drainage or serum amylase concentration on postoperative day 3, drainage period, or length of stay. There were no operative deaths or complications such as anastomotic leak or surgical site infection, but a pancreatic fistula developed in one patient in Group A and in two patients in Group B. The patient in Group A, who presented with sharp abdominal pain on the scheduled day of surgery, had a pancreatic leak. (This was not the patient with pan-peritonitis.) We quantified the incidence of pancreatic fistula, defined as any measurable output at or after postoperative day 3 from an operatively placed drain with an amylase content greater than three times the upper normal serum concentration (477 U/L), according to the International Study Group on Pancreatic Fistula definition [8]. All fistulas were grade A and treated conservatively. Pancreatitis was diagnosed when more than two of the following signs were present: a documented episode of epigastralgia, hyperamylasemia, and abnormal findings associated with pancreatitis on computed tomography or ultrasonography. Postoperative pancreatitis was observed one case in Group B and treated conservatively.
3. Discussion To the best of our knowledge, this study is the first to compare the complications and short-term outcomes of single-stage excision of perforated and non-perforated CCs. No significant differences in the clinical outcomes during the perioperative period were observed between the two groups. The advantages of performing a single radical operation include the need for only one operation and the potential cost-effectiveness [6]. It has been reported, however, that such an operation could be difficult to perform during emergency exploratory laparotomy because of the presence of severe inflammation and the potential disruption of the anastomosis during the primary closure [6]. Two-stage surgeries, which may include simple drainage, cholecystostomy [9,10], patch closure [11], and T-tube drainage [4], are considered safer because of the lower risk of disrupting the anastomosis. Nevertheless, two operations are required [6]. An advantage of the single-stage operation is that it has been reported safe for most perforated CCs in children [12]. Controversy exists over whether to plan a single- or two-stage surgery [4,6,7]; this is likely similar to the controversy in cases of acute cholecystitis. Early cholecystectomy following drainage or emergency cholecystectomy is reportedly a treatment option for acute cholecystitis [13,14]. A postoperative pancreatic fistula developed in three patients. All patients were treated conservatively. We speculate that these patients developed capillary leakage from the raw pancreatic surface secondary to intraoperative abrasion of the pancreatic capsule, resulting in a transient but slight elevation of the pancreatic enzymes in the drainage. Because there was no significant difference between the two groups, the
Table 2 Characteristics and perioperative courses of Groups A and B.
Operative time (min) Bleeding (ml) Perforation site Anterior wall Right wall Posterior wall Full feeding day Serum amylase on postoperative day 3 (IU/l) Drainage amylase on postoperative day 3 (IU/l) Drainage period (days) Length of hospitalization (days) Postoperative complications
Group A (perforated) (n = 6)
Group B (non-perforated) (n = 26)
P
268 (190–320) 51 (0–180)
249 (175–398) 49 (0–329)
.23 .47
7.8 (4–29) 186 (9–1066) (median, 86) 1945 (4–34,900) (median, 56) 6.9 (4–24) 12.8 (7–40) 3 (11%) Pancreatic fistula (n = 2) Pancreatitis (n = 1)
.23 .12
2 2 2 6 (5–7) 59 (38–122) (median, 78) 255 (27–996) (median, 162) 7.5 (7–9) 11.3 (9–14) 1 (16%) Pancreatic fistula (n = 1)
Data are presented as mean (range) unless otherwise indicated. Full feeding day = the postoperative day on which the patients returned to their normal diet.
.30 .37 .32 .60
G. Ohba et al. / Journal of Pediatric Surgery 53 (2018) 653–655
occurrence of the pancreatic fistulas was considered unrelated to whether the cyst was perforated or non-perforated. A single-stage operation is considered to have a risk of anastomotic disruption [6]; however, there were no cases of anastomotic leakage in our study. The diagnosis of CC perforation is difficult [15]. Bile peritonitis is usually characterized by sterile chemical inflammation and therefore may not create signs similar to those associated with bacterial peritonitis [9]. Because of this characteristic, the abdominal signs and symptoms are nonspecific. Only one patient had pan-peritonitis, and none was in shock in our study. If a patient is in shock, it is necessary to complete the operation in the shortest time possible; in such cases, a two-stage operation is preferred. However, for patients who were not in shock, no differences in perioperative complications were observed in this study. If the patient's condition is stable, a single-stage operation for a perforated CC is a safe procedure. This study was limited by the small number of patients. Furthermore, we evaluated only short-term complications; it is also necessary to evaluate long-term complications such as malignancy or the formation of stones. Further accumulation of cases is expected in the future.
4. Conclusion A single-stage operation for a perforated CC is feasible if the patient's condition is stable.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
655
References [1] Yamaguchi M. Congenital choledochal cyst. Analysis of 1,433 patients in the Japanese literature. Am J Surg 1980;140:653–7. [2] Tan KC, Howard ER. Choledochal cyst: a 14-year surgical experience with 36 patients. Br J Surg 1988;75:892–5. [3] Howard ER, Johnston DI, Mowat AP. Spontaneous perforation of common bile duct in infants. Arch Dis Child 1976;51:883–6. [4] Ando H, Ito T, Watanabe Y, et al. Spontaneous perforation of choledochal cyst. J Am Coll Surg 1995;181:125–8. [5] Moore TC. Massive bile pertonitis in infancy due to spontaneous bile duct perforation with portal vein occlusion. J Pediatr Surg 1975;10:537–40. [6] Minagawa T, Dowaki S, Kikunaga H, et al. Endoscopic biliary drainage as a bridging procedure to single-stage surgery for perforated choledochal cyst: a case report and review of the literature. Surg Case Rep 2015;1:117. [7] Franga DL, Howell CG, Mellinger JD, et al. Single-stage reconstruction of perforated choledochal cyst: case report and review of the literature. Am Surg 2005;71: 398–401. [8] Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8–13. [9] Chiang L, Chui CH, Low Y, et al. Perforation: a rare complication of choledochal cysts in children. Pediatr Surg Int 2011;27:823–7. [10] Yamoto M, Urushihara N, Fukumoto K, et al. Usefulness of laparoscopic cholecystostomy in children with complicated choledochal cyst. Asian J Endosc Surg 2015;8:153–7. [11] Dunn DC, Lees VC. Spontaneous perforation of the common bile duct in infancy. Br J Surg 1986;73:929. [12] Ngoc Son T, Thanh Liem N, Manh Hoan V. One-staged or two-staged surgery for perforated choledochal cyst with bile peritonitis in children? A single center experience with 27 cases. Pediatr Surg Int 2014;30:287–90. [13] El-Gendi A, El-Shafei M, Emara D. Emergency versus delayed cholecystectomy after percutaneous Transhepatic gallbladder drainage in grade II acute Cholecystitis patients. J Gastrointest Surg 2017;21:284–93. [14] Amirthalingam V, Low JK, Woon W, et al. Tokyo guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too. Surg Endosc 2016;31:2892–900. [15] Ando K, Miyano T, Kohno S, et al. Spontaneous perforation of choledochal cyst: a study of 13 cases. Eur J Pediatr Surg 1988;8:23–5. [16] Todani T, Watanabe Y, Mizuguchi T, et al. Hepaticoduodenostomy at the hepatic hilum after excision of choledochal cyst. Am J Surg 1981;142:584–7.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Single-stage operation for perforated choledochal cyst Go Ohba a,⁎, Hiroshi Yamamoto a, Masato Nakayama a, Shohei Honda b, Akinobu Taketomi b a b
Department of Surgery, Tenshi Hospital, North 12 East 3-1-1, Higashi-ku, Sapporo 065-8611, Japan Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo 060-8638, Japan
a r t i c l e
i n f o
Article history: Received 14 March 2017 Received in revised form 14 June 2017 Accepted 15 July 2017 Key words: Choledochal cyst Perforation
a b s t r a c t Background: The option of either single- or two-staged cyst excision has been proposed for perforated choledochal cysts (CCs), but which of the two methods is more effective remains controversial. We examined the complications and short-term outcomes of single-stage excision of perforated and non-perforated CCs. Methods: The medical records of patients treated for CCs from 2003 to 2016 were retrospectively reviewed. Outcomes were compared between patients with perforated CCs (Group A) and non-perforated CCs (Group B). The operative time, intraoperative bleeding, length of stay, and postoperative complications were analyzed. Results: Group A comprised 6 patients (2 males, 4 females; mean age, 29 months), and Group B comprised 26 patients (2 males, 24 females; mean age, 41 months). All patients underwent single-stage complete excision with Roux-en-Y hepaticojejunostomy. There were no significant differences in the operative time, bleeding, and/or length of stay. There were no operative deaths or complications such as anastomosis leakage or postoperative cholangitis, but a pancreatic fistula developed in one patient in Group A and two in Group B. Conclusion: Single-stage excision for a perforated CC is feasible if the patient's condition is stable. Levels of evidence: Treatment Study, LEVELIII. © 2017 Elsevier Inc. All rights reserved.
Perforation of a choledochal cyst (CC) is extremely rare, with a reported frequency ranging from 1.8% to 2.8% [1,2]. The pathogenesis of spontaneous perforation has not been established, but proposed mechanisms include reflux of pancreatic secretions [3], increased intraluminal pressure due to protein plugs [4], and viral infection [5]. The option of either single- or two-staged cyst excision has been proposed for perforated CCs, but the more effective method of the two remains controversial [4,6,7]. In this study, we evaluated the complications and short-term outcomes of single-stage excision of CCs, including perforated CCs, to determine the best approach to treating perforated CCs.
1. Materials and methods The medical records of patients treated for CCs from 2003 to 2016 were retrospectively reviewed. We covered all cases from 2003, when we began to perform pediatric surgery in our hospital, up to 2016. The children comprising the study group were those who had presented with either a plain CC or a perforated CC that was treated during the study period, with no exclusions. The following outcomes were Abbreviation: CC, choledochal cyst. ⁎ Corresponding author. Tel.: +81 11 711 0101; fax: +81 11 751 1708. E-mail addresses: [email protected] (G. Ohba), [email protected] (H. Yamamoto), [email protected] (M. Nakayama), [email protected] (S. Honda). http://dx.doi.org/10.1016/j.jpedsurg.2017.07.014 0022-3468/© 2017 Elsevier Inc. All rights reserved.
compared between patients with perforated CCs (Group A) and those with non-perforated CCs (Group B): operative time, intraoperative bleeding, length of hospital stay, full feeding day (i.e., the postoperative day on which the patients returned to their normal diet), and postoperative complications. All operations were performed in the same institution, and the surgeons had N10 years of clinical experience. SPSS version 19.0 for Windows was used to create a database and perform statistical analyses. Data were analyzed using Student's t test. P b .01 was considered statistically significant. 2. Results Group A comprised 6 patients (2 males, 4 females; mean age, 29 months; median age, 23.5 months). Group B comprised 26 patients (2 males, 24 females; mean age, 41 months; median age, 31.5 months). In Group A, three patients were diagnosed with a perforated CC preoperatively based on the presence of a massive fluid collection in the abdomen viewed on computed tomography (CT). Intraoperative findings included bile ascites and perforation of the anterior or right wall. Two patients had perforation of the posterior wall, with biliary edema in the retroperitoneum that was revealed during surgery. Preoperative CT showed that the retroperitoneum was edematous. One patient presented with sharp abdominal pain on the day of the scheduled surgery. Surgery revealed a perforated anterior wall and bile ascites. Only one patient had pan-peritonitis. No patients were in shock (which was defined as a decline in blood pressure due to
654
G. Ohba et al. / Journal of Pediatric Surgery 53 (2018) 653–655
Table 1 Patients' background characteristics.
Age (months) Male:female Comorbidities Prenatal diagnosis Todani classification [16] Preoperative white blood cell count (/μl) Preoperative C-reactive protein (mg/dl) Preoperative serum amylase (IU/l)
Group A (perforated) (n = 6)
Group B (non-perforated) (n = 26)
P value
29 (13–61) (median, 23.5) 2:4 0 0 Type I (n = 4) Type IVa (n = 2) 11,618 (6830–19,380) 3.50 (0.12–7.28) 166 (34–275)
41 (0–131) (median, 31.5) 2:24 0 2 Type I (n = 18) Type IVa (n = 8) 9357 (4310–15,220) 0.31 (0.01–2.60) 326 (7–1358)
.21
.09 .00* .17
Data are presented as mean (range), median or the number of patients. *P b .01.
circulatory failure). All patients underwent single-stage complete excision with Roux-en-Y hepaticojejunostomy. The patients' characteristics are summarized in Table 1. No significant differences in background characteristics were noted between the two groups except for the C-reactive protein concentration, which was significantly elevated in both groups (Group A: 3.50 mg/dl; Group B: 0.31 mg/dl). Table 2 shows the outcome data for the two groups. The mean operation time was 268 min in Group A and 249 min in Group B, without a significant difference. There were also no significant differences in bleeding, full feeding day, the drainage or serum amylase concentration on postoperative day 3, drainage period, or length of stay. There were no operative deaths or complications such as anastomotic leak or surgical site infection, but a pancreatic fistula developed in one patient in Group A and in two patients in Group B. The patient in Group A, who presented with sharp abdominal pain on the scheduled day of surgery, had a pancreatic leak. (This was not the patient with pan-peritonitis.) We quantified the incidence of pancreatic fistula, defined as any measurable output at or after postoperative day 3 from an operatively placed drain with an amylase content greater than three times the upper normal serum concentration (477 U/L), according to the International Study Group on Pancreatic Fistula definition [8]. All fistulas were grade A and treated conservatively. Pancreatitis was diagnosed when more than two of the following signs were present: a documented episode of epigastralgia, hyperamylasemia, and abnormal findings associated with pancreatitis on computed tomography or ultrasonography. Postoperative pancreatitis was observed one case in Group B and treated conservatively.
3. Discussion To the best of our knowledge, this study is the first to compare the complications and short-term outcomes of single-stage excision of perforated and non-perforated CCs. No significant differences in the clinical outcomes during the perioperative period were observed between the two groups. The advantages of performing a single radical operation include the need for only one operation and the potential cost-effectiveness [6]. It has been reported, however, that such an operation could be difficult to perform during emergency exploratory laparotomy because of the presence of severe inflammation and the potential disruption of the anastomosis during the primary closure [6]. Two-stage surgeries, which may include simple drainage, cholecystostomy [9,10], patch closure [11], and T-tube drainage [4], are considered safer because of the lower risk of disrupting the anastomosis. Nevertheless, two operations are required [6]. An advantage of the single-stage operation is that it has been reported safe for most perforated CCs in children [12]. Controversy exists over whether to plan a single- or two-stage surgery [4,6,7]; this is likely similar to the controversy in cases of acute cholecystitis. Early cholecystectomy following drainage or emergency cholecystectomy is reportedly a treatment option for acute cholecystitis [13,14]. A postoperative pancreatic fistula developed in three patients. All patients were treated conservatively. We speculate that these patients developed capillary leakage from the raw pancreatic surface secondary to intraoperative abrasion of the pancreatic capsule, resulting in a transient but slight elevation of the pancreatic enzymes in the drainage. Because there was no significant difference between the two groups, the
Table 2 Characteristics and perioperative courses of Groups A and B.
Operative time (min) Bleeding (ml) Perforation site Anterior wall Right wall Posterior wall Full feeding day Serum amylase on postoperative day 3 (IU/l) Drainage amylase on postoperative day 3 (IU/l) Drainage period (days) Length of hospitalization (days) Postoperative complications
Group A (perforated) (n = 6)
Group B (non-perforated) (n = 26)
P
268 (190–320) 51 (0–180)
249 (175–398) 49 (0–329)
.23 .47
7.8 (4–29) 186 (9–1066) (median, 86) 1945 (4–34,900) (median, 56) 6.9 (4–24) 12.8 (7–40) 3 (11%) Pancreatic fistula (n = 2) Pancreatitis (n = 1)
.23 .12
2 2 2 6 (5–7) 59 (38–122) (median, 78) 255 (27–996) (median, 162) 7.5 (7–9) 11.3 (9–14) 1 (16%) Pancreatic fistula (n = 1)
Data are presented as mean (range) unless otherwise indicated. Full feeding day = the postoperative day on which the patients returned to their normal diet.
.30 .37 .32 .60
G. Ohba et al. / Journal of Pediatric Surgery 53 (2018) 653–655
occurrence of the pancreatic fistulas was considered unrelated to whether the cyst was perforated or non-perforated. A single-stage operation is considered to have a risk of anastomotic disruption [6]; however, there were no cases of anastomotic leakage in our study. The diagnosis of CC perforation is difficult [15]. Bile peritonitis is usually characterized by sterile chemical inflammation and therefore may not create signs similar to those associated with bacterial peritonitis [9]. Because of this characteristic, the abdominal signs and symptoms are nonspecific. Only one patient had pan-peritonitis, and none was in shock in our study. If a patient is in shock, it is necessary to complete the operation in the shortest time possible; in such cases, a two-stage operation is preferred. However, for patients who were not in shock, no differences in perioperative complications were observed in this study. If the patient's condition is stable, a single-stage operation for a perforated CC is a safe procedure. This study was limited by the small number of patients. Furthermore, we evaluated only short-term complications; it is also necessary to evaluate long-term complications such as malignancy or the formation of stones. Further accumulation of cases is expected in the future.
4. Conclusion A single-stage operation for a perforated CC is feasible if the patient's condition is stable.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
655
References [1] Yamaguchi M. Congenital choledochal cyst. Analysis of 1,433 patients in the Japanese literature. Am J Surg 1980;140:653–7. [2] Tan KC, Howard ER. Choledochal cyst: a 14-year surgical experience with 36 patients. Br J Surg 1988;75:892–5. [3] Howard ER, Johnston DI, Mowat AP. Spontaneous perforation of common bile duct in infants. Arch Dis Child 1976;51:883–6. [4] Ando H, Ito T, Watanabe Y, et al. Spontaneous perforation of choledochal cyst. J Am Coll Surg 1995;181:125–8. [5] Moore TC. Massive bile pertonitis in infancy due to spontaneous bile duct perforation with portal vein occlusion. J Pediatr Surg 1975;10:537–40. [6] Minagawa T, Dowaki S, Kikunaga H, et al. Endoscopic biliary drainage as a bridging procedure to single-stage surgery for perforated choledochal cyst: a case report and review of the literature. Surg Case Rep 2015;1:117. [7] Franga DL, Howell CG, Mellinger JD, et al. Single-stage reconstruction of perforated choledochal cyst: case report and review of the literature. Am Surg 2005;71: 398–401. [8] Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8–13. [9] Chiang L, Chui CH, Low Y, et al. Perforation: a rare complication of choledochal cysts in children. Pediatr Surg Int 2011;27:823–7. [10] Yamoto M, Urushihara N, Fukumoto K, et al. Usefulness of laparoscopic cholecystostomy in children with complicated choledochal cyst. Asian J Endosc Surg 2015;8:153–7. [11] Dunn DC, Lees VC. Spontaneous perforation of the common bile duct in infancy. Br J Surg 1986;73:929. [12] Ngoc Son T, Thanh Liem N, Manh Hoan V. One-staged or two-staged surgery for perforated choledochal cyst with bile peritonitis in children? A single center experience with 27 cases. Pediatr Surg Int 2014;30:287–90. [13] El-Gendi A, El-Shafei M, Emara D. Emergency versus delayed cholecystectomy after percutaneous Transhepatic gallbladder drainage in grade II acute Cholecystitis patients. J Gastrointest Surg 2017;21:284–93. [14] Amirthalingam V, Low JK, Woon W, et al. Tokyo guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too. Surg Endosc 2016;31:2892–900. [15] Ando K, Miyano T, Kohno S, et al. Spontaneous perforation of choledochal cyst: a study of 13 cases. Eur J Pediatr Surg 1988;8:23–5. [16] Todani T, Watanabe Y, Mizuguchi T, et al. Hepaticoduodenostomy at the hepatic hilum after excision of choledochal cyst. Am J Surg 1981;142:584–7.