Characteristics and outcomes of minimally invasive surgery for congenital biliary dilatation in children aged <6 years: Comparison between children and adults
Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
Abstract
Background/Purpose
We evaluated the minimally invasive surgery for congenital biliary dilatation (CBD) in adults and children and analyzed the surgical outcomes, especially in children aged <6 years.
Methods
Characteristics and surgical outcomes of patients with CBD who underwent minimally invasive surgery at our hospital between 2013 and 2023 were retrospectively reviewed.
Results
Overall, 129 patients (89 children aged <6 years, 9 children aged between 6 and 18 years, and 21 adults) were included in this study. Children exhibited more protein plug presence and abnormal biochemical data than adults. Incidence of postoperative pancreatic fistulas was highest in the adult group (3.4%, 11%, and 33%, respectively, p < .01). In children aged <6 years, postoperative bile leakage and pancreatic fistulas occurred in 9.0% and 3.4% of patients, respectively. Multivariate logistic regression analysis revealed that the Todani IVA was associated with a decrease in postoperative bile leakage (odds ratio: −1.7; 95% confidence interval: (−3.3)–(−0.22), p = .03).
Conclusion
Adults with CBD required prolonged operative times and had more short‐term complications than children with CBD. In children aged <6 years, minimally invasive surgery for CBD can be safely performed; however, a small diameter of the bile duct may be associated with bile leakage.
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Keywords: adult, child, choledochal cyst, minimally invasive surgery, pancreaticobiliary maljunction
Short abstract
Nakagawa and colleagues found that minimally invasive surgery for congenital biliary dilatation resulted in longer operative times and more short‐term complications, especially pancreatic fistula, in adults than in children. While the procedure is safe in children under age 6, a small bile duct diameter may be associated with bile leakage.
Article notes
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Issue date 2024 Dec.
1.INTRODUCTION
Congenital biliary dilatation (CBD) is characterized by pancreaticobiliary maljunction (PBM) and abnormal dilatation of the bile duct 1 ; however, its pathogenesis remains unknown. This condition can cause various complications, including malignant tumors. 2 , 3 Patients with CBD often present with intermittent symptoms, including abdominal pain, vomiting, and jaundice, due to protein plugs, 4 most of which are composed of lithostathine. 5 Most plugs are fragile and disappear spontaneously, which explains why patients with CBD present this condition later in life. 5 However, not all patients present with symptoms, and some are incidentally diagnosed with CBD based on laboratory data and/or medical checkups.
Generally, children with CBD are treated in pediatric surgery departments, whereas adults with CBD are treated in general surgical departments. Few studies have discussed the symptoms and surgical outcomes of CBD in adults and children who underwent the same surgical procedure at a single institution. 6 Since 2013, laparoscopic CBD surgery has been the standard procedure at our institution, 7 and robotic CBD surgery has been gradually replaced by laparoscopic surgery since April 2021. 8 Our institution has presented various techniques and knowledge regarding CBD to reduce postoperative complications, mainly in children. 4 , 5 , 9 , 10 , 11 , 12 Recently, we have performed minimally invasive surgery (MIS) for CBD in adults and children to prevent long‐term complications by checking and treating hilar bile duct stenosis (HBDS). 7 , 13 , 14 , 15 , 16 The clinical manifestations and prognosis of CBD differ between adults and children 6 ; however, the evidence is still lacking. We aimed to compare the characteristics and surgical outcomes of CBD among adults, children aged <6 years, and children aged ≥6 years to appropriately manage the disease. In addition, MIS for the CBD, especially in children aged <6 years, was evaluated.
2.METHODS
We retrospectively reviewed the symptoms, biochemical data, preoperative imaging findings, and surgical and medical records of patients who underwent MIS for CBD at Nagoya University Hospital between September 2013 and September 2023. Laparoscopic CBD surgery was started at our hospital in September 2013, and since September 2021, robotic CBD surgery has been selected in all cases, except for emergency cases such as perforation.
2.1.Preoperative examination and assessment
In all patients, anatomical variations in the hepatic artery and portal vein and the presence of HBDS were assessed using computed tomography and magnetic resonance cholangiopancreatography (MRCP), 14 , 17 respectively. As adult patients with CBD may have malignancy, endoscopic retrograde cholangiopancreatography (ERCP) with cytology and/or endoscopic ultrasonography was used to exclude malignancy in adults. We performed MIS for CBD in children and adults without malignancy.
2.2.Surgical technique
Patients were placed in the supine lithotomy position under general anesthesia. Laparoscopic 14 and robotic procedures 8 were performed as previously described.
In laparoscopic surgery, a multichannel port with two 5‐mm ports was inserted following an umbilical Benz incision. Subsequently, two 5‐mm ports were inserted into the right and upper left abdomens as working ports. The other 3‐mm port was inserted into the upper right abdomen as an assistant port.
Robotic surgery was performed using the da Vinci Surgical System Xi employing 4 + 1 ports in patients weighing >40 kg or 3 + 1 ports in patients weighing ≤40 kg. Of the five ports, an 8‐mm three‐dimensional camera port was inserted at the umbilicus, and the other two 8‐mm ports were inserted at the left‐ and right‐side robotic operating ports. A 12‐mm assistant port was placed in the left lower abdomen. For the four ports, a Benz incision was made in the umbilicus, and a multichannel port with an 8‐mm three‐dimensional camera port was inserted. In addition, two 8‐mm ports were inserted on either side of the abdomen. A 5‐mm assistant port was inserted into the left lower abdomen.
The distal end of the common biliary duct was traced until it converged with the pancreatic duct. After the remnant intrapancreatic bile duct was reduced, it was ligated and dissected. To investigate the presence of HBDS, the proximal side of the common bile duct was incised in the hilar region. We carefully observed and checked for as much narrowing as possible up to the secondary branch by inserting a hook into the bile duct and trying to see if it was caught. If HBDS was present, the HBDS‐causing membrane or septum was resected using scissors or hook radiofrequency cautery. To prevent scar stenosis, the resection site was sutured with 6–0 or 5–0 absorbable monofilaments. Finally, hepaticojejunostomy was performed. In patients with narrow anastomoses, the incision was extended along the lateral wall of the hepatic duct to widen the anastomosis. 18
2.3.Data collection
The symptoms presented by the patients were reviewed using the patients' charts. Since infants and some children do not complain of abdominal pain, symptoms include vomiting and jaundice. Patient details, including age, sex, height, and weight at surgery, were collected. Biochemical data, including liver function tests (LFTs) and pancreatic enzyme and direct bilirubin levels, were evaluated at the time of symptom onset and/or outpatient consultation. Imaging data such as computed tomography, MRCP, ERCP, endoscopic ultrasonography, operative cholangiography, Todani classification, and PBM classification (Figure 1) 19 were used to evaluate the maximum diameter of the extrahepatic bile duct and the presence of a protein plug.
2.4.Primary purpose: Assessment of characteristics and surgical outcomes in adults and children
Patients aged ≥18 years were classified as adults. Patient characteristics and surgical outcomes were compared among the adult, children aged <6 years, and children aged ≥6 years group. The explanatory variables included the surgical approach, presence of HBDS, bile duct plasty, operation time, blood loss, timing of enteral nutrition, timing of drain tube removal, and timing of hospitalization after surgery. Short‐term complications within 30 days were compared among the three groups. Pancreatitis and cholangitis were defined as elevated serum pancreatic enzyme levels and LFTs, respectively. Bile leakage was defined as bilirubin concentration in the drain fluid at least three times the serum bilirubin concentration on or after postoperative day 3 or as the need for radiological or operative intervention resulting from biliary collections or bile peritonitis. 20 A pancreatic fistula was defined as the drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of the institutional normal serum amylase activity associated with a clinically relevant development/condition directly related to postoperative pancreatic fistula. 21 Clavien–Dindo (CD) ≥ IIa were included. 22
2.5.Secondary purpose: Evaluation of MIS for CBD in especially young children aged <6 years
Surgical outcomes in patients aged <6 years were evaluated. Laparoscopic‐ and robot‐assisted approaches were compared in these patients. Risk factors for postoperative complications were evaluated using multivariate logistic regression analysis.
2.6.Statistical analysis
Continuous variables are expressed as medians (interquartile ranges). The Mann–Whitney U‐test and Kruskal‐Wallis rank sum test were used to compare two and three continuous variables, respectively. Fisher's exact test was used to analyze the differences between discrete variables. Factors contributing to postoperative complications were analyzed using multivariate logistic regression analysis. Statistical significance was set at p < .05. All statistical analyses were performed using R software 4.2.2. 23
2.7.Ethical approval and informed consent
This study was approved by the Institutional Review Board of Nagoya Graduate School of Medicine (approval no. 2022–0221). This study was conducted in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. As this was a retrospective study, patients were not required to provide informed consent because the analysis used anonymous clinical data obtained after each patient agreed to the treatment by submitting written informed consent. We applied an opt‐out method to obtain consent for this study, which was approved by the Institutional Review Board of Nagoya University Graduate School of Medicine.
3.RESULTS
Overall, 129 patients with CBD underwent primary surgery at our institution during the study period. All patients underwent MIS bile duct resection and hepaticojejunostomy (laparoscopy, 99 patients; robot‐assisted surgery, 30 patients). Tables 1 and 2 show a comparison of patient details, diagnoses, and surgical outcomes among the adult, children aged <6 years, and children aged ≥6 years group. Table 3 shows a comparison of the surgical outcomes between laparoscopy and robot‐assisted surgery in children aged <6 years. Table 4 shows the multivariate logistic regression analysis of postoperative complications in children aged <6 years.
| Children aged <6 years (n = 89) a | Children aged ≥6 years (n = 19) a | Adult (n = 21) a | p‐value b | |
|---|---|---|---|---|
| Symptom | ||||
| Prenatal diagnosis | 16 (18%) | 0 (0%) | 0 (0%) | <.01 |
| Vomiting | 46 (52%) | 9 (47%) | 2 (9.5%) | <.01 |
| Jaundice | 10 (11%) | 0 (0%) | 0 (0%) | .13 |
| No symptoms (incidental found) | 4 (4.5%) | 1 (5.3%) | 9 (33%) | <.01 |
| Background | ||||
| Age (year) | 2 (0–3) | 9 (8–13) | 28 (24–41) | <.01 |
| Sex female | 62 (70%) | 14 (74%) | 15 (71%) | >.9 |
| Height (cm) | 84 (72–97) | 130 (127–153) | 159 (154–166) | <.01 |
| Bodyweight (kg) | 11 (8–14) | 29 (24–51) | 51 (48–58) | <.01 |
| Laboratory data | ||||
| LFTs elevation | 69 (78%) | 10 (53%) | 3 (14%) | <.01 |
| Pancreatic enzyme elevation | 52 (58%) | 5 (26%) | 4 (19%) | .01 |
| Direct bilirubin elevation | 44 (49%) | 4 (21%) | 1 (4.8%) | <.01 |
| Imaging | ||||
| Todani class | <.01 | |||
| Type IVA | 66 (74%) | 11 (58%) | 6 (29%) | |
| Type IA | 20 (22%) | 5 (26%) | 9 (43%) | |
| Type IC | 3 (3.4%) | 3 (16%) | 6 (29%) | |
| PBM type | .9 | |||
| Type A | 48 (54%) | 15 (79%) | 15 (71%) | |
| Type B | 19 (21%) | 3 (16%) | 3 (14%) | |
| Type C | 17 (19%) | 1 (5.3%) | 3 (14%) | |
| Type D | 1 (1.1%) | 0 (0%) | 0 (0%) | |
| Not evaluated | 4 (4.5%) | 0 (0%) | 0 (0%) | |
| Protein plug | 61 (69%) | 11 (58%) | 6 (29%) | <.01 |
| EHBD maximum diameter | 21 (12–33) | 32 (17–48) | 23 (15–35) | .8 |
| Children aged <6 years (n = 89) a | Children aged ≥6 years (n = 19) a | Adult (n = 21) a | p‐value b | |
|---|---|---|---|---|
| Surgery | ||||
| Approach (robotic assisted) | 15 (17%) | 3 (16%) c | 11 (52%) | <.01 |
| Presence of HBDS | 55 (62%) | 12 (63%) | 10 (48%) | .5 |
| Bile duct plasty | 59 (66%) | 12 (63%) | 10 (48%) | .3 |
| Outcomes | ||||
| Operation time (min) | 385 (337–438) | 464 (410–625) | 525 (445–617) | <.01 |
| Blood loss (mL/kg) | 2.7 (1.1–5.6) | 1.4 (0.6–3.3) | 1.1 (0.5–2.3) | .03 |
| Enteral nutrition (POD) | 4 (3–4) | 4 (4–5) | 3 (3–5) | .08 |
| Remove drain (POD) | 6 (5–7) | 6 (6–8) | 6 (5–8) | .8 |
| Hospitalization after surgery | 9 (8–12) | 9 (8–12) | 8 (8–14) | >.9 |
| Short‐term complication | ||||
| Bile leakage (≥CD IIa) | 8 (9.0%) | 1 (5.3%) | 1 (4.8%) | >.9 |
| ISGLS grade A | 2 (2.2%) | 0 (0%) | 0 (0%) | |
| ISGLS grade B | 5 (5.6%) | 1 (5.3%) | 1 (4.8%) | |
| ISGLS grade C | 1 (1.1%) | 0 (0%) | 0 (0%) | |
| Cholangitis and/or LFTs elevation (≥ CD IIa) | 1 (1.1%) | 0 (0%) | 3 (14%) | .06 |
| Pancreatitis and/or pancreatic enzyme elevation (≥CD IIa) | 0 (0%) | 0 (0%) | 1 (4.8%) | .07 |
| Pancreatic fistula (≥CD IIa) | 3 (3.4%) | 2 (11%) | 7 (33%) | <.01 |
| ISGPS grade B | 3 (3.4%) | 0 (0%) | 7 (33%) | |
| ISGPS grade C | 0 (0%) | 2 (11%) | 0 (0%) | |
| Readmission (within 30 days) | 4 (4.5%) | 0 (0%) | 5 (24%) | <.01 |
| Fever (CD IIa) (n = 1), obstruction (CD IIIb) (n = 2), enteritis (CD IIa) (n = 1) | Pancreatic fistula (CD IIIa) (n = 1), cholangitis (CD IIa) (n = 1), obstruction (CD IIa) (n = 1), roux limb dilatation (CD IIIb) (n = 1), fever (n = 1) | |||
| Overall (n = 89) a | Laparoscopy (n = 74) a | Robot‐assisted (n = 15) a | p‐value b | |
|---|---|---|---|---|
| Background | ||||
| Age (year) | 2 (0–3) | 2 (0–4) | 2 (1–3) | .6 |
| Female sex | 62 (70%) | 54 (73%) | 8 (53%) | .2 |
| Height (cm) | 84 (72–97) | 84 (69–96) | 84 (77–98) | .5 |
| Bodyweight (kg) | 11 (8.2–14.4) | 11.2 (7.7–12.8) | 11 (9.6–15.5) | .3 |
| Outcomes | ||||
| Operation time (min) | 385 (337–438) | 389 (336–446) | 381 (349–409) | .8 |
| Blood loss (mL/kg) | 2.7 (1.1–5.6) | 2.8 (1.1–5.9) | 1.6 (1.1–3.4) | .1 |
| Enteral nutrition (POD) | 4 (3–4) | 4 (3–5) | 3 (3–3) | <.01 |
| Remove drain (POD) | 6 (5–7) | 6 (6–7) | 5 (5–5) | <.01 |
| Hospitalization after surgery | 9 (8–12) | 10 (8–13) | 7 (7–8) | <.01 |
| Short‐term complication | 12 (11%) | 11 (15%) | 1 (6.7%) | .7 |
| Bile leakage (≥CD IIa) | 8 (9.0%) | 8 (11%) | 0 (0%) | .3 |
| ISGLS grade A | 2 (2.7%) | 0 (0%) | ||
| ISGLS grade B | 5 (6.8%) | 0 (0%) | ||
| ISGLS grade C | 1 (1.4%) | 0 (0%) | ||
| Cholangitis and/or LFTs elevation (≥CD IIa) | 1 (1.1%) | 1 (1.4%) | 0 (0%) | >.9 |
| Pancreatitis and/or pancreatic enzyme elevation (≥CD IIa) | 0 (0%) | 0 (0%) | 0 (0%) | >.9 |
| Pancreatic fistula (≥CD IIa) | 3 (3.4%) | 2 (2.7%) | 1 (6.7%) | .4 |
| ISGPS grade B | 2 (2.7%) | 1 (6.7%) | ||
| ISGPS grade C | 0 (0%) | 0 (0%) | ||
| Readmission (within 30 days) | 4 (4.5%) | 1 (1.4%) | 3 (20%) | .01 |
| Enteritis (CD IIa) (n = 1) | Fever (CD IIa) (n = 1), obstruction (CD IIIb) (n = 2) | |||
| Characteristic | Log (OR) | 95% CI | p‐value |
|---|---|---|---|
| Bodyweight (kg) | 0.02 | (−0.13)–0.17 | .8 |
| Todani class | |||
| Type IA | – | – | – |
| Type IC | 0.51 | (−3.2)–4.2 | .8 |
| Type IVA | −1.7 | (−3.3)–(−0.22) | .03 |
| PBM type | |||
| A | – | – | – |
| B | −0.81 | (−3.9)–1.3 | .5 |
| C | −18 | (−824)–90 | >.9 |
| D | −17 | – | >.9 |
| Nonevaluable | −18 | – | >.9 |
| Operation approach | |||
| Laparoscopy | – | – | – |
| Robot‐assisted | −0.35 | (−3.4)–1.7 | .8 |
3.1.Patients' details and surgical outcomes in the adult and child groups
Table 1 shows a comparison of the patients' symptoms, background, laboratory data, and imaging results. The adult group had fewest vomiting episodes (9.5%, 52%, and 47%, in the adult, children aged <6 years, and children aged ≥6 years, respectively, p < .01), and the number of asymptomatic patients was highest in the adult group (33%, 4.5%, and 5.3%, in the adult, children aged <6 years, and children aged ≥6 years, respectively, p < .01). The presence rate of protein plugs was lowest in the adult group (29%, 69%, and 58%, in the adult, children aged <6 years, children aged ≥6 years, respectively, p < .01). Abnormal biochemical data, including LFT pancreatic enzyme and direct bilirubin elevation, were less common in the adult group. The distribution of Todani classification was significantly different among the three groups (p < .01); however, the distribution of PBM type and maximum diameter of the extrahepatic bile duct were not different among the groups (p = .9 and .8, respectively).
Table 2 shows a comparison of the surgical outcomes among the adult, children aged <6 years, and children aged ≥6 years group. The robot‐assisted approach was most common in the adult group (52%, 17%, and 16%, in the adult, children aged <6 years, children aged ≥6 years, respectively). The frequency of HBDS with bile duct plasty was not significantly different among the three groups (p = .5 and .3, respectively). The operative time was longer in the following order: adult, children aged ≥6 years, and children aged <6 years. However, blood loss per bodyweight (kg) was higher in the following order: children aged <6 years, children aged >6 years, and adult. The number of days of starting enteral nutrition, drain removal, and hospitalization after surgery was not significantly different among the three groups (p = .08, .8, and >.9, respectively). In short‐term complications, bile leakage (≥CD IIa), pancreatitis and/or elevated pancreatic enzyme (≥CD IIa), and cholangitis and/or LFTs elevation (≥CD IIa) were not significantly different among the three groups (p > .9, .06, and .07, respectively). Pancreatic fistula (≥CD IIa) was highest in the adult group (p < .01). In addition, the rate of readmission within 30 d was highest in the adult group (24%, 4.5%, and 0%, in the adult, children aged <6 years, and children aged ≥6 years, respectively, p < .01).
3.2.Comparison of surgical outcomes between robot‐assisted and laparoscopy in children aged <6 years
Table 3 shows a comparison of the surgical outcomes between robot‐assisted and laparoscopic procedures in children aged <6 years. The operative time and blood loss per kg were not significantly different between the robot‐assisted and laparoscopic procedures. The number of days of starting enteral nutrition, drain removal, and hospitalization duration was longer in the laparoscopy group (enteral nutrition: 4 vs. 3, p < .01; drain removal: 6 vs. 5, p < .01; length of hospitalization: 10 vs. 7, p < .01). Regarding short‐term complications, bile leakage occurred in 11% and 0% of patients in the laparoscopy and robot‐assisted groups, respectively; however, the difference was not statistically significant. The incidences of pancreatic fistulas and cholangitis were also not significantly different between the groups. Readmission within 30 days of surgery was significantly higher in the robot‐assisted group than in the laparoscopy group (1.4% vs. 20%, p < .01).
Table 4 shows the results of the multivariate logistic regression analysis of short‐term complications in children aged <6 years. Bodyweight, Todani class, PBM type, and surgical approach were selected as the potential contributing factors. Multivariate logistic regression analysis showed that the Todani IVA was associated with a decrease in postoperative bile leakage (odds ratio: −1.7; 95% confidence interval: (−3.3)–(−0.22), p = .03).
4.DISCUSSION
In this study, adults with CBD complained of fewer vomiting episodes than child patients with CBD, and 33% of adult patients did not have any symptoms. Protein plug formation and abnormal biochemical parameters, including LFTs and levels of bilirubin and pancreatic enzymes, were lower in the adult group. Although the PBM type was not different among the three groups, the distribution of the Todani classification was significantly different among the three groups. In addition, the protein plugs differed significantly among the three groups.
Patients with CBD often present with intermittent symptoms due to protein plugs 4 and previous studies have reported that protein plug formation was 9.3%–40%. 4 , 19 This study revealed that protein plug formation was relatively high at 29%, 69%, and 58%, in the adult, children aged <6 years, and children aged ≥6 years, respectively. The presence of protein plug formation was checked in all images that patients underwent, including ultrasonography, MRCP, and ERCP. We predicted that adult patients with CBD would have less protein plug formation because their symptom occurrence was assumed to be less frequent than in children, suggesting less protein plug formation than in children with CBD. This study revealed that protein plug formation was lower in the adult group; however, the protein plug formation rate was 29%, which was not very low. The incidence rate of protein plugs in this study was high; however, a previous study reported that the incidence of protein plugs increased with age. 24 Considering the mechanism of protein plug formation, adults with CBD are expected to form protein plugs similar to those in children with the disease. These data suggest that adult patients with CBD can form a protein plug; however, it is fragile and easily resolves spontaneously. Even when the protein plug forms, it is assumed smoothly excreted into the duodenum. The distribution of the PBM type, which is associated with protein plug formation, 19 did not differ among the three groups; hence, symptom severity and timing were hypothesized to be associated with the Todani classification. This study suggested that Todani IVA caused symptoms early in life.
Regarding surgical outcomes, the operative time was longer, but blood loss per kg of bodyweight was lower in the adult group. Adult patients with CBD required a longer operation time than child patients with CBD because the dissection area during the operation was larger, and chronic inflammation caused stronger adhesion around the bile duct. Blood loss was expected to be higher in the adult group than in the child group but was unexpectedly lower. The reason for this unexpected result was unclear; however, it was assumed that blood loss included bile juice spills during surgery. Pancreatic fistulas and readmission within 30 days were highest in the adult group than in the other groups. Adult patients have higher postoperative morbidity and need to repeat procedures than child patients, 25 while a report showed that the incidence of major morbidity (CD ≥ IIIa) was similar in adults and children. 26 Postoperative cholangitis and/or LFTs elevation (5.4%–11.1% vs. 0%–2.2%) and postoperative pancreatitis (2.8%–3.5% vs. 0–0.7%) were higher in adults 26 , 27 than in children, and postoperative pancreatic fistulas occurred in 6%–8% of adults 28 , 29 and in 4% 29 of children. In this study, the postoperative cholangitis and/or LFT elevations were equivalent to those reported in previous studies. However, pancreatitis, especially pancreatic fistulas, occurred at a higher rate than that reported in previous studies. This high occurrence rate of postoperative pancreatic fistulas was considered to be due to the complete excision of the intrapancreatic portion of the common bile duct. Intrapancreatic bile duct remnants can cause pancreatitis via pancreatic stone formation; therefore, complete excision of the intrapancreatic portion of the bile duct is essential. 9 In this study, postoperative pancreatic fistulas occurred in 3.4% of the children aged <6 years, which was consistent with our previous report of postoperative pancreatic fistulas at 2.3% after laparoscopy and 6.7% after laparotomy using the same surgical concept. 7 The higher incidence of postoperative pancreatic fistulas in adults suggests that adult patients are more likely to develop pancreatic fistulas than child patients who underwent MIS CBD surgery. Immature pancreatic function likely prevented pancreatic fistulas in the child group. Pancreatic function is immature for the first 6–12 months of life owing to the inadequate secretion of lipase and bile acids. 30 Adult duodenal amylase levels are not reached until the age of 2–3 years. 30 This immaturity was assumed to be the cause of the low incidence of postoperative pancreatic fistulas in the child group. In contrast, the number of postoperative pancreatic fistulas in the adult group was quite high and severe in this study. The pancreatic function in children is immature; therefore, postoperative pancreatic fistula was potentially prevented. We hypothesized that the reason for pancreatic fistula in both adults and children was inflammation around the intrapancreatic portion of the bile duct. Although we dissected the intrapancreatic portion of the bile duct in adults and children in the same way, the higher rate of postoperative pancreatic fistulas in adults in this study may be due to our technique. Standard procedures need to be improved and performed carefully to prevent postoperative pancreatic fistulas. Cholangitis occurs more frequently in adults than in children. The mechanism of cholangitis is multifactorial, and cholestasis is a significant risk factor for postoperative cholangitis. 31 Previous studies have shown that cholangitis occurs more frequently in adults than children. 26 , 27 However, the reasons for the different rates of postoperative cholangitis between adults and children are not fully understood.
In children aged <6 years, short‐term complications were not significantly different between the laparoscopy and robot‐assisted groups; however, bile leakage occurred in 9% of cases and only in the laparoscopy group. This result suggests that robot‐assisted surgery anastomosed better than laparoscopy; however, a multivariate logistic regression analysis showed that only Todani type IVA was associated with a decrease in bile leakage and that the surgical approach was not related to the occurrence of short‐term complications. No clear data regarding differences in hepatic duct diameter among the Todani classifications are available; however, in our experience, Todani type IVA has a relatively wider hepatic duct diameter than the other types. A wider hepatic duct diameter at the site of anastomosis may be associated with reduced postoperative bile leakage.
Our study had a few limitations. This was a single‐center, retrospective study with a small sample size. Our results should be validated in multicenter studies with larger sample sizes. Second, PBM type classification was performed by doctors at our institution. The PBM type classification could differ among doctors, which may have influenced the results of this study. Third, this study did not focus on long‐term complications. As long‐term complications are essential for patients with CBD, these patients, especially adults, should be followed up in the future.
In conclusion, adult patients with CBD had relatively fewer symptoms without abnormal biochemical data than children, and 33% of the adult patients were asymptomatic. The incidence of protein plugs was lowest in the adult than in the other groups. The distribution of the Todani classification differed among the three groups and was assumed to be one of the causes of the later symptom onset. Adult patients with CBD required a prolonged operation time and had more short‐term complications than pediatric patients, such as pancreatic fistula and readmission. In children aged <6 years, MIS for the CBD can be safely performed; however, a small diameter of the bile duct may be associated with bile leakage.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest for this article.
ACKNOWLEDGMENTS
We would like to thank Editage (www.editage.jp) for the English language editing. YN was supported by the Nagoya University CIBoG WISE Program of MEXT.
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Nakagawa Y, Uchida H, Shirota C, Tainaka T, Makita S, Satomi M, et al. Characteristics and outcomes of minimally invasive surgery for congenital biliary dilatation in children aged <6 years: Comparison between children and adults. J Hepatobiliary Pancreat Sci. 2024;31:876–885. 10.1002/jhbp.12069
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