A narrative review of the modern surgical management of pediatric choledochal cysts

Abstract

Choledochal cysts (CC) ae rare congenital dilations of the biliary tract that harbor lifelong malignancy risk. CC are treated with surgical excision and bilioenteric reconstruction. In the modern era, the surgical approach to pediatric patients has enjoyed significant innovation with regards to minimally invasive techniques. In this review, we discuss these advances, including laparoscopic, single-incision laparoscopic, and robotic strategies, with a focus on the clinical outcomes of patients undergoing these procedures. By presenting an overview of the technical pearls emphasized by pioneers of these procedures, we examine the benefits and limitations of various minimally invasive techniques and analyze the utility and effectiveness of laparoscopy and robotics in comparison to each other and open techniques. Additionally, we highlight the importance of surgeon experience and skill in the management of this rare pediatric disease and explore the significance of the surgical learning curve in minimally invasive approaches in the excision of CC. We discuss the challenge of achieving surgical competency along this learning curve, and present proposed strategies to improve skill sets in the face of low case volumes. Finally, the relative dearth of data discussing long-term follow-up in these patients is discussed, and additional research regarding outcomes, malignancy risk and surveillance, and quality of life is necessary to better understand this disease and the implications of its surgical management.

Choledochal Cyst: Clinical Features, Diagnosis and Treatment Perspectives

“…Medical treatment limits to the administration of antimicrobial therapy in case of cholangitis or supportive therapy in pancreatitis, trying to stabilize the patient prior to operative approach. If rupture of the cyst manifests, a drainage must be placed, pointing out the weirdness of these presentation [53].…”

“…Historically, drainage or cystenterostomy was the surgical management, but the high risk of malignant transformation and the recurrence of the symptoms demands aggressive surgical management as the overriding treatment [53,54].…”

“…[56,57]. Examination of the data regarding robotic CC excision is needed to determine the utility of this approach in children [53].…”

Modified single-port versus multiport laparoscopic choledochal cysts excision and Roux-en-Y hepaticojejunostomy: a retrospective comparative cohort study

“…Singleport laparoscopic surgery is a new technique in which the entire procedure is performed through an incision with a single port containing 3 or 4 small ports. The feasibility and safety of single-port laparoscopic CDC excision and Rouxen-Y hepaticoenterostomy (SPCH) have been confirmed in some case series (6)(7)(8)(9), and it has demonstrated cosmetic advantages, the likelihood of less pain, and a shorter recovery period due to the reduction of trocar sites (10). However, SPCH is a technically challenging procedure and requires the surgeon to have abundant experience with the traditional laparoscopic procedure; moreover, single-port operations usually last 30% longer than their traditional laparoscopic counterparts and are more likely to produce incision complications (11).…”

Case report: Severe hepatic fibrosis induced by chronic cholestasis of congenital biliary dilation treated by laparoscopic surgery after immunonutrition support– An infantile case

“…Type V is treated synonymously with Caroli disease, one of the so-called fibropolycystic diseases, but differs from congenital hepatic fibrosis in the thickness of the bile ducts that are damaged ( 10 , 11 ). Almost 80% of choledochal cysts (CCs) are now discovered prenatally or in infancy ( 12 ), but it has been reported that biliary cirrhosis rapidly progresses from the neonatal period to the infantile period in some cases of CBD ( 13 ). We herein report an infantile case of CBD that showed severe biliary cirrhosis at the diagnosis, which was treated by laparoscopic surgery.…”