Laparoscopic/robotic embedding hepaticojejunostomy with FHDO for biliary tract malformations with a small-diameter
Jing-Feng Tang1, Meng-Xin Zhang2, Xi Zhang2
1Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
Insights
A modified hepaticojejunostomy technique involving flipping the hepatic duct outward (FHDO) is safe and effective for preventing postoperative anastomotic stricture in children with choledochal cysts (CC) or pancreaticobiliary maljunction (PBM). This approach shows promise for pediatric surgical outcomes.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Surgical Innovation
Background:
- Small hepatic duct opening is a key factor in postoperative anastomotic stricture (PAS) after bile duct or cyst excision in children.
- Choledochal cysts (CC) and non-dilated pancreaticobiliary maljunction (PBM) are common conditions requiring surgical intervention.
- Preventing PAS is crucial for favorable long-term outcomes in pediatric hepatobiliary surgery.
Purpose of the Study:
- To compare the efficacy of a modified hepaticojejunostomy (embedded hepaticojejunostomy with flipping the hepatic duct outward - FHDO) versus standard embedded hepaticojejunostomy in preventing PAS.
- To evaluate the safety and feasibility of the FHDO technique in pediatric patients with small hepatic duct openings.
- To analyze operative parameters and postoperative outcomes associated with both surgical techniques.
Main Methods:
- Retrospective study of pediatric patients (CC or non-dilated PBM) with small hepatic duct openings from January 2012 to July 2023.
- Comparison between standard embedded hepaticojejunostomy (30 patients) and modified hepaticojejunostomy with FHDO (55 patients).
- Laparoscopic and robotic approaches were utilized, with detailed comparison of clinical characteristics, operative parameters, and outcomes.
Main Results:
- No significant differences in patient demographics or portal bile duct diameter between groups.
- Modified anastomosis with FHDO had longer total operative and anastomosis times but comparable complications and hospital stays.
- Robotic surgery was associated with shorter anastomosis times compared to laparoscopic surgery in the modified group.
- PAS rates were low in both groups (1 in embedded, 0 in modified), suggesting comparable efficacy in preventing strictures.
Conclusions:
- Embedded hepaticojejunostomy with the FHDO technique is a safe and feasible option for pediatric patients with CC or non-dilated PBM and small hepatic ducts.
- The FHDO method demonstrates potential in preventing postoperative anastomotic stricture.
- Larger, multicenter studies with extended follow-up are recommended to validate these findings.
Background:
Small hepatic duct opening diameter is an important cause of postoperative anastomotic stricture (PAS) following excision of cyst or extrahepatic bile duct for children with choledochal cyst (CC) or non-dilated pancreaticobiliary maljunction (PBM). We compared an embedded hepaticojejunostomy with flipping the end of hepatic duct outward (FHDO; modified anastomosis) to embedded hepaticojejunostomy (embedded anastomosis) and evaluated its feasibility in preventing PAS.
Methods:
This retrospective study included CC or non-dilated PBM children with a small-diameter hepatic duct opening between January 2012 and July 2023. Further modified hepaticojejunostomy, comprising complete cyst or extrahepatic bile duct excision, mixed ductoplasty, embedding hepaticojejunostomy with FHDO, was performed via a laparoscopic or robotic approach. Clinical characteristics, operative parameters, and postoperative outcomes were compared.
Results:
Of the 85 patients, 39 patients had Todani type I, 23 cases had Todani type IVa cysts, and 23 cases had non-dilated PBM. Thirty patients underwent embedded anastomosis, and fifty-five underwent modified anastomosis. There were no significant differences in gender, age at operation, and diameter of portal bile duct between two groups. Total operative time (P < 0.001) and time for anastomosis (P = 0.034) were significantly longer in modified anastomosis group. Intraoperative blood loss, length of hospital stays, and intraoperative and postoperative complications were comparable between two groups. Time for anastomosis was significantly shorter with robotic surgery than with laparoscopic surgery in modified anastomosis group (P = 0.001). Further stratified analysis of patients with type I and type IVa CC revealed no significant difference in PAS rate between two groups, with one case of PAS in the embedded anastomosis group and no cases in the modified anastomosis group during follow-up.
Conclusions:
Embedded hepaticojejunostomy with FHDO method is safe and feasible in CC or non-dilated PBM children with a small-diameter portal bile duct. Further multicenter studies with larger samples and longer follow-up are needed to confirm these findings.
