Internal drainage by cyst-enterostomy or partial cyst excision was once considered the preferred surgical treatment for congenital bile duct cysts. However, its poor prognosis (frequent cholangitis, cholangiolithiasis, and even cholangiocarcinoma) confined its application severely [3
]. In recent years, total cyst excision is regarded a more ideal and reasonable treatment for this disease. Our previous study has also confirmed that the total cyst excision has better prognosis than single internal drainage [13
]. However, the optimal surgical treatment timing is still controversial.
Congenital bile duct cysts cause abnormal bile duct structure, which is the main factor for cholangiolithiasis and cholangiocarcinoma. The dilated bile ducts cause dilatation-stenosis-like biliary stricture, which subsequently leads to the abnormality of bile dynamics, causing cholestasis and then inducing biliary tract inflammation. In addition, cholestasis could further cause cholangitis and cholangiolithiasis [14
], and even cholangiocarcinoma after long-term inflammatory stimulation [15
]. The above evidence suggests that the longer the disease course is, the higher the morbidity of complications will be. This study also suggests that obvious discrepancy exists in cholangiolithiasis morbidity among three groups before the surgical treatment. Of all patients, eight suffer from advanced cholangiocarcinoma (the maturity = 7 and immaturity = 1), which did not arise in infancy. No significant difference was abserved among the three age groups, which may be explained by the limited period of observation.
At present, considering the growth and development of the patients and the surgical risks, most surgeons suggest that the infants should not undergo the surgical treatment until they have grown up. However, compared with the adults, the infants have advantages in receiving the surgery. For example, the infants have shorter disease course, which means much milder inflammation and less tissue adherence (Figure ), which subsequently reduce the probability of hemorrhage and tissue injury, thus lowering the risk of operation. In this study, we have confirmed that the intraoperative blood loss is significantly different (p < 0.05) among the three groups, and the infant group has the lowest loss. Similarly, our long-term follow-up data have shown that the postoperative complications are not significantly different among the three groups. The above evidence suggests that the optimal treatment timing for congenital biliary duct cyst is in infancy, which causes the lowest risk. However, our data have shown a significant difference in the postoperative complications among the three groups (p = 0.012 < 0.05), with the morbidity of postoperative complications in the immaturity and maturity groups significantly lower than in the infant group (p = 0.036 < 0.05). Three patients in the infant group have complications. However, these postoperative complications are not lifethreatening and unresolvable, and they may be due to the difficulty in the respiratory management of infants, indicating that preventing pulmonary infection is very important after total cyst excision in infants.
These gross images of the bile duct cyst specimen. (A) The image of the bile duct cyst in operation. (B) The specimen of the bile duct cyst.
Patients with congenital biliary duct cysts are commonly young women, who value cosmetic results as well as cure of the disease. Thus, minimally invasive surgery is important. To date, totally laparoscopic resection, which is safer and more feasible, has been applied for congenital biliary duct cysts [12
] (Figure ). In addition, the laparoscopic technology can relieve and even eliminate tissue adhesion, and early postoperative pain, and can promote resumption of peristalsis, excellent esthetics, and resumption of activities. Furthermore, our data suggest that no significant difference exists in postoperative complications and long-term outcomes between the laparoscopic and open surgery groups. These findings suggest that totally laparoscopic resection for congenital bile duct cysts is feasible and causes low risk.
These laparoscopic images show the bile duct cyst specimen. (A) The image of cyst before operation (arrow), (B) The image of laparoscopic resection (arrow indicates cyst).