Risk factors for anastomotic stenosis after congenital choledochal cyst surgery and efficacy analysis of laparoscopic reoperation.

BACKGROUND

Congenital choledochal cyst (CCC) is a common congenital biliary dysplasia in children, with higher incidence in Asia, treated by complete cyst excision plus Roux-en-Y hepaticojejunostomy (laparoscopy as preferred). Anastomotic stenosis, a common long-term postoperative complication, increases patient burden and treatment difficulty. Previous studies lacked systematic analysis of its influencing factors, and laparoscopic reoperation for it was once contraindicated, with only small-scale studies showing its efficacy comparable to open surgery.

OBJECTIVE

To systematically analyze influencing factors of anastomotic stenosis after CCC surgery and explore medium- and long-term efficacy of laparoscopic hepaticojejunostomy for this complication, providing clinical reference.

METHODS

This single-center retrospective cohort study (approved by Ethics Committee of Capital Institute of Pediatrics, No.: SHELL20240103; informed consent waived) screened patients with anastomotic stenosis (diameter <3 mm) after CCC surgery (Jan 2015-Jun 2024), dividing them into Group A (41 cases, initial surgery in our hospital) and Group B (98 cases, initial surgery in other hospitals). Group A underwent 1:3 propensity score matching (surgical age, gender, period) to get 120 stenosis-free patients as Group C. Data on surgery, imaging, laboratory tests and pathology were collected. Laparoscopic bile duct plasty + hepaticojejunostomy was preferred for reoperation. Follow-up (1, 3, 6 months post-reoperation, then annual, 3-yearly after 5 years) and statistical analysis (R software) were conducted.

RESULTS

A total of 139 reoperation patients with anastomotic stenosis were admitted, with a stenosis incidence of 2.2 % (139/1853 CCC excisions). Multivariate analysis showed proximal cyst wall thickness (OR = 4.28, 95 % CI 2.15-8.53) and 3rd postoperative day CRP (OR = 1.55, 95 % CI 1.24-1.93) were independent risk factors, while common hepatic duct outlet diameter (OR = 0.17, 95 % CI 0.07-0.47) was a protective factor; the prediction model had an AUC of 0.863 with good calibration. Eighty-two percent of reoperations were laparoscopic (18 % converted to open), with anastomotic diameter expanded from a preoperative median of 0.1 cm-1.5 cm. Postoperatively, liver function improved significantly. The median postoperative follow-up duration was 831 days (372, 2501): by June 2025, 66.2 % of patients had normal intrahepatic bile ducts, 3.6 % had recurrent intrahepatic bile duct stones, and 4.3 % had mild liver function abnormalities (all improved with conservative treatment, no reoperation needed).

CONCLUSION

A prediction model for pediatric CCC postoperative anastomotic stenosis was first constructed to identify high-risk patients. Laparoscopic bile duct plasty + hepaticojejunostomy has reliable medium- and long-term efficacy for this stenosis, serving as preferred surgery. The study has limitations like single-center design and missing initial surgery data of transferred patients.