Impact of previous cyst-enterostomy on patients’ outcome following resection of bile duct cysts

Table 1 Patients’ demographic data, todani bile duct cyst subtypes and imaging studies

	Patient with previous CE	Patient without previous CE	Total	P value
Patients	16	227	243	-
Median age (yr) at the time of BDC resection	47.8 (26-60)	29.2 (0-81)	30.8 (0-81)	0.0074
Sex ratio F/M	7	3.73	3.8	0.5359
Adults/children	16/0	148/79	164/79	0.0041
ASA score1
1 or 2	15 (93.75%)	217 (95.6%)	232 (95.0%)	0.5350
≥ 3	1 (6.3%)	10 (4.4%)	11 (4.5%)
Types of imaging studies
None (incidental detection)	1 (6.3%)	2 (0.9%)	3 (1.2%)	0.1855
Percutaneous ultrasound	8 (50.0%)	188 (82.8%)	196 (80.7%)	0.0042
Computed tomography	7 (43.8%)	119 (52.4%)	126 (51.9%)	0.5022
MR- cholangiography	9 (56.3%)	138 (60.8%)	147 (60.5%)	0.7194
ERCP	7 (43.8%)	40 (17.6%)	47 (19.3%)	0.0186
Endoscopic ultrasound	8 (50.0%)	36 (15.9%)	44 (18.1%)	0.0026
Percutaneous cholangiography	0	17 (7.5%)	17 (7.0%)	0.6115
Intravenous cholangiography	2 (12.5%)	13 (5.7%)	15 (6.2%)	0.2583
Intraoperative cholangiography	0	6 (2.6%)	6 (2.5%)	1.0000
Todani bile duct cyst types
Type I	16	221	237
Type IVB	0	6	6	1.0000
MBC adequately analyzed	12 (75%)	196 (86%)	208 (85.5%)
Cyst involvement of MBC	5/12 (41.6%)	47/196 (24.0%)	52 (21.4%)	0.3173
MBC-1	3	39	42
MBC-2	2	8	10	0.2420
Presence of PBM adequately explored	10	180	190
Presence of anomalous PBM	8 (80.0%)	141 (78.3%)	149 (78.4%)	1.0000

¹The American Society of Anesthesiology physical status score; CE: Cyst-enterostomy; ERCP: Endoscopic retrograde cholangio-pancreatography; PBM: Pancreato-biliary malunion; MBC: Main biliary confluence.

Table 2 Patients’ clinical presentation

	Patients with previous CE n = 16	Patients without previous CE n = 227	Total n = 243	P value
Median delay between symptoms and diagnosis (mo) (range)	2 (0-486)	2 (0-360)	2 (0-486)	0.8848
Type of symptoms and signs
Asymptomatic	2 (12.5%)	31 (13.7%)	33 (13.6%)	1.0000
Isolated pain	2 (12.5%)	104 (45.8%)	106 (43.6%)	0.0094
Cholangitis	12 (75%)	52 (22.9%)	64 (26.3%)	< 0.0001
Pancreatitis	2 (12.5%)	49 (21.6%)	51 (21.0%)	0.5344
Abdominal mass	2 (12.5%)	22 (9.7%)	24 (9.9%)	0.6631
Jaundice1	6 (37.5%)	59 (26.0%)	65 (27.2%)	0.3843
Pruritus	1 (6.2%)	2 (0.9%)	3 (1.2%)	0.1855
Weight loss	2 (12.5%)	6 (2.6%)	8 (3.2%)	0.0903
Complicated presentation	12 (75%)	92 (40.5%)	104 (42.8%)	0.0071
Number of patients with > 2 symptoms	9 (56.25%)	92 (40.5%)	102 (42.0%)	0.2942

CE: Cyst-enterostomy;

¹without fever.

Table 3 Coexistent hepato-biliary and pancreatic diseases

	Patients with previous CE n = 16	Patients without previous CE n = 227	Total n = 243	P value
Biliary disease	9 (56.2%)	52 (22.9%)	61 (25.1%)	0.0059
Common biliary atresia	0	1 (0.4%)	1 (0.4%)	1.0000
Stones	4 (25%)	37 (16.3%)	41 (16.9%)	0.3216
Gallbladder	0	16 (7.0%)	16 (6.6%)	-
Cyst	3 (18.8%)	9 (4.0%)	12 (4.9%)	-
Common bile duct	1 (6.3%)	22 (9.7%)	23 (9.5%)	-
Intra hepatic duct	0	4 (1.8%)	4 (1.6%)	-
Synchronous cancer	5 (31.3%)	14 (6.2%)	19 (7.8%)	0.0043

CE: Cyst-enterostomy.

Table 4 Preoperative treatment and types of surgery

	Patients with previous CE n = 16	Patients without previous CE n = 227	Total n = 243	P value
Preoperative biliary drainage	2 (12.5%)	14 (6.2%)	16 (6.6%)	0.2842
Types of surgical procedures
Absence of resection	1 (6.3%)	5 (2.2%)	6 (2.5%)	0.3384
Elective surgery	14 (87.5%)	214 (94.3%)	228 (93.8%)	0.2583
Emergency surgery	1 (6.2%)	9 (4.0%)	10 (4.1%)	0.5007
Complete cyst excision	13 (81.2%)	199 (87.6%)	212 (87.2%)	0.6631
Incomplete cyst excision	2 (12.5%)	23 (10.1%)	25 (10.3%)
Superior excision	1 (6.3%)	13 (5.7%)	14 (5.8%)
Inferior excision	1 (6.3%)	9 (4.0%)	10 (4.1%)	-
Unknown	0	1 (0.4%)	1 (0.4%)
Associated procedures
Hepatectomy	2 (12.5%)	4 (1.8%)	6 (2.5%)	0.0523
Pancreaticoduodenectomy	4 (25.0%)	4 (1.8%)	8 (3.3%)	0.0008
Stone extraction	2 (12.5%)	10 (4.4%)	12 (4.9%)	0.2072
Synchronous cancer excision	5 (31.3%)	13 (5.7%)1	18 (7.8%)	0.0043
Biliary reconstruction
Hepatico-jejunostomy	13 (81.2%)	208 (91.6%)	221 (90.9%)	0.1658
Hepatico-duodenostomy	2 (12.5%)	7 (3.1%)	9 (3.7%)	0.1116
Choledoco-duodenostomy	0	1 (0.4%)	1 (0.4%)	1.0000
MBC anastomosis	8/14 (57.1%)	96/180 (53.3%)	104/194 (53.6%)	0.7831

CE: Cyst-enterostomy; MBC: Main biliary convergence;

¹secondary central hepatectomy was performed after good response of chemotherapy.

Table 5 Early postoperative and long term outcome of patients

	Patients with previous CE n = 16	Patients without previous CE n = 227	Total n = 243	P value
Median postoperative hospital stay (d) (range)	16 (9-110)	10 (2-150)	10 (2-150)	0.0014
Mortality rate	0 (0.0%)	1 (0.4%)	1 (0.4%)	1.0000
Overall complications	12 (75.0%)	75 (33%)	87 (35.8%)	0.0018
Grade I-II	5 (31.3%)	47 (20.9%)	52 (21.4%)	0.3454
Grade III-IV	7 (43.8%)	28 (12.3%)	35 (15.4%)	0.0031
Surgical complications	7 (43.8%)	45 (19.8%)	52 (21.4%)	0.0509
Biliary	0 (0.0%)	20 (8.8%)	20 (8.2%)	0.3750
Mixed pancreatic and biliary fistula	1 (6.3%)	5 (2.2%)	6 (2.5%)	0.3384
Pancreatic	1 (6.3%)	17 (7.5%)	18 (7.4%)	1.0000
Bleeding	5 (31.3%)	3 (1.3%)	8 (3.3%)	< 0.0001
Reoperation rate	6 (37.5%)	20 (8.8%)	26 (10.7%)	0.0032
Long-term outcome of patients
	Patients with previous CE n = 13	Patients without previous CE n = 185	n = 198
Median follow-up (mo) (range)	59 (12-175)	36 (4-372 )	37.5 (4-372)	0.2482
Mayo clinic score
Excellent	5 (38.5%)	138 (74.6%)	143 (72.2%)
Good	2 (15.4%)	18 (9.7%)	20 (10.1%)	0.0099
Fair	0	5 (2.7%)	5 (2.5%)
Poor	6 (46.2%)	24 (13.0%)	30 (15.1%)
Mayo clinic score
Excellent + good	7 (53.8%)	156 (84.3%)	163 (82.3%)	0.0136
Fair + poor	6 (46.2%)	29 (15.7%)	35 (17.7%)

CE: Cyst-enterostomy.

Table 6 Predictive factors of poor and fair long-term outcome according to Mayo clinic score in 198 patients with a follow-up > 3 mo, including patients suffering from synchronous cancer

Covariate	Univariate			Multivariate
	OR	95%CI	P value	OR	95%CI	P value
Adult patient vs child	3.587	1.322-9.735	0.0084	-	-	-
Previous cyst-enterostomy; Yes vs No	4.611	1.445-14.712	0.0136	3.165	0.829-12.077	0.0918
Synchronous cancer; Yes vs No	18.462	4.687-72.71	< 0.0001	16.612	3.999-69.013	0.0001
Post-operative complications; Yes vs No	2.397	1.143-5.028	0.0186	-	-	-
Postoperative biliary complications; Yes vs No	4.356	1.669-11.367	0.0038	4.597	1.635-12.925	0.0038

OR: Odds ratio.