IPEG 2024 Round Table Discussion from East Asia - Dr. Shoko Ogawa

OK. Can we move to the next presentation? Thanks, Doctor Far. Thanks again. So next presentation is uh Doctor Shoko Ogawa. OK, uh, thank you very much. First of all, I would like to thank Doctor Ishimaru, Doctor Myano, Doctor Yedi, and all the related IPEC members for this great opportunity. I'm Shokoga, a pediatric surgical resident of Saitama Children's Medical Center in Japan. I would like to share with you a case of giant type 4A choliochial cyst and our experience. Um, the patient was a six year old girl with no significant medical history. She visited a hospital with a symptom of abdominal pain and MSS. Laboratory studies showed jaundice and elevated hepatic transaminase. Oh, I'm sorry. My video doesn't really work well. Uh, the MRI showed very large and distended extra and intrahepatic bile ducts. The diagnosis was atoleni type 4A choliochiosis. Uh, since her bilirubin continued elevated, we conducted a laparoscopic fistulotomy, uh, laparoscopic, uh, cholecystic fistulotomy for, for the biliary drainage on hospital day 9. Uh, on day 2029, she developed cholangitis, and the obstructed cholecystic duct was observed by the flooscopy. We, therefore, placed a percutaneous transhepatic cholangio drainage, but the cholangitis recurred afterwards. On day 54, we performed a laparoscopic excision of extrahepatic duct and hepaticojuinnostomy. Uh, I'm really sorry, my movie doesn't really, my video doesn't really work well. Um, let me explain about the operation. Uh, the inflammatory change around the biliary duct was intensive. During the dissection along the CHD, the anterior wall was opened. Um, so we cut the CHD circumferentially at the level and kept dissection to the hylung. We got the CBD at the higher level. The intrahepatic duct was resected blunt, uh, sorry, the intrapancreatic duct was dissected bluntly, and the distal end was osan. We conducted hepaticogeinnostomy. There was no significant postoperative complication, although she had been doing well with no elevated tumor marker or suspecting sus suspicious image findings for years. Uh, however, she developed intrahepatic cholangiocarcinoma with hyal lymphatic metastasis, uh, 6.5 years after the surgery. She underwent a left hepatectomy with lymphoidectomy and adjuvant chemotherapy. Um, however, the carcinoma recurred 4 months later, and she died 8 months after the hepatectomy. We have learned from this case that biliary drainage can be beneficial in the cases of giant choloidoco cysts with jaundice, jaundice, and elevated ran aminoranage before the definitive surgery. Uh, the issues I would like to discuss here, uh, are one, when is the best time for surgery on a giant cholidochial cyst. And the other is whether a giant cholidochiosis can be the risk factor for biliary malignancy. As far as I reviewed the literature of giant cholodochiosis, although most of them are the case reports of this rare presentation, I could not find any advocating the risk. Thank you very much for listening. Sorry about that, uh, the, the video is not working. Sorry about that. I'm very sorry for that. Can we get the pole? Yeah, this is a simple question. Large cyst, for cyst without symptoms, you guys do the drainage first or primary surgeries? Most of the audience will try the primary surgery first. So, can we get a second poll? Please So large cyst. Choleoco cyst with chlangitis or pancreatitis, would you do the lab or open? Actually, I personally do, I, I, I may choose the, the open if the cortical cyst is large cyst with the severe cholangitis or pancreatitis. That's one of the, my contraindication for the minimally invasive surgery, so I may choose the open. Thank you. So, is there any comments or questions for these presentations? Yes. So, uh, thank you, Doctor Ogawa for interesting case. According to our experience, In giant cle consists. We have such a 15 centimeters in diameter of cysts in even on the patient, 10 or 15 years old. I think we prefer to do laparoscopic. So Regardless of the size of the seas. And as you show you guys, even you do pre-op, uh, drainage. There's also Uh, cholangitis 2 times. So I think no need for preoperative drainage. You can proceed straight away to the operation. It depends on your expertise and experience, but in our experience, we can always do laparoscopic surgery, even for giant cysts, because After introducing Trua, you make right. Drainage interoperatively with the aspiration or to buy, uh, juice. So after decompressing the cyst, it's easier to do uh the excision of the cyst, no problem at all. So Tran, do you change the strategy for such a large cystic tightening of the cortical cyst like uh increase the number of the trochards or change the position of the trochards? Um, Actually, uh, it very, a little bit changed because when the cyst is very large, the lower edge of the cyst maybe come to the bakas level or even lower. So maybe you should place the tucha at lower level of the bakas to see the cyst first. And then we do not, uh, put all the tuka. We put only one tuka and, uh, make aspiration. the cyst first. After this, uh, reduction of cyber cyst, then you put other trocas as so-called the most comfortable for you to do the operation. Yeah, thank you. Question, what, what do you guys do, uh, for a seminar, newborn, prenatal diagnosis, large colordo, asymptomatic. Uh, how long do you wait? I mean, the last one I did, I wear it out, and by the time before I took her to the OR, I did 3 months, she was already symptomatic, presented with a colic stools and I mean, I was able to do it, but sometimes you say, we'll wait till they become symptomatic or uh and or bigger, but sometimes they become symptomatic pretty soon, so I don't know, you guys obviously know more about this than us. Uh, I never know what a good timing is. Obviously you don't want to do a newborn, but I've been burned by waiting even months, sometimes on these large ones. I think, you know, we used to uh try to do the, the wait until the 2 or 3 years old, but right now, currently, we start doing the laparoscopic corridorco uh around 3 or 4 months old. Even in the neonats, I think we can do the uh laparoscopic corridor for the, the large cyst. Even uh with the prenatal diagnosis. I think we don't have to wait. I agree I think in this case, we have, uh, the strategy. Our strategy like this, if you have clinical diagnosis, but the patient After, uh, you know, after birth, you should screen the liver functional test. If there's no jaundice and, uh, liver enzymes are almost normal, you can wait for 2 or 3 months. But if you see jaundice and elevated liver enzymes, I think we can indicate it earlier, even in neonatal period. And you do also laparoscopically. Agree, I agree, and I think Maybe screen labs because when they're born, they're fine, but follow those labs at a month because that's what I've been born before. I mean, the baby's healthy and then, you know, it shows up uh early and I agree it can be done laparoscopically. You just drain it and, and, and it's. Doable. OK, I have a question to Doctor Ogawa. Uh, it is about the malignant transformation of cholecyst. Uh, was there no malignant tissue found in the pathology after the excision of giant cholecyst? Uh, if so, where, where did the cholangiocarcinoma originate? Uh, in Korea, the malignant transformation after a surgery of cholecysts is known to occur between ages of 40 to 60 in older ages, and with a cumulative incidence of approximately 8%. Is, is there any uh uh moral explanation about the malignant transformation of your cases? Um, thank you very much for the question. Um, What I know about the case is that um there was no um. Malignant sign or they are um. For the like pathology like results of the like primary surgery. And uh And the like recurrence occurred in the intrahepatic duct. For this case. Um, Mm. So. I mean, um, this is really difficult issue for this giant, um, giant cyst type of cholooptosis. Um, whether you do the hepatectomy or the primary surgery. I, I don't, I think like most of the, uh, pediatric surgeon like don't really choose the, uh, hepatectomy for the primary because it's too extensive. Um, but, um, I, I still don't know whether the, um, uh, like, uh, left, um, like dilated, um, intrahepatic duct. Was the One of the reasons, one of the causes of the carcinoma, I don't know that. Am I like answering correctly? OK, thank you. I think that's a difficult point. Yes, please. Yeah, yes, uh, I totally agree with, uh, Professor Yong from the Korea. Yes, I'm just wondering, uh, the follow-up of the patient after the cardiococyst resection, if the intrahepatica dilation, uh, biodilation released after, uh, the first, uh, operation. And uh where or what or the location of the carcinoma, uh, six years later, you find the carcinoma. And uh can you tell us the pathology of this carcinoma or if we can wondering uh the first treatment for this carcinoma, just the transplantation, if there are no uh extra heptic metastasis. That's my question. Uh, Should I say it again? Mhm. Sorry, could you Yeah, first, I want to know the outcome of the patient after the first operation. Is the intrahepatica uh biodilation relieved or released after the operation? Maybe, uh, there are still dilation or the uh uh con Uh, direction of the bio ductum, maybe it's the It's the reason of the uh following, following, uh, following outcome like the happiness of the carcinoma, I think. Uh, thank you very much. Um, yes, as you, uh, as you said, like there are like residual, um, intrahepatic biliary duct, it remained, uh, even with the follow-ups, uh, after the primary surgery. Um, but It's, it's remained, but there was no suspicious image findings by, like, uh, ultrasound or MRI. We, we followed up really regularly for this case, but we couldn't catch that like uh 4, 6.5 years. I'd like to add some comments about the malignant transformation. So, basically, the most of the uh malignant transplantation occurred for the patients who got the initial operation after 5 years old or something. It's rare for us to get the, the malignant transformation if the patients got the first initial operation like uh in infants or 1 or 2 years old. Or less. So, uh, especially we need to, uh, cross follow up for the patients who had the initial operation after 5 years old or even 10 years old or something. That's kind of the, the key issue to look at the post-operative status. I think actually this matches one of the Yeah, one of the questions about using ERCP for the follow-up on this kids, would you guys use it, ERCP biopsy, yeah. We don't do the ELCP. You guys do the ERCP? In your centers. Uh In in my facility. Yeah, um, no, um, the follow-up was done by echo and MRI, not the RCP. I think it's impossible to do follow-up by RCP because if you do hepatic cardiodenostomy, then you can do some. But if you do a hepaticodigenostomy, it's impossible to do IRCP. You know, we can discuss later about the hepatico duodenal or hepaticosion, so. OK. Can we move to the next presentation? Thanks, Doctor Ogawa. Great presentations. Thank you.