title: Minimally invasive resection of choledochal cyst: a feasible and safe surgical option.
abstract: BACKGROUND
  The use of minimally invasive surgery (MIS) for choledochal cyst (CC) has not been well documented. We sought to define the overall utilization and outcomes associated with the use of the open versus MIS approach for CC. We examined the factors associated with receipt of MIS for CC, as well as characterized perioperative and long-term outcomes following open versus MIS for CC.
  
  
  METHODS
  Between 1972 and 2014, a total of 368 patients who underwent resection for CC were identified from an international, multicenter database. A 2:1 propensity score matching was used to create comparable cohorts of patients to assess the effect of MIS on short-term outcomes.
  
  
  RESULTS
  Three hundred thirty-two patients had an open procedure, whereas 36 patients underwent an MIS approach. Children were more likely to be treated with a MIS approach (children, 24.0 % vs. adults, 2.1 %; P<0.001). Conversely, patients who had any medical comorbidity were less likely to undergo MIS surgery (open, 26.2 % vs. MIS, 2.8 %; P=0.002). In the propensity-matched cohort, MIS resection was associated with decreased length of stay (open, 7 days vs. MIS, 5 days), lower estimated blood loss (open, 50 mL vs. MIS, 17.5 mL), and longer operative time (open, 237 min vs. MIS, 301 min) compared with open surgery (all P<0.05). The overall and degree of complication did not differ between the open (grades I-II, n=13; grades III-IV, n=15) versus MIS (grades I-II, n=5; grades III-IV, n=5) cohorts (P=0.85). Five-year overall survival was 98.6 % (open, 98.0 % vs. MIS, 100.0 %; P=0.45); no patient who underwent MIS developed a subsequent cholangiocarcinoma.
  
  
  CONCLUSIONS
  MIS resection of CC was demonstrated to be a feasible and safe approach with acceptable short-term outcomes in the pediatric population. MIS for benign CC disease was associated with similar perioperative morbidity but a shorter length of stay and a lower blood loss when compared with open resection.
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Georgios Antonios
authors.initials: GA
authors.lastname: Margonis
authors.forename: Gaya
authors.initials: G
authors.lastname: Spolverato
authors.forename: Yuhree
authors.initials: Y
authors.lastname: Kim
authors.forename: Hugo
authors.initials: H
authors.lastname: Marques
authors.forename: George
authors.initials: G
authors.lastname: Poultsides
authors.forename: Shishir
authors.initials: S
authors.lastname: Maithel
authors.forename: Luca
authors.initials: L
authors.lastname: Aldrighetti
authors.forename: Todd W
authors.initials: TW
authors.lastname: Bauer
authors.forename: Nicolas
authors.initials: N
authors.lastname: Jabbour
authors.forename: T Clark
authors.initials: TC
authors.lastname: Gamblin
authors.forename: Kevin
authors.initials: K
authors.lastname: Soares
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D015529:Choledochal Cyst / Q000601:surgery*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D061646:Operative Time; D055815:Young Adult