Open versus minimally invasive surgery for pediatric choledochal cyst in a propensity score matched cohort

BACKGROUND: This study aims to evaluate 30-day outcomes for children undergoing open versus minimally invasive surgery (MIS) for choledochal cysts using a propensity score matched cohort created from a national database.

METHODS: Children undergoing surgery for choledochal cyst from 2013-2023 were identified using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database. A propensity score match was performed. Outcomes were compared between operative approaches using an intention-to-treat analysis. Pearson's chi-square, Fisher's exact, and Mann-Whitney's U tests were used as appropriate. A Cochran-Armitage test was used to assess operative trends.

RESULTS: A total of 773 children who underwent surgery for choledochal cyst were identified. Pre-match, children undergoing open surgery were more likely to be younger, smaller in weight, have Roux-en-Y hepaticojejunostomy performed, have a history of gastrointestinal disease, and have higher American Society of Anesthesiology (ASA) class. Post-match, the groups were similar and included 247 cases per group. The MIS approach was associated with a longer median operative time (311 mins vs. 261 mins, p<0.001) and more surgical site infections (SSI) (6.5% vs. 1.6%, p=0.006). There were no differences in composite morbidity, postoperative length of stay, and readmission or reoperation at 30 days. MIS utilization increased over the study period (p<0.001).

CONCLUSIONS: MIS utilization has steadily increased within the NSQIP-P cohort. The MIS approach takes longer to perform and may be associated with a higher rate of SSIs. We observed no significant differences in overall morbidity, postoperative length of stay, readmission, or reoperation. Multicenter prospective trials would be useful to further compare these two approaches. Type of StudyRetrospective comparative study Level of EvidenceLevel III.