Pancreatic fistula and bleeding following choledochal cyst excision: Experience of two decades.

Objectives: Choledochal cyst excision (CDCE) with hepaticojejunostomy is standard of care in choledochal cysts. Complications related to inadequate healing of distal stump like post-operative pancreatic fistula (POPF) and bleeds have not been addressed in literature. We report two decade experience with these complications following CDCE. Material and Methods: Retrospective analysis of demographics, operative details and post-operative course of patients who developed POPF (according to International Study group of Pancreas surgery classification) and bleeds following CDCE were compared with those who did not develop these complications. Results: POPF was seen in in 34 out of 377 operated patients (incidence of 9%). In those with POPF, 24/34 (70%) had biochemical leak and 10/34 (30%) had clinically relevant POPF (B and C). All grade B POPF 6/34, required additional percutaneous drains while all grade C 4/34 required operative intervention to control sepsis. There was no mortality in the POPF group while two patients in control died from non-surgical causes. A difficult distal stump precluding closure was the only factor found associated with subsequent development of POPF (5.9% in POPF group vs. 0.5% in control group, p= 0.03). Post-operative bleeding was seen in 2 (6%) patients with POPF and in 5/343 (1.4%) in control group. Conclusion: It is possible to anticipate development of POPF intraoperatively, during CDCE. Most of these POPFs can be managed conservatively with adequate drainage. Surgery is required only in grade C fistula and bleeds. Since these are isolated pancreatic fistulas, unlike those seen after pancreaticoduodenectomy, they are associated with more favourable outcomes.