Comparison of hepaticoantrostomy and hepaticojejunostomy for biliary reconstruction after resection of a choledochal cyst

Pediatric choledochal cysts: diagnosis and current management

Choledochal cysts are rare congenital disorders first described by Vater and Ezler in 1723. Their exact etiology remains incompletely understood; however, an anomalous pancreaticobiliary union (APBDU) and subsequent reflux of biliary contents into the biliary tree are thought to play a role. Accordingly, APBDU-associated choledochal cyst patients are significantly more likely to have evidence of hepatitis, cholangitis or pancreatitis and pathologically confirmed inflammation. In 1977, Todani and colleagues modified the original Alonso-Lej classification to include five types of CC. Type I and IV are the most common and most likely to be associated with malignancy. The majority of choledochal cysts are diagnosed in childhood. Clinical presentation varies and most often consists of nonspecific abdominal pain. Diagnosis is typically accomplished using multimodality imaging techniques including computed tomography, magnetic resonance imaging, ultrasound and MRCP. The use of diagnostic PTC and ERCP in CC has been largely replaced by MRCP. Appropriate management consists of prompt, complete cyst excision followed by restoration of biliary enteric continuity when necessary. Minimally invasive CC resection in the pediatric population has demonstrated acceptable outcomes. Prognosis is generally excellent; however, malignancy risk remains higher than the general population even after complete surgical excision.

Hepaticoduodenostomy for Biliary Reconstruction After Surgical Resection of Choledochal Cyst: a 25-Year Experience

We reviewed our experience of hepaticoduodenostomy done for choledochal cyst from 1982 to 2007 at our center. The aim of the study was to evaluate the efficacy of hepaticoduodenostomy as a mode of biliary reconstruction after surgical resection of choledochal cyst, to look for any complications associated with hepaticoduodenostomy, with review of the literature. A total of 56 patients underwent hepaticoduodenostomy after surgical resection of choledochal cyst, of which 54 patients underwent primary cyst excision with hepaticoduodenostomy and 2 patients underwent redo surgery (hepaticoduodenostomy). Most of the patients had an uneventful postoperative recovery. Early complications were biliary leak in three patients which subsided on conservative treatment. Long-term complication was seen in only one patient who developed anastomotic stricture 18 years after primary resection of choledochal cyst and hepaticoduodenostomy. Hepaticoduodenostomy is a relatively safe procedure with very low complication rates. It requires a single anastomosis and is simple to perform.

Laparoscopic resection of type I choledochal cyst

Type I choledochal cyst is a rare saccular or fusiform congenital dilatation of the extrahepatic biliary tract. It is usually treated by laparotomy at which the cyst is completely excised and a Roux-en-Y hepaticojejunostomy is performed to establish biliary enteric drainage. We report the laparoscopic excision and hepaticoduodenostomy of type I choledochal cyst in two girls aged 1 and 3 years. The entire procedure was performed laparoscopically using needlescopic instruments. A 7-mm telescope port was inserted at the umbilicus, a 3-mm port in the right upper quadrant, and a 6-mm port in left upper quadrant. An additional 3-mm fan-shaped liver retractor was passed through the abdominal wall without a trocar. The gallbladder and choledochal cyst was dissected and removed en bloc. The lower end of the common bile duct was closed with 5-0 polydioxanone. The duodenum was anastomosed to the common hepatic duct below the confluence of the right and left hepatic ducts. There were no intraoperative complications, and the children were asymptomatic with no episodes of cholangitis at 6 months follow-up. Pediatric surgeons trained in advanced laparoscopic techniques including intracorporeal suturing can perform laparoscopic repair of choledochal cyst safely.

A case of recurrent cholangitis after bile duct injury during laparoscopic cholecystectomy: value of scintigraphy with Tc-99m GSA and hepatobiliary scintigraphy for indication of lobectomy

A 39-year-old woman with acute cholecystitis and gallstones underwent laparoscopic cholecystectomy. She suffered from recurrent episodes of cholangitis due to injury of the major bile ducts during laparoscopic cholecystectomy. Hepatobiliary scintigraphy with Tc-99m Sn-N-pyridoxyl-5-methyltryptophan was performed. Although normal bile excretion was found from the left hepatic duct to the percutaneous transhepatic biliary drainage (PTBD) tube, excretion from the right hepatic lobe was prolonged. Scintigraphy with Tc-99m diethylenetriaminepentaacetic acid-galactosyl human serum albumin demonstrated atrophy of the right hepatic lobe and enlargement of the left hepatic lobe. Cholangiography via the PTBD tube revealed complete obstruction of the left hepatico-jejunal anastomosis and could not enhance the right intrahepatic bile duct. A right hepatic lobectomy was performed because of the atrophy, glissonitis and the absence of an appropriate bile duct for reconstruction. Postoperatively she was active and exhibited no evidence of recurrent cholangitis.