Congenital biliary tract disease

The Role of Prenatal Ultrasound Examination in Predicting the Outcomes of Ovarian Fetal Cysts: A Pictorial Essay

Objectives: The aim of this study was to evaluate prenatal ultrasound features, fetal postnatal outcomes, and the need for postnatal surgery in the suspicion of ovarian torsion. Methods: We included patients with a singleton pregnancy with a suspicion of ovarian fetal cyst referred to our center. Data derived from prenatal ultrasound evaluations, delivery, and postnatal follow-up were then extracted from the hospital registers. Results: The ultrasound features of 32 fetal ovarian cysts and related neonatal outcomes were analyzed. The mean gestational age at diagnosis was 32 weeks (28-36), while the mean diameter of the cyst diagnosis was 34.8 ± 13.2 mm. In 78.1% of cases, the cysts did not change their characteristics during pregnancy, while in 9.4%, they increased their dimensions, and in 12.5%, they reduced their size. In 78.1% of cases, the diagnosis was confirmed postnatally, and in 40% of cases, a spontaneous regression occurred during follow-up. Surgery was performed in 60% of cases, and most of the time (66.7%), an adnexectomy was required. Conclusions: An unfavorable outcome was associated with cystic dimensions and ultrasound feature modifications during pregnancy. However, our study demonstrated that a hemorrhagic content is not always indicative of adnexal torsion, and spontaneous resolution may occur. In addition, only a few of the simple anechoic cysts managed surgically presented with necrosis at histopathological examination; therefore, a conservative approach might be proposed in those cases.

Fetal abdominal tumors and cysts

This article reviews the contemporary diagnosis and management of the most common abdominal neoplasms and cystic lesions diagnosed in the fetus. Fetal tumors discussed include teratomas (sacrococcygeal, cervical or mediastinal), mesoblastic nephroma, nephroblastoma (Wilms' tumor), neuroblastoma, and hepatoblastoma. Fetal abdominal cystic lesions discussed include ovarian cyst, choledochal cyst, intestinal duplication cyst, mesenteric cyst, simple hepatic cyst, and meconium pseudocyst. We discuss the rare indications for fetal intervention or fetal surgery and other perinatal management, including prenatal interventions and fetal surgery for sacrococcygeal teratoma. The lesions reviewed are detected by widespread use of screening ultrasonography during pregnancy. Work-up for these abnormalities may include fetal MRI which enhances the diagnostic accuracy of abdominal tumors and cystic lesions and can aid in characterization of the lesion in relationship to surrounding anatomic structures. Accurate prenatal diagnosis of such lesions permits recommendations for optimal location and timing of delivery, and inclusion of appropriate caregivers and expertise to facilitate postnatal management. Perinatal management of the fetus with a neoplasm requires consideration of the optimal timing and mode of delivery, and pediatric oncology and surgical specialty care. The majority of tumors diagnosed antenatally have good prognosis with current multimodality treatment.

Arterio-Duodenal Fistula: A Rare Complication of Laparoscopic Choledochal Cyst Excision

Choledochal cysts (CDC) are rare biliary tract anomalies characterized by congenital dilatation of the extrahepatic and/or intrahepatic bile ducts. CDC excision with hepatico-enterostomy is the preferred surgery in modern era. Perioperative blood loss in a case of laparoscopic choledochal cyst excision (LCCE) is usually minimal and managed by conservative treatment such as blood transfusion and correction of coagulation factors. Massive hemorrhage in LCCE is rare and reported intraoperatively or within the first 3 postoperative days. Hereby, we present an unusual case of arterio-duodenal fistula, post LCCE presenting as delayed massive upper gastrointestinal bleeding in a male child and its successful endovascular management.

Endoscopic management of choledochocele complicated with choledocholithiasis and pancreatitis in an old patient

Choledochocele, or type III choledochal cyst, is a rare congenital disease and is even less common among adults compared with children. In this case, a 75-year-old female was admitted to our hospital presented with epigastric pain and vomiting for one day. Abdominal computed tomography revealed dilated common bile duct, pancreatitis and peripancreatic effusion. The patient was treated with fasting, fluid resuscitation, anti-acid agents, somatostatin and antibiotics. Endoscopic retrograde cholangiopancreatography was employed for the further diagnosis of choledochocele, choledocholithiasis and biliary stenosis. Endoscopic sphincterotomy, stone extraction and plastic stent placement were performed for treatment. The patient recovered quickly after the treatment and no signs of recurrence and complications were observed during the first follow-up. Endoscopic management may be a promising and alternative therapy for choledochocele although long-term follow-up is necessary to confirm the efficacy and safety of this procedure in the future.

Effects of age at Kasai portoenterostomy on the surgical outcome: a review of the literature

The efficacy of early Kasai portoenterostomy has been repeatedly reported. However, the optimal age for performing this procedure remains controversial. This article reviews the literature on the age of patients at the time of Kasai portoenterostomy and its utility as a prognostic indicator. The age at the time of surgery is a known predictor of outcome; however, its exact predictive value in this context is unclear. Multicenter studies involving large volumes of data have tended to show advantages of early Kasai portoenterostomy, and there is no clear evidence to recommend any delay in the timing of surgery. At present, a reasonable strategy would be to perform a Kasai portoenterostomy as early as possible. The stool color card system has recently been implemented in Japan as part of a nationwide screening program, and it is expected to work well based on the early reports. However, efforts to identify an optimal screening system for ensuring the earliest diagnosis of biliary atresia should continue. An early diagnosis of biliary atresia is difficult, and global efforts are required to improve the early diagnosis rates.

Systemerkrankungen

Systemerkrankungen als Ursache einer Lebererkrankung sind häufig, ohne dass man genaue Zahlen angeben kann. Die verschiedenen Grunderkrankungen sind für sich betrachtet zwar selten, nur dadurch, dass viele Erkrankungen in Betracht gezogen werden müssen, ergibt sich eine relative Häufung. Durch Fortschritte auf dem Gebiet der molekularbiologischen Diagnostik insbesondere bei den Stoffwechselerkrankungen lassen sich heute bereits viele der in Frage kommenden Grunderkrankungen eindeutig nachweisen. Allerdings ist bei keiner der Erkrankungen ein hundertprozentiger molekularbiologischer Nachweis möglich. Damit ergibt sich eine sichere Diagnose nur bei einem positiven Nachweis. Bei fehlendem Nachweis einer bisher bekannten für die Erkrankung spezifischen Mutation bleibt die Zuordnung entweder enzymatischen Tests oder klinischer Diagnose vorbehalten. Insbesondere bei der Manifestation als akutes Leberversagen ist die für die Diagnosesicherung erforderliche Zeit damit oft nicht vorhanden.

Early experience with laparoscopic excision of choledochal cyst in 41 children

OBJECTIVE

This study aims to review our center's early experience in managing children with choledochal cysts using laparoscopic excision.

METHODS

A retrospective study was carried out from the time of our first case of laparoscopic excision (2010). A total of 41 patients with choledochal cysts underwent laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy. Patient demographics, operative data, and post-operative outcomes were recorded and analyzed.

RESULTS

Forty patients underwent the operation successfully, and the mean time of operation was 210 min (range 140 min to 380 min). One case was converted to an open operation due to dense adhesions. All patients recovered uneventfully and were discharged between seven and ten days post-operatively. Four patients suffered minor bile leaks after their operations, but they required only percutaneous drainage. The mean time for follow-up was six months (range 1 month to 1 year). No significant complication was noted during that time.

CONCLUSIONS

We successfully introduced laparoscopic excision of choledochal cyst in our center and have found this to be a safe and effective method. Long-term follow up is awaited.

A very low-birth-weight infant with spontaneous perforation of a choledochal cyst and adjacent pseudocyst formation

Spontaneous perforation of a choledochal cyst with ensuing pseudocyst formation is a very rare complication. We report the development of a pseudocyst adjacent to a choledochal cyst in a very low-birth-weight infant at 2 months of age. Elective excision of the choledochal cyst and biliary tract reconstruction were successfully performed 2 months later when the infant weighed 3 kg. Delayed primary repair may be a viable alternative treatment for low-birth-weight infants with choledochal cysts.

Role of endoscopic retrograde cholangiopancreatography in diagnosis and management of congenital choledochal cysts: 28 pediatric cases

BACKGROUND/PURPOSE

Management of choledochal cysts consists of surgical excision and hepaticojejunal anastomosis. Endoscopic retrograde cholangiopancreatography (ERCP) can be used to resolve complications and to evaluate the biliary tract and pancreatobiliary duct junction. Our aim was to underline the importance of ERCP for optimal management.

METHODS

From 2005 to 2011, 28 patients were reviewed (21 female, 7 male; mean age, 5.71 years; range, 2-16 years). After imaging, all patients underwent elective ERCP and were referred for surgery.

RESULTS

Choledochal cyst was diagnosed at ultrasound and magnetic resonance cholangiopancreatography in all examined patients; common biliopancreatic duct was diagnosed in 3 (20%) of 15 patients at magnetic resonance cholangiopancreatography and in none at ultrasound. Endoscopic retrograde cholangiopancreatography showed choledochal cyst in all patients and common biliopancreatic duct in 19 (68%) of 28 patients. Twelve patients underwent sphincterotomy. All patients underwent surgical extrahepatic biliary tree resection and hepaticojejunal anastomosis. Mean period of hospitalization was 9.5 days (range, 6-13 days). No major complications related to ERCP were observed. Two patients needed postoperative ERCP for complications (pancreatitis during follow-up).

CONCLUSIONS

In our pediatric experience, ERCP is feasible and safe. It can rule out other possible biliary tract anomalies and help plan the timing and choice of the appropriate surgical procedure.

A rare case of bile duct cyst

Choledochal cyst is an uncommon disease usually seen in young women and can be divided into five types. We report a 66-year-old woman who was diagnosed with types I and III bile duct cyst simultaneously after surgery, which is a rare type of bile duct cyst.

Spontaneous rupture of choledochal cyst with pseudocyst formation-report on 2 cases and literature review

Spontaneous rupture and subsequent bile peritonitis are rare complications of choledochal cysts. Of these complications, the formation of a biliary pseudocyst is an unusual form, and its preoperative diagnosis is difficult. In this report, we describe 2 cases showing spontaneous rupture with biliary pseudocyst formation. Inflammatory tissue surrounded those pseudocysts, one of which was adjacent to the perforation and the other formed in the transverse mesocolon apart from the biliary tract. These pseudocysts were removed by careful dissection, and single-stage cyst excision with biliary reconstruction was successfully performed in both cases.

A long-term follow-up of five patients with atresia of the common bile duct

BACKGROUND/PURPOSE

Description of the long-term follow-up of 5 patients operated on for atresia of the common bile duct.

METHODS

During a 25-year period (1960 to 1985) 45 infants underwent surgical exploration for biliary atresia (BA), of which, 5 (11.1%) were found to have atresia of the common bile duct. The children were followed up into adult life by pediatric surgeons, pediatricians, and later, adult hepatologists with the range of 19 to 36 years. Liver function tests, histology, complications, and somatic development (including sexual maturation and mental development) were obtained continuously.

RESULTS

Liver function test results were normal in all but 1 patient. Repeated ultrasound scan and postoperative liver biopsies were normal in 2 patients and moderately and mildly abnormal in 3 patients, respectively, suggesting hepatic fibrosis. HIDA hepatic scans in all but 1 patient showed prompt uptake by the liver with passage into the bowel within 30 minutes. Endoscopic retrograde cholangiography (ERCP; 1 patient) and duodenography (4 patients) showed, at most, mild reflux of contrast material into the extra- or intrahepatic bile ducts. One patient with cholecysto-duodenostomy had 3 episodes of clinically proven ascending cholangitis. All 5 patients had normal physical growth and mental development, they are all age-appropriate schooled, and they are working and living a normal life.

CONCLUSIONS

Long-term favorable outcome has been suggested to be more influenced by anatomic and biological features rather than the surgical correction. The hypothesis is supported that BA is not a static congenital malformation but a progressive inflammatory panductular obliterative disease of the bile ducts starting in the antenatal period, which might cease, either early at birth or any time in infancy. The destructive inflammatory process might involve only the distal part of the extrahepatic bile duct causing obstruction and leaving the proximal ducts patent.

Spontaneous biliary perforation: a rare entity in late infancy and childhood

Spontaneous perforation of the biliary tract is rare in infants & children with less than 100 cases reported in English Literature till date. We report two cases of this rare clinical entity in a 9-month-old boy and other of a 2-year old boy. Both patients presented with clinical features of acute peritonitis. Laparotomy revealed sterile biliary peritonitis with a normal cholangiogram in the infant and biliary perforation in other child. Simple drainage in the former and cholecystostomy with external biliary drainage in later resulted in a satisfactory outcome.

Choledochal cysts and multilocular cysts of the pancreas

Choledochal cyst is a rare congenital anomaly of the biliary system that may be associated with other abnormalities of the hepatobiliary tract. We report a case of an 11-year-old boy in whom the preoperative evaluation revealed a choledochal cyst and intraoperative cholangiopancreatography showed a cystic mass in the pancreas. Examination of the choledocho-pancreatico-duodenectomy specimen showed a multilocular cyst in the pancreas in addition to a segmental dilation of the common bile duct. The findings in our case adds pancreatic cyst to the spectrum of abnormalities associated with choledochal cyst and may also support the theory that choledochal cyst is the predominant abnormality in a widespread spectrum of the pancreatobiliary duct dysplasia.

CT and MRI of hepatic pseudotumor in long-standing biliary atresia

Two patients who developed a hepatic pseudotumor in long-standing biliary atresia treated by hepatoportoenterostomy are presented. Both masses were detected during routine imaging surveillance prior to liver transplantation. The CT, MR, and pathologic appearances are described. Accurate radiologic identification of this entity is important for appropriate clinical management.

The Kasai portoenterostomy: when is it too late?

BACKGROUND/PURPOSE

Kasai portoenterostomy is recommended as the primary initial therapy for extrahepatic biliary atresia if the procedure can be performed within 10 to 12 weeks of life. The optimal management for infants with delayed presentation of biliary atresia remains controversial. The purpose of this study was to determine the success rate and outcome for patients who underwent a "late" Kasai portoenterostomy.

METHODS

The authors conducted a retrospective review of the medical records of all patients with biliary atresia who underwent a Kasai portoenterostomy at their institution from 1986 to 1999 (n = 31). The authors analyzed success rates compared with age at the time of the Kasai procedure and the association with patient demographics. Surgical success was defined as achievement of a total serum bilirubin < or = 2 mg/dL. Long-term follow-up assessments included the need for liver transplantation and patient survival rate.

RESULTS

The demographics of this study cohort showed a predominance of African-Americans, 19 of 31 (61%), and girls, 23 of 31 (74%). Assessment of success compared with subject age at the time of the initial portoenterostomy showed that 52% (13 of 25) had successful Kasai procedure at 0 to 75 days, compared with 83% success rate (5 of 6) at age 76 days or older (P = .359). Liver transplantation was performed in 16 of 31 patients (45%). Overall survival rate for the entire cohort is 23 of 31 (74%), whereas 12 of 31 (39%) are currently alive without a liver transplant.

CONCLUSION

These data suggest that there is no contraindication to performing a Kasai portoenterostomy for biliary atresia in children over 75 days of age.

Classifying choledochal cysts using hepatobiliary scintigraphy

PURPOSE

This retrospective study was designed to classify choledochal cysts on the basis of the findings of hepatobiliary scintigraphy.

METHODS

Twenty-one patients with choledochal cysts (15 female, 6 male; mean age, 20 years) proved on the findings of endoscopic retrograde cholangiopancreatography (ERCP) or surgery and histopathologic analysis were included in the study. Two nuclear medicine physicians, blinded with regard to cholangiographic and operative details, were asked to review and to classify the type of choledochal cyst seen on the hepatobiliary scan. Later, scintigraphic results were compared with ERCP and surgical findings for a reference standard.

RESULTS

The findings of hepatobiliary scintigraphy correlated with ERCP and surgical findings in 18 of 21 cases (86%). Scintiscans correctly identified all type 1 cysts (12/12). The sensitivity of scintigraphy in diagnosing type 4 cysts was 66% (6 of 9 cases). It underestimated the intrahepatic extent of disease in type 4a biliary cysts (37%).

CONCLUSION

This study illustrates the utility of hepatobiliary scintigraphy in diagnosing type 1 and 4 choledochal cysts.

Spontaneous Perforation of the Bile Duct

We present a classic but rare case of spontaneous perforation of the bile duct in infancy and a previously undescribed treatment technique. The patient, a male age 5 weeks, was admitted with abdominal distention, ascites, and conjugated hyperbilirubinemia. Ultrasound revealed ascites but did not provide visualization of the gallbladder. Although hepatobiliary scintigraphy with technetium [dimethyl iminodiacetic acid (HIDA scan)] showed normal uptake peritoneal excretion suggested perforation of the common bile duct (CBD). Exploratory laparotomy revealed 200 cm3 dark amber ascitic fluid in the peritoneal cavity and cholestasis of the liver. Intraoperative cholangiogram performed via the gallbladder showed a large perforation at the cystic duct/CBD junction. The perforation was large and leakage of contrast prevented demonstration of the distal CBD despite our attempt to primarily repair the perforation. The CBD was explored; a T-tube was placed. T-tube cholangiogram demonstrated flow of contrast into the duodenum. A large leak remained at the cystic CBD junction. A cholecystectomy was performed and a vascularized flap of the gallbladder wall was used to repair the CBD over the T-tube. The T-tube was clamped intermittently beginning 3 weeks postoperatively. T-tube cholangiogram performed 6 weeks postoperatively revealed no extravasation and normal intra- and extrahepatic biliary tree. The T-tube was subsequently discontinued and liver function tests remained normal at 6 months follow-up.

Benign liver and biliary tract masses in infants and toddlers

There is a remarkable diversity of conditions encompassed by benign liver masses in infants and toddlers. The most common benign hepatic tumor in this age group is infantile hepatic hemangioendothelioma. Other commonly seen benign tumors are mesenchymal hamartoma and focal nodular hyperplasia. Hepatic adenoma is almost exclusively a disease of older children; primary hepatic teratoma is exceedingly rare. There are several distinguishing characteristics of these benign tumors on radiographic evaluation; however, imaging techniques such as ultrasound scan, computed tomography, and angiography are not always reliable in differentiating benign from malignant tumors. The differential diagnosis of benign hepatic tumors includes nonneoplastic cystic masses including biliary and simple hepatic cysts, hematoma, parasitic cysts, and pyogenic and amebic liver abscess. Choledochal cyst presents with a classic triad of abdominal pain, cholestatic jaundice, and a palpable abdominal mass. They are classified anatomically into 5 subtypes with the most popular types being type I and type IV. Treatment is with complete cyst excision with hepaticojejunostomy reconstruction.

Porta choledochal fistula: an unusual complication of a cholangiocarcinoma arising from a type I choledochal cyst

A vena porta choledochal fistula caused by an adenocarcinoma arising from a type I choledochal cyst was detected in a 42-year-old woman. The diagnostic and therapeutic aspects of this malignancy are discussed.

Hepaticoenterostomy after excision of choledochal cyst in children: a 30-year experience with 180 cases

In the long-term follow-up of patients with choledochal cyst, postoperative ascending cholangitis and/or stone formation in the intrahepatic bile ducts (IHBD) owing to anastomotic stricture present serious problems. To prevent the formation of anastomotic strictures, some surgeons recently have performed hepaticoenterostomy at the hepatic hilum, with a wide stoma, in all patients with choledochal cyst. The authors of the present study review the surgical procedures performed on a total of 180 children with choledochal cyst and discuss the treatment of choice, with special reference to the types of hepaticoenterostomy. The medical records and radiographs of all patients treated for choledochal cyst between January 1964 and December 1993 at the authors' institutions were reviewed. A total of 180 patients (mean age at time of surgery, 4.3 years) had follow-up for a mean of 11.1 years; 174 of them had cyst excision and hepaticoenterostomy, and six had cystoenterostomy. Of the 174 patients who underwent cyst excision, 171 had a conventional hepaticoenterostomy; two had an intrahepatic cystoenterostomy, and one had a hepaticoenterostomy at the hepatic hilum. IHBD stones with or without cholangitis developed postoperatively in four (2.3%) of the 171 patients who had conventional hepaticoenterostomy. The age at time hepaticoenterostomy of these four patients was 12, 7, 16, and 6 years. Postoperative IHBD stone formation and cholangitis were not found in 121 patients under 5 years of age. The authors recommend conventional hepaticoenterostomy as the treatment of choice for children with choledochal cyst. Hepaticoenterostomy at the hepatic hilum is indicated in only selected cases.

Choledochal cysts: special emphasis on the usefulness of intraoperative endoscopy

Long-term complications after excisional surgery for choledochal cyst include stone formation within the intrahepatic bile duct (IHBD) and within the intrapancreatic portion of the bile duct (IPBD). The authors reviewed 180 patients with choledochal cysts (137 women) seen during a 30-year period and report their recent experience with intraoperative cyst endoscopy. Primary cyst excision with hepaticoenterostomy was performed in 150 cases, and a secondary cyst excision, after various lesser drainage procedures, in 24. Six children were treated early in the series with a cyst enterostomy. The mean age and follow-up period were 4.3 and 9.4 years, respectively. At surgery, dilatation of the IHBD was identified in 96 patients, and protein plugs or stones were observed in 31 common pancreaticobiliary channels. Fifty-five common channels were noted to be dilated. Hepaticojejunostomy was performed in 123 patients without intraoperative endoscopy. Late stone formation occurred within the IHBD in 4 of these cases and within residual segments of intrapancreatic cyst in 2 (mean age and follow-up period were 4.9 and 13.0 years, respectively). Intraoperative endoscopy was performed in 51 patients (mean age and follow-up period 3.6 and 4.3 years), and stone formation has not been observed in any patients in this group. Intraoperative cyst endoscopy is recommended as a valuable adjunct to choledochal cyst excision.