Management of congenital choledochal cyst with intrahepatic involvement

A new clinical classification of congenital biliary dilatation - HUAXI CBD classification

BACKGROUND

Current biliary dilatation (BD) classifications are complex and based on cases including secondary BD, leading to unclear distinctions. Notably, congenital and secondary BD differ in etiology, symptoms, and prognosis.

OBJECTIVE

To propose a more concise and more suitable classification of congenital biliary dilatation (CBD), and exploring the feasibility and effectiveness of this classification in diagnosis and treatment.

METHODS

Based on the preoperative imaging data of patients with CBD admitted to the Department of Pediatric Surgery of West China Hospital of Sichuan University, from January 2015 to December 2018, a new classification of CBD was accomplished according to the site of bile duct dilatation lesions, which was named HUAXI CBD classification. The CBD was classified into 4 types: type I (distal extra-hepatic bile duct dilatation), type II (distal extra-hepatic combined with right and left primary hepatic bile duct dilatation), type III (extra-hepatic combined with secondary and above hepatic bile duct dilatation), and type IV (intra-hepatic bile duct dilatation). Meanwhile, the feasibility and reliability of the HUAXI CBD classification were analyzed by analyzing the clinical treatment strategies, perioperative complications and long-term follow-up results of different subtypes.

RESULTS

A total of 300 patients with CBD were included in this study. According to the HUAXI CBD classification method, 240 cases were type I, 48 cases were type II, 10 cases were type III, and 2 cases were type IV. After treatment, patients with type I had a normal hepatobiliary function after surgery and a good prognosis; patients with type II had good recovery of liver function in 37 cases (77.1%), but 11 cases (22.9%) had postoperative complications during follow-up; patients with type III and IV had high incidence of cholangitis (6/10, 2/2, respectively) and choledocholithiasis (5/10, 2/2, respectively) after surgery, especially those with diffuse intrahepatic dilatation having a poor prognosis, eventually developing cirrhosis and necessitating liver transplantation.

CONCLUSIONS

The HUAXI CBD classification is consistent with treatment principles, concise and easy to remember, and more suitable for CBD clinical application.

Choledochal cyst

Choledochal cyst (CC) or congenital biliary dilatation, has a skewed distribution with hereditary features that is far more common in East Asian females. CC is usually associated with pancreaticobiliary malunion (PBMU) forming a common channel. CC requires early definitive diagnosis, since there is a risk for malignancy occurring in the CC and/or intrahepatic bile ducts (IHBD). Complete CC excision and Roux-en-Y hepaticoenterostomy is required and can be performed by open or minimally invasive surgery with hepatojejunostomy the recommended procedure of choice. Principles of open surgical intervention form the basis of minimally invasive management with laparoscopy and robotic assistance. Current surgical management is associated with fewer early and late complications, such as hepaticoenterostomy anastomotic leakage, cholangitis, anastomosis stricture, and cholangiocarcinoma. Specific features of CC management at Juntendo include: intraoperative endoscopy of the common channel and IHBD for inspecting and clearing debris to significantly reduce post-operative pancreatitis or stone formation; near infra-red fluorescence with indocyanine green for visualizing tissue planes especially during minimally invasive surgery for CC; and a classification system for CC based on PBMU that overcomes inconsistencies between existing classification systems and clinical presentation.

Usefulness of hepatobiliary scintigraphy for predicting late complications in patients with choledochal cysts

PURPOSE

Hepatobiliary scintigraphy is a minimally invasive imaging method that evaluates bile flow dynamics. At our hospital, it has been performed for postoperative evaluation of patients with choledochal cysts (CC). This study evaluated the usefulness of biliary scintigraphy for predicting late complications in patients with CCs.

METHODS

The study included pediatric patients with CC who underwent surgery at Chiba University Hospital from 1978 to 2020, followed by postoperative biliary scintigraphy and subsequent radiologic evaluation. The patients were divided into two groups according to the presence or absence of "biliary cholestasis" on biliary scintigraphy.

RESULTS

The study included 108 patients, with a median age at surgery of 2 years and 11 months. The median follow-up period was 5203 days, with 11 hepatolithiasis cases and 8 cholangitis cases. No patients had cholangiocarcinoma. Twelve patients were considered to have "cholestasis" following biliary scintigraphy evaluation. There was no significant difference in the occurrence of hepatolithiasis between the cholestasis and non-cholestasis groups (p = 0.47), but cholangitis was significantly more common in the cholestasis group (p = 0.016).

CONCLUSION

Biliary cholestasis on postoperative hepatobiliary scintigraphy was a risk factor for cholangitis in patients with CCs. These particular patients should be monitored carefully.

Choledochal cyst type I with dilated intrahepatic biliary radicles: a type IVA mimic

Background

A choledochal cyst is a relatively rare congenital anomaly of the biliary tree requiring surgery as the definitive treatment. Amongst the five Todani variants, type I poses a diagnostic and treatment challenge owing to its infrequent, yet clinically significant mimicry for type IVA cysts.

Case presentation

We present a case of a 4-year-old female diagnosed to have a giant type IA choledochal cyst that mimicked a type IVA cyst on radiological imaging. The patient was treated by complete cyst excision, cholecystectomy, and restoration of the biliary-enteric communication by a Roux-en-Y hepaticojejunostomy. Regression of the dilated intrahepatic radicles that counterfeited a type IVA cyst was confirmed on follow-up imaging studies.

Conclusion

Such an encounter, although rare, can significantly alter the course of management. We recommend extrahepatic cyst excision with biliary reconstruction as the standard treatment when preoperative and intraoperative imaging studies fall short in differentiating the aforementioned variants.

Predictors of postendoscopic retrograde cholangiopancreatography associated cholangitis: a retrospective cohort study

BACKGROUND

Post-ERCP cholangitis (endoscopic retrograde cholangiopancreatography) and associated sepsis can be lifethreatening. Despite the wealth of studies on post-ERCP pancreatitis risk factors, there is limited data on post-ERCP cholangitis. This study aimed to investigate the rates, predictors, and outcomes of post-ERCP cholangitis.

METHODS

A retrospective review of 452 ERCP cases performed by a single endoscopist at a tertiary center between March 2019 and February 2021 was performed. Patient-related, organizational and periprocedural factors that could affect post-ERCP cholangitis were evaluated. Predictors of post-ERCP cholangitis were determined by multivariable analysis.

RESULTS

The post-ERCP cholangitis rate was 19.5%. Cholangiocarcinoma (OR 15.72, CI 2.43-101.55, p = 0.004), the American Society of Anesthesiologist Score (ASA) (OR 2.87, CI 1.14-7.21, p = 0.024), an increase in bilirubin after ERCP (OR 1.81 CI 1.01-3.22, p = 0.043), body mass index (OR 1.15, CI 1.00-1.33, p = 0.04) and procedure duration (OR 1.02, CI 1.00-1.05, p = 0.049) were predictors of post-ERCP cholangitis. Biliary stone extraction using a balloon was found to be protective against cholangitis (OR 0.18, CI 0.05-0.60, p = 0.005). Sepsis rate related to post-ERCP cholangitis was 2.4% and death 1%.

Accuracy of Magnetic Resonance Imaging in Prenatal Diagnosis of Choledochal Cysts: A Single-Center Retrospective Analysis

BACKGROUND

The purpose of this study is to evaluate the accuracy of prenatal MRI in diagnosing choledochal cysts (CDC), evaluate the sensitivity and specificity of MRI signs in the diagnosis of fetal CDC, and first compare the trend of size of CC between prenatal and postpartum.

METHODS

A total of 18 fetal who were diagnosed with CDCs through prenatal MRI were enrolled in the study. We summarized and analyzed the prenatal clinical data and prognosis information of prenatal and postpartum surgery, then compared the sensitivity, specificity, and diagnostic accuracy of various signs of MRI and postpartum MRCP diagnosis of CC. Finally, we tried to compare the earliest prenatal detection of common bile duct cysts with the size of surgery, and calculated the growth rate of common bile duct cysts for the first time.

RESULTS

All 18 patients were delivered in our institution. Among these patients, 14 were confirmed with CDCs after postpartum surgery, two patients had CDCs that disappeared, and two patients were confirmed with cystic biliary atresia (CBA) through the Kasai operation. Furthermore, 13 patients with CDCs and two patients with CBA underwent MRCP before the operation, and one patient with CDCs ruptured at birth and underwent ultrasound diagnosis. The sensitivity and diagnostic compliance of prenatal MRI signs for the location were higher when compared to postnatal MRCP (100% vs. 76.9% and 83.3% vs. 66.7%): the cyst was located at the porta hepatis, which was higher than the lowest edge of the liver, and parallel to the hepatoduodenal ligament.

CONCLUSION

Prenatal MRI is higher than that of US for diagnosing CDCs, specifically in identifying the location of the cyst and confirming the origin of the cyst. The length, width, and size of the CDC become slightly bigger in our study.

Biliary Tree Cysts and Surgical Treatment: Outcomes in a Multicentric Study

Background: Biliary tree cysts (BTCs) represent an either localized or multifocal abnormal dilatation of the biliary tree, which entails an increased risk of acute cholangitis and cholangiocarcinoma (2.5%-16%). Its incidence in Western countries is ∼1/100.000-1/150.000, being more frequent in Asia (1/1.000). These cysts are usually classified according to Todani classification, which is based on site and morphology of cysts. Patients and Methods: This is a retrospective multicentric descriptive study of patients surgically treated for BTCs. From 2005 to 2018, 25 cases were collected between Hospital de la Santa Creu i Sant Pau (Barcelona, Spain) and Ospedale San Paolo (Savona, Italy). Clinical presentation was characterized by abdominal pain, jaundice, fever, and sometimes weight loss. Eight patients presented Todani type I, 1 patient Todani type II, 3 patients Todani III, 1 patient Todani type IV, and 12 patients Todani type V. Results: Among the 25 surgically treated patients, 12 patients underwent liver resection, 7 patients underwent resection of the extrahepatic biliary tree, 3 patients underwent BTC removal through a duodenotomy, 1 patient underwent resection of the extrahepatic biliary tree and liver resection, and 2 patients underwent pancreatoduodenectomy. Overall 30-day morbidity rate was 20%, and 90-day mortality was 0%. Pathologic examination confirmed diagnosis of cholangiocarcinoma in 5 patients (20%). After a median follow-up of 59 months, 20 patients are alive and in good conditions, whereas 50% of patients with cholangiocarcinoma died for disease progression. Conclusions: Surgical treatment for BTCs is associated with acceptable postoperative outcomes, with moderate morbidity and null mortality rates. Moreover, the risk of developing cholangiocarcinoma is still high that prompts surgical treatment once diagnosis is made.

[Squamous cell carcinoma of the gallbladder complicating a cystic dilation of the cystic duct and common bile duct: a case report]

Congenital cystic disease of the biliary tree is a known risk factor for gallbladder cancer. We here report a case of squamous cell carcinoma of the bile duct (BD) complicating a cystic dilatation of the bile ducts in a 54-year-old woman hospitalized for biliary pancreatitis. Abdominal scanner showed nodular thickening of the fundus of the gallbladder and fusiform dilation of the cystic duct and the main bile duct (VBP) with lesion of the tail of the pancreas, initially suggesting mucinous cystadenoma. Extended cholecystectomy involving the gallbladder fossa with resection of the distal biliary tract, choledocoduodenal anastomosis with caudal splenopancreatectomy + drainage were performed. Histopathological examination of the gallbladder mass revealed moderately differentiated invasive squamous cell carcinoma without infiltration of the hepatic parenchyma. The patient underwent adjuvant chemotherapy. The patient did not have the common symptoms of gallbladder cancer. Then radiology was necessary to make a diagnosis. Surgery is the best therapeutic option for early-stage gallbladder cancer, but adjuvant chemo-radiation may also be useful in treating these patients. Cholecystectomy with resection of cystic dilatation of the bile duct in high-risk patients are the most effective means of prevention.

A giant biliary cyst of Todani IA in a young woman: A case report

RATIONALE

Biliary cysts (BC) are rare dilatations of various parts of a biliary tract. They account for approximately 1% of all benign biliary diseases. Total cyst excision and Roux-Y hepaticojejunostomy is the treatment method of choice in most patients. In this paper, a novel surgical treatment with the use of internal biliary and pancreatic catheters was presented.

PATIENT CONCERNS

A 21-years-old woman with a giant choledochal cyst of Todani IA type presenting with abdominal pain, nausea, fever and palpable abdominal mass. It had been previously drained as a misdiagnosed pancreatic cyst in another hospital.

DIAGNOSIS

A very high amylase level (107140,0 U/l) in drain fluid was noted in laboratory tests. Endoscopic retrograde cholangiopancreatography revealed a biliary cyst located in the distal common bile duct and a pancreaticobiliary anomaly was suggested. A cholangiography per catheter inserted to the biliary cyst showed a large round contrast-filled cyst. A cholangiography following cyst decompression revealed a very long, tortuous bile duct entering the duodenum.

INTERVENTIONS

Cholecystectomy, cyst resection, Roux-Y hepaticojejunostomy, and implantation of catheters into pancreatic and bile duct were performed. The postoperative course was uneventful and she was discharged on 12th day without any complications. Histopathology revealed a cyst wall partially lined with biliary-type and mucinous epithelium, with dysplasia ranging from low to high grade (biliary intraepithelial neoplasia, high grade), without invasion.

OUTCOMES

The biliary and pancreatic catheters were removed during endoscopic retrograde cholangiopancreatography 8 weeks following surgery without any complications. Fourteen months later, the patient reported good health.

LESSONS

Diagnosis of the abdominal cyst should be very precise in order to avoid misdiagnosis and inadequate management. The early diagnosis and proper treatment of BC are needed in order to avoid serious complications. The cholangiocarcinoma is the most dangerous potential complication of BC due to dysplasia within the cyst wall as in our young female patient.

Carcinoma of the Papilla of Vater after Diversion Operation for Pancreaticobiliary Maljunction

Pancreaticobiliary maljunction (PBM) is a congenital malformation that is associated with biliary cancer development. When patients are diagnosed with PBM, a diversion operation is recommended. Although a risk remains for developing residual bile duct carcinoma following diversion, the development of a carcinoma of the ampulla of Vater after a diversion operation for PBM is rare. We present a treated case of carcinoma of the ampulla of Vater after a diversion operation for PBM. A 65-year-old woman presented with abdominal pain. She had undergone extrahepatic bile duct resection and cholecystectomy 2 years 9 months previously for the treatment of type Ic PBM according to the Todani classification. At the current admission for evaluation of the abdominal pain, computed tomography and magnetic resonance imaging showed only dilation of the main pancreatic duct. However, gastrointestinal endoscopy showed a tumor at the papilla of Vater, and biopsy revealed adenocarcinoma of the papilla of Vater. We performed pylorus-preserving pancreaticoduodenectomy, and the pathological diagnosis was moderately differentiated tubular adenocarcinoma of the papilla of Vater with no metastasis to the lymph nodes. The patient remained in good health for 3 years postoperatively. Carcinoma of the papilla of Vater after a diversion operation for PBM is rare. In this case, a diagnosis could not be made by computed tomography or magnetic resonance imaging; the definitive diagnosis was obtained with gastrointestinal endoscopy. Careful postoperative follow-up with gastrointestinal endoscopy in addition to imaging examination may be needed after a diversion operation for PBM.

Japanese clinical practice guidelines for congenital biliary dilatation

Until now, there have been no practical clinical guidelines for congenital biliary dilatation (CBD). In this review article, the Japanese Study Group on Congenital Biliary Dilatation (JSCBD) propose to establish clinical practice guidelines for CBD. Because the evidence-based literature is relatively small, we decided to create guidelines based on the consensus of experts, using the medical literature for reference. A total of 20 clinical questions (CQs) were considered by the members of the editorial committee responsible for the guidelines. The CQs included the distinct aspects of CBD: (1) Concepts and Pathology (three CQs); (2) Diagnosis (six CQs); (3) Pancreaticobiliary Complications (three CQs); Treatments and Prognosis (eight CQs). Each statements and comments for CQs were made by the guidelines committee members. CQs were finally approved after review by members of the editorial committee and the guidelines evaluation board of CBD. These guidelines were created to provide assistance in the clinical practice of CBD management; their contents focus on clinical utility, and they include general information on CBD to make this disease more widely recognized.

Laparoscopic excision versus open excision for the treatment of choledochal cysts: a systematic review and meta-analysis

In 1723, Vater first described choledochal cyst and in 1977, Todani et al classified this disease. For many years, open excision (OP) as the standard procedure made a great impact in the treatment of choledochal cyst. Since 1995, when Farello et al first reported laparoscopic choledochal cyst excision, laparoscopic excision (LA) has been used worldwide. However, its safety remains a major concern. The aim of this meta-analysis was to compare OP with LA in treating choledochal cyst and then to determine whether LA is safe and valid. The design of this study involved systematic review and meta-analysis. Data sources were Medline, Ovid, Elsevier, Google Scholar, Embase, and Cochrane library. The study selection entailed comparative cohort studies. For data extraction, 2 investigators independently assessed selected studies and extracted the following information: study characteristics, quality, outcomes data, etc. For the results, 7 comparative cohort studies about the effectiveness of LA compared with OP were performed meta-analysis. The results showed that although the LA group had a longer operative time (MD = 56.57; 95% CI = 32.20–80.93; P < 0.00001), LA had a shorter duration of hospital stay (MD = −1.93; 95% CI = −2.51 to −1.36; P < 0.00001), and recovery of bowel function (MD = −0.94; 95% CI = −1.33 to −0.55; P < 0.00001). Meta-analysis found no significant difference between most of the 2 groups: bile leak (RR = 0.60; 95% CI = 0.29–1.24; P = 0.17), abdominal bleeding (RR = 0.33; 95% CI = 0.01–8.98; P = 0.51), pancreatitis (RR = 0.26, 95% CI = 0.06–1.03; P = 0.06), total postoperative complications (RR = 1.04; 95% CI = 0.66–1.62; P = 0.88). The LA group had significant lower rates in intraoperative blood transfusion (RR = 0.20; 95% CI = 0.11–0.38; P < 0.00001), and adhesive intestinal obstruction (RR = 0.17, 95% CI = 0.04–0.77; P = 0.02). In conclusion, compared with open excision, laparoscopic excision is a safe, valid, and feasible alternative to open excision.

Totally laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy for choledochal cyst in adults: a single-institute experience of 5 years

PURPOSE

The present study aimed to describe the authors' experience and the intermediate-term outcome for totally laparoscopic choledochal cyst excision and Roux-en-Y hepatoenterostomy at a single center in a 5-year period.

METHODS

We retrospectively analyzed the clinical data of totally laparoscopic choledochal cyst excision and Roux-en-Y hepatoenterostomy on 31 adult patients from January 2009 to November 2013.

RESULTS

Thirty-one cases successfully underwent totally laparoscopic choledochal cyst excision laparoscopy and Roux-en-Y hepatoenterostomy. The operation time varied from 200 to 360 minutes. The intraoperative blood loss was 50 to 210 mL. The patients passed flatus in 3.0 ± 1.3 days. The mean time interval to resume oral intake from the time of surgery was 3.8 ± 1.4 days. The duration of postoperative intravenous fluids was 4 to 11 days. Postoperative ambulation varied from 2 to 4 days. The duration of hospital stay was 4 to 13 days. Follow-up observations lasted 3 to 59 months and complications were noted in 4 patients. Of these patients, 1 patient suffered postoperative respiratory tract infection, 1 patient had an episode of adhesive small bowel obstruction, biliary leakage occurred in 1 patient, and 1 patient developed an anastomotic stoma stricture and cholangitis. There were no perioperative deaths.

CONCLUSIONS

Totally laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy is a safe, efficacious, and minimally invasive procedure for the most instances of adult choledochal cyst. The key of success is skilled laparoscopic skills, good team cooperation, and stapler anastomosis.

What is the incidence of biliary carcinoma in choledochal cysts, when do they develop, and how should it affect management?

The incidence of cancer in choledochal cysts (CCs) in adults was calculated to determine the timing and need for surgery. In 78 publications (1996-2010), 434 of 5780 reported CCs patients had cancer. Cholangiocarcinoma (70.4 %) and gallbladder cancer (23.5 %) were the most common malignancies. Only nine malignancies were reported before age 18 (0.42 %). In contrast, the incidence of malignancy in adults was 11.4 %. The median age for diagnosis of cancer was 42 years, and the incidence increased with each decade.

Common bile duct dilatations in asymptomatic neonates: incidence and prognosis

Background. This retrospective study reviewed 213 asymptomatic neonates with common bile duct (CBD) dilatations diagnosed via ultrasound to evaluate their incidence and outcomes. Materials and Methods. From August 2001 to July 2010, 18,230 abdominal ultrasound scans were performed as newborn screening. There were 213 (1.17%) cases of CBD dilatation. Dilatation of neonatal CBD was defined when its diameter was ≥2 mm. The neonates' birth history, CBD size, and follow-up results were analyzed. Results. In the 213 infants, four cystic dilatations (1.88%, 4/213) that were eventually diagnosed as choledochal cysts (CC). Among 209 neonates with fusiform dilatations (size 2.0-6.7 mm), 77 had ultrasound follow-up and 87% of them resolved spontaneously which were diagnosed as transient CBD dilatation (TCBDD). Eighty percent of TCBDDs resolved within 6 months. Patients with initial CBD size ≥3 mm had significantly lower resolution rate and neonates whose mothers are older than 35 years took longer time to resolve. Conclusion. The incidence of CBD dilatation in asymptomatic neonates was 1.17%. Eighty percent of TCBDDs resolved within 6 months. Regular ultrasound follow-up every 6 months may be appropriate for asymptomatic neonates with fusiform CBD dilatations to ensure resolution or progression.

[Cancer developed in cystic dilatation of the bile duct: report of a case]

Les auteurs rapportent un cas de dilatation kystique du cholédoque intra- pancréatique découvert chez une femme de 46 ans et compliqué d'un carcinome tubulo-papillaire n'envahissant pas le pancréas. Le traitement a consisté en une duodénopancréatectomie céphalique avec un curage ganglionnaire et anastomose hépatico-jéjunale; la survie était de 30 mois; les auteurs abordent les aspects radiologiques, anatomopathologiques, thérapeutiques et pronostiques de ces cancers développé sur dilatation kystique de la voie biliaire et discutent la place d'une radiothérapie complémentaire de la chirurgie susceptible d'améliorer la survie.

Early experience of laparoscopic choledochal cyst excision in children

Purpose

Laparoscopic choledochal cyst excision with Roux-en-Y hepaticojejunostomy (LCE) in children is being attempted more frequently around the world, and although it has been performed in Korea, no publication has been published on it. However, cholangitis and/or pancreatitis are limitations that make open conversion more likely. The aims of this study, through a retrospective clinical analysis, were to prove the efficacy of LCE in children and to validate that preoperative management expands its indications.

Methods

From May 2011 to November 2012, 13 pediatric LCEs were performed. Demo graphics, preoperative findings, management, operative and postoperative outcomes were reviewed.

Results

The mean age at operation was 48.5 months and mean bodyweight 19.0 kg. Ultrasonography was conducted in all patients followed by either magnetic resonance cholangiopancreatography (8 cases) or computed tomography (5 cases). The mean diameter of the cysts was 30.2 mm. Eight patients with cholangitis and/or pancreatitis were given antibiotics preoperatively. Four had their condition resolved by administration of antibiotics, 3 underwent additional endoscopic retrograde biliary drainage or percutaneous transhepatic biliary drainage, and one, due to aggravating tenderness, underwent surgery after 4 days of administrating antibiotics without improvement of the inflammation. Two faced open conversions, one because of a very narrow bile duct, and the other because of remnant inflammation after inadequate preoperative management already mentioned above. Patients were discharged on the eighth postoperative day. There were no complications.

Conclusion

Pediatric LCE is a feasible option for choledochal cyst. Proper preoperative management such as antibiotics and drainage procedures enhances its efficacy by broadening its indications, even with concomitant cholangitis and/or pancreatitis.

Surgical treatment of type IV-A choledochal cyst in a single institution: children vs. adults

BACKGROUND

The treatment of type IV-A choledochal cyst is particularly difficult and remains a challenge because of the rareness and the various presentations of the disease involving not only the extrahepatic but also the intrahepatic biliary tract. The purpose of this study is to analyze our clinical experience for surgical treatment of type IV-A choledochal cyst, and compare between children and adults.

METHODS

During a 10-year period of time (2000-2010), clinical data of 81 consecutive patients with type IV-A choledochal cyst were retrospectively analyzed. We divided these patients into two groups, the child group (age ≤ 18 years) and the adult group (age >18 years). According to whether the patient received additional liver resection, patients were divided into a extrahepatic cystectomy (EHC) group and an additional liver resection (LR) group. The long-term outcomes after surgery were evaluated in two groups.

RESULTS

Of all 81 patients, there were 17 children and 64 adults; 16 children and 35 adults belonged to EHC group, one child and 29 adults belonged to LR group. The morbidity of biliary stricture and/or lithiasis in the adults was significantly higher than that in the children (p = 0.041 < 0.05). In the EHC group, the reoperation rate of adults was significantly higher than that of children (p = 0.019 < 0.05). For adult patients, the morbidity of biliary stricture and/or lithiasis and the reoperation rate in EHC group was significantly higher than that in LR group (p = 0.037 < 0.05 and p = 0.026 < 0.05 respectively). Five adults were found to have cholangiocarcinoma within a follow-up period, while no child was found to. However, for adult patients, no significant discrepancy was observed between EHC group and LR group (p = 0.366 > 0.05).

CONCLUSIONS

The present study suggests that the children have better outcomes than adults for patients with type IV-A choledochal cyst after EHC, while LR brings better outcomes than EHC for adult patients.

Technical note on complete excision of choledochal cysts

BACKGROUND

Choledochal cysts are congenital cystic dilatations of the extrahepatic or intrahepatic portion of the biliary tree. Complete excision of choledochal cysts is currently regarded as the gold standard treatment, while less extensive procedures including cystoduodenostomy have become obsolete due to the potential for malignant change in the remnant cyst. For type-1 choledochal cysts, which sometimes extend to the main pancreatic duct closely, some surgeons may adopt a less aggressive approach in order to avoid damage to the main pancreatic duct as such damage can lead to serious consequences. However, incomplete excision of choledochal cysts may also cause problems.

METHOD

Here we report on a reoperation treating incomplete excision of a choledochal cyst with focus on the technical aspect.

RESULTS

In the reoperation, meticulous dissection of the liver hilum which had been previously operated on was performed. The hepaticojejunostomy was left intact. With the assistance of intraoperative cholangiography, the residual pancreatic portion of the choledochal cyst was completely excised. The pancreatic opening and the lower end of the common bile duct were reconstructed. Whipple operation was avoided.

CONCLUSION

Careful planning with the aid of precise imaging before and during the operation largely enhanced the accuracy of the excision of the choledochal cyst.

Biliary cysts: etiology, diagnosis and management

Biliary cysts (BC) are rare dilatations of different parts of a biliary tract. They account for approximately 1% of all benign biliary diseases. BC occur the most frequently in Asian and female populations. They are an important problem for pediatricians, gastroenterologists, radiologists and surgeons. Clinical presentation and management depend on the BC type. Cholangiocarcinoma is the most serious and dangerous BC complication. The other complications associated with BC involve cholelithiasis and hepatolithiasis, cholangitis, acute and chronic pancreatitis, portal hypertension, liver fibrosis and secondary liver cirrhosis and spontaneous cyst perforation. Different BC classifications have been described in the literature. Todani classification dividing BC into five types is the most useful in clinical practice. The early diagnosis and proper treatment are very important, because BC are associated with a risk of carcinogenesis. A malignancy risk increases with the age. Radiological investigations (ultrasonography, computed tomography, endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography) play an important role in BC diagnostics. Currently, prenatal diagnosis using ultrasonography is possible. It allows to differentiate biliary disorders in fetals and to perform the early surgical treatment that improves results. In most patients, total cyst excision with Roux-Y hepaticojejunostomy is the treatment of choice. Surgical treatment of BC is associated with high success rate and low morbidity and mortality. The early treatment is associated with a lower number of complications. Patients following BC surgery require permanent and careful postoperative observation using laboratory and imaging investigations because of possibility of biliary anastomosis stricture and biliary cancer in tissue remnant.

Computed tomography virtual endoscopy with angiographic imaging for the treatment of type IV-A choledochal cyst

Type IV-A choledochal cysts (CCs) are a congenital biliary anomaly which involve dilatation of the extrahepatic and intrahepatic bile ducts. We present the case of a 30-year-old woman with type IV-A CC, on whom three-dimensional computed tomography (3D CT) and virtual endoscopy were performed. 3D CT revealed partial dilatation in the posterior branch of the intrahepatic bile duct and a relative stricture between it and the extrahepatic bile duct. Virtual endoscopy showed that this stricture was membrane-like and separated from the surrounding blood vessels. Based on these image findings, complete cyst resection, bile duct plasty for the stricture, and hepaticojejunostomy were safely performed. To the best of our knowledge, there are no reports of imaging by virtual endoscopy of the biliary tract which show the surrounding blood vessels running along the bile duct.

Diagnosis and management of choledochal cysts

Choledochal cysts are rare disease and of unknown etiology. These are typically a surgical problem of infancy and childhood, but in nearly 20 % of the patients the diagnosis is delayed until adulthood. The presentation and therapeutic strategies for choledochal cysts in adult may differ from that of childhood. The surgical management of choledochal cysts in adults is complicated by associated hepatobiliary pathology. Despite the absence of clinical trials, a consensus for the management of choledochal cysts is excision. This review examines the spectrum of hepatobiliary pathology encountered with choledochal cysts and the surgical alternatives for managing choledochal cysts based on review of relevant literature in English language indexed on MEDLINE.

Forty-year experience with flow-diversion surgery for patients with congenital choledochal cysts with pancreaticobiliary maljunction at a single institution

BACKGROUND

Congenital choledochal cyst with pancreaticobiliary maljunction (PBM) is known as a high-risk factor for various complications such as cholangitis, pancreatitis, and carcinogenesis of the biliary system by mutual refluxes of bile and pancreatic juice. Furthermore, it is not rare to suffer from postoperative complications if the wrong operative procedure is chosen. Therefore, we sought to review the relationship between operative procedure for types I and IV-A (Todani's classification) congenital choledochal cyst with PBM, and long-term treatment outcome.

SUBJECTS AND METHODS

A retrospective review was carried out of 144 patients who underwent flow diversion surgery in our institution during the 40-year period from 1968 to 2008 and who did not have a coexisting malignant tumor at the time of surgery.

RESULTS

Of these 144 patients, 137 underwent complete cyst excision and 7 underwent pancreas head resection as flow diversion surgery. The follow-up periods ranged from 1 to 345 months and from 1 to 271 months (average, 100.2 and 94.1) in patients with type I and type IV-A cysts, respectively. Regarding surgical treatment outcome, postoperative progress was good in 130 (90.3%) of the 144 patients. Fourteen patients required hospitalization for long-term postoperative complications such as cholangitis, pancreatitis, intrahepatic calculi, pancreatic calculus, and carcinogenesis during postoperative follow-up. Of these, 2 patients who underwent surgery for type IV-A cysts died because of secondary biliary cirrhosis with liver failure and advanced intrahepatic cholangiocarcinoma, respectively.

CONCLUSIONS

The present study shows that flow diversion surgery for congenital choledochal cysts with PBM significantly reduces the risk of subsequent development of malignancy in the biliary tract, and it is vital to choose the appropriate operative procedure to prevent occurrence of these postoperative complications.

Diagnosis and management of choledochal cysts

Choledochal cysts are rare disease and of unknown etiology. They are typically a surgical problem of infancy and childhood, but in nearly 20% of the patients the diagnosis is delayed until adulthood. The presentation and therapeutic strategies for choledochal cysts in adult may differ from that of childhood. The surgical management of choledochal cysts in adults is complicated by associated hepatobiliary pathology. Despite the absence of clinical trials, a consensus for the management of choledochal cysts is excision. This review examines the spectrum of hepatobiliary pathology encountered with choledochal cysts and the surgical alternatives for managing choledochal cysts based on review of relevant literature in the English language indexed on MEDLINE.

The effect of laparoscopic excision vs open excision in children with choledochal cyst: a midterm follow-up study

PURPOSE

Cyst excision with hepaticojejunostomy has been the classic procedure for treating choledochal cysts. Recently, laparoscopic treatment of the disease has gained popularity worldwide. The aim of this study is to evaluate whether laparoscopic management of choledochal cysts is as feasible and safe as conventional open surgery in children with this disease.

METHODS

A retrospective study comparing the laparoscopic and the open procedures was performed in 77 consecutive patients with choledochal cyst in our hospital. Thirty-nine patients operated on between June 2001 and September 2003 were in the laparoscopic group, whereas 38 patients in the open group were operated on between February 1999 and May 2001.

RESULTS

Patient demographics were similar between the 2 groups. The duration of operation was significantly longer in the laparoscopic group than in the open group (median, 230 vs 190 minutes; P < .001). In contrast, the durations of delayed oral feeding and hospital stay postoperatively were significantly shorter in the laparoscopic group (median, 4 vs 5 days [P < .01] and median, 5 vs 7 days [P < .01], respectively.) There were no differences in the early and late complication rates between the 2 groups.

CONCLUSIONS

Laparoscopic treatment of choledochal cyst in children is feasible and safe. For experienced centers, this procedure can be recommended.

Choledochal cysts: part 1 of 3: classification and pathogenesis

Much about the etiology, pathophysiology, natural course and optimal treatment of cystic disease of the biliary tree remains under debate. Gastroenterologists, surgeons and radiologists alike still strive to optimize their roles in the management of choledochal cysts. To that end, much has been written about this disease entity, and the purpose of this 3-part review is to organize the available literature and present the various theories currently argued by the experts. In part 1, we discuss the background of the disease, describing the etiology, classification, pathogenesis and malignant potential of choledochal cysts.

Resection of the intrapancreatic bile duct preserving the pancreas

Benign neoplasms of the distal bile duct are rare, but pose a therapeutic challenge. Usually, these lesions are resected by means of ampullectomy if located in close proximity to the ampulla of Vateri or by partial pancreaticoduodenectomy if located intrapancreatic and distant from the ampulla. Here, we present a case of an intrapancreatic benign neuroendocrine tumor that was resected by performing a pancreas-preserving distal bile duct resection. First, a duodenotomy was carried out and a probe was inserted into the pancreatic duct to avoid inadvertent injury. Subsequently, the bile duct was divided proximal the lesion and dissected towards the ampulla. Pancreatic parenchyma was dissected dorsally and closed using absorbable interrupted sutures. The duodenal incision was closed, and reconstruction was performed by an end-to-side hepaticojejunostomy and a Roux-Y jejunojejunostomy. The postoperative course of the patient was uneventful. In conclusion, pancreas-preserving distal bile duct resection might be an option for intrapancreatic benign lesions of the distal bile duct that would otherwise require a partial pancreaticoduodenectomy.

Synchronous Todani types I and III choledochal cysts in a 10-month-old-infant: type IVb

A 10-month-old, previously healthy boy presented with one week of mild jaundice, light-colored stools and irritability. Abdominal sonography showed a large type I choledochal cyst and a separate, distinct cystic mass at the head of the pancreas. Magnetic resonance cholangiopancreatography was performed to evaluate the relationship of the two lesions. A type I choledochal cyst was confirmed, and a coexisting type III choledochocele was identified as the second cystic structure in conjunction with pancreaticobiliary malunion. The infant had complete resection of the type I choledochal cyst with Roux-en-Y hepaticojejunostomy, and anterior duodenotomy with marsupialization of the choledochocele. After five years of follow-up, the child is thriving and has had no recurrence of his symptoms. An exhaustive review of the literature identifies only one previous case of synchronous types I and III choledochal cysts, and this association is not clearly defined among the traditional classifications of type IV multiple choledochal cysts. Because operative management of a type III cyst requires the addition of a transduodenal approach, we encourage accurate reporting of mixed type choledochal cysts for the benefit of surgical planning, epidemiologic tracking and outcomes.

Hepaticojejunostomy and intrahepatic cystojejunostomy for type IV-A choledochal cyst

BACKGROUND

The incidence of choledochal cyst with intrahepatic involvement (Todani's type IV-A cyst) is considerably high. Dilatation of the intrahepatic bile duct is frequently observed around the hepatic hilum, occasionally in the umbilical portion, and rarely in the more upstream intrahepatic bile duct, associated with or without downstream stricture. We recently encountered 2 children with type IV-A cyst associated with upstream intrahepatic ductal dilatation; one with a cystic dilatation of the medial branch arising from the left hepatic duct and another with a cyst of the medial branch arising from the anterior hepatic duct.

METHODS

After excision of the extrahepatic bile duct cyst at the hilum and making a large fenestration of the intrahepatic duct cyst, hepaticojejunostomy and intrahepatic cystojejunostomy were performed using a Roux-en-Y jejunal loop in both children.

RESULTS

Postoperatively, both intrahepatic cysts were remarkably reduced in size, and recurrent bouts of abdominal pain did not occur for up to 4 or 5 years.

CONCLUSION

Hepaticojejunostomy at the hepatic hilum, combined with intrahepatic cystojejunostomy, appears to be a recommendable procedure for an upstream intrahepatic ductal cyst of type IV-A, preventing postoperative cholangitis owing to bile stone formation.

Choledochal cysts: analysis of disease pattern and optimal treatment in adult and paediatric patients

BACKGROUND

Choledochal cysts are dilations of the biliary tree. Although commonly reported in Asian populations, the incidence outside of Asia is as low as 1:150 000. The largest series of patients with choledochal cyst disease outside of Asia is this one, studying 70 patients treated in Vancouver between 1971 and 2003.

PATIENTS AND METHODS

This was a retrospective chart review.

RESULTS

In all, 19 paediatric and 51 adult patients were evaluated; 21% of paediatric and 25% of adult patients were Asian. All paediatric patients had type I or IV cysts, whereas adult patients represented the different subtypes. Abdominal pain was the presenting symptom in 79% of children and 88% of adults, vomiting was present in 42% of children and 63% of adults and jaundice was seen in 31.5% of children and 39% of adults. Ultrasound was used in 94.7% of children, and ERCP in 80% of adults. In all, 84% of paediatric patients, 100% of adult patients with type I cysts and 85.7% of adult patients with type IV cysts received complete cyst excision and Roux-en-Y hepaticojejunostomy. Complications in both groups were low.

CONCLUSIONS

Although Vancouver does have a large Asian population, this does not explain how common choledochal cysts are in this city. Although some authors argue that paediatric and adult disease are caused by different aetiologies, presentation patterns in our study between the two groups were very similar. We recommend complete cyst excision and Roux-en-Y hepaticojejunostomy as the surgery of choice, and advocate early surgery after diagnosis to promote ease of surgery and prevention of future complications.

Bile duct cyst as precursor to biliary tract cancer

BACKGROUND

Bile duct cysts (BDC) are rare, of uncertain origin, and occur most often in young females of Asian descent. Increasingly, BDCs are reported in the Western population, often with coexistent biliary tract cancer.

METHODS

The PubMed and Medline literature databases were searched for pertinent publications regarding the clinical association and molecular biological development of cancerogenesis in BDC. Reports from the last two decades were emphasized.

RESULTS

Cancer is found in 10-30% of adults with BDC. The cancer-risk is low in childhood (<1% in the first decade), and shows a clear increase with age. Cholangiocarcinoma is the most common malignancy in BDC, and represents a 20- to 30-fold risk compared to the general population. The mean age of malignancy in BDC is 32 years (about two decades earlier than in the general population). Type I and type IV cysts show a higher cancer incidence, even after cyst excision. Pathological findings strongly suggest a hyperplasia-dysplasia-carcinoma sequence in carcinogenesis of pancreatico-biliary maljunction (PBM). Reflux of pancreatic enzymes, amylase, bile stasis, and an increased intraductal concentration of bile acids contribute to proliferative activity of bile acids in BDC. While microsatellite instability, k-ras mutations, expression of COX-2 and bcl-2, and increased telomerase activity seem to occur early; involvement of cyclin D1, beta-catenin, DPC-4/Smad4 and p53 appear later in carcinogenesis.

CONCLUSION

Increased molecular knowledge substantiates the clinically related cancer-risk in BDC. Surgery remains the golden standard for treatment, relieves patients from associated complications, and interrupts the cancerous potential in BDC.

Une forme anatomique exceptionnelle et trompeuse de kyste du cholédoque

The authors report a case of choledocal cyst extended to left and right hepatic ducts. An heterogeneous intracystic fluid, partial calcification of cystic wall, a slight positivity of echinoccosis serology in a patient from a highly endemic country erroneously led to diagnosis of hydatid cyst invading the left hepatic duct. The diagnosis of choledocal cyst was done on the resection specimen after left hepatectomy. A small patch of cyst wall with terminations of both right sectorial hepatic ducts was used for cysto-jejunal Roux-en-Y loop anastomosis. Peculiarities of this type of choledocal cyst are discussed.

Cystic involvement of the roof of the main biliary convergence in adult patients with congenital bile duct cysts: a difficult surgical challenge

BACKGROUND

Complete cyst excision of the extrahepatic disease component with biliary reconstruction on proximal healthy bile ducts is considered to be the treatment of choice in patients with congenital bile duct cysts (BDC). Proximal cystic disease that extends to the roof of the main biliary convergence (MBC) might challenge this standard of surgical care.

METHODS

A retrospective multicenter study was conducted in 4 European surgical centers concerning their experience with adult patients suffering from type I and IV BDC according to the Todani classification. Clinical presentation, operative management, and postoperative outcome were compared between patients with or without proximal extrahepatic cystic disease that involved at least the roof of the MBC (defined as being BDC with MBC involvement subgroup).

RESULTS

From an overall series of 49 adult patients suffering from type I or IV BDC according to the Todani classification, 7 patients had BDC with MBC involvement (14%). Patient age, clinical presentation, duration of symptoms, associated major coexistent hepatobiliary and pancreatic diseases, and synchronous cancer were not significantly different in these patients compared with a control group of 42 adult patients with BDC without MBC involvement. Incomplete proximal cyst excision rate was 86% in the cases of BDC with MBC involvement. Early and late postoperative results were similar in BDC with MBC involvement and in the control group of adult patients, but the incidence of subsequent cancer was significantly higher in the BDC with MBC involvement group (29% vs 0%; P < .02).

CONCLUSION

BDC that involves the roof of the MBC is a real surgical challenge to obtain complete proximal cystic disease excision. As suggested in this small study, primary incomplete excision of this particular form of BDC might expose the patient to the risk of subsequent cancer, a feature that must be confirmed in larger series.

Choledochal cyst in adults: aetiological considerations to intrahepatic involvement

BACKGROUND

Choledochal cysts are rare anomalies of the biliary tree and their presentation in adults is infrequent. The high incidence of associated anomalous pancreaticobiliary duct junction (APBDJ) has been well documented. However, the prevalence of APBDJ in different anatomic distribution of cysts has yet to be clarified.

METHODS

A total 39 adult patients with choledochal cysts were consecutively enrolled: 22 patients had Todani type I cysts, 16 patients had type IVa cysts, and one patient had a type IVb cyst.

RESULTS

No statistical differences were found in age, sex or manifestations. A higher frequency of associated APBDJ was identified in patients with type IVa cyst (100%) than those with type I cyst (P < 0.05). With a mean follow-up of 7.2 years after cyst excision, three patients with type I choledochal cyst and four with type IVa cyst have had episodes of recurrent cholangitis, all accompanied with preoperatively diagnosed APBDJ.

CONCLUSION

Anomalous pancreaticobiliary duct junction has a close relationship with adult choledochal cysts, particularly type IVa. We propose the hypothesis that intrahepatic involvement results from progressive enzymatic destruction. Adult choledochal cysts in association with APBDJ, with or without intrahepatic component, should be carefully monitored.

Bile duct cysts in adults

BACKGROUND

Bile duct cysts are rare and of uncertain origin. Most have been reported in young females of Asian descent, but an increasing number have occurred in Western adults.

METHODS

A Medline literature search was performed to locate articles on the pathophysiological concepts, clinical behaviour and management controversies pertaining to bile duct cysts in adults. Emphasis was placed on reports from the past two decades.

RESULTS AND CONCLUSION

An increasing rate of occurrence of bile duct cyst is reported in adults. Type IV cysts are more frequent in adults than children. Presentation tends to be non-specific abdominal discomfort. Related hepatobiliary or pancreatic disease frequently precedes recognition, and may complicate the postoperative course. Surgical treatment aims to relieve complications deriving from the cysts and to reduce the significant risk of malignant change within the biliary tree. Complete cyst resection, cholecystectomy and Roux-en-Y hepaticojejunostomy reconstruction is standard. Controversy exists about the role of hepatic resection in type IV and V cysts, and the role of minimally invasive and laparoscopic treatment. In general, the outcome is good and a near-zero mortality rate has been reported in institutional series over the past decade.

Experience of congenital choledochal cyst in adults:treatment, surgical procedures and clinical outcome in the Second Affiliated Hospital of Harbin Medical University

This study was undertaken to analyze and evaluate the diagnosis and principal treatment methods for congenital choledochal cyst, focusing on various surgical procedures and clinical outcome. A comprehensive, retrospective study was conducted on 72 adult patients who presented with choledochal cyst from 1985 to 2002. Surgical procedures were cyst excision with hepaticojejunostomy in 25 cases for type I or type IV-B, extrahepatic cyst excision with hepaticojejunostomy in 8 cases for type IV-A, extrahepatic cyst excision with modified hepaticojejunostomy in 2 cases for type IV-B, non-cyst excision with or without hepaticojejunostomy in 27 cases for types I, II, IV-A, IV-B. The early postoperative morbidity and mortality rate were 16.1% (9/62) and 6.5% (4/62) respectively, and the complication rate related to surgical procedure was 30.6% (19/62). The incidence of cholangiocarcinoma with non-cyst excision or non-operated congenital choledochal cyst was 10.8% (4/37). One patient died of primary hepatocellular carcinoma after cyst excision with hepatojejunostomy. In conclusion, our results showed that complete excision of choledochal cyst for types I, II, and IV-B and complete excision of extrahepatic choledochal cyst from the hepatic hilum in type IV-A with hepaticojejunostomy or modified hepaticojejunostomy are the treatment of choice for choledochal cyst in adult patients.

Laparoscopic-assisted total cyst excision of choledochal cyst and Roux-en-Y hepatoenterostomy

PURPOSE

The aim of this study was to describe the technical experience and outcome in laparoscopic-assisted total cyst excision of choledochal cyst with Roux-en-Y hepatoenterostomy.

METHODS

Thirty-five patients with choledochal cyst were studied. Their age ranged from 3 months to 9 years (average age, 3.6 years). The choledochal cysts were cyst type in 33 cases and fusiform type in the other 2 cases. Four trocars were utilized with 3- to 5-mm instrumentation. Under laparoscopic guidance, the gallbladder and the dilated bile duct were excised completely. The Roux-en-Y jejunojejunostomy was performed extracorporeally by exteriorizing the jejunum through the extending umbilical incision (1.5 to 2 cm), and an end-to-side hepaticojejunostomy was carried out intracorporeally by the hand suture methods.

RESULTS

Average duration of operation was 4.3 hours (range, 3.5 to 7.6 hours), intraoperative blood loss was 5 to 10 mL, and 8 of the 35 patients had associated hepatic ductal stenosis and underwent laparoscopic excision of the cyst and ductoplasty. In 1 of the 8 cases, bile leak was noticed from day 1 through 26 postoperatively. The postoperative course was uneventful in the other 34 patients with a hospital postoperative stay ranging from 3 to 6 days. There were no postoperative complications in the 3-month to 1(1/2)-year follow-up.

CONCLUSIONS

Laparoscopic-assisted total cyst excision with Roux-en-Y hepatoenterostomy is feasible for the treatment of choledochal cyst in children.

Choledochal cysts in pregnancy: Case management and literature review

AIM: To evaluate the diagnosis, management principles and long-term results of congenital choledochal cysts in pregnancy.

METHODS: Three adult patients were diagnosed as choledochal cysts in pregnancy from 1986 to 1989 and their long-term results were evaluated.

RESULTS: The first patient had a Roux-en-Y cysto-jejunostomy with T-tube external drainage and died of septic shock and multi-organ failure 25 d after operation. In the second patient, 4 wk after percutaneous trans-choledochal cyst was drained externally with a catheter under US guidance, four weeks later the patient delivered vaginally, and had a cysto-jejunostomy 3 mo after delivery, and lived well without any complications for 15 years after operation. The third patient received Roux-en-Y cysto-jejunostomy after a vertex delivery by induced labor at 28 wk gestation, and demonstrated repetitively intermittent retrograde cholangitis within 10 years, and then died of well-differentiated congenital cholangioadenocarcinoma one month after re-operation with exploratory biopsy at the age of 36.

CONCLUSION: More conservative approaches such as external drainage of choledochal cyst should be considered for pregnant patients with high risk, complete excision of choledochal cyst during hepaticojejunostomy or modified hepaticojejunostomy is highly recommended at the optimal time.

Potential diagnostic value of pancreatic isoamylases for pancreaticobiliary maljunction with mild biliary dilatation in patients and a porcine model

PURPOSE

The aim of this study was to evaluate the diagnostic value of serum pancreatic isoamylases for pancreaticobiliary maljunction (PBM) with mild biliary dilatation.

METHODS

Serum and bile from 8 children with PBM and mild biliary dilatation (6 to 11 mm in diameter) and 4 young pigs with an anastomosis constructed between an isolated pancreas-duodenal segment and the gallbladder were studied for pancreatic isoamylases. Using an electrophoretic technique, the assay of pancreatic isoamylases was expressed by peak appearance rate (PAR). Serum from 20 healthy children served as normal controls.

RESULTS

In the serum of the patients, preoperatively there were 5 pancreatic peaks with PAR as follows: P1, 100%; P2, 100%; P3, 100%; P4, 100%; and P5, 66.7%. These abnormal pancreatic isoamylases disappeared 2 weeks after operative treatment. In normal controls, there were only P1 (PAR, 40%) and P2 (PAR, 100%). Mild cylindrical dilatation (6 to 8 mm in diameter) of the common bile duct developed in the porcine PBM model. There were P1 (PAR, 100%) and P2 (PAR, 100%) in the porcine serum preoperatively. Thirty days and 60 days after establishing the model, there appeared in the serum 6 pancreatic peaks with PAR as follows: P1, 100%; P2, 100%; P3, 75%; P4, 100%; P5, 100%, and P6; 75%. The bile patterns of pancreatic isoenzymes in the patients and pigs were similar to those in serum.

CONCLUSIONS

Abnormal pancreatic isoamylases are characteristically present in the serum from both children and a porcine model of PBM and mild biliary dilatation. Assay for these abnormalities is promising to recognize this subset of patients in whom diagnosis remains a challenge.

Development of intrahepatic biliary stones after excision of choledochal cysts

BACKGROUND

The incidence of intrahepatic cholelithiasis and cholangitis has not yet been well studied postoperatively in patients with choledochal cysts.

METHODS

One hundred three patients with choledochal cysts had operative cholangiography, underwent standard excision of a choledochal cyst with Roux-en-Y hepatico-jejunal anastomosis, and were at a mean follow-up of 12 1/2 years. The incidence of intrahepatic bile duct stones was analyzed according to the 3 morphologic types of intrahepatic bile duct observed at initial operative cholangiography: type 1, no dilatation of the intrahepatic bile ducts; type 2, dilatation of the intrahepatic bile ducts but without any downstream stenosis; and type 3, dilatation of the intrahepatic bile ducts associated with downstream stenosis. Initially, there was no evidence of intrahepatic bile duct stones in any of the 103 patients.

RESULTS

Among 50 type 1 patients, intrahepatic cholelithiasis developed in only 1 patient (2%). Among 43 type 2 patients, 1 patient (2%) had intrahepatic cholelithiasis, and 2 (5%) had postoperative cholangitis. Among 10 type 3 patients, 4 (40%) had intrahepatic cholelithiasis (P <.01), and 3 (30%) had postoperative cholangitis. Time intervals between the initial surgery and the first identification of intrahepatic stones ranged from 3 to 22 years.

CONCLUSIONS

One of the major causes of formation of intrahepatic cholelithiasis has been clarified; patients with intrahepatic biliary dilatation with downstream stenosis can get intrahepatic bile duct stones long after excision of a choledochal cyst.

Congenital biliary dilatation

Congenital biliary dilatation is commonly associated with pancreaticobiliary malunion. Its etiology remains unknown. With the advent of accurate cholangiography, combined abnormalities of the intrahepatic duct, common channel, and pancreatic duct are being identified more frequently in patients with congenital biliary dilatation. Early diagnosis followed by cyst excision is the treatment of choice, even in asymptomatic cases. The treatment of intrahepatic and intrapancreatic ductal diseases such as intrahepatic duct dilatation and stone debris in the intrahepatic duct and common channel are also discussed. The value of intraoperative endoscopy as an adjunct to cyst excision for the prevention of postoperative complications is explained.

Left Hepatic Lobectomy for Type IV-A Choledochal Cyst

We report a case of a 37-year-old woman who was diagnosed with a type IV-A choledochal cyst with intrahepatic bile duct strictures. Because the stricture in the medial segment was located too far from the hilum for a hepaticojejunostomy we performed a left hepatic lobectomy. In this report we evaluate the therapeutic benefit of hepatectomy in a patient with a type IV-A choledochal cyst involving the intrahepatic bile ducts.

Choledochal cysts in adults: a report of two cases and review of the literature

A choledocal cyst is a dilation of some component of the biliary tract that may include both intra- and extra-hepatic sites. They are classified into six types, all of which are relatively rare. Previously, choledochal cysts were treated with biliary-enteric bypass procedures. The current recommendation is to attempt complete excision to minimize the known risk of malignancy and the development of recurrent cholangitis or pancreatitis that may occur in patients with these cystic lesions. Two cases are discussed in which type I choledochal cysts presented. One was removed from a 31-yr-old man who presented with vague abdominal complaints the other from a 32-yr-old man who presented with pancreatitis. The epidemiology, diagnosis, surgical treatment, and risk of cancer in choledochal cysts is described.