Management of adult choledochal cysts

Choledochocele with hyperplastic epithelium in a patient who developed severe acute pancreatitis and underwent subtotal stomach-preserving pancreatoduodenectomy: a case report

Choledochocele is defined as a congenital dilatation of the distal intramural part of the common bile duct protruding into the wall of the descending duodenum, typically without pancreaticobiliary maljunction. However, some cases present with a similar pathophysiology to pancreaticobiliary maljunction, including reciprocal reflux of pancreatic juices and bile, leading to protein plugs, pancreatitis, and biliary tract carcinogenesis. Choledochocele is relatively rare and its anatomy, physiology, pathology, and clinical features are thus not well known. We describe a patient with choledochocele who suffered from repeated severe acute pancreatitis and underwent subtotal stomach-preserving pancreatoduodenectomy, in whom the pathological findings of choledochocele showed hyperplasia.

Diagnosis and management of choledochal cysts

BACKGROUND

Choledochal cysts (CCs) are rare cystic dilatations of the intrahepatic and/or extrahepatic bile ducts. We review the pathophysiology, diagnosis, and management of CCs.

METHODS

MEDLINE/PubMed and Web of Science databases were queried for "choledochal cyst", "bile duct cyst", "choledochocele", and "Caroli disease". Data were synthesized and systematically reviewed.

RESULTS

Classified according to the Todani Classification, CCs are generally believed to arise secondary to reflux of pancreatic enzymes into the biliary tree due to anomalous pancreaticobiliary duct union. Complications of CCs include abdominal pain, jaundice, cystolithiasis, cholecystitis, pancreatitis, liver abscess, liver cirrhosis and malignant transformation (3-7.5%). Radiological and endoscopic imaging is the cornerstone of CC diagnosis and full delineation of cyst anatomy is imperative for proper management. Management is generally guided by cyst classification with complete cyst excision necessary for CCs with high potential of malignant transformation such as types I and IV. 5-year overall survival after choledochal cyst excision is 95.5%.

CONCLUSION

Most CCs should undergo surgical intervention to mitigate the risk of cyst related complications such as cholangitis and malignant transformation.

Choledochal cysts in children: How to Diagnose and Operate on

OBJECTIVE

To identify the best mode for diagnosing and treating the patients with choledochal cysts.

METHODS

A retrospective study was performed with medical records of patients diagnosed with choledochal cysts from January 1994 to December 2017. In all cases, the diagnosis was based on ultrasound examination. All the patients underwent cyst resection and were divided in two groups: bile enteric anastomosis in the high portion of the common hepatic duct or in the dilated lower portion.

RESULTS

Eighty-one cases were studied. The age of presentation was 4 y 2 mo ± 4 y 1 mo, and the age for the surgical treatment was 5 y 5 mo ± 4 y 6 mo. In 61 cases, US was the only image examination performed. There were 67 cases of Todani type I (82.7%), 13 cases of type IV (16.0%) and one case of type III (1.2%). Nine patients (29.0%) in the first period and 2 patients (4.0%) in the second period presented with postoperative complications (p=0.016).

CONCLUSION

In patients with choledochal cysts, US is the only necessary diagnostic imaging. Performing the bile enteric anastomosis in the lower portion of the common hepatic duct is safer and has a lower risk of complications.

Preoperative Ultrasound Assessment of Choledochal Cysts

Ultrasonography performed with modern equipment is capable of outlining the anatomy of the biliary and pancreatic ducts within the head of the pancreas. We present two typical cases of choledochal cysts where ultrasound provided complete anatomic information and a more complicated case which required more extensive radiology.

Impact of previous cyst-enterostomy on patients’ outcome following resection of bile duct cysts

AIM: To analyze the impact of previous cyst-enterostomy of patients underwent congenital bile duct cysts (BDC) resection.

METHODS: A multicenter European retrospective study between 1974 and 2011 were conducted by the French Surgical Association. Only Todani subtypes I and IVb were included. Diagnostic imaging studies and operative and pathology reports underwent central revision. Patients with and without a previous history of cyst-enterostomy (CE) were compared.

RESULTS: Among 243 patients with Todani types I and IVb BDC, 16 had undergone previous CE (6.5%). Patients with a prior history of CE experienced a greater incidence of preoperative cholangitis (75% vs 22.9%, P < 0.0001), had more complicated presentations (75% vs 40.5%, P = 0.007), and were more likely to have synchronous biliary cancer (31.3% vs 6.2%, P = 0.004) than patients without a prior CE. Overall morbidity (75% vs 33.5%; P < 0.0008), severe complications (43.8% vs 11.9%; P = 0.0026) and reoperation rates (37.5% vs 8.8%; P = 0.0032) were also significantly greater in patients with previous CE, and their Mayo Risk Score, during a median follow-up of 37.5 mo (range: 4-372 mo) indicated significantly more patients with fair and poor results (46.1% vs 15.6%; P = 0.0136).

CONCLUSION: This is the large series to show that previous CE is associated with poorer short- and long-term results after Todani types I and IVb BDC resection.

Isolated cystic duct cyst with associated stones in a 4-month-old boy

Isolated cystic duct cysts are rare entities, with few cases having been reported. We present the case of a 4-month-old male patient presenting with abdominal pain and vomiting. Ultrasonography and magnetic resonance cholangiopancreatography revealed an isolated cystic duct cyst with associated stones. The patient underwent open cholecystectomy with complete cyst excision and cystic duct transection; there were no postoperative complications. While lesions like the one described herein are extremely rare, they should be included as a separate category in classifications of choledochal cysts.

Choledochal Cyst Mimicking Gallbladder with Stones in a Six-Year-Old with Right-sided Abdominal Pain

Choledochal cysts are rare but serious bile duct abnormalities are found in young children, usually during the first year of life.1 They require urgent surgical intervention due to the risk of developing cholangiocarcinoma.2 Clinicians should consider this diagnosis and perform a point-of-care ultrasound (POCUS) when a child presents to the emergency department (ED) with findings of jaundice, abdominal pain, and the presence of an abdominal mass. We present the case of a six-year-old child presenting only with abdominal pain upon arrival to our ED and was ultimately diagnosed by POCUS to have a choledochal cyst.

Spontaneous choledochal cyst rupture in pregnancy with concomitant chronic pancreatitis

Choledochal cysts are rare cystic transformations of the biliary tree that are increasingly diagnosed in adult patients. We report here a case of spontaneous rupture of a choledochal cyst in a pregnant young lady with chronic pancreatitis.

A new variant of Todani type I choledochal cyst. Imaging evaluation

BACKGROUND AND AIM

Choledochal cysts are congenital segmental aneurysmal dilatations of any portion of bile ducts, most commonly of the main portion of the common bile duct. The classification system of choledochal cysts is based on the site of the cyst or dilatation and currently includes 5 major types. The purpose of our study is to describe the imaging findings of a new variant of choledochal cyst.

MATERIALS AND METHODS

Six patients (4 children and 2 adults, 4 females and 2 males, 3-67 year old) were evaluated by US, CT, CT-cholangiography, MRI, magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP), because of jaundice, abdominal pain and a palpable mass.

RESULTS

A new type of choledochal cyst was demonstrated in all cases. In this new variant apart from the dilatation of the common hepatic and the common bile duct, dilatation of the central portion of the cystic duct was also observed, giving a bicornal configuration to the cyst.

CONCLUSION

The imaging findings of a new variant of choledochal cyst with participation of the cystic duct are described. We propose the classification of this type of choledochal cyst as a new subtype of Todani I cyst, namely Todani ID.

Smallest Todani's type II choledochal cyst

A choledochal cyst is defined as an isolated or combined congenital dilation of the extra hepatic or intrahepatic biliary tree. Todani and colleagues proposed the five types of congenital choledochal cysts which have gained widespread acceptance. Type II choledochal cyst, a diverticulum of common bile duct, is rarest, and most reported cases of Type II were as large as several centimeters in size. We herein report the case of a small Type II choledochal cyst which was resected at pancreatoduodenectomy for carcinoma of the papilla of Vater. A 58-year-old Japanese male was referred to our hospital for the evaluation of jaundice. Preoperative cholangiogram via the percutaneous transhepatic biliary drainage tube revealed a complete obstruction at the narrow terminal segment. Furthermore, a small diverticular protrusion was demonstrated on the lower part of the common bile duct. The resected specimen showed a 2.2 x 1.7 x 1.2 cm carcinoma of the major papilla, and a deep, 2 mm in diameter and 5 mm in depth, depression on the posterior wall of the common bile duct. The anomalous pancreatobiliary duct was not seen. The deep depression was confirmed microscopically to penetrate the fibromuscular layer of the common bile duct and diagnosed as a Todani's Type II choledochal cyst. To our knowledge, the current case is the smallest Type II choledochal cyst which was completely resected.

Choledochal cysts in adults and their complications

BACKGROUND

Despite refinements in the management of choledochal cysts in children, an increasing number of patients present with ongoing symptoms in adult life. The aim of this study was to review the management of adult patients with choledochal cysts in a tertiary referral centre.

METHOD

A retrospective review was carried out of all adult patients presenting with choledochal cysts to this department between 1992 and 2000. Patient records were reviewed and detailed analyses were made of the clinical presentation, radiological and biochemical findings, anatomical anomalies, management, complications and outcomes.

RESULTS

Of 16 patients (12 women and 4 men; median age 23 years), 8 had undergone previous upper gastrointestinal operations before referral, including 5 who had had previous cyst drainage procedures. All patients underwent elective complete cyst excision with Roux-en-Y hepaticojejunostomy. There were no operative deaths and there was a low early postoperative morbidity rate (25%). There was no evidence of biliary malignancy in any cyst. During a median postoperative follow-up of 44 months, five patients (31%) continued to experience cholangitis and two of these required additional revisional procedures, but are now symptom-free.

CONCLUSION

Patients with choledochal cysts should be referred to specialised tertiary surgical units. Total choledochal cyst excision with Roux-en-Y hepaticojejunostomy is the treatment of choice. Patients with previous inadequate cyst excisional procedures should undergo revisional surgery, to reduce recurrent symptoms and the risk of developing cholangiocarcinoma.

Choledochocele demonstrated by computed tomographic cholangiography: report of a case

Choledochocele is a rare cystic congenital malformation of the distal common bile duct, the precise pathogenesis of which remains unclear. It is usually diagnosed in adulthood after many examinations for unclear digestive symptoms, as in the patient whose case is described herein. Of all the diagnostic techniques available, endoscopic retrograde cholangiography (ERCP) seems to be the best; however, it is an invasive procedure associated with some morbidity. Spiral computed tomographic cholangiography with three-dimensional reconstruction is also an interesting screening technique. Malignant transformation of a choledochocele occurs very rarely, compared with other cystic malformations of the biliary tract. If a choledochocele is small and symptomatic, the lesion can be treated by endoscopic sphincterotomy, but larger cysts are more effectively removed by a surgical cystoduodenostomy. We present herein the case of a 25-year-old woman admitted to our hospital in March 1998 with upper right quadrant abdominal pain caused by a choledochocele, who was successfully treated by a cystoduodenostomy.

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.

Cystic dilatation of the common bile duct in adults: report of five cases and review of literature

The authors report five cases of cystic dilatation of the common bile duct Type I (Todani’s classification) in adults patients, in Division of General Surgery of a University Hospital, treated over a- 25-year- period from 1974 to 1999, among 16.057 operations, and not previously published. Diagnosis was obtained by operative cholangiogram (OC) in the first case, percutaneous transhepatic cholangiogram on the second one (PTHC) and by ultrasonography (US), endoscopic retrograde cholangiopancreatography (ERCP), and operative cholangiogram (OC), respectively, on the last three cases. The second patient had an adenocarcinoma arising in the cystic wall associated with peritoneal metastasis. The first two cases were treated by internal drainage and the last three by excision of the cysts and bilioenteric anastomoses. Classification, incidence, etiology, diagnosis, malignization and surgical treatment of biliary cystic disease (BCD) were revised, with the conclusion that resection must be the preferable method of treatment, when possible, especially due to the concern of malignization.

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.

Early and late results of excision of choledochal cysts

BACKGROUND/PURPOSE

Reports on the late results of choledochal cyst excision with hepaticojejunostomy in children are relatively few.

METHODS

Of the 84 patients who had choledochal cyst who came under our care, 79 have had definitive surgery, three are awaiting surgery, one is being observed with Caroli's disease, and the parents of one child have refused surgery. Thirty-eight patients treated decades ago had internal drainage procedures. Since 1972, 41 patients have had cyst excision with hepaticojejunostomy using a 40-cm Roux loop without an antireflux procedure. Early complications in those who underwent cyst excision with hepaticojejunostomy included anastomotic leak in three patients who required reoperation, cholangitis in two, and fluid collection in the gall-bladder bed that required no intervention in one.

RESULTS

During a follow-up period ranging from 4 months to 17 years (mean, 8.5 years), anastomotic stricture, cholangitis, and intrahepatic stone formation developed in two children after being well for 8 years and over 11 years. These children required additional surgical procedures to overcome their problems. Asymptomatic intrahepatic stones 2 years after cyst excision with hepaticojejunostomy developed in a third child. There was no mortality in the entire group that underwent cyst excision and they are all enjoying a good quality of life.

CONCLUSIONS

Careful, long-term follow-up is important in children who have choledochal cyst excision with hepaticojejunostomy.

Reoperative surgery for choledochal cysts

BACKGROUND

Complications often follow if a choledochal cyst is treated simply by drainage, either internal or external. This study reviews 17 patients who had had previous cystoenterostomy (n = 9) or external drainage (n = 8) and who required reoperation and cyst excision.

METHODS

The study was a retrospective review including ten women and seven men managed over 9 years. The indications for reoperation were stone formation (10 patients), pancreatitis (three), portal hypertension (two) and hepatic abscess (one); two patients were asymptomatic.

RESULTS

Definitive surgery with cyst excision was possible in all patients who had previously had external cyst drainage and in seven of nine who had had previous cystoenterostomy. There were no deaths. Two postoperative biliary leaks and two duodenal fistulas resolved spontaneously.

CONCLUSION

Excision of a choledochal cyst is possible and desirable even after a previous drainage operation. In severely ill patients with a complication of choledochal cyst, external drainage may be a preferable initial manoeuvre.

Acute pancreatitis complicating pregnancy in a patient with co-existing choledochal cyst

Choledochal cyst, although more common in females than in males, has only rarely been encountered in association with pregnancy. A 29-year-old nulliparous woman at 32nd week gestation was diagnosed as acute pancreatitis with co-existing type l choledochal cyst. Resection of the choledochal cyst was performed and a Roux-en-Y hepatico-jeunostomy was carried out to provide biliary drainage. Although the preferred management of a choledochal cyst is excision and Roux-en Y reconstruction, this may have to be deferred until after delivery, depending on gestational age, because of the risk of fetal mortality and maternal morbidity that is associated with this procedure.

Pancreaticobiliary maljunction without choledochal cysts in infants and children: clinical features and surgical therapy

Pancreaticobiliary maljunction (PBM) usually is associated with choledochal cyst. PBM without dilatation of the common bile duct is rare in infants and children. This rare type of the anomaly may lead to the development of malignancy of the bile duct in later life. The authors report the clinical presentation and surgical treatment of seven pediatric patients with PBM. Symptoms and signs included repeated episodes of abdominal pain (7 of 7), nausea and vomiting (6 of 7), intermittent jaundice (3 of 7), and acholic stools (2 of 7). Some patients presented with high levels of serum and urinary amylase. These symptoms and signs might have been related to the temporary obstruction of bile flow in the common channel, where endoscopic retrograde cholangiopancreaticography (ERCP) disclosed a protein plug in four of the patients. The common bile duct proximal to the junction of the main pancreatic duct was excised, and a Roux-en-Y hepaticojejunostomy reconstruction was performed. To prevent iatrogenic injury of the main pancreatic duct, repeat cholangiography was performed with the aid of radiopaque silver clips placed on the line of dissection to evaluate the distance between the site of dissection and the main pancreatic duct. All patients have been free of symptoms since the surgery. PBM without dilatation of the common bile duct can be detected more frequently if ERCP is performed on every patient who has repeated episodes of abdominal pain refractory to conventional therapy. Complete excision of the common bile duct and gallbladder followed by hepaticojejunostomy is recommended for PBM, while the goals of decreasing the high risk of carcinoma of the bile duct and preventing recurrent symptoms.

Choledochal cyst in the adult

OBJECTIVE

The authors examined the natural history of choledochal cysts in adults treated surgically.

BACKGROUND

An initial diagnosis of choledochal cyst is uncommon in adults. The recommended treatment is excision, rather than bypass, to achieve effective biliary drainage and because of the risk of cancer.

METHODS

A retrospective study of 27 adult patients was completed to determine the frequency of anastomotic complications and the incidence of cancer.

RESULTS

Fifteen patients were treated by cyst excision, and one developed an anastomotic stricture, treated by percutaneous dilation. Eight of 11 patients treated by cyst enterostomy required additional surgery for anastomotic revision. A final patient was treated by T-tube drainage. Five of the seven patients with cancer have died at a mean of 21.6 months.

CONCLUSION

This experience documents the high incidence of cancer (26%), and high rate of stricture after cyst enterostomy (73%). The dismal prognosis once cancer has developed warrants cyst excision, even in asymptomatic patients, including those with prior cyst enterostomies.

Choledochal cysts in adults

Fourteen adults who presented with choledochal cysts were studied. Symptoms in most cases were non-specific, which resulted in delayed diagnosis. Associated extracystic hepatobiliary disease occurred in 11 patients, including two with cholangiocarcinoma. Nine patients underwent total cyst excision (eight Todani classification type I and one type II), while four with type IVa cysts had excision of the extrahepatic cyst component. There were no surgical deaths. One patient with metastases was treated conservatively. Median follow-up was 6.5 years. Two of three patients who developed anastomotic strictures underwent successful revision surgery, while one with secondary sclerosing cholangitis developed biliary cirrhosis and died from hepatic failure after 8 years. Both patients with cholangiocarcinoma have died. Ten survivors are well and one patient was lost to follow-up. This study highlights the complexity of choledochal cysts in adults and emphasizes the need for earlier diagnosis and treatment. Cyst excision should be performed where possible, with reconstruction modified to deal with the cyst type as well as associated hepatobiliary pathology.

Surgical management of choledochal cysts

Choledochal cysts are an unusual cause of biliary obstruction with up to 85% of reported cases being of the type I variety, that is, fusiform dilations of the common bile duct. Recommended management of this type I cyst is complete surgical excision; however, difficulties arise in type IVa cysts when the cystic dilation extends up into the intrahepatic biliary tree. The purpose of this study is to review the management of choledochal cysts with particular reference to the type IVa variety. Statistical analysis of outcome differences was undertaken using Fisher's exact test. A total of 23 consecutive patients with choledochal cysts seen at our institution in a 5-year period were reviewed: 8 patients had type I cysts, 1 patient had a type III cyst, and 14 patients had type IVa cysts. All type I cysts underwent complete cyst excision with hepaticojejunostomy and modified Houston loop formation. Of 14 patients with type IVa cysts, 13 underwent complete excision of the extrahepatic portion of the cyst with hepatico- and cystojejunostomy and modified Hutson loop formation. One patient required hepatic lobectomy. With a mean follow-up of 33 months, 4 patients with type IVa choledochal cyst have had episodes of recurrent cholangitis, with access to the library tree being achieved via the Hutson loop in 3 of the 4 patients. Three of these cases represented anastomotic strictures that were treated nonoperatively. We concluded that recurrent cholangitis and anastomotic stricture after resection of type IVa choledochal cysts is frequent and recommend Hutson loop formation at the time of primary resection.

Choledochal cysts: a nine-year review

Hospital records of 24 Chinese infants and children (7 males and 17 females) with choledochal cysts were reviewed. The patients were aged 1 day to 17 years. Abdominal pain, palpable abdominal mass and jaundice, either alone or in combination, accounted for most of the initial presentations. Twenty-two patients were classified as type I with surgery, while the other two patients were type V without surgery. Ultrasonography is a rapid and accurate diagnostic method in the initial evaluation. Cyst excision with Roux-en-Y hepaticojejunostomy was the treatment of choice in this series. Chronic cholecystitis with or without inflammation of choledochal cyst was the most common pathological finding. Five patients underwent liver biopsies, showing four biliary cirrhosis and one portal fibrosis. So far, there is no evidence of malignancy in any patient.

Surgical management and long-term follow-up of patients with choledochal cysts

The medical records of 46 patients treated for choledochal cysts at Kyushu University from 1965 to 1990 were reviewed, and long-term follow-up results were evaluated based on the type of cyst and on the choice of surgical procedure. Of 46 patients, 41 (89%) were female and 5 (11%) were male, with a mean age of 24 years at the time of the initial operation. Seventy-eight percent of patients presented with an abdominal pain, 43% with jaundice, and 33% with an abdominal mass. Only seven patients (15%) presented with the classic triad. According to the Todani classification system, 26 patients (57%) had type I cysts, 2 (4%) had type II, and 18 (39%) had type IV. Four patients (9%) had biliary tract carcinoma. At the time of the initial operation, the major associated diseases were cholangitis in 15% and choledocholithiasis in 26% of cases. In 24 patients who had undergone previous cyst enterostomy, cholangitis developed in 88%, choledocholithiasis in 25%, and hepatolithiasis in 33% of patients, indicating a high complication rate after cyst enterostomy. Seventy percent of these patients needed reoperation. In contrast, cyst excision with Roux-en-Y hepaticojejunostomy gave excellent long-term results. Thus, cyst excision with hepaticojejunostomy is the definitive treatment of choice for type I and IV choledochal cysts.

Cholangiocarcinoma in a type III choledochal cyst

We present the case of an 85 year old woman who was found to have a type III choledochal cyst with cholangiocarcinoma. The case is unusual because of the advanced age of the patient, the presence of both stones and a carcinoma in a type III cyst, and the associated congenital abnormalities.

Variation in management based on type of choledochal cyst

The management of 23 patients treated for choledochal cysts at the Oregon Health Sciences University between 1969 and 1990 is reviewed. The median age was 27 years, with a range from 1 month to 90 years. Seventy-eight percent of patients presented with abdominal pain, and 35% were jaundiced. Three patients presented with cholangitis, two with cyst rupture, and one with recurrent pancreatitis. Nine patients had had previous biliary surgery. The diagnosis was made in all patients with ultrasound and/or cholangiography. Fifteen patients (65%) had type I cysts, 2 had a type II cyst, 5 (22%) had type III cysts, and 1 had a type IV cyst. Stones were present in four (17%) cysts, and all excised cysts were benign. Seventeen patients with type I and II choledochal cysts had complete cyst excision and choledochoenterostomy. Four of five patients with type III cysts had endoscopic cyst incision and drainage, while the fifth patient had transduodenal cyst excision and sphincteroplasty. The patient with a type IV cyst had extrahepatic cyst excision and choledochojejunostomy. There were no operative deaths. Two postoperative complications occurred: cholangitis and a prolonged ileus. All patients had resolution of their pain and jaundice. Two patients had late cholangitis. Cyst excision and choledochojejunostomy are the treatment of choice for types I and II choledochal cysts. Extrahepatic cyst excision and choledochojejunostomy may be adequate treatment for type IV cysts. Endoscopic incision and drainage is appropriate for selected patients with type III cysts.

Bile duct cysts in adults. Pitfalls in diagnosis and management

Six women have been referred to us for treatment of bile duct cysts during the past 6 years. In three patients the disorder was misdiagnosed by the referring institution, and they were admitted because of continuing severe symptoms; two of them had been treated with internal drainage procedures which led to unnecessary treatment delay and complications. Two patients had developed cyst carcinoma, the most feared complication of cyst disease. It is concluded that clinical symptoms are nonspecific, and the diagnosis is only ascertained after complete cholangiographic imaging of the biliary tree. Primary cyst excision and hepaticojejunostomy is the treatment of choice.

Occult carcinoma in an adult choledochal cyst

The complications of choledochal cyst are avoidable if diagnosed early, and adequate resection undertaken. This case report describes the long history of right subcostal pain in a young man of 26 who had a squamous carcinoma in a choledochal cyst diagnosed after serial section of the excised cyst. Subsequent resection of the head of the pancreas showed histological residual tumour from which he died 4 months later. This case illustrates the need for complete early excision of a choledochal cyst to prevent this complication.

Intestinal intussusception as a presenting feature of choledochocele

Choledochocele is a rare form of choledochal cyst [1, 2]. Usually, it manifests clinically with epigastric pain of colic type, jaundice, and/or pancreatitis. Occasionally, a palpable mass may be found. We describe two cases of intestinal intussusception as a presenting feature of choledochocele.

Complications of choledochal cysts in adulthood

Choledochal cyst is a well-recognised entity, presenting primarily in infants and young children. Where symptoms are delayed until adulthood, associated hepatobiliary pathology may complicate the presentation. These problems may be aggravated by previous treatment with bypass surgery rather than resection. We report seven cases from our recent experience presenting with complications in adulthood. These included cholangitis, hepatic abscess, pancreatitis and malignancy within the cyst. Two patients presented during pregnancy. These complications and their implications for management are discussed.

Surgical treatment of congenital dilatation of the bile duct with special reference to late complications after total excisional operation

The surgical treatment of 100 cases with congenital dilatation of bile duct with special reference to late complications was analyzed. There were no deaths nor occurrences of malignancy. Among 91 patients who had undergone the standard operation, namely total excision of the dilated extrahepatic bile duct and reconstruction after Roux-en-Y hepaticojejunostomy, there were one early complication (pancreatic juice leakage) and five late complications (four intrahepatic gallstones and one liver abscess). The cause of intrahepatic gallstone formation after a total excisional operation was attributed to the remaining intrahepatic bile duct dilatation and the stenosis located between the intrahepatic bile duct dilatation and the common hepatic duct. Accordingly, these results support the total excisional procedure for this condition; however, with regard to the cases associated with cystic dilatation of intrahepatic bile ducts, completely free bile drainage from the dilated intrahepatic biliary system should be performed at the radical operation.

Endoscopic biliary manometry in patients with suspected sphincter of Oddi dysfunction and in patients with cystic dilatation of the bile ducts

We studied the motility of the sphincter of Oddi in 12 patients with suspected sphincter of Oddi dysfunction, in four patients with cystic dilatation of the bile ducts (two Caroli's cases and two fusiform choledochal cyst cases), and in 33 patients with retained common duct stones. In these last 33 patients, the motor activity of the sphincter of Oddi was similar to that recorded in nine control subjects without pancreatic or biliary diseases. In the suspected Oddi dysfunction cases, both the basal sphincteric pressure and the frequency of the phasic contractions were significantly elevated (P less than 0.001). Patients with biliary cystic dilatation showed an increased basal pressure, but the frequency of the contractions was elevated in only those with choledochal cysts and the amplitude in only one of the two patients with Caroli's disease. Motor disorders of the sphincter of Oddi provide a basis for an alternative etiopathogenesis of cystic disease of the biliary system and a possible explanation for pain and dilatation of the bile duct in patients with suspected sphincter of Oddi dysfunction.

Choledochocoele complicated by carcinoma

A choledochocoele may rarely cause obstructive jaundice. A case is described that was initially diagnosed by ultrasound and subsequently found to be associated with an ampullary carcinoma. To the best of our knowledge, only one other such case has previously been recorded.

Choledochal cyst: case reports and current concepts

Choledochal cyst is an unusual but serious condition which most commonly affects Oriental people. Recent experience of three patients with this condition in whom diagnosis was made by ultrasound examination is reported. Cholangiography (ERCP or PTC) was performed in two of the cases to define the anatomy. All three cases were successfully managed by cyst excision and biliary reconstruction by Roux-en-Y hepaticojejunostomy. The rationale for and importance of cyst excision are discussed.

Choledochal cyst: a 33-year review

We present 13 patients who were seen at Glasgow hospitals over a 33-year period. Only five (38 per cent) were children. Of the eight adults, two had complications of the cyst at presentation, namely biliary cirrhosis and cholangiocarcinoma respectively. Another adult patient developed a carcinoma in the cyst 9 years after internal drainage. The incidence of malignant change in the series was therefore 15 per cent. Only five patients have remained well after surgery: three had complete excision and two internal drainage. Of the eight other patients, one had complete excision, five had internal drainage, one had partial excision and one had cholecystectomy and (years later) sphincterotomy. We believe that excision of the cyst is the treatment of choice.

Reoperation for congenital choledochal cyst

A reoperation after excisional procedure was carried out in seven cases due to early or late postoperative complications. Of the 12 patients with early complications, four underwent relaparotomy due to anastomotic leakage and bleeding. Late complications were seen in nine patients with recurrent cholangitis caused by an anastomotic stricture, and three patients with intrahepatic involvement required a reoperation several years after the initial surgery. Recurrent cholangitis after biliary reconstruction mainly occurs due to an anastomotic stricture of the hepaticoenterostomy. There was no significant difference in the results between hepaticoduodenostomy and hepaticojejunostomy over a long follow-up period. A wide anastomotic stoma that permits free drainage of bile into the intestine is imperative to the prevention of cholangitis, and can be created by an incision extending along the lateral wall of both the hepatic ducts with a hepaticoenterostomy at the hilum. This procedure is obviously necessary in all patients with or without intrahepatic involvement. Carcinoma of the intrahepatic ducts and the retained distal choledochus have rarely developed in patients undergoing cyst excision followed by biliary reconstruction. Complete excision of the whole extrahepatic bile duct could prevent carcinoma arising in the distal choledochus, although it could not prevent carcinoma arising from the intrahepatic ducts. However, patients with carcinoma of the intrahepatic duct were reported to have had symptoms of biliary stricture for a long time since the cyst excision. Bile stagnation in the intrahepatic ducts is possibly responsible for the development of carcinoma. A wide anastomosis resulting in free drainage of bile appears to be essential to the prevention of carcinoma arising in the intrahepatic ducts after cyst excision.

Emergency management of choledochal cysts in adult patients

Congenital cystic dilation of the biliary tree is rarely considered as cause of cholangitis in the adult patient. Emergency operation in seven adults with unsuspected choledochal cysts resulted in reoperation in all seven. Each patient presented with right upper quadrant pain, a mass, and cholangitis or jaundice. Abdominal ultrasonography incorrectly identified the cyst as a dilated gallbladder in three of the patients. All initial emergency drainage procedures required subsequent modification to cyst excision and Roux-Y reconstruction. From review of the experience presented and the literature to date, we recommend that otherwise stable patients be managed nonsurgically and undergo endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography to plan primary single-stage excisional operation. Patients requiring emergency decompression should have cholecystostomy or choledochostomy for good control without compromising subsequent operation. At the time of excision, a technical consideration not previously reported is the presence of small daughter cysts in Calot's triangle which must be distinguished from the hepatic bile ducts. The surgical literature has frequently addressed the problems of elective surgery for choledochal cysts; however, emergency complications requiring urgent operative intervention are seldom addressed. We believe emergency intervention should correct the urgent complication without compromising the definitive surgical treatment.

Endoscopic management of choledochocele. A case report and review of the English literature

Choledochocele or type III choledochal cyst is a rare lesion of the biliary tree. It may be of acquired or congenital etiology and can assume one of two anatomic variants. Either the common bile duct and the pancreatic duct enter the choledochocele together, or it is formed by the common bile duct alone with the pancreatic duct entering as a separate opening. The most frequent presenting symptoms are abdominal pain, pancreatitis, and jaundice. Traditional therapy has been either marsupialization of the cyst into the duodenum or complete surgical excision. This paper cites the eighth patient reported in the English-language literature whose choledochocele was treated endoscopically. It is the authors' opinion that either an endoscopic papillotomy or an endoscopic fistulotomy with extension of the incision over the cyst is the simpler and preferred method of treatment.

Biliary peritonitis due to choledochal cyst presenting in late pregnancy

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Management of choledochal cysts in adults

The management of 7 adults with choledochal cysts is described. Three patients presented with abdominal pain, 3 with jaundice and one with cholangitis. Three patients underwent total or partial cyst excision and the remaining patients underwent cyst drainage into a Roux-en-Y jejunal loop. There was no operative mortality and all patients have remained well for up to 6 years following surgery. It is argued that total cyst excision is the treatment of choice, but where this is not possible a Roux-en-Y choledochocystojejunostomy is the recommended alternative.

Choledochal cyst--a review of 25 cases

Twenty-five cases of choledochal cysts operated at the University Hospital between 1969 and 1981 were reviewed. Nineteen of the patients were females. An accurate pre-operative diagnosis of choledochal cyst was made in 10 patients (40%). We have found the 99Tcm-diethyl-IDA (EHIDA) scan to be the safest and most sensitive diagnostic tool. In recent years excision has been performed whenever possible in view of reports of malignancy developing in the cyst wall. It has a lower morbidity and re-operation rate compared to internal drainage. In excision we advise the use of a cuff of the cyst wall for a wider anastomosis. As the biliary tract shrinks and retracts into the porta following excision of the cyst, stricture formation may still occur despite a wide anastomosis.