Choledochal cysts--differences in children and adults

Biliary cysts in adults. 26 years experience at a single center

Background

Biliary cysts are duct dilatation that can occur on all biliary ducts, 20–25% is diagnosed in adults. The classic triad for the clinical presentation consists on abdominal pain, jaundice and abdominal mass. The standard treatment is surgical resection and bilioenteric anastomosis. The objective of this study is to analyze the prevalence and characteristics of biliary cysts in our center.

Methods

This is an observational retrospective study, we included patients older than 16 years old with biliary cyst from march 1989 to February 2015. The demographic and clinical information was collected from the charts and electronic records available at our Hospital.

Results

Biliary cysts were reported on 52 patients, only 25 clinical charts were available. The main symptom was abdominal pain in 21 (84%). The diagnosis was performed with abdominal ultrasound in 16 (64%). The most frequent type was IA in 9 (36%). All patients were treated with surgery as a definitive management.

Discussion

Vague clinical presentation results on a delay of the diagnosis and treatment. Surgical resection is recommended for patients since they have an increased risk for malignant transformation. Postoperative complications in our patients were stenosis of bilioenteric anastomosis in 3 (12%) patients.

Conclusions

Biliary cysts require an accurate diagnosis and surgical treatment in order to decrease the risk of malignant transformation and progression of the disease. Precise surgical treatment is needed to achieve complete resection and a long term postoperative follow up is mandatory.

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The objective is to analyze prevalence and characteristics of biliary cysts in our center.

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Vague clinical presentation results on a delay of the diagnosis and treatment.

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Surgery is recommended because of increased risk for malignant transformation.

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Most common complication in our patients was stenosis of bilioenteric anastomosis.

Congenital bile duct cyst (BDC) is a more indolent disease in children compared to adults, except for Todani type IV-A BDC: results of the European multicenter study of the French Surgical Association

AIM

To compare clinical presentation, operative management and short- and long-term outcomes of congenital bile duct cysts (BDC) in adults with children.

METHODS

Retrospective multi-institutional Association Francaise de Chirurgie study of Todani types I+IVB and IVA BDC.

RESULTS

During the 37-year period to 2011, 33 centers included 314 patients (98 children; 216 adults). The adult population included more high-risk patients, with more active, more frequent prior treatment (47.7% vs 11.2%; p < 0.0001), more complicated presentation (50.5% vs 35.7%; p = 0.015), more synchronous biliary cancer (11.6% vs 0%; p = 0.0118) and more major surgery (23.6% vs 2%; p < 0.0001), but this latter feature was only true for type I+IVB BDC. Compared to children, the postoperative morbidity (48.1% vs 20.4%; p < 0.0001), the need for repeat procedures and the status at follow-up were worse in adults (27% vs 8.8%; p = 0.0009). However, severe postoperative morbidity and fair or poor status at follow-up were not statistically different for type IVA BDC, irrespective of patients' age. Synchronous cancer, prior HBP surgery and Todani type IVA BDC were independent predictive factors of poor or fair long-term outcome.

CONCLUSION

BDC is a more indolent disease in children compared to adults, except for Todani type IV-A BDC.

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.

Choledochal cyst in childhood: review of 30 cases

Objective: To analyze and discuss the clinical data, diagnosis and treatment of a number of patients with cystic dilatation of the common bile duct of a Brazilian pediatric hospital.Methods: We analyzed 30 patients treated at the Martagão Gesteira Institute of Pediatrics and Child Care of the Federal University of Rio de Janeiro for 23 years ,with statistical analysis of epidemiological data, clinical manifestations, diagnosis, treatment and postoperative outcome.Results: We observed a marked female predominance (73.4% of cases), the diagnosis being made in the first decade of life in 90% of patients. The most prevalent clinical manifestation was jaundice (70% of cases) and the classic triad of choledochal cyst was not observed. Abdominal ultrasound was the first imaging examination performed, with a sensitivity of 56.6%, with diagnostic definition in 17 children. Two patients (6.6%) had prenatal diagnosis. All patients underwent surgical treatment, cyst resection with Roux-en-Y hepaticojejunostomy being performed in 80% of cases. The incidence of postoperative complications was 13.3% and the mortality rate was 6.6%, ie two patients were diagnosed with Caroli's disease.Conclusion: The non-observance of the classic triad of choledochal cyst suggests that its incidence is lower than that reported in the medical literature. The surgical treatment of choledochal cysts, with resection and bilioenteric anastomosis, is safe even for small children.

Choledochal cysts: a clinicopathologic study of 36 cases with emphasis on the morphologic and the immunohistochemical features of premalignant and malignant alterations

Choledochal cysts (CDCs) are believed to represent a risk factor for the development of neoplasia. However, the frequency and morphology of neoplastic changes have not been systematically studied, especially in North America. Our aims were to study the frequency and morphology of preneoplastic/neoplastic changes of CDCs. Thirty-six cysts were subjected to clinicopathological analyses. Metaplasia was found in 14 of 35, of which 9 had biliary intraepithelial neoplasia (BilIN). Of the 14 with metaplasia, 13 showed pyloric gland; 5, intestinal; and 2, squamous. BilINs included 6 BilIN-1, 2 BilIN-2, and 2 BilIN-3. Carcinoma was identified in 5 cases of which 3 were associated with metaplasia and BilIN. Only 1 of 18 cases without metaplasia had BilIN, and none had carcinoma (P = .0008). There was a trend toward more BilIN and carcinoma with intestinal rather than with pyloric gland metaplasia. All cases with metaplasia or/and BilIN were negative for MUC1. All cases with intestinal metaplasia were positive for CK20, CDX2, and MUC2, whereas cases with pyloric gland were positive for MUC6. MUC1, CEA, and B72.3 were positive only in carcinoma. There was a trend toward increasing p53 and Ki-67 from metaplasia to BilIN to carcinoma. Four of 5 patients with carcinoma died, and one was alive with disease. All others were free of disease except for one who developed new cysts. CDCs are associated with a high rate of BilIN (28.5%) and carcinoma (14.3%). CDCs show a sequence of tumor progression from metaplasia to BilIN and carcinoma.

Biliary cysts: a review and simplified classification scheme

Biliary cystic disease has been known of for centuries. It has traditionally been classified as 5 major types of disease, each with different clinical profiles and attributes. In this article, the basis for the existing classification schemes is reviewed and a simplified classification scheme and treatment regimen are suggested.

Strategies for diagnosis of expansion of the intrahepatic or extrahepatic bile ducts

Expansion of the intrahepatic or extrahepatic bile ducts is a clinically common disease. Patients visit hospital often due to bile duct expansion (with or without self-conscious symptoms). The causes of expansion of the bile ducts are diverse: some are obvious, such as bile duct stones, parasites and tumors; and others are not clear, which makes the diagnosis and treatment of this disease is very difficult. In this paper we divide expansion of the intrahepatic or extrahepatic bile ducts into two major categories: congenital and secondary. Since there are more than 60 kinds of known causes of this disease, it can be classified based on disease type, relationship to the bile duct and bile duct pressure. The classification based on etiology can help clarify the diagnosis of this disease and thus provide a theoretical basis for its early diagnosis and treatment.

The relationship between biliary amylase and the clinical features of choledochal cysts in pediatric patients

BACKGROUND

Although the clinical features of choledochal cysts (CC) in different age groups have been widely studied, the causes of differences in clinical features are unknown. To determine the relationship between biliary amylase and the clinical features of CC in pediatric patients, clinical outcomes were compared in two groups with different amylase levels.

METHODS

From May 1995 to August 2010, 80 patients under 18 years old who underwent choledochal cyst excision and hepaticojejunostomy and measurements of biliary amylase levels were allocated to a low-amylase-level group (amylase level < 200 U/L, n = 26) and a high-amylase-level group (amylase level > 200 U/L, n = 54). Their medical records were retrospectively reviewed.

RESULTS

The median age was 4 months (range = 17 days-169 months) in the low group and 48 months (range = 22 days-147 months) in the high group (p = 0.008). In the low group, jaundice was the most common symptom, while abdominal pain was the main symptom in the high group. In histological findings, bile duct proliferation and cholestasis predominated in the low group and portal inflammation predominated in the high group. Radiological findings and preoperative laboratory data were also significantly different between the groups. Postoperative complications occurred in the high group only. There was no mortality in either group.

CONCLUSION

This study shows a relationship between biliary amylase level and clinical manifestations in pediatric patients with CC, implying that there are different underlying pathophysiologies with anomalous pancreaticobiliary ductal union (APBDU).

Management of Choledochal Cysts and Their Complications

Choledochal cysts are increasingly reported in adults. The presence of cyst-related complications alters its presentation and complicates the management. We reviewed our experience to find the clinical presentation, complications, and the management of choledochal cysts. The records of 132 patients with choledochal cysts presented to us between 2003 and 2010 maintained as a prospective database were analyzed for demography, clinical presentation, radiological investigation, management, and outcome. There were 12 children and 120 adults. Based on preoperative cholangiogram, 93 (71%) patients had Type I and 39 (29%) Type IVA cysts. The overall incidence of complicated choledochal cyst was 4 of 12 (33%) in children and 85 of 120 (71%) in adults. The most common complication was cystolithiasis (49%) followed by cholangitis (32%), acute pancreatitis (10%), hepatolithiasis (7%), malignancy (3%), portal hypertension (2%), and chronic pancreatitis (2%). Acute pancreatitis and cholangitis were managed conservatively. Endoscopic stenting was performed in patients with cholangitis and those requiring staged treatment as a result of portal hypertension. Overall 114 patients underwent cyst excision with Roux-en-y hepaticojejunostomy. The overall morbidity was 17.5 per cent (wound infection 13% and bilioenteric anastomotic leak 7%). There was one postoperative death resulting from cardiac failure. Three patients developed anastomotic stricture and underwent redo hepaticojejunostomy. Choledochal cysts in adults are often associated with complications. Complications are more common in adults compared with children. Acute pancreatitis, cholangitis and portal hypertension are managed conservatively and then followed up by definitive surgery. Cyst excision with Roux-en-Y hepaticojejunostomy is necessary to prevent the recurrence of complications.

Surgical experience of 204 cases of adult choledochal cyst disease over 14 years

BACKGROUND

This study presents our 14-year surgical experience with adult choledochal cyst disease (CCD), focusing on the clinical outcomes after surgical treatment.

METHODS

Medical records of 204 adult patients who had undergone surgery for CCD were reviewed retrospectively.

RESULTS

Median patient age was 40.2 years, and 157 (77%) of the patients were female. Todani classification was type I in 116 patients (56.9%), type II in 1 patient (0.5%), type IVa in 86 patients (42.2%), and type V in 1 patient (0.5%). Extrahepatic cyst excision and hepaticojejunostomy were performed in 185 patients (90.7%). Major perioperative complications occurred in 5 patients (2.5%), resulting in no mortality. Late complications occurred in 48 patients (23.6%). Concurrent cancer was diagnosed in 20 patients (9.8%). Mean age of patients with or without biliary cancer was 48.1±13.2 years and 39.1±11.8 years, respectively (P=0.001). Anomalous union of the pancreaticobiliary duct was more frequently associated with gallbladder cancer than with bile duct cancer. De novo malignancy at the cyst remnant occurred in 2 patients (1%). The survival outcomes in CCD patients with concurrent biliary cancer were comparable to those in cancer patients without CCD.

CONCLUSIONS

As a result of diverse features of adult CCD, various clinical problems occurred after surgical excision. Surgical treatment for adult patients with CCDs having complex features should be individualized to maintain a balance between risk of surgery and potential risk of late complications.

Choledochal cysts: differences between pediatric and adult patients

Choledochal cysts in children and adults are believed to be different, but direct comparison between them is lacking in the literature. This study was aimed to identify the clinicopathological differences between 42 children and 59 adults with choledochal cyst treated by same surgeons at the Cathay General Hospital. The mean follow-up period was 8.9 years. The result showed that the female-to-male ratios were 1.5:1 in pediatric patients and 4.9:1 in adult patients. Compared with adults with choledochal cyst, the pediatric patients presented more abdominal mass (52.4% vs 21.2%, P = 0.002) and less abdominal pain (76.2% vs. 98.0%, P = 0.002), are more frequently associated with anomalous pancreaticobiliary ductal union (85.7% vs. 59.6%, P = 0.005) and sudden severe stenosis of terminal choledochus (76.2% vs. 42.3%, P = 0.001), are less commonly associated with choledocholithiasis, are not associated with malignant transformation (0% vs 21.2%), and have fewer perioperative and long-term complications. Nevertheless, patients who received total excision had fewer surgical complications in both groups. This result shows that choledochal cysts in pediatric and adult patients are different in clinicopathological manifestations, prognosis, and the underlying abnormalities of the pancreaticobiliary system, suggesting that patients with choledochal cyst should be managed according to these differences.

Course of choledochal cysts according to the type of treatment

OBJECTIVE

To compare natural course and treatment results of various types of choledochal cysts.

MATERIAL AND METHODS

Complication rate in treated (T) and natural course in not treated (NT) patients with choledochal cysts were compared. The level of bilioenteric anastomosis after cyst resection was categorized and their post-procedure courses were analyzed.

RESULTS

A total of 204 patients (T, 174; NT, 30) were included. Patients with initial malignancies were excluded from the outcome analysis (n = 13). Of the remaining 191 patients, the mean follow-up time was 35.9 months (range 6-310.7 months). Biliary stricture was the most troublesome post-operative complication, and occurred in 10 patients (6.1%). It occurred significantly more frequently in the above hilar anastomosis group than in at or below (p-trend = 0.017), and also with older age (p-trend = 0.019). Common bile duct stone was the most frequent adverse event among NT (42.9%). Overall, there were fewer complications among treated patients (T, 17.2%; NT, 67.9%; p < 0.001). Anomalous pancreaticobiliary union (APBU) was present in 69 patients (37.5%), which was associated with higher prevalence of carcinoma (APBU-present, 13%; APBU-absent, 3.5%; p = 0.019). No malignancy developed in both T and NT groups during follow-up.

CONCLUSIONS

This study suggests, that even asymptomatic choledochal cysts should be treated, not only for prevention of malignancies, but also to lower the future adverse events. Bilioenteric anastomosis at larger caliber duct is recommended for prevention of post-operative biliary strictures.

The changing presentation of choledochal cyst disease: an incidental diagnosis

BACKGROUND

Choledochal cysts are uncommon biliary lesions. Due to the evolution of imaging and laparoscopic surgery, we sought to describe our last 3 years experience with the presentation and management of choledochal cysts in adults.

METHODS

A retrospective review of a prospectively established database of adults who were managed for primary choledochal cyst disease between 2005 and 2008 was performed.

RESULTS

Between 8/2005 and 8/2008, 14 adults were managed for primary choledochal cyst disease. The average age was 41 years (range 17-86) and 79% were female. Presentations included biliary sepsis (3), pancreatitis (2), abdominal pain (3), or painless jaundice (1). Three patients had the cyst found during laparoscopic cholecystectomy, and two had an incidental finding after CT scan for an unrelated issue. The length of stay for those who had the cyst removed was 7.8 days (range 5-11). There were no operative or post-operative complications.

CONCLUSIONS

Over the last 3 years 36% of our patients with choledochal cysts presented after incidental finding, either during a laparoscopic operation or after a CT scan for an unrelated problem. Increasing utilization of laparoscopy and CT scan for abdominal complaints has lead to a change in the pattern of presentation.

Clinicopathological feature and surgical outcome of choledochal cyst in different age groups: the implication of surgical timing

BACKGROUND/AIMS

Surgical resection of choledochal cysts (CC) has become standard treatment. However, surgery is not universally recommended in early infancy and/or asymptomatic patients. In order to investigate the optimal timing of CC excision, we analyzed clinicopathological data and surgical results from different age groups.

MATERIAL AND METHODS

This retrospective review included 107 patients (77 females, 30 males) who underwent CC resection at the National Taiwan University Hospital between January 1988 and December 2005. Patient demographic, clinical, and surgical data were collected and analyzed.

RESULTS

The patients were divided into three groups according to age at the time of surgery: <1 year old (group I, n = 26), 1-16 years old (group II, n = 48), and >16 years old (group III, n = 33). About two thirds of the patients in group I had jaundice, while abdominal pain related to inflammation was the commonest symptom in groups II and III. Group I suffered significantly fewer surgical complications and less severe liver fibrosis than groups II or III.

CONCLUSION

CC surgery in infancy and in asymptomatic patients is safe and may prevent the complications of this condition. The results support a recommendation for early excision.

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.

Type IV-a choledochal cyst--a rare adolescent presentation as acute abdomen

A 17-year-old adolescent girl from El Salvador presented to the emergency room (ER) with severe abdominal pain associated with one episode of nausea and vomiting. The pain that started 5 days earlier was sharp in nature and epigastric in location with radiation to back and was relieved by half a tablet of Vicodin. The patient has a history of intermittent epigastric pain for the past 2 years and was treated for Helicobacter pylori for 1 year. In the ER, the serum chemistry demonstrated elevated amylase. Further workup with abdominal ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and hepatobiliary scintigraphy confirmed a type IV-a choledochal cyst with intra- and extrahepatic dilation of bile ducts. We report an unusual acute abdomen presentation of type IV-a choledochal cyst in a 17-year-old young adult from El Salvador.

[Asymptomatic or paucisymptomatic CBD dilatation on US after cholecystectomy: management]

In western countries, 10-15% of the population has gallbladder stones with 46,000 cholecystectomies performed in France in 2003. So, daily ultrasonography of the abdomen performed in patients without gallbladder is a routine exam. However, identification of an enlarged common bile duct is frequent and the normal nature of this finding remains uncertain. The purpose of this article is to perform a literature review of the impact of cholecystectomy on the diameter of the common bile duct. Furthermore, it is important not to dismiss common bile duct dilatation after cholecystectomy because it may be the result of post operative complication or secondary to a congenital disease of bile duct.

Preferable operative age of choledochal dilation types to prevent patients with pancreaticobiliary maljunction from developing biliary tract carcinogenesis

BACKGROUND

Pancreaticobiliary maljunction (PBM), which frequently accompanies choledochal dilation, is a high risk factor for biliary tract (gallbladder, bile duct) carcinoma because of the continuous reflux of pancreatic juice into the biliary tract. The aim of this study was to clarify the preferable operative age in PBM patients for the prevention of biliary tract carcinogenesis, with reference to the dilation types of bile ducts.

METHODS

There were 165 PBM patients in total studied, including 92 pediatric patients (< or =15 y) (cystic, 63; spindle-like, 29; nondilation, 0) and 73 adult patients (>15 y) (cystic, 45; spindle-like, 18; nondilation, 10) who underwent operative excision of extrahepatic bile ducts or cholecystectomy. We investigated incidence by age of biliary tract malignancies and the risk according to types of dilation.

RESULTS

In the pediatric group, no carcinoma case could be found preoperatively or postoperatively (mean follow-up period, 11.7 y). In the adult group, bile duct carcinomas could be detected in 6 cases of a cystic type (6 of 45; 13.3%) (3 preoperative, 3 postoperative). Among the bile duct carcinoma cases, the youngest patient was a 21-year-old woman who had undergone excision of an extrahepatic bile duct 3 years previously. Gallbladder carcinomas were detected in 16 patients: 3 of 45 cystic (6.7%), 6 of 18 spindle-like (33.3%), and 8 of 10 nondilation (80.0%), in whom the youngest patient was a 41-year-old woman with a spindle-like type.

CONCLUSIONS

To prevent biliary tract carcinogenesis in PBM patients, cystic-dilated choledochus should be excised in childhood before the development to a precancerous stage. In spindle-like and nondilation types, cholecystectomy is absolutely necessary in early adulthood before age 40.

Management of adult choledochal cysts--a 15-year experience

BACKGROUND

Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology.

METHODS

The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed.

RESULTS

The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months.

CONCLUSIONS

Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary-enteric communication by hepaticojejunostomy form the basis of ideal treatment.

Narrow portion of the terminal choledochus is a cause of upstream biliary dilatation in patients with anomalous union of the pancreatic and biliary ducts

AIM

To clarify the pathogenesis of biliary dilatation associated with anomalous union of the pancreatic and biliary ducts (AUPBD).

METHODS

Direct cholangiopancreatograms of 350 adult patients with or with suspicion of hepatobiliary or pancreatic disorders were reviewed. AUPBD was diagnosed cholangiopancreatographically, when the pancreaticobiliary ductal union was located above the narrow distal segment of the bile duct, which represents the action of the sphincter of Oddi. The narrow portion of the terminal choledochus was defined as symmetrical stricture of the common bile duct just above the pancreaticobiliary ductal union.

RESULTS

AUPBD was found in 36 patients. Among cholangiopancreatographic features, the narrow portion of the terminal choledochus was the most pathognomonic for AUPBD (accuracy, 98%); it was present in 29 (81%) patients with AUPBD, but was not found in any patients without AUPBD. Among patients with AUPBD, biliary dilatation (>10 mm) was more frequent in those with the narrow portion of the terminal choledochus (23/29) than in those without (2/7; P=0.018) AUPBD. Among the patients with both AUPBD and the narrow portion of the terminal choledochus, there was a strong negative correlation between the minimum diameter of the narrow portion and the maximum diameter of the choledochus (r=-0.78, P<0.001), suggesting that the degree of biliary narrowing at the narrow portion correlates with that of upstream biliary dilatation.

CONCLUSION

The narrow portion of the terminal choledochus, a pathognomonic radiologic feature of AUPBD, may be a cause of biliary dilatation in patients with AUPBD.

Epidemiology, presentation, diagnosis, and outcomes of choledochal cysts in adults in an urban environment

BACKGROUND

Choledochal cysts (CDC) are rare congenital cystic lesions of the biliary tract. In North America the incidence of CDC is estimated as 1/150,000; it is not clear that the disease pattern in North America is similar to that in Asia.

METHODS

Retrospective chart review. Statistical analysis was under taken using Fisher's exact test.

RESULTS

Presentation, epidemiology, diagnosis, and outcome were evaluated in 51 patients with CDC. Malignant transformation was identified in 4 patients presenting uniformly with jaundice (P = .027). Type 4a cysts (54.9%) were the most common cyst identified. Four (14%) type IVa and two (13%) type I cysts developed postoperative stricture. No patient developed cholangiocarcinoma after complete resection of their cyst.

CONCLUSIONS

Types I and IVa cysts can be treated similarly with excellent outcome. However, our observation of a high proportion of type 4a cysts may represent a specific North American pattern of this disease requiring a re-evaluation of the classification system.

Amylase level in extrahepatic bile duct in adult patients with choledochal cyst plus anomalous pancreatico-biliary ductal union

AIM: To investigate the relationship between pancreatic amylase in bile duct and the clinico-pathological features in adult patients with choledochal cyst and anomalous pancreatico-biliary ductal union (APBDU).

METHODS: From 39 patients who underwent surgery for choledochal cyst between March 1995 and March 2003, we selected 15 adult patients who had some symptoms and were radiologically diagnosed as APBDU, and their clinico-pathological features were subsequently evaluated retrospectively. However, we could not obtain biliary amylase in all the patients because of the surgeon’s slip. Therefore, we measured the amylase level in gall bladder of 10 patients and in common bile duct of 11 patients.

RESULTS: Levels of amylase in common bile duct and gall bladder ranged from 11500 to 212000 IU/L, and the younger the patients, the higher the biliary amylase level (r = -0.982, P<0.01). Pathologically, significant correlation was found between the size of choledochal cyst and the grade of inflammation (r = 0.798, P<0.01). And, significant correlation was found between the level of amylase in gall bladder and the grade of hyperplasia. On the other hand, there was no correlation to the age of symptomatic onset or inflammatory grade (r = 0.743, P<0.05). Level of lipase was elevated from 6000 to 159000 IU/L in bile duct and from 14400 to 117000 IU/L in the gall bladder; however, there was no significant correlation with age or clinico-pathological features.

CONCLUSION: The results support the notion that amylase has a particular role in the onset of symptoms, and suggest that a large amount of biliary amylase induces early onset of symptom, thereby making early diagnosis possible.

Endoscopic management of choledochal cyst

BACKGROUND

Choledochal cyst is an uncommon anomaly of the biliary tract. Experience with this disorder, with emphasis on the role of ERCP in management, is presented.

METHODS

All pertinent data for 13 patients with choledochal cyst seen between 1987 and 1998 were reviewed, retrospectively.

OBSERVATIONS

Cholangitis, either alone or associated with other findings, was the main presenting feature (69.23% of patients). Bilobar Caroli's disease was the most common cyst type (46.15% of patients). ERCP was diagnostic alone in 46.15% of patients and therapeutic in 53.85%.

CONCLUSIONS

Choledochal cyst is a complex condition that requires early diagnosis. Long-term management remains controversial, and guidelines for treatment require revision. Whether interventional ERCP will obviate the need for surgery or alter the malignant potential of the disorder remains uncertain.

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.

Choledochal Cystic Diseases

Cystic disease of the intrahepatic and extrahepatic bile ducts results in rare malformations with a variable presentation. The majority of patients present during childhood with symptoms of abdominal pain, cholangitis, and an abdominal mass. A palpable mass is unusual in adults, and adult patients tend to present with recurrent cholangitis, pancreatitis, or rarely portal hypertension. The cause of this disorder also is debated, with both congenital and acquired origins postulated. The gold standard for the treatment of choledochal cysts is complete excision with the establishment of biliary flow into the gastrointestinal tract. The well described malignant potential of the cyst and the high rate of recurrent cholangitis with internal drainage procedures mandate cyst excision when possible. In the event of extensive scarring or malignant changes of the cyst, the posterior wall of the cyst may be left in situ to avoid endangering the portal vessels, which are found posteriorly. Alternatively, various endoscopic or percutaneous interventions may provide symptomatic relief. However, every effort should be directed towards complete resection of the cyst and the re-establishment of biliary-enteric continuity.

Influence of age on the presentation and outcome of choledochal cyst

PURPOSE

The aim of this study was to identify the most appropriate timing for surgery in newborns with choledochal cysts.

METHODS

The clinical and histological data of 8 newborn cases of choledochal cysts (newborn group) were compared with 45 cases that were diagnosed later than the newborn period (late group).

RESULTS

The mean and standard deviation of age at diagnosis was 0.4+/-0.4 months and 43.4+/-37.8 months in the newborn and late group, respectively. The age at operation was significantly earlier in the newborn group than in the late group (4.9+/-4.5 months v54.7+/-47.0 months). Although no significant difference in the time that elapsed between the operation and the onset of symptoms between the newborn and late groups (4.5+/-4.7 months v11.3+/-21.1 months), the serum bilirubin level (4.6+/-3.8 mg/dL v1.8+/-3.4 mg/dL) and the grade of liver fibrosis (2.0+/-0.8 v1.1+/-0.8) were significantly higher in the newborn group than in the late group.

CONCLUSION

The newborn group should be considered as a special group of patients with different clinical course and pathology than those of the late group, which necessitate the early surgical intervention to prevent progression of liver fibrosis.

Biliary atresia and biliary cysts

The authors present a review of the classification, aetiology, presentation, treatment and long-term outcome of children and adults with biliary atresia and choledochal cyst disease. Biliary atresia should be suspected in any infant with jaundice beyond the second week of life. Although the aetiology and pathogenesis remain unclear, early management with portoenterostomy has significantly improved the course of this disease. Recent advances in immunosuppression have made liver transplantation a valuable and necessary adjunct to biliary bypass. With choledochal cyst disease, adults, unlike children, often present with acute biliary tract symptoms or pancreatitis. The treatment of choice remains extrahepatic cyst excision and biliary bypass. This treatment has excellent long-term results that minimize the development of malignancy.