Cholecystectomy alone is inadequate for treating forme fruste choledochal cyst: evidence from a rare but important case report

Bile duct cyst in adults: Interventional treatment, resection, or transplantation?

Cystic dilatations of the bile ducts may be found along the extrahepatic biliary tree, within the liver, or in both of these locations simultaneously. Presentation in adults is often associated with complications. The therapeutic possibilities have changed considerably over the last few decades. If possible, complete resection of the cyst(s) can cure the symptoms and avoid the risk of malignancy. According to the type of bile duct cyst, surgical procedures include the Roux-en-Y hepaticojejunostomy and variable types of hepatic resection. However, the diffuse forms of Todani type V cysts (Caroli disease and Caroli syndrome) in particular remain a therapeutic problem, and liver transplantation has become an important option. The mainstay of interventional treatment for Todani type III bile duct cysts is via endoscopic retrograde cholangiopancreatography. The diagnostic term “bile duct cyst” comprises quite different pathological and clinical entities. Interventional therapy, hepatic resection, and liver transplantation all have their place in the treatment of this heterogeneous disease group. They should not be seen as competitive treatment modalities, but as complementary options. Each patient should receive individualized treatment after all of the clinical findings have been considered by an interdisciplinary team.

Choledochal cyst: A review of 79 cases and the role of hepaticodochoduodenostomy

AIM

To analyze our experience of choledochal cysts. The results of complete excision of cyst and hepaticodochoduodenostomy have been analyzed in particular.

MATERIAL AND METHODS

PERIOD OF STUDY

January 1993 to August 2010. Apart from basic investigations, we did ultrasonography (USG) of abdomen, contrast-enhanced computerized axial tomography scan (CECT), endoscopic retrograde cholangiopancreatography (ERCP), operative cholangiogram, hepatic isotope scan (HIDA), magnetic resonance cholangiopancreatogram (MRCP) and choledochoscopy. The patients were divided into six groups according to the management done and the results analyzed.

RESULTS

The total number of cases was 79 (Male : Female = 26 : 53). The mean age of presentationwas 5.18 years. The most common mode of presentation was abdominal pain in 86% cases. Types of cysts - Type I: 63; Type IV: 12; Forme fruste: 1; Caroli's disease: 1; Cyst with atresia in the lower end of common bile duct: 2. Two patients of group A (cyst excision and Roux-en-Y hepaticojejunostomy) had recurrent pain and cholangitis. One patient required revision for stricture. In group E (n=53) (excision of cyst and hepaticodochoduodenostomy), three patients developed occasional epigastric pain and they responded to omeprazole. One patient developed anastomotic stricture and was lost to follow up. One patient of cyst with biliary atresia with biliary cirrhosis died.

CONCLUSIONS

In choledochal cyst, complete excision of cyst and good bilioenteric anastomosis with wide stoma should be done. Hepaticodochoduodenostomy with wide stoma is a simple, quick procedure with preservation of normal anatomy and physiology and minimum complications. It also avoids multiple intestinal anastomoses and so should be the preferred approach.

Choledochal cyst in two pediatric heart transplant patients

Choledochal cyst is a relatively uncommon entity in Western countries. No reports of choledochal cyst in heart transplant patients have been reported to date. We report two cases of choledochal cyst in pediatric heart transplant recipients, one with post-transplant lymphoproliferative disorder (PTLD) within the cyst. The first patient had abdominal pain, increased liver enzymes and was seropositve for Epstein-Barr virus. A choledochal cyst with PTLD was removed 4 years after heart transplantation. The second patient presented 14 years after heart transplantation with a choledochal cyst that was excised for severe abdominal pain. This previously unreported association between choledochal cysts in conjunction with PTLD and heart transplantation is interesting and a possible common pathogenesis is proposed. The management and alternative treatments were briefly noted. We recommend an aggressive treatment for patients with suspected choledochal cyst after heart transplantation because of the increased potential for malignant transformation.

Pancreaticobiliary maljunction without bile duct dilatation in children: distinction from choledochal cyst

OBJECTIVES

Pancreaticobiliary maljunction without bile duct dilatation (nondilated type) is rare in children, and its definition remains unclear. There is controversy over treatment between pediatric and adult patients. We reevaluated our previous definition of the nondilated type in children (common bile duct diameter <or=6 mm on cholangiography).

PATIENTS AND METHODS

Of 150 children with pancreaticobiliary maljunction, 14 fulfilled the definition of the nondilated type. Clinical and cholangiographic findings were reviewed and compared with cholangiograms of 17 children without biliary diseases (controls). The age-related normal range of the choledochal diameter was defined in combination with previous data.

RESULTS

All of the patients had symptoms and signs similar to those of choledochal cysts. Cholangiographic features of choledochal cysts were detected in all of the patients (dilated common channel, 8; distal bile duct stenosis, 5; dilated cystic duct, 4; filling defect in the common channel, 8). The choledochal diameter in control children increased with age. Only 4 patients (29%) had a choledochal caliber within the normal range.

CONCLUSIONS

Most pediatric cases reported as the nondilated type are slightly dilated (forme fruste) choledochal cysts and differ from the nondilated type seen in adults. The nondilated type in children should be defined on the basis of the age-related choledochal diameter.

Mixed type I and II choledochal cyst: a new clinical subtype?

Traditionally, choledochal cyst (CC) is classified into five types according to Todani's classification. Of 356 cases of CC treated at our institute since 1965, we experienced four cases of mixed type I and II choledochal cyst (MTCC). The incidence of MTCC was 1.1%. All four patients had a fusiform common bile duct (CBD) with a diverticulum originating from the mid-portion of the CBD. The cystic duct drained into the right side of the diverticulum. All had pancreaticobiliary malunion (PBMU). All presented with recurrent abdominal pain. MTCC was suggested on ultrasonography or computerized tomography and confirmed by endoscopic retrograde cholangiopancreatography (three cases) or magnetic resonance cholangiopancreatography (one case). Age at surgery ranged from 3 to 12 years. All had hepaticoenterostomy, and total excision of the CC/diverticulum/gallbladder. There were no complications and all cases are currently well. In all cases, histopathology showed that the wall of the diverticulum was identical to the CBD. Although the incidence of MTCC is very low, pediatric surgeons should be aware of it as a new subtype of CC. Based on our experiences and a review of the literature, we suggest that its etiology does not affect treatment because the surgical management of choice is the same as for type I CC.