Different types of congenital biliary dilatation in dizygotic twins

Congenital pancreaticobiliary anomalies in an urban medical center in the United States

Background and Aim

Pancreaticobiliary anomalies are rare and often present with cryptic signs and symptoms, thus delaying appropriate treatment.

Methods

Endoscopic retrograde cholangiopancreatography (ERCP) was used to define pancreaticobiliary anomalies. A retrospective review was performed of 5522 ERCPs conducted at a tertiary care center from 1972 to 2015.

Results

There were 249 (4.5%) patients with pancreaticobiliary anomalies, including 179 patients with pancreas divisum (PD), 44 patients with choledochal cyst (CC) (Todani's classification Type I: extrahepatic cyst 31, Type III; choledochocele 9, Type V: Caroli's disease 4), 20 patients with anomalous pancreaticobiliary ductal union (APDU), and 6 patients with other abnormalities. Of 179 patients with pancreas divisum, 8 (4.5%) required minor sphincterotomies for multiple unexplained acute pancreatitis. Of the 31, 15 (48%) Type I CC patients underwent an operation. In patients with Type III CC (choledochocele), seven of the nine were treated by endoscopic sphincterotomy, and two patients were treated by surgery. Four patients with Type V CC (Caroli's disease) were managed nonoperatively. Of the 20 patients with APDU, 8 (40%) required operative intervention. Six patients were found to have other anomalies: two with pancreas bifidum, one with a duplication of the gallbladder, one with a cystic duct diverticulum, one with an annular pancreas, and one with an abnormal cystic duct origin. These patients were treated based on their etiology.

Conclusion

Pancreaticobiliary anomalies are rare and can be defined using ERCP. The appreciation of these abnormalities is important for the proper diagnosis and treatment of these rare biliary and pancreatic disorders.

Bile duct cysts: contemporary surgical management

PURPOSE OF REVIEW

Surgical treatment of bile duct cysts remains the mainstay to reduce cyst-related complications and risk of malignancy. Optimizing treatment outcomes is dependent upon a thorough preoperative evaluation and selecting the appropriate intervention. This review summarizes the recent progress in the evaluation and treatment of bile duct cysts, particularly in relation to contemporary operative approaches.

RECENT FINDINGS

Ongoing efforts continue in optimizing the evaluation, classification and management of bile duct cysts. The risk of cholangiocarcinoma is not limited to the bile duct cyst itself and appropriate management and surveillance is paramount. Recent advances in laparoscopic and endoscopic equipment have paralleled an increasing interest in minimally invasive approaches in the management of patients with bile duct cysts. Favorable results of laparoscopic approaches are increasingly reported and suggest the feasibility of this technique in select patients.

SUMMARY

Although the surgical premise of resection has not changed for the treatment of bile duct cysts, there has been an increasing utilization of minimally invasive approaches. Results thus far are promising, but long-term, controlled data is needed before this approach can be considered standard.

Familial occurrence of congenital bile duct dilatation

Congenital bile duct dilatation (CBD) that developed in a parent and son is presented. Familial occurrence of CBD is rare, with only a few male cases having been reported. Since the initial report of CBD occurring in siblings in 1981, a total of 20 cases (10 pairs) have been published as of 2007. Clinical and genetic features of CBD are discussed.

Congenital biliary dilatation in dizygotic twins

Congenital biliary dilatation (CBD) of different types was recently noted in dizygotic twins. Our cases suggest the possibility of hereditary involvement in CBD. On the other hand, CBD discordance in six sets of monozygotic twins has been reported, which would suggest that the occurrence of CBD is not compatible with single gene control, although environmental factors are plausible. To evaluate the genetic factors that may be implicated in CBD, it would be necessary to accumulate more familial cases and examine further studies on inheritance.

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.