Choledochal cyst

Spontaneous perforation of the common bile duct: an uncommon complication of primary sclerosing cholangitis

OBJECTIVES

To describe the MR features and prognosis of patients with an uncommon complication of primary sclerosing cholangitis (PSC) characterized by a spontaneous perforation of the common bile duct (CBD) resulting in a peri-biliary collection and a pseudo-cystic appearance of the CBD.

METHODS

A single-center cohort of 263 patients with PSC who had at least two MRIs between 2003 and 2022 and a minimum follow-up of 1 year was retrospectively analyzed. MRI data (characteristics of CBD perforation and MR features of PSC) and clinical data were assessed. Analysis of survival without liver transplantation according to type of PSC (classical or CBD spontaneous perforation) was performed according to the Kaplan-Meier method and the curves were compared using the Log-Rank test.

RESULTS

A total of nine (3.4%) PSC patients (5 males) had perforation of the CBD with a median age at diagnosis of 18 years compared to 33 years for the control group (p = 0.019). The peri-biliary collections were variable in appearance (fusiform or pedunculated), with a diameter ranging from 5 to 54 mm. All nine patients showed intra- and extra-hepatic bile duct involvement, dysmorphia, and high ANALI scores. The clinical course was characterized by numerous complications in most patients, and five patients (56%) underwent liver transplantation at a median time of 5 years from diagnosis, compared to 40 patients (16%) in the control group (p = 0.02).

CONCLUSION

The spontaneous perforation of the common bile duct is an uncommon complication of primary sclerosing cholangitis that affects young patients and is associated with a poor prognosis.

CLINICAL RELEVANCE STATEMENT

This uncommon complication of primary sclerosing cholangitis with perforation of the common bile duct resulting in a peri-biliary collection and a pseudo-cystic appearance of the common bile duct is characterized by a poor prognosis in younger patients.

KEY POINTS

• Among 263 patients with primary sclerosing cholangitis (PSC), nine patients (3.6%) had an uncommon complication characterized on MRI by perforation of the common bile duct (CBD). • This perforation of the CBD was responsible in all nine cases for the formation of a peri-biliary collection, giving a pseudo-cystic appearance to the CBD. • The spontaneous perforation of the common bile duct is an uncommon complication of primary sclerosing cholangitis that affects young patients with a poor prognosis.

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

OBJECTIVE

To determine if laparoscopic excision is more effective than open excision in the treatment of choledochal cysts.

MATERIAL AND METHODS

A systematic review of randomized clinical trials in 3 databases measuring the efficacy of laparoscopic and open excision of choledochal cysts was performed. The authors considered international and national reports, whose results were analyzed in detail.

RESULTS

Mean duration of laparoscopic excision was 51 min, open excision - 35.4 min. Length of hospital-stay after laparoscopic excision ranged between 5 and 74 days, after open excision - between 7 and 146 days. Bile leakage rate was 1-2% and 4%, respectively. Laparoscopic excision was followed by lower complication rate. Morbidity and mortality in laparoscopic excision was 20% and 0%, in open excision - 60% and 3.3%, respectively.

CONCLUSION

Laparoscopic excision is more effective than open excision in the treatment of choledochal cysts.

Association Among Cystic Volume, Intracystic Pressure, and Histopathological Changes in the Liver in Patients With Choledochal Cyst

Background Choledochal cyst is a congenital cystic dilatation of the biliary tree. Various aspects of pathophysiology are unclear, particularly with reference to intracholedochal cystic pressure (ICCP) and liver histopathology. This study aimed to determine the relationship among cystic volume, ICCP, and histopathological changes in the liver in patients with choledochal cysts. Methods This cross-sectional study was carried out among 21 patients diagnosed with choledochal cysts, who attended the Department of Pediatric Surgery at Bangabandhu Sheikh Mujib Medical University (BSMMU) from April 2021 to August 2022. Cystic volume was measured pre-operatively using ultrasonography, while ICCP was measured per-operatively with a pressure gauge. Liver histology was assessed through an intraoperative liver biopsy and graded using the meta-analysis of histological data in viral hepatitis (METAVIR) scoring system. The data were analyzed using SPSS version 25.0 (IBM Corporation, Armonk, New York). Frequency and percentages were calculated to present categorical variables, and for quantitative variables, mean, standard deviation (SD), median, and interquartile range (IQR) were calculated. Fisher's exact tests were performed to determine the association between cystic volume, ICCP, and the grading of hepatic fibrosis. A p-value of <0.05 was considered statistically significant. Results The age of the patients ranged from 1 to 12 years, with a mean of 5.0±3.4 years. The male-to-female ratio was 1:4.3. Type I cysts were the most prevalent (71.4%). The median and IQR for cystic volume were 3.4 ml and 1.1-8.2 ml, respectively. The median and IQR for ICCP were 7.46 mmHg and 4.67-9.33 mmHg, respectively. The most frequent grade of fibrosis was F1 (38.1%), followed by F2 (23.8%) and F3 (23.8%). A negative relationship between cystic volume and ICCP was observed, which was statistically significant (p=0.008). A positive relationship was also observed between ICCP and the grading of liver fibrosis, which was statistically significant (p=0.002). Although a negative correlation between cystic volume and grading of liver fibrosis was noted, it was not statistically significant (p=0.198). Conclusions This study reveals significant associations between cystic volume, ICCP, and the grading of liver fibrosis in patients with choledochal cysts. Smaller volume cysts may exhibit higher ICCP, resulting in more pronounced fibrotic changes in the liver.

Maternal choledochal cysts in pregnancy: A systematic review of case reports and case series

BACKGROUND

Choledochal cysts (CC) are cystic dilatations of the biliary tract, usually diagnosed during childhood, with an estimated incidence in the general population of 1:100000. Complications related to CC include rupture, biliary obstruction, and cholangitis. Maternal CC in pregnancy are rarely reported, and there are no guidelines on optimal management.

AIM

To systematically review maternal CC diagnosed during pregnancy or postpartum with regard to the clinical presentation of CC, the mode of treatment and delivery, and maternal outcomes.

METHODS

A literature search of cases and case series of maternal CC in pregnancy and postpartum was conducted using MEDLINE/PubMed, Web of Science, Google Scholar, and Embase. There were no restrictions on language or publication year. Databases were lastly accessed on September 1, 2022.

RESULTS

Overall, 71 publications met the inclusion criteria, reporting 97 cases. Eighty-eight cases were diagnosed during pregnancy and nine in the puerperium. The most common symptoms were abdominal pain (81.2%) and jaundice (60.4%). Interventions for CC complications were required in 52.5% of the cases, and 34% of pregnancies were induced. Urgent cesarean section (CS) was done in 24.7%. The maternal mortality was 7.2%, while fetal mortality was inconsistently reported. Cholangitis, CC > 15 cm, and bilirubin levels > 80 mmol/L were associated with a higher likelihood of urgent CS and surgical intervention for CC. Bilirubin levels positively correlated with CC size. There was no correlation between age and cyst dimension, gestational age at cyst discovery, and CC size.

CONCLUSION

Although rare, maternal CC in pregnancy should be included in the evaluation of jaundice with upper abdominal pain. Symptomatology and clinical course are variable, and treatment may range from an expectative approach to emergent surgical CC treatment and urgent CS. While most cases were managed by conservative measures or drainage procedures, CC > 15 cm and progressive cholangitis carry the risk of CC rupture and septic complications, which may increase the rates of unfavorable maternal and fetal outcomes. Therefore, such cases require specific surgical and obstetric interventions.

Infantile choledochal cyst presenting with an epigastric bilioma: An iceberg phenomenon

INTRODUCTION

Choledochal cysts (CC) are rare congenital biliary dilatations that are capable of presenting with a gamut of clinical findings. Perforation, a rather rare presentation, can account for 1.8-7% of cases. In an infant with non-specific abdominal complaints and a vaguely palpable upper abdominal mass, a perforated CC may be overlooked, leading to a delayed or misdiagnosis and a detrimental outcome.

CASE PRESENTATION

We describe a 10-month-old girl who presented to the office with upper abdominal pain and associated fullness for two weeks. An abdominal ultrasonogram revealed perihepatic collections and an evident dilatation of the common bile duct. The bile aspirated from the collections prompted pigtail drainage as an emergency. Magnetic resonance cholangiopancreatography later revealed a spontaneously perforated CC with residual bilioma. Elective resection after six weeks, followed by bilio-enteric reconstruction, resulted in an uneventful recovery.

CLINICAL DISCUSSION

Biliary peritonitis and localized biliomas are rare forms among the wide range of findings that can accompany CC. Satisfactory outcomes can be achieved with a two-stage procedure that entails biliary drainage with sepsis control, followed by resection of the CC and bilio-enteric reconstruction a few weeks later.

CONCLUSION

It is important to be aware of the spectrum of findings that CC may present. We discussed our experience successfully treating a perforated type IVa CC.

Liver transplantation for biliary cysts: perioperative and long-term outcomes

BACKGROUND

Biliary cysts (BC) is a rare indication for orthotopic liver transplantation (OLT).

METHODS

We queried the UNOS dataset to identify patients who underwent OLT for Caroli's disease (CD) and choledochal cysts (CC). All patients with BC (CD + CC) were compared to a cohort of patients transplanted for other indications. Patients with CC were also compared to those with CD. Cox proportional hazard model was performed to assess predictors of graft and patient survival.

RESULTS

261 patients underwent OLT for BC. Patients with BC had better pre-operative liver function compared to those transplanted for other indications. 5-year graft and patient survival were 72% and 81%, respectively, similar to those transplanted for other indications after matching. Patients with CC were younger and had increased preoperative cholestasis compared to those with CD. Donor age, race, and gender were predictors of poor graft and patient survival in patients transplanted for CC.

CONCLUSIONS

Patients with BC have similar outcomes to those transplanted for other indications and more frequently require MELD score exception. In patients transplanted for choledochal cysts, female gender, donor age, and African-American race were independent predictors of poor survival. Pediatric patients transplanted for Caroli's disease had better survival compared to adults.

The Curious Case of the Choledochal Cyst—Revisiting the Todani Classification: Case Report and Review of the Literature

Choledochal cysts (CCs) are rare occurrences presenting as dilatations of biliary structures, which can present as single or multiple dilatations and can appear as both intra- and extrahepatic anomalies. The most widespread classification of CCs is the Todani classification, but there have been numerous reports of cysts that do not fall into any of the types described. We present such a case—a male patient 36 years of age who underwent preoperative CT, MRCP, and ERCP, which mistakenly indicated a type II Todani CC, and intraoperatively was found to be located at the confluence of the hepatic ducts and encompassed the origin of the common bile duct. Complete resection of the cyst and the proximal segment of the common bile duct was performed, and reconstruction was carried out by Roux-en-Y double-tutorized hepaticojejunostomy. Considering the risk of malignant transformation, the frequent preoperative misdiagnosis, as well as the technically challenging surgery required in such cases, we advocate for a revision of the classification and raise awareness of the need for guidelines regarding the proper short-term and long-term management of this disease to ensure adequate quality of life and disease-free survival for patients.

Efficacy of robot-assisted hepaticojejunostomy and laparoscopic-assisted hepaticojejunostomy in pediatric congenital choledochal dilatation: a system review and meta-analysis

PURPOSE

The efficacy of robot-assisted hepaticojejunostomy (RAHJ) and laparoscopic-assisted hepaticojejunostomy (LAHJ) in children with congenital choledochal dilatation has been a topic of much debate and controversy. The purpose of this study was to evaluate the role of RAHJ and LAHJ in pediatric congenital choledochal dilatation.

METHOD

The review program has been prospectively registered (PROSPEROID: CRD42022306868). We searched the PubMed, Embase, Cochrane, CBM, VIP, Web of Science, CNKI databases, and Wanfang databases from March 2021. The Mantel-Haenszel method and a random-effects model were used to figure out the hazard ratio (95% CI).

RESULTS

Ten studies evaluated eight hundred and sixty-nine subjects (three hundred and thirty-two in the robotic group and five hundred and thirty-seven in the laparoscopic group), meeting all inclusion criteria. Compared with the laparoscopic group, robotic group demonstrated fewer postoperative complications [p = 0.0009; OR = 0.34 (95% CI, 0.18-0.64); I² = 3%], shorter postoperative hospital stay [p < 00,001; MD = - 2.05 (95% CI, - 2.40-1.70); I² = 0%], and less intraoperative bleeding [p = 0.008; MD = - 10.80 (95% CI, - 18.80-2.81); I² = 99%]. There was no significant difference in operative time between the two groups [p = 0.10; MD = 24.53 (95% CI, - 5.11-54.17); I² = 99%]. The same situation happened in short-term complication outcomes [p = 0.06; RR = 0.45 (95% CI, 0.19-1.04); I² = 0%]. However, children in the RAHJ group had significantly lower levels of long-term complications [p = 0.04; OR = 0.41 (95% CI, 0.17-0.96); I² = 0%]. Hospitalization costs were significantly higher in the RAHJ group [p < 0.00001; OR = 27,113.86 (95% CI, 26,307.24-27,920.48); I² = 0%]. For overall complications, subgroup analysis of literature published after 2020 and of literature with high quality scores showed a significant decrease in the RAHJ group.

CONCLUSION

In children with congenital choledochal dilatation, RAHJ is associated with reduced intraoperative bleeding, postoperative complications, and length of stay. Robotic surgery has a bright future in the treatment of pediatric common hepatic duct cysts and deserves to be promoted and popularized.

Simultaneous laparoscopic removal of a Todani type II choledochal cyst and a microlithiasic cholecystitis

Diverticula of the choledochus, better known as Todani type II cysts, are very rare and represent a predominantly pediatric pathology. Their identification by radiological methods, even if occasional, requires clinical doctors to request a surgical consultation, even for asymptomatic subjects, to proceed with their removal, given the risk of associated neoplasms. The laparoscopic approach for surgical treatment of these cysts has been recently introduced with excellent results. Due to the poor clinical records, currently there are neither shared protocols about their management nor long-term follow-up of operated patients. We report a case of an adult female suffering for years from biliary colic due to the presence of a duodenal diverticulum associated with microlithiasis' cholecystitis, who was laparoscopically treated, with excellent results in terms of symptomatic regression, reduced hospitalization, and no surgery-related complications.

A Review of the Etiology and Epidemiology of Gallbladder Cancer: What You Need to Know

Gallbladder cancer (GBC) is the sixth most prevalent cancer of the gastrointestinal system but the most prevalent cancer of the biliary tract. This tumor is a highly fatal condition. The importance of early diagnosis cannot be overstated because GBC develops quietly with late detection. Several genetic and environmental variables have been associated with the onset of GBC. Cholelithiasis and chronic inflammation from the biliary tract and parasite infections are prime examples of environmental factors that significantly influence the development of GBC. Abnormal pancreaticobiliary duct junction and biliary cysts are examples of congenital causes. In the past decade, new imaging technologies and a more radical and aggressive surgical approach have improved patient outcomes and aided prolonged survival for GBC patients. This review article focuses on the epidemiology of GBC, its risk factors, and clinical characteristics.

Choledochal cyst: A challenging diagnostic and therapeutic entity in low-resource settings

Background

Choledochal cyst is an uncommon congenital biliary tract abnormality of unknown etiology. Its classical symptoms are jaundice, abdominal pain, and right upper quadrant mass. However, the disease may present with a vague and non-specific chronic abdominal discomfort. Delay in diagnosis and management may increase the risk of complications particularly the malignancy, which can directly affect the prognosis and outcome. Complete excision of the extra-hepatic duct, cholecystectomy, and Roux-en-Y hepaticojejeunostomy through the open surgical intervention or laparoscopic procedure is the mainstay of treatment.

Case Presentation

A 14-year-old male was presented to our hospital complaining of vague abdominal pain for 5 years. The radiologic imaging showed the features of a type IVa choledochal cyst. He underwent complete excision of the extra-hepatic duct, cholecystectomy, and Roux-en-Y hepaticojejeunostomy. Although the bile leakage occurred as a complication of the procedure, our team best managed the patient in the post-operative period until full recovery.

Discussion

The Choledochal cyst was first described by Vater, which is a congenital anomaly that sometimes may remain asymptomatic till adulthood. Surgical intervention is the mainstay of treatment. However, postoperative complications including bile leakage need a close follow-up of the patient.

Conclusion

Diagnostic delay (antenatal and postnatal) and non-specific symptoms will mask the real feature of the disease, especially in low-resource settings. Technical facilities and professional care of the patient may preclude complications.

•

The choledochal cyst is an uncommon congenital biliary tract anomaly.

•

Early diagnosis and management can directly affect the prognosis and outcome.

•

Low-resource settings and less symptomatic cases may lead to diagnostic delay.

•

Open surgery or laparoscopic intervention is the mainstay of treatment.

Identification and evaluation of fructose-bisphosphate aldolase B as a potential diagnostic biomarker in choledochal cysts patients: a quantitative proteomic analysis

BACKGROUND

Choledochal cyst (CC) is a congenital bile duct malformation, with a higher incidence in minors. Patients with CCs are at risk of pancreatitis and ascending cholangitis. The main forms of treatments aim to avoid any possible hepatic, pancreatic, or biliary complications. Since early diagnosis is of great importance for CC treatment and prognosis, this investigation was designed to screen and identify potential biomarkers from the serum samples of CC patients for CC early diagnosis.

METHODS

Quantitative label free proteomic analysis was used to identify differentially expressed proteins in serum samples from CC patients and normal healthy children. The expression levels of biomarker candidates were further confirmed using quantitative polymerase chain reaction (Q-PCR), Western blot analysis, and immunohistochemistry in the choledochal tissues.

RESULTS

The quantitative label free proteomic analysis identified 47 differentially expressed proteins in the serum samples from the CC patients and the normal children, including 14 up-regulated proteins and 33 down-regulated proteins. The expression profile of eight biomarker candidates in CC patients, namely, insulin-like growth factor binding protein 2 (IGFBP2), tropomyosin (TPM3), fructose-bisphosphate aldolase B (ALDOB), fumarylacetoacetate hydrolase (FAH), superoxide dismutase 3 (SOD3), secreted protein acidic and cysteine rich (SPARC), apolipoprotein E (APOE), and retinol binding protein 4 (RBP4), were selected for further examination in choledochal tissues, showing that ALDOB was significantly increased.

CONCLUSIONS

The results demonstrated that the ALDOB protein increased significantly in choledochal tissues and the serum samples of CC patients, which may serve as an effective predictor for early diagnosis of CC.

Artificial intelligence in gastrointestinal radiology: A review with special focus on recent development of magnetic resonance and computed tomography

Artificial intelligence (AI), particularly the deep learning technology, have been proven influential to radiology in the recent decade. Its ability in image classification, segmentation, detection and reconstruction tasks have substantially assisted diagnostic radiology, and has even been viewed as having the potential to perform better than radiologists in some tasks. Gastrointestinal radiology, an important subspecialty dealing with complex anatomy and various modalities including endoscopy, have especially attracted the attention of AI researchers and engineers worldwide. Consequently, recently many tools have been developed for lesion detection and image construction in gastrointestinal radiology, particularly in the fields for which public databases are available, such as diagnostic abdominal magnetic resonance imaging (MRI) and computed tomography (CT). This review will provide a framework for understanding recent advancements of AI in gastrointestinal radiology, with a special focus on hepatic and pancreatobiliary diagnostic radiology with MRI and CT. For fields where AI is less developed, this review will also explain the difficulty in AI model training and possible strategies to overcome the technical issues. The authors’ insights of possible future development will be addressed in the last section.

Squamous cell carcinoma arising within choledochal cyst managed by pancreaticoduodenectomy: A case report

Introduction and importance

Choledochal cysts (CC) are rare cystic dilatation of the biliary trees. Malignancy is one of the important significant findings in CC and its incidence increases with age. Associated squamous cell carcinoma of the choledochal cyst is an uncommon pathological finding.

Case presentation

We present a 21-year-old male diagnosed with type 1 CC and planned for excision of the cystic dilated extrahepatic biliary tract with hepaticojejunal anastomosis in Roux-en-Y but underwent pancreaticoduodenectomy due to intraoperative palpable mass of CC which was adhered to the duodenum and pancreatic head. Histopathology of the excised specimen revealed squamous cell carcinoma (SCC) of the choledochal cyst.

Discussion

CC represents a rare biliary cystic disease. Though infrequent, malignant transformation in CC includes cholangiocarcinoma, adenocarcinoma, and rarely SCC. The post-operative management for SCC in CC is ill-defined and carries a grave prognosis.

Conclusion

The choledochal cyst should be completely excised wherever possible to avoid the possible malignant transformation in CC including SCC.

•

Associated malignancy of the Choledochal cyst (CC) is unusual and squamous cell carcinoma in CC is rare.

•

An underlying malignancy should be suspected when a palpable mass in CC is found intraoperatively.

•

Management of choledochal cyst can vary from cyst excision to more radical surgery like Pancreaticoduodenectomy.

Differences in post-operative complications after reconstruction for congenital biliary dilatation in a single institution-Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy

BACKGROUND

The standard surgical procedure for congenital biliary dilatation (CBD) consists of excision of extrahepatic bile duct and Roux-en-Y hepaticojejunostomy (HJ). However, alternative reconstructive operations for CBD includes hepaticoduodenostomy (HD). We compared postoperative complications and therapeutic outcomes of these two operations at our institution.

METHODS

From 1981 to 2009, there were 23 traceable patients who underwent operation for CBD, They were divided into an HJ Group (n = 15) and an HD Group (n = 8). Demographic and outcome data were compared.

RESULTS

There were no significant differences in postoperative complications (cholangitis, pancreatitis, and anastomotic stenosis) and current blood test data (AST, ALT, Total Bilirubin, Direct Bilirubin, Amylase) between the two groups. Current abdominal pain and carcinogenesis were not observed in either group. Intrahepatic stones occurred in one patient in each group, both > 25 years post-operation.

CONCLUSION

HD is considered to be an acceptable reconstruction method compared to HJ, based on our results. There has been a suggestion that inadequate diversion in HD might increase the risk of cholangiocarcinoma. To date, in this series, that has not happened.

Type VI choledochal cyst with gall bladder carcinoma

An isolated dilatation of the cystic duct (type VI choledochal cyst (CDC)) is extremely rare with only 21 cases reported in the world literature until now. There is only one case of in situ gall bladder cancer (GBC) reported in association with type VI CDC in the literature. Here we are reporting a case of type VI CDC with papillary GBC.

Biliary Pseudocyst: A Rare Complication of Antenatal Perforation of Forme Fruste Choledochal Cyst

Spontaneous perforation of choledochal cyst (CDC) is rare with an incidence of 1.8%–7%. Perforation with pseudocyst formation is even rarer, there being only two case reports. We report the first case of antenatal perforation of CDC with biliary pseudocyst formation in a newborn and its management.

Minimally-invasive neonatal surgery: laparoscopic excision of choledochal cysts in neonates

Purpose

Improvements in surgical techniques and a better understanding of the unique anesthetic requirements in neonates undergoing laparoscopy have suggested that laparoscopic surgery may be effective in newborns. This study therefore evaluated the safety and feasibility of laparoscopic excision of the cyst (LEC) in neonates.

Methods

This retrospective study included 43 neonates who underwent excision of choledochal cysts between November, 2001, and January, 2018, including 21 who underwent open excision and 22 who underwent LEC. Their perioperative and surgical outcomes were reviewed. The patients were followed up for a median 37 months (range, 3–141 months).

Results

Baseline characteristics did not differ significantly in the open and LEC groups. Mean intraoperative peak partial pressure of arterial CO₂ (PaCO₂) (45.5 mmHg vs. 48.0 mmHg) and total operation time (208.3 ± 71.0 minutes vs. 235.0 ± 47.2 minutes) were similar in both groups. Parents of the patients in the LEC group provided a more positive evaluation of scar scale and greater satisfaction with wound. No patient in either group experienced any critical complications. Three patients in the open excision group required readmission for cholangitis and 2 patients had ileus. No patient in the laparoscopic excision group experienced any postoperative complications during follow-up.

Conclusion

Despite difficulties performing laparoscopic surgery in neonates, LEC was safe and feasible when intraperitoneal peak pressure was maintained under 10 mmHg and PaCO₂ was closely monitored by a pediatric anesthesiologist. Compared with open excision, LEC provided improved cosmetic outcomes without severe complications. Prospective randomized studies with large numbers of patients are warranted.

Cholangiocarcinoma in a Resected Biliary Cyst: Importance of Follow-up

Biliary cysts are rare cystic dilatations of the biliary tree. Biliary cysts are positively associated with several significant complications, amongst them, cholangiocarcinoma befalls the most dreadful one. The elevated incidence is 20-30% in the unresected cyst and 0.7% in resected cysts. Magnetic resonance imaging (MRI) scan, magnetic resonance cholangiopancreatography (MRCP) or a contrast-enhanced computed tomography (CECT) is applied for the initial diagnostic study but the ultimate diagnosis ordinarily requires the tissue biopsy. Currently, the sole curative option involves the complete surgical resection of the lesion, with standard chemotherapy and active radiation applied as an alternative for the unresectable tumors. Despite the curative surgery the percentage of eternal recurrence of the tumor indefinitely persists, and effective post-surgical surveillance is reasonably demanded. We report a case of 29-year-old female with local recurrence of cholangiocarcinoma in a previously resected biliary cyst type I. The curative resection of the choledochal cyst only minimizes the considerable risk of the possible development of future cholangiocarcinoma but it does not completely prevent it. The appropriate follow-up for potential patients who have been typically treated for a biliary cyst is unclear. The lethal course of cholangiocarcinoma is believed due to its slow asymptomatic growing phase. Therefore, to adequately screen for malignancy, periodic imaging along with annual liver tests represents a reasonable approach to prevent the possible development of this appalling complication.

Endoscopic biliary drainage management for children with serious cholangitis caused by congenital biliary dilatation

Congenital biliary dilatation (CBD) is usually associated with complications such as recurrent cholangitis, manifested as abdominal pain, vomiting, and jaundice. If cholangitis cannot be controlled by conservative treatment, a good therapeutic effect can be obtained through percutaneous biliary drainage or open T-tube drainage. We aimed to evaluate our experiences in biliary drainage through endoscopic retrograde cholangiopancreatography in children with cholangitis caused by CBD. From January 2014 to December 2017, 167 children with CBD were treated in our hospital. 17 patients (10.18%) with serious cholangitis caused by CBD underwent ERCP. There were 4 males and 13 females with an age range of 10-120 months (average 56.4 months). Placement of a biliary stent was attempted for biliary drainage through endoscopic retrograde cholangiopancreatography. Of the 17 patients studied, 13 children had jaundice and 15 had elevated aminotransferases. ERCP showed CBD in all patients and a common biliopancreatic duct in 12 of 17 patients (70.6%). Five patients underwent nasobiliary drainage and 12 patients underwent biliary drainage through double pigtail tubes. All patients achieved successful biliary drainage. Postoperative pancreatitis occurred in one patient. Biochemical indicators decreased significantly in 12 patients (70.6%) on the second postoperative day. The average length of hospital stay after surgery was 4.5 (range 3-7) days. No major complications related to ERCP were observed and all children had a good prognosis so far. Endoscopic biliary drainage is a safe, simple, and reliable technique. It can be used to resolve CBD-associated cholangitis, evaluate the biliary tract and pancreatobiliary duct junction, and guide pediatric surgeons to choose the right time and the correct procedure for CBD.

Robotic-assisted surgery for pediatric choledochal cyst: Case report and literature review

Our paper describes the key surgical points of pediatric choledochocystectomy performed completely by Da Vinci robotic system. A choledochocystectomy was safely carried out for a girl at our hospital, and without any complication. Then systematic literature review was done to discuss the methods of intestine surgery and intestinal anastomosis, the use of 3^rd robotic arm, the surgical safety and advantages comparing open and laparoscopic surgery. We systematically reviewed choledochocystectomy for children performed by robotic surgery. We included a total of eight domestic and foreign reports and included a total of 86 patients, whose average age was 6.3 (0.3-15.9) years; the male-to-female ratio was 1:3.5 (19:67). Seven patients experienced conversion to open surgery, and the surgery success rate was 91.9% (79/86). The average total operation time was 426 (180-520) min, the operation time on the machine was 302 (120-418) min, 11 cases used the number 3 arm, and the remaining mainly used the hitch-stitch technique to suspend the stomach wall and liver. Forty-seven patients underwent pull-through intestine and intestinal anastomosis, and 39 patients underwent complete robotic intestine surgery and intestinal anastomosis. The hospitalization time of robotic-assisted choledochocystectomy was 8.8 d. Eight patients had biliary fistula and were all cured by conservative treatment and continuous observation. One patient had anastomotic stenosis, and one patient had wound dehiscence, both cured by surgery. Choledochocystectomy for children performed by completely robotic surgery and Roux-en-Y hepaticojejunostomy is safe and feasible. The initial experience shows that this surgical approach has a clearer field than the traditional endoscopy, and its operation is more flexible, the surgery is more accurate, and the injury is smaller. With the advancement of technology and the accumulation of surgeons’ experience, robotic surgery may become a new trend in this surgical procedure.

Choledochal Malformation in Children: Lessons Learned from a Dutch National Study

Introduction

A choledochal malformation (CM) is a rare entity, especially in the Western world. We aimed to determine the incidence of CM in the Netherlands and the outcome of surgery for CM in childhood.

Methods

All pediatric patients who underwent a surgical procedure for type I–IV CM between 1989 and 2014 were entered into the Netherlands Study group on choledochal cyst/malformation. Patients with type V CM were excluded from the present analysis. Symptoms, surgical details, short-term (<30 days) and long-term (>30 days) complications were studied retrospectively.

Results

Between January 1989 and December 2014, 91 pediatric patients underwent surgery for CM at a median age of 2.1 years (0.0–17.7 years). All patients underwent resection of the extrahepatic biliary tree with restoration of the continuity via Roux-en-Y hepaticojejunostomy. Twelve patients (12%) were operated laparoscopically. Short-term complications, mainly biliary leakage and cholangitis, occurred in 20 patients (22%), without significant correlations with weight or age at surgery or surgical approach. Long-term postoperative complications were mainly cholangitis (13%) and anastomotic stricture (4%). Eight patients (9%) required radiological intervention or additional surgery. Surgery before 1 year of age (OR 9.3) and laparoscopic surgery (OR 4.4) were associated with more postoperative long-term complications. We did not observe biliary malignancies during treatment or follow-up.

Conclusion

Surgery for CM carries a significant short- and long-term morbidity. Given the low incidence, we would suggest that (laparoscopic) hepatobiliary surgery for CM should be performed in specialized pediatric surgical centers with a wide experience in laparoscopy and hepatobiliary surgery.

Clinical significance of intrapancreatic choledochal cyst excision in surgical management of type I choledochal cyst

Objective To investigate the effectiveness of intrapancreatic choledochal cyst excision in treating type I choledochal cyst, and increase understanding of the need for thorough surgical management of the disease. Methods Primary and secondary (including multiple) surgical cases, treated between 2005 and 2015, were retrospectively analysed, and follow-up data of post-treatment effectiveness to date were reviewed. Differences in curative effects were compared between whole and partial excision of the choledochal cyst. Results Out of 350 cases, patients with whole excision of the choledochal cyst ( n = 272) experienced no associated symptoms in the long-term (3/272 [1.1%] experienced stomach ache or fever). Patients with partial resection of the choledochal cyst ( n = 78) developed associated symptoms, including new cyst, calculus of the bile duct (51/78 [65.4%]), and carcinogenesis (11/78 [14.1%]) in the residual intrapancreatic biliary duct. Post-treatment clinical manifestations were significantly different between patients with partial resection versus whole excision of the choledochal cyst ( P<0.05). Conclusion Surgical re-excision should be considered in patients with a residual intrapancreatic portion of the choledochal cyst due to prior incomplete surgery, regardless of clinical symptoms.

The role of endoscopic retrograde cholangiopancreatography in choledochal cysts and/or abnormal pancreatobiliary junction in children

Introduction

Biliary cysts with an abnormal pancreatobiliary junction are one of the most common pancreatobiliary malformations. The main symptom is cholestasis; endoscopic retrograde cholangiopancreatography (ERCP) plays a key role in diagnosis.

Aim

Retrospective evaluation of ERCP performed to diagnose abnormalities of the pancreatobiliary junction.

Material and methods

We retrospectively evaluated ERCP performed to diagnose abnormalities of the pancreatobiliary junction, mainly choledochal cysts, in 112 children between 1990 and 2011.

Results

We performed 112 examinations of 50 children with abnormal pancreatobiliary junction and choledochal cysts (15 males and 35 females, average age: 5 years, range: 1 month – 15 years). Cysts were associated with a common channel in 37 (74%) cases, were not associated with a common channel in 9 (18%) cases, and in 3 (6%) cases the common channel lacked cysts. We performed endoscopic papilla sphincterotomy on 33 (66%) patients; endoscopic drainage was performed 62 times, including 17 patients without papilla sphincterotomy. In 15 (30%) cases, we only performed sphincterotomy. Extraction of lithiasis was done in 2 (4%) cases. Both ERCP and magnetic resonance cholangiopancreatography (MRCP) were performed on 13 patients. There was concordance of the choledochal cyst and of the type of cyst in both methods; however, common channels could not be observed by MRCP. There was 1 serious complication (perforation after sphincterotomy) and 11 (9%) mild adverse events.

Conclusions

When performed at an expert centre, ECRP is a safe and reliable procedure for children with choledochal cysts and/or an abnormal pancreatobiliary junction. Endoscopic retrograde cholangiopancreatography remains a reasonable alternative because MRCP has a limited ability to diagnose the precise anomalies of the pancreatobiliary junction and has no therapeutic capabilities.

Pediatric types I and VI choledochal cysts complicated with acute pancreatitis and spontaneous perforation: A case report and literature review

RATIONALE

Choledochal cysts are a congenital disorder of the common bile duct that can cause progressive biliary obstruction and biliary cirrhosis. They were classified by Todani into five types. Of these, type VI choledochal cysts are rarely reported in the literature.

PATIENT CONCERNS

A 22-month-old girl presented with intermittent epigastralgia for approximately 10 days and fever for three days. Fasting and total parenteral nutrition were administered after admission. However, sudden onset of severe epigastric pain occurred. An abdominal sonogram showed turbid ascites and peritonitis was impressed.

DIAGNOSES

An emergent exploratory laparotomy was performed, and perforation of the posterior wall of types I and VI choledochal cysts was observed.

INTERVENTIONS

Intraoperative cholangiography revealed concomitant types I and VI choledochal cysts with stricture of the distal common bile duct. Definite surgery for resection of the choledochal cysts and gallbladder was performed with Roux-en-Y choledochojejunostomy.

OUTCOMES

The patient had no evidence of ascending cholangitis at three years after the operation.

LESSONS

Type VI choledochal cysts are rarely reported in the literature. To our knowledge, this is the first reported pediatric case of concomitant types I and VI choledochal cysts complicated with acute pancreatitis and spontaneous perforation.

Duel-stage treatment for biliary cysts with cholangitis during pregnancy

Background & Objective:

Biliary cysts in pregnant women are a complex medical issue, especially when complicated with cholangitis. It is a serious and life-threatening diagnosis that can seriously endanger both the expectant mother and the fetus. However, during pregnancy, surgical treatment would lead to further complications and higher fetal mortality. Here, we propose a novel therapeutic approach that would be safe for both mother and child during pregnancy, with a definitive treatment postponed until after delivery.

Methods:

In this retrospective study we have summarized the clinical course of six adult patients diagnosed with choledochal cysts during pregnancy. Treatment was conducted in two stages, firstly, percutaneous cholecystostomy under ultrasound guidance and sustained negative pressure suction until delivery, and secondly, selective choledochal cyst excision when the patients recovered from delivery.

Results:

All the six patients gave birth to healthy babies. Four patients had Type-I choledochal cysts, and underwent Roux-en-Y hepaticojejunostomy surgery. Two patients had a Type-IV choledochal cyst. The first patient with Type-IV choledochal cyst underwent anastomosis between the secondary hepatic bile duct and jejunum and the second patient underwent laparoscopic cyst internal drainage. No serious complications were recorded after gallbladder drainage or during the perioperative period.

Conclusions:

Based on our single-centre experience we can conclude that treatment of choledochal cyst with cholangitis during pregnancy can be conducted safely and efficiently through the two stages strategy that we proposed in this paper. The first stage should be percutaneous cholecystostomy followed by elective surgical treatment following delivery.

Better long-term outcomes with hilar ductoplasty and a side-to-side Roux-en-Y hepaticojejunostomy

BACKGROUND

Whether a wide hilar hepaticojejunostomy after bile duct cyst (BDC) excision can prevent the development of postoperative complications remains an unanswered question. We compared our outcomes after a minimum of 2-y follow-up in patients with Todani type Ia choledochal cyst treated with hilar ductoplasty followed by a side-to-side Roux-en-Y hepaticojejunostomy (ductoplasty group) or radical cyst resection with an end-to-side Roux-en-Y hepaticojejunostomy (conventional group).

METHODS

We retrospectively reviewed the records of patients with Todani type Ia choledochal cyst who received radical cyst excision from January 1997 to December 2012, and we compared the groups' postoperative complications and surgical outcomes.

RESULTS

The groups' baseline demographics were similar, except for age. The gender distribution and preoperative presenting symptoms were comparable in the ductoplasty (n = 72) and conventional (n = 53) groups (all P > 0.05). Average age was 37.0 y for the ductoplasty group and 41.8 y for the conventional group (P = 0.024). The short-term complication rate of the groups was not significantly different (conventional group, 13.2% [7/53]; ductoplasty group, 8.3% [6/72]; all P > 0.05). A significant between-group difference was found in the long-term complication rate of biliary-enteric anastomotic strictures (9.4% in the conventional group and 0% in the ductoplasty group, P = 0.012). The rates of satisfactory surgical outcomes were 91.1% and 77.1% in the ductoplasty and conventional groups, respectively (P = 0.036).

CONCLUSIONS

The application of hilar ductoplasty with a side-to-side Roux-en-Y hepaticojejunostomy as the primary surgery for bile duct cyst excision significantly reduced the postoperative complication of biliary-enteric anastomotic stricture and greatly improved our patients' prognosis with regard to biliary function.

Type VI Choledochal Cyst-An Unusual Presentation of Jaundice

Choledochal cysts involving the cystic duct are extremely rare, and are usually associated with cystic dilatations of the extrahepatic biliary tract. We describe a patient who presented with jaundice and was found to have a dilatation of the common bile duct on computed tomographic imaging, consistent with a choledochal cyst. He underwent a laparoscopic-converted-to-open cholecystectomy with excision of the choledochal cyst which was found to involve the cystic duct. Choledochal cysts involving the cystic duct are notably missing from the Todani classification. Although exceedingly rare, new cases of these types of cysts are being reported, in part due to advancement of diagnostic imaging modalities. We discuss the current classification scheme for choledochal cysts and we propose an expansion of this scheme.

Ulcerated choledochocele: A case report

•

Upper gastro-intestinal endoscopy is part of diagnostic work-up for massive bleeding per rectum.

•

A positive ‘pillow sign’ in a mass in the region of the ampulla of Vater may be a choledochocele.

•

Cyst excision and marsupialization is the definitive treatment for a choledochocele.

•

Laparoscopic adhesiolysis is useful in adhesive small bowel obstruction.

Background

The cystic dilatation of the biliary tract is an uncommon anomaly. Choledochocele, a cystic dilatation of the distal common bile duct, rarely presents clinically as massive gastrointestinal bleeding.

Aim

This is to report a very rare disease condition and highlight minimal access options in surgical care.

Case summary

A 13 year-old boy was referred with a day history of sudden onset of passage of bright red blood per rectum with a fainting episode. There was no anal protrusion, jaundice, recurrent epigastric pain nor bleeding from any other orifice. An initial endoscopic assessment of the upper digestive tract showed profuse bleeding from a sub-mucosal mass in the region of ampulla of Vater. Emergency laparotomy revealed small intestine filled with blood from duodenum to ileum. A duodenotomy showed a cystic mass with an ulcerated mucosa at the dome containing bilious fluid in the second part of the duodenum. The cyst was de-roofed and marsupialized. Post-operative recovery was complicated by features of adhesive small bowel obstruction on the 9th post op day and treated by laparoscopic adhesiolysis. He was discharged home in good clinical state.

Conclusion

Choledochocele is a differential diagnosis in the endoscopic finding of a submucosal mass in the second part of the duodenum. An initial oesophagogastroduodenoscopy endoscopy is necessary in the evaluation of massive lower gastrointestinal bleeding.

Cholestasis beyond the Neonatal and Infancy Periods

Cholestasis results from impairment in the excretion of bile, which may be due to mechanical obstruction of bile flow or impairment of excretion of bile components into the bile canaliculus. When present, cholestasis warrants prompt diagnosis and treatment. The differential diagnosis of cholestasis beyond the neonatal period is broad and includes congenital and acquired etiologies. It is imperative that the clinician differentiates between intrahepatic and extrahepatic origin of cholestasis. Treatment may be supportive or curative and depends on the etiology. Recent literature shows that optimal nutritional and medical support also plays an integral role in the management of pediatric patients with chronic cholestasis. This review will provide a broad overview of the pathophysiology, diagnostic approach, and management of cholestasis beyond the neonatal and infancy periods.

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.

Comparison of Single-Incision and Conventional Laparoscopic Cyst Excision and Roux-en-Y Hepaticojejunostomy for Children with Choledochal Cysts

The purpose of this study was to elucidate the potential benefits of single-incision laparoscopic Roux-en-Y hepaticojejunostomy comparing the conventional laparoscopic procedures. From January 2013 to July 2013, 17 consecutive children with choledochal cysts received single-incision laparoscopic Roux-en-Y hepaticojejunostomies by a single surgeon at our institution. Seventeen standard laparoscopic hepaticojejunostomies of consecutive children with choledochal cysts from July 2012 to December 2012 were employed as control. Demographic and perioperative information was identified retrospectively using clinic and hospital records including gender, age, total operating time, estimated blood loss, time to oral intake, drainage removal time, postoperative complications, and postoperative hospital stay. One patient was converted to open surgery and another 8-year-old boy conversed to conventional four-port laparoscopic procedure. There were no significant differences between the conventional laparoscopic group and the single-incision laparoscopic group with regard to preoperative variables including age (P = 0.697) and sex distribution (P = 1.000). For mean operative time (209.9 ± 7.5 vs 204.1 ± 6.9 min, P = 0.951), estimated blood loss (10.7 ± 1.1 vs 13.4 ± 1.7 ml, P = 0.103), time to oral intake (3.73 ± 0.21 vs 3.77 ± 0.20 days, P = 0.889), drainage removal time (4.20 ± 0.45 vs 4.06 ± 0.23 days, P = 0.067), and postoperative hospital stay (7.60 ± 0.25 vs 7.41 ± 0.21 days, P = 0.627), the differences were also nonsignificant. Nevertheless, this technique demonstrated improved cosmetic outcomes comparing with the conventional laparoscopic group. The results showed better cosmetic results and comparable postoperative outcomes. However, well-designed prospective studies are warranted to better address this issue.

Choledochal cyst of the cystic duct: Report of imaging findings in three cases and review of literature

The choledochal cysts, which refer to the cystic dilatation of the biliary duct, are rare lesions generally seen in children. Choledochal cyst of the cystic duct is an uncommon entity. Often, it is associated with the choledochal cyst of the rest of the biliary tree. Isolated cystic duct choledochal cyst is quite rare. Most of these lesions have been recognized only on surgery. Modern cross-sectional imaging methods have facilitated preoperative recognition and characterization of cystic duct cyst enabling formulation of appropriate management strategy. We report the imaging findings in three cases of choledochal cyst involving the cystic duct. All these cases were correctly diagnosed preoperatively. A review of cases reported in the literature and the role of imaging in guiding the management are also presented.

Comparative analysis of spherical and fusiform choledochal cyst based on three-dimensional magnetic resonance cholangiopancreatography, biliary amylase, and histopathological examination

Aims:

The aim was to compare biliary amylase, common channel, and gall bladder/liver histopathology between spherical and fusiform choledochal cysts.

Materials and Methods:

Children undergoing cyst excision with Roux-en-Y hepatico-jejunostomy over a 17 months period were prospectively studied. The common channel was assessed by three-dimensional (3D) magnetic resonance cholangiopancreatography (MRCP).

Results:

Among 22 patients (spherical = 10, fusiform = 12), there was a higher incidence of spherical cysts in infants (5/7-71.4%) and fusiform cysts in older children (10/15-66.7%) (P = 0.09). Common channel identified in 14 (64%) cases was long (>10 mm) in 5 (38.2%) (one spherical, four fusiform [P = 0.5]) with associated high biliary amylase levels (>500 IU/L) in four (one spherical, three fusiform) (P = 0.05). Exact point of junction of common bile duct with pancreatic duct was visible with coronal half-Fourier-acquisition single-shot turbo spin-echo and 3D sampling perfection with application with optimize contrast using different flip angle evolution sequence using a reformatted plane of axis, particularly coronal, and coronal oblique orientation. Biliary amylase was raised (>100 IU/L) in 4 (40%) in the spherical group, compared to 8 (67%) in the fusiform group. Mean biliary amylase was similar in gallbladder and cyst in spherical but higher in gallbladder in fusiform cysts. Mean biliary amylase was <500 IU/L in 85.7% infants. Five out of 7 infants had liver fibrosis or cirrhosis on histopathology (P = 0.05). There were no dysplastic changes in the gallbladder epithelium.

Conclusion:

Three-dimensional MRCP delineated the common channel in two-third cases especially in coronal and coronal oblique orientation. The long common channel may have an etiological role in fusiform cysts. Spherical cysts, especially in infants, have a higher incidence of obstructive cholangiopathy.

Minimally invasive resection of choledochal cyst: a feasible and safe surgical option

BACKGROUND

The use of minimally invasive surgery (MIS) for choledochal cyst (CC) has not been well documented. We sought to define the overall utilization and outcomes associated with the use of the open versus MIS approach for CC. We examined the factors associated with receipt of MIS for CC, as well as characterized perioperative and long-term outcomes following open versus MIS for CC.

METHODS

Between 1972 and 2014, a total of 368 patients who underwent resection for CC were identified from an international, multicenter database. A 2:1 propensity score matching was used to create comparable cohorts of patients to assess the effect of MIS on short-term outcomes.

RESULTS

Three hundred thirty-two patients had an open procedure, whereas 36 patients underwent an MIS approach. Children were more likely to be treated with a MIS approach (children, 24.0 % vs. adults, 2.1 %; P<0.001). Conversely, patients who had any medical comorbidity were less likely to undergo MIS surgery (open, 26.2 % vs. MIS, 2.8 %; P=0.002). In the propensity-matched cohort, MIS resection was associated with decreased length of stay (open, 7 days vs. MIS, 5 days), lower estimated blood loss (open, 50 mL vs. MIS, 17.5 mL), and longer operative time (open, 237 min vs. MIS, 301 min) compared with open surgery (all P<0.05). The overall and degree of complication did not differ between the open (grades I-II, n=13; grades III-IV, n=15) versus MIS (grades I-II, n=5; grades III-IV, n=5) cohorts (P=0.85). Five-year overall survival was 98.6 % (open, 98.0 % vs. MIS, 100.0 %; P=0.45); no patient who underwent MIS developed a subsequent cholangiocarcinoma.

CONCLUSIONS

MIS resection of CC was demonstrated to be a feasible and safe approach with acceptable short-term outcomes in the pediatric population. MIS for benign CC disease was associated with similar perioperative morbidity but a shorter length of stay and a lower blood loss when compared with open resection.

Analysis of bile in various hepatobiliary disease states: A pilot study

AIM

Our study aims to find various enzymatic and biochemical components of bile and their clinical or prognostic correlation with regard to progression and severity of hepatobiliary diseases.

MATERIALS AND METHODS

It was a cross-sectional study where all the patients suffering from choledochal cyst (CDC), extrahepatic portal venous obstruction (EHPVO), and infantile obstructive cholangiopathy undergoing diagnostic preoperative cholangiogram; and patients with history of total parenteral nutrition (TPN) undergoing surgery for some other condition were included in the study. Intraoperatively, bile was collected from the gallbladder and sent for estimation of amylase, lipase, sodium, potassium, calcium, chloride, bicarbonate, total bilirubin, pH, cholesterol, triglycerides, and total bile acid.

RESULTS

A total of 80 patients were included in the study (20 in each of the four disease-based groups). Amylase, lipase, and pH were significantly different among the patients of CDC when compared with the presence or absence of dilated intrahepatic biliary radicals. Similarly, amylase, lipase, and pH were also significantly different among the patients of EHPVO when compared with presence or absence of biliopathy. Levels of cholesterol and bile acid were significantly higher in patients who were evaluated after 1 year following TPN than those who were evaluated before 1 year. The patients of infantile cholangiopathy, who had history of fever, had significantly higher level of calcium.

CONCLUSION

The components of bile show close correlation with various clinical and prognostic markers, there is a very close correlation between these parameters and the clinical severity, disease progression, and final outcome.

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.

A new operative approach for type I choledochal cysts

To present a novel modification of the surgical technique for open excision of type I choledochal cysts. The treatment of choice for choledochal cyst is surgical excision because such cysts are associated with an increased incidence of cancer. The commonly used operative technique provides poor access to the structures posterior to the cyst, principally the portal vein, and poor visibility of the junction of the cyst with the hepatic ducts and the pancreatic duct. The modification reduces these problems. The key operative step involves early transection of the choledochal cyst near its midpoint. This provides improved access to the back of the cyst. Slitting the sides of the cyst allows clear visibility from within the cyst of the union of the hepatic ducts with the cyst, and the entrance of the pancreatic duct, thus protecting them. Excision of type I choledochal cysts using the described method was completed in 11 adult patients between 2003 and 2012. One patient (9%) was found to have a concurrent gallbladder cancer and underwent an R0 resection at the time of choledochal cyst excision. No patients experienced any intraoperative complications. One patient (9%) developed a portal vein thrombosis postoperatively. The described technique is a safe and feasible method for the excision of extrahepatic choledochal cysts, and provides an advantage in allowing the surgeon to visualize the hepatic and pancreatic ducts from within the cyst and thus protect them during cyst excision.

Comparison of therapeutic effects of laparoscopic and open operation for congenital choledochal cysts in adults

Background. Laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy for treating congenital choledochal cysts (CCCs) have proved to be efficacious in children. Its safety and efficacy in adult patients remain unknown. The purpose of this study was to determine whether the laparoscopic procedure was feasible and safe in adult patients. Methods. We reviewed 35 patients who underwent laparoscopic operation (laparoscopic group) and 39 patients who underwent an open procedure (open group). The operative time, intraoperative blood loss, time until bowel motion recovery, duration of drainage, postoperative stay, time until resumption of diet, postoperative complications, and perioperative laboratory values were recorded and analyzed in both groups. Results. The operative time was longer in the laparoscopic group and decreased significantly with accumulating surgical experience (P < 0.01). The mean intraoperative blood loss was significantly lower in the laparoscopic group (P < 0.01). The time until bowel peristalsis recovery, time until resumption of diet, abdominal drainage, and postoperative stay were significantly shorter in the laparoscopic group (P < 0.01). The postoperative complication rate was not higher in the laparoscopic group than in the open group (P > 0.05). Conclusions. Laparoscopic cyst excision and hepaticojejunostomy are a feasible, effective, and safe method for treating CCCs in adult patients.

Liver histology in choledochal cyst- pathological changes and response to surgery: the overlooked aspect?

BACKGROUND

Histological changes in the liver in cases of choledochal cyst are seldom reported. The severity of liver pathology has an impact on the presentation, course and prognosis of hepatobiliary lesions. This study aims to record the histological changes in the liver and response to surgery in patients with choledochal cyst and to correlate these with the clinical symptoms and recovery.

MATERIALS AND METHODS

All children <12 years diagnosed with choledochal cyst were evaluated clinically, radiologically and biochemically at presentation. Excision of the cyst with intra-operative liver biopsy was done. Liver biopsy was repeated after 6 months of surgery. Both the liver biopsies were compared objectively in terms of hepatocellular damage, cholestasis, parenchymal inflammation, bile duct inflammation, bile duct proliferation, portal fibrosis and central venous distension with appropriate statistical tests. Clinical presentation and recovery were correlated with grades of liver pathology.

RESULTS

Forty-six patients were included. Pathological damage was observed in all the livers preoperatively. Post-operatively, significant resolution of histological changes was seen in hepatocellular damage (p < 0.0001), parenchymal inflammation (p = 0.0001), cholestasis (p = 0.0003) and bile duct proliferation (p = 0.0001). Portal fibrosis did not resolve. Central venous distension worsened. Severity of damage correlated significantly with younger age, symptom severity, anomalous pancreatico-biliary junction (APBJ) and obstructive biliary clearance on Tc-99 HIDA scan. Post-operative bile duct proliferation, bile duct inflammation and portal fibrosis were associated with cholangitis, re-do surgery and obstructive Tc-99 HIDA scan clearance in the post-operative period.

CONCLUSIONS

All patients with choledochal cyst show pathological changes in liver of varying severity. More severe symptoms, younger age and APBJ are associated with higher degree of liver damage. Except portal fibrosis and central venous distension, all other pathological changes regress after surgery. Regression can be hindered by post-op cholangitis, obstructive biliary clearance and post-op IHBR dilatation.

Endoscopic approach to the patient with congenital anomalies of the biliary tract

Congenital biliary tract anomalies typically present with neonatal cholestasis. In children and adults, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound are used to evaluate and treat choledochal cysts. Contrarily, endoscopy has traditionally played a minor role in the diagnosis of the cholestatic infant. Recent studies support the incorporation of ERCP into the diagnostic algorithm for biliary atresia and neonatal cholestasis. But at present, most pediatric liver centers do not consider its use essential. This article reviews the congenital biliary tract anomalies in which endoscopy has been shown to contribute to the evaluation of the cholestatic infant.

Concordance of imaging modalities and cost minimization in the diagnosis of pediatric choledochal cysts

PURPOSE

Given evolving imaging technologies, we noted significant variation in the diagnostic evaluation of pediatric choledochal cysts (CDC). To streamline the diagnostic approach to CDC, and minimize associated expenses, we compared typing accuracy and costs of ultrasound (US), intraoperative cholangiography (IOC), and magnetic resonance cholangiopancreatography (MRCP).

METHODS

Records of 30 consecutive pediatric CDC patients were reviewed. Blinded to all clinical data, two pediatric radiologists reviewed all US, MRCPs, and IOCs to type CDCs according to the Todani classification. When compared with pathologic findings, the concordance between and accuracy of each diagnostic test were determined. Inflation-adjusted procedure charges and collections for imaging modalities were analyzed.

RESULTS

Mean typing accuracy overlapped for US, IOC, and MRCP. Inter-rater reliability was 87 % for US (κ = 0.77), 80 % for IOC (κ = 0.62), and 60 % for MRCP (κ = 0.37). MRCP procedure charges ($1204.69) and collections ($420.85) exceeded IOC and US combined ($264.80 charges, p = 0.0002; $93.40 collections, p = 0.0021).

CONCLUSION

Our data support the use of US alone in the diagnosis of pediatric CDC when no intrahepatic biliary ductal dilatation is visualized. However, when dilated intrahepatic ducts are encountered on US, MRCP should be utilized to distinguish a type I from a type IV CDC, which may alter the operative approach.