A very low-birth-weight infant with spontaneous perforation of a choledochal cyst and adjacent pseudocyst formation

A nomogram for predicting choledochal cyst with perforation

BACKGROUND

Choledochal cyst with perforation (CC with perforation) rarely occurs, early diagnosis and timely treatment plan are crucial for the treatment of CC with perforation. This study aims to forecast the occurrence of CC with perforation.

METHODS

All 1111 patients were conducted, who underwent surgery for choledochal cyst at our hospital from January 2011 to October 2022. We conducted univariate and multivariate logistic regression analysis to screen for independent predictive factors for predicting CC with perforation, upon which established a nomogram. The predictive performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA) curves.

RESULTS

The age of children with choledochal cyst perforation is mainly concentrated between 1 and 3 years old. Logistic regression analysis indicates that age, alanine aminotransferase, glutamyl transpeptidase, C-reactive protein, vomiting, jaundice, abdominal distension, and diarrhea are associated with predicting the occurrence of choledochal cyst perforation. ROC curves, calibration plots, and DCA curve analysis curves demonstrate that the nomogram has great discriminative ability and calibration, as well as significant clinical utility.

CONCLUSION

The age of CC with perforation is mainly concentrated between 1 and 3 years old. A nomogram for predicting the perforation of choledochal cyst was established.

External biliary drainage before choledochal cyst treatment in a very low birth weight infant

Choledochal cysts (CC) are congenital biliary tract dilatations. Infantile CC (IFCC) in very low birth weight (VLBW) infants is rare. This is a case of a huge IFCC presented in VLBW preterm infant managed with external biliary drainage prior to definitive treatment. Electrolyte imbalance, poor weight gain, and infections were managed during external biliary drainage maintenance. Choledochal cyst excision and Roux-en-Y hepaticoenterostomy were successfully performed when the infant weighed 4.9 kg 5 months later. Delayed definitive treatment with external biliary drainage could be a feasible alternative for managing CC in low-birth-weight infants.

Comparison of Clinical and Radiologic Findings Between Perforated and Non-Perforated Choledochal Cysts in Children

OBJECTIVE

To compare the clinical and radiologic findings between perforated and non-perforated choledochal cysts in children.

MATERIALS AND METHODS

Fourteen patients (mean age ± standard deviation, 1.7 ± 1.2 years) with perforated choledochal cysts (perforated group) and 204 patients (3.6 ± 3.8 years) with non-perforated choledochal cysts (non-perforated group) were included between 2000 and 2019. All patients underwent choledochal cyst excision after ultrasound, CT, or MR cholangiopancreatography. Relevant data including demographics, clinical symptoms, laboratory findings, imaging findings, and outcomes were analyzed. Statistical differences were compared using the Mann-Whitney U test and Fisher's exact test.

RESULTS

Choledochal cyst perforation occurred only in children under the age of 4 years. Acute symptoms, including fever (p < 0.001), were more common in the perforated group than in the non-perforated group. High levels of white blood cells (p = 0.004), C-reactive protein (p < 0.001), and serum amylase (p = 0.002), and low levels of albumin (p < 0.001) were significantly associated with the perforated group. All 14 patients with perforated choledochal cysts had ascites, whereas only 16% (33/204) of patients in the non-perforated group had ascites (p < 0.001). In the subgroup of patients who had ascites, a large amount of ascites (p = 0.001), increase in the amount of ascites in a short time (p < 0.001), complex ascites (p < 0.001), and perihepatic pseudocysts (p < 0.001) were more common in the perforated group than in the non-perforated group.

CONCLUSION

Children with perforated choledochal cysts have characteristic clinical and radiologic findings compared to those with non-perforated choledochal cysts. In young children with choledochal cysts, perforation should be differentiated in cases with acute symptoms, laboratory abnormalities, and characteristic ascites findings.

Value of serum GGT level in the timing of diagnosis of choledochal cyst perforation

BACKGROUND

Choledochal cyst perforation is extremely rare, and early diagnosis or prediction is important for the immediate therapeutic intervention of perforations. This study aimed to define the predictor(s) of an impending or complete spontaneous perforation of choledochal cyst and establish the optimal operative timing.

METHODS

All 429 consecutive choledochal cyst patients from January 2015 to December 2021, were included. A retrospective study was performed based on Kaplan-Meier analysis, and Cox univariate and multivariate analyses.

RESULTS

A total of 429 patients were included, among which, 21 had choledochal cyst perforations (group A), and 408 did not (group B). Compared to group B, the serum alanine aminotransferase, aspartate aminotransferase, direct bilirubin, gamma-glutamyl transpeptidase, indirect bilirubin, total bilirubin, and alkaline phosphatase were significantly higher in group A (p = 0.025, 0.006, < 0.0001, 0.0001, 0.001, < 0.0001, and 0.033). High serum gamma-glutamyl transpeptidase was negatively associated with perforation-free preoperative survival, and multivariate Cox regression revealed that serum gamma-glutamyl transpeptidase was an independent predictive factor for an impending or complete perforation (p = 0.042).

CONCLUSIONS

A gamma-glutamyl transpeptidase level ≥ 346.5 U/L accompanied with significantly elevated liver enzymes and bilirubin levels was indicative of the possibility of an impending or complete choledochal cyst perforation, and a proactive surgical approach should be considered.

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.

Clinical features and risk factors of bile duct perforation associated with pediatric congenital biliary dilatation

PURPOSE

This study aimed to investigate the clinical features and risk factors of bile duct perforation in pediatric congenital biliary dilatation (CBD) patients.

METHODS

CBD patients, whose initial symptom was abdominal pain, were enrolled in this study and were divided into perforated and non-perforated groups. The clinical features of the perforated group were investigated. Moreover, the age at operation, sex, and morphologic features of the extrahepatic bile duct were compared between the groups.

RESULTS

Fifteen cases of bile duct perforation (10.4%) were identified among the 144 CBD patients who had abdominal pain. Majority of bile duct perforation occurred in patients aged < 4 years. The median duration from onset of abdominal pain to bile duct perforation was 6 (4-14) days. Age at onset [< 4 years old; P = 0.02, OR 13.9, (1.663, 115.3)], shape of extrahepatic bile duct [non-cystic type; P = 0.009, OR 8.36, (1.683, 41.5)], and dilatation of the common channel [P = 0.02, OR 13.6, (1.651, 111.5)] were risk factors of bile duct perforation.

CONCLUSIONS

Emergent bile duct drainage might be planned to prevent bile duct perforation if CBD patients have the abovementioned risk factors and experience persistent abdominal pain lasting for a few days from onset.

Laparoscopic management of antenatally detected choledochal cyst: a 10-year review

BACKGROUND

The aim of this review was to study the characteristics and the outcome of children who underwent laparoscopic management of the antenatally detected choledochal cyst.

METHODS

A retrospective review was conducted for all children who underwent excision of antenatally detected choledochal cyst and hepaticojejunostomy from 2005 to 2015.

RESULTS

Fourteen patients (11 females and 3 males) were included in this study. The mean diameter of the cyst was 5.0 cm (range 2-12 cm). The mean age at operation was 3.5 months (range 11 days to 9 months). The mean body weight was 6.0 kg (range 3.9-10.0 kg). Five patients were symptomatic before operation. Laparoscopic excision of choledochal cyst was successful in all cases. The distal end of common bile duct (CBD) was cauterized in all but two cases. Conversion to open hepaticojejunostomy was required in two children. There was no intraoperative complication. Two patients had postoperative fever. One patient had minor bile leak that resolved on conservative management. The mean operative time was 286 min (range 200-390 min). The median hospital stay was 8 days (range 6-25 days). At a median follow-up of 46 months (range 6-118 months), all patients were freed from cholangitis or intestinal obstruction. Symptomatic patients had earlier operation (mean, 1.7 vs. 4.5 months p = 0.012) and were associated with postnatal increase in cyst size (p = 0.023) but were not associated with increased risk of complication or conversion (p = 1.000).

CONCLUSIONS

Laparoscopic excision of choledochal cyst and hepaticojejunostomy could be safety performed in patients with the cyst detected antenatally. The distal CBD was usually small and stenotic. Symptomatic patients had earlier operation with no increase in morbidity.

Usefulness of laparoscopic cholecystostomy in children with complicated choledochal cyst

INTRODUCTION

In children with choledochal cysts (CC), obstruction of the discharge of bile or pancreatic juice is frequently observed, and biliary perforation and severe pancreatitis may occur. In such cases, temporary drainage is necessary to stabilize these patients. We employed laparoscopic cholecystostomy followed by laparoscopic cyst excision in cases with complicated CC.

METHODS

Between 2009 and 2013, emergency laparoscopic cholecystostomy for bile drainage was performed in seven girls with complicated CC in whom conservative treatment failed to ameliorate abdominal pain, vomiting, and jaundice; among these seven patients included two with biliary perforation, one with a huge cyst, and four with peribiliary edema suggestive of impending biliary rupture. Protein plugs in the common channel or the terminal portion of the cyst were present in six patients.

RESULTS

Amelioration of symptoms, such as abdominal pain and jaundice, was achieved in all patients after laparoscopic cholecystostomy. Saline irrigation of the bile duct via cholecystostomy was commenced 2 days postoperatively. All patients underwent laparoscopic cyst resection after improvement of their general condition and detailed evaluation of the intrahepatic and extrahepatic bile ducts and pancreaticobiliary maljunction. Impacted protein plugs or gallstones were eliminated in all patients by the time of laparoscopic cyst excision.

CONCLUSION

Laparoscopic cholecystostomy followed by laparoscopic cyst excision is a useful and safe procedure for the treatment of complicated CC. This technique is also favorable from a cosmetic viewpoint because the resultant wound can be reused as the trocar insertion site at the time of laparoscopic cyst excision.