Smallest Todani's type II choledochal cyst

Does Congenital Biliary Dilatation Todani Type II (Diverticular Type) Really Exist?

AIM OF THE STUDY

The aim of the study is to clarify the clinicopathological and biliary morphological characteristics in reported cases of diverticular congenital biliary dilatation (CBD).

METHOD

Using PubMed and the Japan Medical Abstracts Society, articles on possible diverticular CBD were extracted and the clinical pictures examined. We also sought evidence for definitions of diverticular CBD and the associated condition of pancreaticobiliary maljunction (PBM) using the original articles by Alonso-Lej and Todani. The characteristic biliary morphologies of cases with images were also investigated.

RESULTS

Analyses of 211 possible cases superficially demonstrated multiple diverticula in 12 (12%) and single diverticulum in 89 (88%), with diverticula located in the upper (n = 38, 38%), middle (n = 32, 32%), or lower (n = 26, 26%) biliary tract in and presence of intra-diverticular stones, PBM, and biliary carcinoma in 23% (n = 18), 39% (n = 25), and 11% (n = 14), respectively. However, evidence defining diverticular CBD or justifying the lack of associated PBM was not demonstrated even in the original articles. Scrutiny of the biliary anatomy in 59 cases with images showed incorrect inclusions of types I or IV-A with an irregular biliary duct wall or dilated cystic duct, periampullary choledochal diverticula, or even solitary biliary cysts. Authentic diverticular CBD, representing the diverticulum connected to the middle of the common bile duct via a thin, patent stalk was seen in only 6 cases.

CONCLUSION

Real diverticular CBD appears extremely rare. The lack of an objective definition allows wide interpretations of clinical pictures, creating inconsistencies in the diagnosis and treatment of CBD and raising questions regarding the utility of conventional classifications.

LEVEL OF EVIDENCE

Level III.

Surgical management of cystic dilatation bile ducts in adults

Background

The cystic dilatation of the biliary tract is a rare disease and uncertain origin. It is recognized more frequently in children; however, its incidence comes increasing in adults, representing 20% of the cases.

Aim

To evaluate morbimortality rates, evolution and handing of patients with cystic dilatation bile ducts in adults.

Methods

Were evaluated, retrospectively, five adults who had the diagnosis of choledochal cyst and that had been submitted to some surgical procedure.

Results

Abdominal pain was the commonest complain to all patients. Jaundice was present in 80%. Ultrasound scanning was done in all the cases as initial examination. CT scan, magnetic resonance imaging and endoscopic retrograde cholangiopancreatography were also done in some patients; however, the diagnosis was established intra-operatively in all cases. The cyst resection with reconstruction of the biliary tract was done in 60%; the cystojejunostomy in 20%; and in 20% biliary tract drainage.

Conclusions

Biliary tract cystic dilatation is a rare disease. However, its incidence is increasing in the adult population, so, it must be thought as differential diagnosis when facing obstructive jaundice.

Congenital choledochal cysts in adults: twenty-five-year experience

BACKGROUND

Choledochal cyst is rare in western countries. The relatively high incidence of coexistent hepatobiliary disease increases the difficulty of the surgical management of choledochal cyst. Here we analyze the diagnosis and treatment of congenital bile duct cyst in 122 Chinese adults.

METHODS

The clinical data of 122 patients with congenital choledochal cysts admitted from 1981 to 2006 were analyzed.

RESULTS

Clinical symptoms in most cases were nonspecific, resulting in delayed diagnosis. Sixty-one patients (50%) had coexistent pancreatobiliary disease. Among the 122 patients, 119 patients underwent ultrasonic examination; ERCP/MRCP was performed in 63 cases and CT in 102 cases. Abnormal pancreatobiliary duct junction was found in 48 patients. Sixteen patients had malignant lesions in the bile duct, arising in 11 of them from incomplete choledochal cyst that underwent various operations including cystenterostomy or cystojejunostomy. There was significant difference between the patients who underwent incomplete cyst resection and complete cyst resection in malignancy rate of bile duct (Chi square test, P = 0.000; odds ratio, 7.800; 95% confidence interval, 2.450 to 24.836).

CONCLUSIONS

ERCP, CT and MRCP had proved their great values in the classification of the disease. Cyst excision with Roux-en-Y hepaticojejunostomy is recommended as the treatment of choice for patients with type I or type IV cysts. For type V cyst (Caroli's disease) with recurrent cholangitis, liver transplantation should be considered.