Defining an optimal surveillance strategy for patients following choledochal cyst resection: results of a systematic review

Surgical aspects of choledochal cyst in children and adults: an experience of 106 cases

PURPOSE

To describe clinical features of choledochal cyst (CC) patients in terms of demographic data, clinical presentation, investigations, treatment, and outcomes among children and adults.

METHODS

The medical records of patients undergoing choledochal cyst (CC) surgery from 2002 to 2021 at a university hospital were retrospectively reviewed. The patients were divided into two groups: children (< 15 years) and adults (≥ 15 years). Descriptive statistics were used.

RESULTS

There were 106 cases of CC (Female/male = 88/18, children/adult = 53/53). Abdominal pain was the predominant presenting symptom, followed by jaundice in both groups. Adults were significantly more prone to present with abdominal pain compared to children (86.8% vs. 52.8%; p < 0.001), while children were more likely to experience acholic stool than adults (22.6% vs. 3.8%; p = 0.004). Ultrasound was the preferred investigation screening modality (75.5%). Most patients were presented with type I CC (71.7%). Laparoscopic-assisted approach was performed in 8.5%. CC excision with roux-en-y hepatico-jejunostomy was the main procedure (88.7%). Adults had a higher incidence of post-op complications, including stones, anastomosis stricture, abdominal collection, and cholangitis. Adults were significantly more likely to require intervention after surgery, compared to children (26.4% vs. 5.7%; p = 0.04).

CONCLUSIONS

Ultrasound was the most common screening tool for diagnosis. Postoperatively, adults with CC experience more serious post-op complications compared to children. This could be attributed to long-standing cystic inflammation. Therefore, prompt definitive surgery is recommended for CC patients.

Characteristics and malignancy rates of adult patients diagnosed with choledochal cyst in the West: a systematic review

BACKGROUND

The approach to patients with choledochal cysts (CCs) remains varied and subject to institutional practices. Owing to the rarity of the disease, the optimal treatment remains poorly defined, particularly in the adult population. This study aimed to review the literature on adult patients with CCs to evaluate trends of diagnosis and management in Western countries.

METHODS

A literature search of 3 electronic databases was performed on adult patients diagnosed with CCs in Western institutions. A review of published literature was completed with comprehensive screening by 2 independent reviewers. Studies were analyzed, and data on surgical approach, malignancies, and follow-up were collected. Findings are presented in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

RESULTS

Of the 3488 articles retrieved, 21 studies evaluated Western adults with CCs for a combined population of 1337 patients. The most common Todani subtypes included types I (64%) and IV (22%). Symptoms at presentation included abdominal pain and jaundice, although many were asymptomatic. Ultrasound was used most frequently for diagnosis, followed by computed tomography and endoscopic cholangiopancreatography. The combined malignancy rate was 10.9%, with cholangiocarcinoma being the most prevalent. Complete extrahepatic cyst resection was standard for type I and IV CCs. Among malignancies, 18.5% and 16.4% were observed in patients with prior resection and internal drainage, respectively.

CONCLUSIONS

A significant proportion of patients who undergo resection of CC disease harbor malignancy. Cancer risk seems reduced but not eliminated with complete resection, which remains the standard treatment. Additional studies are needed to standardize guidelines for the diagnosis and postoperative care of patients in Western countries.

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.