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

Choledochal cyst type I with dilated intrahepatic biliary radicles: a type IVA mimic

Background

A choledochal cyst is a relatively rare congenital anomaly of the biliary tree requiring surgery as the definitive treatment. Amongst the five Todani variants, type I poses a diagnostic and treatment challenge owing to its infrequent, yet clinically significant mimicry for type IVA cysts.

Case presentation

We present a case of a 4-year-old female diagnosed to have a giant type IA choledochal cyst that mimicked a type IVA cyst on radiological imaging. The patient was treated by complete cyst excision, cholecystectomy, and restoration of the biliary-enteric communication by a Roux-en-Y hepaticojejunostomy. Regression of the dilated intrahepatic radicles that counterfeited a type IVA cyst was confirmed on follow-up imaging studies.

Conclusion

Such an encounter, although rare, can significantly alter the course of management. We recommend extrahepatic cyst excision with biliary reconstruction as the standard treatment when preoperative and intraoperative imaging studies fall short in differentiating the aforementioned variants.

Surgical Management and Prognosis of Congenital Choledochal Cysts in Adults: A Single Asian Center Cohort of 69 Cases

Background

The choledochal cyst (CC) is a rare cystic dilatory condition with malignant tendency, which is more frequently reported in children. Surgical resection of cysts can significantly decrease the risk of malignancy and reduce associated complications. However, CC has been paid lesser attention in adults, and its surgical parameters have been frequently reported to be in dispute. This study aimed to report experience associated with the treatment of an adult with CC and to suggest the appropriate parameters for the surgery, including the extent of excision (complete or not), the length of the Y limb, the diameter of the cholangio-intestinal anastomosis (CIA), and different operative approaches (open, laparoscopic, and laparoscopic converted to open) by comparing the various indicators, including postoperative bile leakage, cholangitis, choledocholithiasis, carcinogenesis, and surgical re-excision.

Methods

We conducted a single-center noninterventional retrospective study of 69 different congenital choledochal cyst patients who were admitted to our hospital between July 2010 and July 2020. We collected and analyzed their demographic data, clinical presentations, underlying complications, imaging tests, endoscopic interventions, and parameters for the surgery, histological data, and prognostic indicators over a mean 77-month follow-up period.

Results

We found that out of the 69 cases, the median age at diagnosis was 32 (IQR = 22–45) years. Seven (10.1%) patients were asymptomatic before the diagnosis, with abdominal pain as the primary complaint in 62 (89.9%) patients, whereas nausea/vomiting was observed in 29 (42.0%) patients. CCs were mainly evaluated by using magnetic resonance cholangiopancreatography (MRCP) (n = 47, 68.1%). It was observed that surgery, cholecystectomy, choledochal cysts excision, and Roux-en-Y hepaticojejunostomy (n = 65, 94.2%), and laparotomy (n = 58, 84.1%) were the dominant therapeutic modalities employed. However, seventeen (24.6%) patients were treated with incomplete cyst resection, while 52 (75.4%) patients received complete cyst resection. We also conducted regular follow-ups after the surgery for a mean duration of 77 months. Postoperative complications were found to be experienced by 35 (50.7%) patients, and a further two patients (2.9%) developed malignancy during the follow-up. Moreover, increasing the diameter of cholangio-intestinal anastomosis served as a potential protective factor for postoperative choledocholithiasis (p = 0.040) and a risk factor for cholangitis (p = 0.002).

Conclusions

Among the 69 CC participants, abdominal pain was their major symptom. Those with an abnormal pancreaticobiliary junction were more likely to have choledocholithiasis and pancreatitis. The diagnosis was found to be highly dependent on the Todani classification scheme and MRCP. Surgical resection remains the key to CC treatment. The results suggested that the complete resection, the length of the Y limb of 40 cm–60 cm, and the diameter of the CIA of 1.0 cm–1.5 cm were appropriate values for predicting the lower risk of postoperative complications.

Long-term Morbidity of Choledochal Malformations in Children

OBJECTIVE

The aim of the study was to assess long-term morbidity in children operated for choledochal malformation (CM) by relating clinical complications to liver histopathology, follow-up imaging, liver stiffness, and biochemistry.

METHODS

A single-center retrospective follow-up study including all CM patients (n = 55, 71% girls) treated during 1976 to 2018 was performed. Mann-Whitney U test and Spearman rank correlation were used for statistical analyses.

RESULTS

During median follow-up of 5.8 (interquartile range, 2.5-12) years, 1 patient was lost to follow-up whereas all survived. Intraoperative liver biopsies showed fibrosis in 32%, and patients with Metavir stage ≥2 were younger at surgery (0.36 [0.11-1.9] vs 3.8 [0.72-10.5] years, P = 0.024) than those without fibrosis. Overall, 21% had long-term complications including cholangitis in 9 (>2 episodes in 5) patients, anastomotic stricture in 2 referred patients and adhesive volvulus or hepatocellular carcinoma in 1 each. Anastomotic strictures were successfully managed nonoperatively and hepatocellular carcinoma with thermoablation. In postoperative magnetic resonance cholangiography (MRCP) performed 6.4 (3.6-16) years after hepaticojejunostomy, diameters of both main intrahepatic ducts had decreased significantly to 3.0 (2.5-3.5) mm (P = 0.0001) but a distal cyst stump was remaining in 30% with a length of 6.0 (4.0-20) mm that associated with operation age (r = 0.71, P = 0.015) and fusiform CM type. Follow-up ultrasound revealed mild dilation of intrahepatic bile ducts in 6.3% and mildly to moderately elevated liver biochemistry in 23%, and liver stiffness (>7 kPa) in 22%.

CONCLUSIONS

Whilst cholangitis was the most common postoperative problem, individual patients experienced other more significant complications and one quarter of patients showed evidence of underlying liver dysfunction.

Development of intrahepatic cholangiocarcinoma at the remnant intrahepatic cyst portion 10 years after resection of type IV choledochal cyst

Complete resection of Todani type IV choledochal cyst (CC) is not possible, because the intrahepatic portion is not resectable. We present a case of intrahepatic cholangiocarcinoma that arose from the remnant CC portion that was located within the liver 10 years after resection. A 59-year-old female patient had undergone resection of type IV CC 10 years ago, leaving large remnant portions of CC at the liver and pancreas. Two and four years after resection of the extrahepatic CC, cholangitis with intrahepatic stones developed hence these episodes were treated with percutaneous transhepatic cholangioscopy. Ten years after the first operation, intrahepatic stones and a new mass were identified in follow-up imaging studies. Because the mass was identified as adenocarcinoma on biopsy, we performed left hepatectomy with redo hepaticojejunostomy. Pathologic examination showed a 4.5-cm-sized moderately differentiated adenocarcinoma arising from the remnant CC with lymph node metastasis. The patient recovered uneventfully and is currently undergoing adjuvant chemotherapy. Our case indicates that the remnant intrahepatic CC can undergo malignant transformation long after resection of CC. Since the intrahepatic CC portion in type IV CC is usually unresectable, wide hepaticojejunostomy and life-long observation with regular imaging study follow-up are highly recommended for prevention and early detection of malignant transformation.

Management of intractable pancreatic leak from iatrogenic pancreatic duct injury following resection of choledochal cyst in an adult patient

Iatrogenic pancreatic duct injury can occur during resection of the choledochal cyst (CC). We herein present a case of postoperative pancreatic fistula (POPF) developed after resection of the CC in an adult patient with variant anomalous union of pancreatobiliary duct. The 55-year-old female patient underwent surgery after the diagnosis of CC-associated gallbladder cancer. During surgery, the CC mass was accidentally pulled out, by which the intrapancreatic CC portion was torn out from the main pancreatic duct. Since the pancreatic duct stump was not identified due to its small size, repair was not possible. The excavated defect at the pancreas head was closed securely combined with insertion of multiple drains. Postoperative POPF and peripancreatic fluid collection developed and the patient had to be fasted for 4 weeks. She was first discharged at 6 weeks after surgery. At 10 weeks, she was readmitted due to progression of peripancreatic fluid collection, which was controlled by percutaneous drain insertion. At 6 months, she was readmitted again due to repeated progression of peripancreatic fluid collection, which were controlled by endoscopic transmural duodenocystostomy. It took 8 months to resolve the pancreatic duct injury-associated pancreatitis. The experience in this case suggests that iatrogenic pancreatic duct injury during resection of CC can induce catastrophic complications, thus special attention should be paid to prevent pancreatic duct injury.

Sex differences in surgically correctable congenital anomalies: A systematic review

PURPOSE

This study aims to compare the prevalence and outcomes of surgically correctable congenital anomalies between sexes.

METHODS

Upon registration on PROSPERO (CRD42019120165), a librarian aided in conducting a systematic review using PRISMA guidelines. The five largest relevant studies were included for each anomaly. Cumulative prevalence differences and confidence intervals were calculated, and the Cochran-Mantel-Haenszel test was performed.

RESULTS

Of 42,722 identified studies, 68 were included in our analysis. All included anomalies had greater than 1000 patients except duodenal atresia (n = 787) and intestinal duplication (n = 148). Males had a significantly higher prevalence than females in 10/14 anomalies (Hirschsprung's disease, omphalomesenteric duct, congenital diaphragmatic hernia, anorectal malformation, malrotation, esophageal atresia, congenital pulmonary airway malformation, intestinal atresia, omphalocele, and gastroschisis; p < 0.001). There was no difference in the prevalence of duodenal atresia or intestinal duplication between sexes (p = 0.88 and 0.65, respectively). Females had a significantly higher prevalence of biliary anomalies (atresia and choledochal cyst).

CONCLUSION

Our study indicates that males have higher prevalence rates of most congenital anomalies. Further investigations are required to illuminate the embryology underlying this sex distribution and whether sex influences outcomes.

TYPE OF STUDY

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Prognostic study, level II.

Development of adenocarcinoma at the remnant intrapancreatic cyst 16 years after resection of the choledochal cyst

One of the main reasons to resect choledochal cyst (CC) is to prevent malignant transformation. After resection of CC, the remnant intrapancreatic bile duct is no longer exposed to the enzymatic insult from pancreatic juice activated by the bile. Thus theoretically, the risk of malignant transformation disappears. We present a case showing development of adenocarcinoma from the remnant CC 16 years after resection of CC. A 43 year-old female patient underwent resection of type I CC 16 years ago, leaving a small remnant portion of CC as it was located deep within the pancreas close to the anomalous union of the pancreatobiliary duct. Four years later, intrahepatic ducts were dilated due to anastomotic stricture of the hepaticojejunostomy, which was resolved after repeated balloon dilatation. On follow-up examination at postoperative 16 years, a mass within the pancreas head was identified. As the mass was identified as adenocarcinoma on biopsy, pylorus-preserving pancreatoduodenectomy was performed. Pathologic examination showed a 3.5 cm-sized moderately differentiated adenocarcinoma arising from the remnant CC, with no lymph node metastasis. The patient recovered uneventfully, and is currently undergoing adjuvant chemotherapy. This case indicates that remnant CC can undergo malignant transformation. Therefore, complete resection of CC coupled with life-long follow-up is emphasized.