Biliary cysts: Etiology, diagnosis and management

Relationships of serum MMP-7 and clinical characteristics in choledochal cyst children

BACKGROUND

Matrix metalloproteinase-7 (MMP-7) is associated with biliary injury. This study aimed to evaluate the relationships of serum MMP-7 with clinical characteristics in choledochal cysts (CDC) children.

METHODS

Between June 2020 and July 2022, we conducted a prospective study of CDCs who underwent one-stage definitive operation at our center. Serum MMP-7 was measured using an enzyme-linked immunosorbent assay. We evaluated the relationships between serum MMP-7 and age, laboratory tests, imaging examinations, liver fibrosis, MMP-7 expression, and perforation.

RESULTS

A total of 328 CDCs were enrolled in the study, with a median serum MMP-7 of 7.67 ng/mL. Higher serum MMP-7 was correlated with younger age at diagnosis (p < 0.001), larger cyst sizes (p < 0.001), higher liver fibrosis stages (p < 0.001), and higher incidence of perforation (p < 0.01). Liver MMP-7 was mainly expressed in intrahepatic and extrahepatic biliary epithelial cells. The area under the receiver operating characteristic curve (AUROC) was 0.630 (p < 0.001) for serum MMP-7 in predicting perforation. When serum MMP-7 was combined with γ-glutamyl transferase (GGT), the AUROC increased to 0.706 (p < 0.001).

CONCLUSIONS

Serum MMP-7 was associated with biliary obstruction in CDCs. Patients with high serum MMP-7 were more likely to have severe liver damage and biliary injury, with higher incidences of liver fibrosis and perforation.

A case of laparoscopic excision of choledochal cyst, hepaticojejunostomy, and Roux-en-Y anastomosis using Artisential®

Choledochal cyst is a condition involving an abnormal dilation of the bile ducts, which can lead to various symptoms and comorbidities, including cancer. The treatment of choice for choledochal cyst is surgical correction including choledochal cyst excision and Roux-en-y hepaticoenterostomy. Minimal invasive methods like laparoscopic methods or robotic methods are used for surgical correction of choledochal cysts; however, it is still controversial which method is superior. A Korean company, LIVESMED, developed Artisential®, a laparoscopic surgical instrument that can overcome the drawbacks of laparoscopic methods. This article presents a case of the first Artisential®-performed surgical excision of a choledochal cyst and hepaticojejunostomy.

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.

Biliary Cyst: An Unusual Cause of Cholestasis Post Cholecystectomy

Biliary cysts are relatively uncommon and they can be congenital or acquired and can have various presentations such as cholelithiasis, cholangitis, jaundice, and pancreatitis. Biliary cysts are associated with a high risk of biliary cancers and such risk increases with age. Identification of biliary cysts warrants an aggressive approach to lower cancer risk. Surgical management has a high success rate and it lowers morbidity, mortality, and cancer risk. We present a 40-year-old female who had a cholecystectomy in 2016. She presented with obstructive jaundice and was found to have a class I biliary cyst. She underwent endoscopic retrograde cholangiopancreatography with stenting which led to complete resolution of her symptoms. Later, she underwent elective Roux-en-Y hepaticojejunostomy with cyst resection three months later. She underwent a successful recovery.

Incidentally exploration of the fusiform cystic duct cyst during laparoscopic cholecystectomy of septate gallbladder - Case Report

INTRODUCTION AND IMPORTANCE

Biliary cysts are rare congenital anomalies of the biliary ductal system. Cystic duct cysts in particular are not included in the widely used Todani classification and remain underreported.

CASE PRESENTATION

A 28-year-old male presented with intermittent right upper quadrant pain exacerbated by fatty foods. Ultrasound showed a septate gallbladder. Laboratory tests were normal. Laparoscopic cholecystectomy identified a 1.5 cm cystic duct cyst.

CLINICAL DISCUSSION

Cystic duct cysts arise from anomalous ductal recanalization/dilatation. Presentation mimics cholelithiasis. Complete surgical excision is the treatment to prevent complications.

CONCLUSION

This case presents an incidental finding of a cystic duct cyst resected during cholecystectomy for septate gallbladder. Increased recognition can improve the management of these rare biliary anomalies.

Clinical characteristics of solitary intrahepatic biliary cyst

Solitary intrahepatic biliary cyst (SIBC) is a rare disease, and due to the lack of adequate understanding of it, SIBC is often misdiagnosed as simple liver cyst (SLC), which in turn affects the therapeutic effect. In order to arouse more attention to SIBC, combined with clinical experience in our center, this study specifically screened 3 representative cases of SIBC, and conducted a comprehensive retrospective analysis of their clinical characteristics, diagnosis and treatment process. Combined with the relevant literature, the diagnosis and treatment process of SIBC is widely discussed.

Diseases of the Gallbladder and Biliary Tree

Diseases of the gallbladder include a spectrum of gallstone diseases (cholelithiasis, cholecystitis, choledocholithiasis, and cholangitis), cysts, polyps, and malignancy. In this review, we present the incidence, risk factors, clinical presentation, diagnosis, and treatment of these various conditions. Importantly, we report when more urgent referral is indicated, as well as red flags that warrant further intervention and/or management.

A Unique Type or Variation of Bile Duct Cyst in a 9-Year-Old Girl:A Remarkable Case Study

Patients with bile duct cysts require careful radiological assessment of the hepatobiliary system prior to surgical intervention. This clinical case is uncommon with an atypical clinical presentation and radiological findings. According to the most widely used classification of choledochal cysts, this case presents a combination of Type I and Type IV of choledochal cyst (CC) combining the form of extra, intrahepatic bile ducts and cystic duct dilations.

Non-cirrhotic portal hypertension secondary to cholangiointestinal anastomotic stricture after choledochal cyst excision: a case report

Background

Cystectomy accompanied by biliary system reconstruction is an important treatment option for choledochal cysts, but the risk of post-operative complications is high. The most famous long-term complication is anastomotic stricture, whereas non-cirrhotic portal hypertension secondary to cholangiointestinal anastomotic stricture is rare.

Case summary

Here we report the case of a 33-year-old female patient with a type I choledochal cyst who underwent choledochal cyst excision with Roux-en-Y hepaticojejunostomy. Thirteen years later, the patient presented with severe esophageal and gastric variceal bleeding, splenomegaly, and hypersplenism. Furthermore, cholangiointestinal anastomotic stricture with cholangiectasis was identified on imaging. A pathological examination of the liver suggested intrahepatic cholestasis, but the fibrosis was mild and inconsistent with severe portal hypertension. Therefore, the final diagnosis was portal hypertension secondary to a cholangiointestinal anastomotic stricture after choledochal cyst surgery. Fortunately, the patient recovered well after endoscopic treatment and dilated cholangiointestinal anastomotic stricture.

Conclusion

Choledochal cyst excision with Roux-en-Y hepaticojejunostomy is the recommended standard of care for type I choledochal cysts; however, the long-term risk of cholangiointestinal anastomotic stricture requires consideration. Moreover, cholangiointestinal anastomotic stricture can lead to portal hypertension, and the degree of elevated portal pressure may be inconsistent with the degree of intrahepatic fibrosis.

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.

Updated epidemiology of gastrointestinal cancers in East Asia

Globally, gastrointestinal cancers represent more than one-fourth of all cancer incidence and one-third of cancer-related mortality. Although there has been much progress in screening colorectal cancer, the prognosis of other gastrointestinal cancers tends to be poor. The highest burden of gastrointestinal cancers, including stomach, liver, oesophageal and gallbladder cancers, was observed in regions in East Asia. The increasing burden of gastrointestinal cancers in East Asian regions is related to population growth, ageing and the westernization of lifestyle habits in this region. Furthermore, the rising incidence of young-onset colorectal cancer is an emerging trend in East Asia. This Review provides a comprehensive and updated summary of the epidemiology of gastrointestinal cancers in East Asia, with emphasis on comparing their epidemiology in East Asia with that in Western regions, and highlights the major risk factors and implications for prevention. Overall, to optimally reduce the disease burden incurred by gastrointestinal cancers in East Asian regions, a concerted effort will be needed to modify unhealthy lifestyles, promote vaccination against the hepatitis virus, control Helicobacter pylori, liver fluke and hepatitis virus infections, increase the uptake rate of colorectal cancer screening, enhance detection of early cancers and their precursors, and improve cancer survivorship through an organized rehabilitation programme.

Advances in the Treatment of Neonatal Biliary Disease

This article discusses current standard of care in neonatal biliary disease, particularly management of biliary atresia and choledochal cysts. It highlights surgical considerations, guidelines for adjuvant therapies, and promising therapeutic options that are under investigation.

Biliary atresia and congenital disorders of the extrahepatic bile ducts

Biliary atresia (BA) and choledochal cysts are diseases of the intrahepatic and extrahepatic biliary tree. While their exact etiopathogeneses are not known, they should be treated promptly due to the potential for irreversible parenchymal liver disease. A diagnosis of BA may be easy or complicated, but should not be delayed. BA is always treated surgically, and performing the surgery before the age of 2 mo greatly increases its effectiveness and extends the time until the need for liver transplantation arises. While the more common types of choledochal cysts require surgical treatment, some can be treated with endoscopic retrograde cholangiopancreatography. Choledochal cysts may cause recurrent cholangitis and the potential for malignancy should not be ignored.

Congenital anomalies of the gastrointestinal tract: the liver, extrahepatic biliary tree and pancreas

Congenital anomalies of the liver, biliary tree and pancreas are rare birth defects, some of which are characterized by a marked variation in geographical incidence. Morphogenesis of the hepatobiliary and pancreatic structures initiates from two tubular endodermal evaginations of the most distal portion of the foregut. The pancreas develops from a larger dorsal and a smaller ventral outpouching; emergence of the two buds will eventually lead to the fusion of the duct system. A small part of the remaining ventral diverticulum divides into a "pars cystica" and "pars hepatica", giving rise to the cystic duct and gallbladder and the liver lobes, respectively. Disruption or malfunctioning of the complex mechanisms leading to the development of liver, gallbladder, biliary tree and pancreas can result in numerous, albeit fortunately relatively rare, congenital anomalies in these organs. The type and severity of anomalies often depend on the exact moment in which disruption or alteration of the embryological mechanisms takes place. Many theories have been brought forward to explain their embryological basis; however, no agreement has yet been reached for most of them. While in some cases pathological evaluation might be more centered on macroscopic evaluation, in other instances small biopsies will be the keystone to understanding organ function and treatment results in the context of congenital anomalies. Thus, knowledge of the existence and histopathological characteristics of some of the more common conditions is mandatory for every pathologist working in the field of gastrointestinal pathology.

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.

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.

Deletion of kif3a in CK19 positive cells leads to primary cilia loss, biliary cell proliferation and cystic liver lesions in TAA-treated mice

BACKGROUND & AIMS

Loss of primary cilia in epithelial cells is known to cause cystic diseases of the liver and kidney. We have previously shown that during experimental and human cirrhosis that primary cilia were predominantly expressed on biliary cells in the ductular reaction. However, the role of primary cilia in the pathogenesis of the ductular reaction is not fully understood.

METHODS

Primary cilia were specifically removed in biliary epithelial cells (BECs) by the administration of tamoxifen to Kif3a^f/f;CK19^CreERT mice at week 2 of a 20-week course of TAA treatment. Biliary progenitor cells were isolated and grown as organoids from gallbladders. Cells and tissue were analysed using histology, immunohistochemistry and Western blot assays.

RESULTS

At the end of 20 weeks TAA administration, primary cilia loss in liver BECs resulted in multiple microscopic cystic lesions within an unaltered ductular reaction. These were not seen in control mice who did not receive TAA. There was no effect of biliary primary cilia loss on the development of cirrhosis. Increased cellular proliferation was seen within the cystic structures associated with a decrease in hepatocyte lobular proliferation. Loss of primary cilia within biliary organoids was initially associated with reduced cell passage survival but this inhibitory effect was diminished in later passages. ERK but not WNT signalling was enhanced in primary cilia loss-induced cystic lesions in vivo and its inhibition reduced the expansion of primary cilia deficient biliary progenitor cells in vitro.

CONCLUSIONS

TAA-treated kif3a BEC-specific knockout mice had an unaltered progression to cirrhosis, but developed cystic lesions that showed increased proliferation.

Choledochal cysts surgical management: Retrospective and historical comparative analysis

INTRODUCTION

Choledochal cysts are rare bile duct dilatations, which have higher prevalence in Asian population. The aim of the study was to analyze clinical and surgical results about biliary cysts management. In addition, a comparative historical analysis was performed.

METHODS

Patients who underwent surgery between January 1988 and December 2019 in a single tertiary level center were retrospectively included. Demographic and clinical patient data; cyst types; diagnostic methods and surgical technique were analyzed, as well as short and long-term follow-up complications. A comparative descriptive study focus on the main historical series was also carried out.

RESULTS

A total of seventeen patients were identified; 58.8% were men. The mean age at diagnosis was 39.9 years (SD: 20.54). The median follow-up was 5 years (IQR 1-15). The most frequent cysts were type I (41.2%). Abdominal pain was the most common presenting symptom (58.8%). Cystic excision with bilio-enteric anastomosis was the main procedure, it was underwent in 85, 7% type I cysts. 29.4% postoperative complications were recorded. Malignancy was not documented in any pathology specimen.

CONCLUSIONS

Choledochal cysts are an uncommon disorder whose diagnosis requires a high level of suspicion. Surgical treatment depends on type of cyst. In most patients with choledochal cysts disease, complete cyst excision with bilio-enteric anastomotic reconstruction is the treatment of choice.

Quiste de colédoco Todani Iva. Reporte de caso y revisión de la literatura

Biliary tree dilations are unusual congenital malformations that may involve the entire bile circulation and, they are common during the first life decade. Most cases initiate with jaundice and chronic abdominal pain which localizes in right upper quadrant. High clinical suspicion accompanied by imaging studies are essential for diagnosisHigh suggestive clinic associated with imaging studies are essential for diagnosis. Treatment has evolved until today complete cyst resection has become the treatment of choice, since it presents a good response, although without being free from long-term complicationsTreatment has been evolving being at the present time cyst complete resection the gold standard in treatment although without being exempt from long-term complications. We present the case of a 27-year-old male patient with a history of 3 months onset epigastric abdominal pain diagnosed as Todani IVa common bile duct choledochal cyst by magnetic resonance imaging. It is performed Open surgical management was performed with total resection of the cyst and biliodigestive Roux-en-Y diversiona total cyst resection with Roux-en-Y biliodigestive bypass by open surgical approach without any complications. He was discharged 7 days post-op. A review of the literatura focused on the surgical approach and management of similar cases was carried out. We carry out bibliography review focused on surgical approach and management of similar cases. Keywords: Bile duct dilation; choledochal cyst; Todani IVa; jaundice.

Differentiation of cystic biliary atresia and choledochal cysts using prenatal ultrasonography

Purpose

This study explored the performance of prenatal ultrasonography in the differential diagnosis of cystic biliary atresia (CBA) and choledochal cyst (CC).

Methods

Fetuses diagnosed with hepatic hilar cyst in the second trimester were included in this study. A series of prenatal ultrasound examinations were performed in the second and third trimesters. The diameter of the gallbladder (GB) and hepatic cyst were measured, as well as the wall thickness of the GB. The GB-cyst connection, visibility of the right hepatic artery (RHA), and other concomitant abnormalities were carefully evaluated. A neonatal transabdominal ultrasound examination was performed within 1 week after birth, and clinical data were followed up to 6 months after birth.

Results

Between January 1, 2016 and January 31, 2020, 53 fetuses diagnosed with hepatic hilar cyst were recruited. Eight were excluded because they were lost to follow-up. Among the 45 cases included in this study, 10 were diagnosed with CBA and 35 with CC after birth. Statistically significant differences were found in GB width, wall thickness, change in GB width, change in cyst length, GB-cyst connection, and RHA visibility between the CBA and CC groups. GB width showed the best diagnostic performance with an area under the curve (AUC) of 0.899. The combination of GB width, GB wall thickness, and GB-cyst connection yielded a comparable AUC of 0.971.

Conclusion

The GB should be carefully evaluated in fetuses with hepatic hilar cyst. Prenatal ultrasound findings could provide suggestive parameters for the differential diagnosis of CBA from CC.

[Surgical treatment of common bile duct malformations in children]

The review is devoted to the current classifications of common bile duct malformations, authors' opinion regarding surgical approach and reconstruction of the bile ducts. The authors describe the modern modifications of bile duct reconstructions and estimate their effectiveness. PubMed database, Google Scholar and National Scientific Electronic Library eLIBRARY.ru databases were used. We analyzed the complications in children depending on various reconstructions, anatomical form, timing of reconstructive surgery and early diagnosis of this pathology.

Choledochal cysts surgical management: Retrospective and historical comparative analysis

INTRODUCTION

Choledochal cysts are rare bile duct dilatations, which have higher prevalence in Asian population. The aim of the study was to analyze clinical and surgical results about biliary cysts management. In addition, a comparative historical analysis was performed.

METHODS

Patients who underwent surgery between January 1988 and December 2019 in a single tertiary level center were retrospectively included. Demographic and clinical patient data; cyst types; diagnostic methods and surgical technique were analyzed, as well as short and long-term follow-up complications. A comparative descriptive study focus on the main historical series was also carried out.

RESULTS

A total of seventeen patients were identified; 58.8% were men. The mean age at diagnosis was 39.9 years (SD: 20.54). The median follow-up was 5 years (IQR 1-15). The most frequent cysts were tipe I (41.2%). Abdominal pain was the most common presenting symptom (58.8%). Cystic excision with bilio-enteric anastomosis was the main procedure, it was underwent in 85, 7% type I cysts. 29.4% postoperative complications were recorded. Malignancy was not documented in any pathology specimen.

CONCLUSIONS

Choledochal cysts are an uncommon disorder whose diagnosis requires a high level of suspicion. Surgical treatment depends on type of cyst. In most patients with choledochal cysts disease, complete cyst excision with bilio-enteric anastomotic reconstruction is the treatment of choice.

Etiological classification and treatment strategies for secondary bile duct dilatation

Secondary intra- and extrahepatic bile duct dilatation is a very common condition that can be caused by several diseases. However, it has been rarely discussed in the specialized literature. Moreover, no distinct etiology can be determined in some cases, which hampers the diagnosis and treatment. Here, we discuss the etiological classification and treatment strategies of secondary intra- and extrahepatic bile duct dilatation based on an extensive literature review, as well as our experimental research and clinical experience. The etiology of secondary intra- and extrahepatic bile duct dilatation can be classified in different ways. From a clinicopathological perspective, it can be classified into obstruction-, lesion-, and compression-induced dilatation. Treatment varies depending on the cause. For example, endoscopic dilation or stenting is used for biliary strictures, laparoscopic choledochectomy for stone removal, and resection for cholangiocarcinoma.

A giant biliary cyst of Todani IA in a young woman: A case report

RATIONALE

Biliary cysts (BC) are rare dilatations of various parts of a biliary tract. They account for approximately 1% of all benign biliary diseases. Total cyst excision and Roux-Y hepaticojejunostomy is the treatment method of choice in most patients. In this paper, a novel surgical treatment with the use of internal biliary and pancreatic catheters was presented.

PATIENT CONCERNS

A 21-years-old woman with a giant choledochal cyst of Todani IA type presenting with abdominal pain, nausea, fever and palpable abdominal mass. It had been previously drained as a misdiagnosed pancreatic cyst in another hospital.

DIAGNOSIS

A very high amylase level (107140,0 U/l) in drain fluid was noted in laboratory tests. Endoscopic retrograde cholangiopancreatography revealed a biliary cyst located in the distal common bile duct and a pancreaticobiliary anomaly was suggested. A cholangiography per catheter inserted to the biliary cyst showed a large round contrast-filled cyst. A cholangiography following cyst decompression revealed a very long, tortuous bile duct entering the duodenum.

INTERVENTIONS

Cholecystectomy, cyst resection, Roux-Y hepaticojejunostomy, and implantation of catheters into pancreatic and bile duct were performed. The postoperative course was uneventful and she was discharged on 12th day without any complications. Histopathology revealed a cyst wall partially lined with biliary-type and mucinous epithelium, with dysplasia ranging from low to high grade (biliary intraepithelial neoplasia, high grade), without invasion.

OUTCOMES

The biliary and pancreatic catheters were removed during endoscopic retrograde cholangiopancreatography 8 weeks following surgery without any complications. Fourteen months later, the patient reported good health.

LESSONS

Diagnosis of the abdominal cyst should be very precise in order to avoid misdiagnosis and inadequate management. The early diagnosis and proper treatment of BC are needed in order to avoid serious complications. The cholangiocarcinoma is the most dangerous potential complication of BC due to dysplasia within the cyst wall as in our young female patient.

A new variant of double common bile duct associated with choledochal cyst

Extrahepatic bile duct duplication is a rare biliary anomaly often associated with conditions like cholecysto-choledocholithiasis, choledochal cyst and malignancy. Precise preoperative diagnosis using conventional radiologic imaging still remains a challenge and use of existing classification system is equally confusing. A female patient diagnosed with choledochal cyst by magnetic resonance cholangiopancreatography was found to have an associated new variant of double common bile duct during surgery. The variant discovered could not be classified by existing classification systems and was missed by preoperative imaging. Recognition of existence of this anomaly that warrants careful dissection during biliary surgery is necessary to avoid inadvertent biliary injury as preoperative diagnosis still remains a challenge. Review of existing classification systems is required to include newly discovered variants.

Management of Choledochal Cysts at a Tertiary Care Centre: A Nine-Year Experience from India

Background

Although choledochal cyst disease is seen predominantly in childhood, it is becomingly increasingly diagnosed in adult patients.

Methods

Data of 36 patients with choledochal cysts managed in our institute between January 2010 and December 2018 were retrospectively analyzed.

Results

Median age at presentation was 37 years (range: 13–72 years). Female-to-male ratio was 3.5 : 1. All patients were symptomatic, and abdominal pain was the most common symptom. 72.2% had other associated conditions. There was a considerable delay from the onset of symptoms to referral, median duration being 348 days. There were 28 cases of type I (77.8%), 5 cases of type IVA (13.9%), and 3 cases of type IVB (8.3%). Cyst excision with Roux-en-Y hepaticojejunostomy was performed in 29 (80.55%) cases. This procedure was combined with a left lateral sectionectomy, left hepatectomy, and radical cholecystectomy in 1, 2, and 1 cases, respectively. Lilly's technique was used in 2 cases, and cyst excision with hepaticoduodenostomy was performed in 1 case. Early complications were seen in 21 patients (58.3%), and late complications were seen in 5 patients (13.8%). 2 patients were found to have associated malignancies. One patient was detected to have cholangiocarcinoma in the resected liver incidentally, and another patient was diagnosed to have gall bladder cancer intraoperatively.

Conclusion

Choledochal cysts should be considered in the differential diagnosis of adults presenting with epigastric or right hypochondrium pain or jaundice. A thorough preoperative evaluation is required. Cyst excision with Roux-en-Y hepaticojejunostomy forms the standard treatment in most cases. Long-term follow-up is essential for management of complications and early detection of malignant change.

What should be the best approach in the management of bile duct cysts in the era of cholangioscopy?

We read with great interest the scientific letter by Sánchez Melgarejo JF et al., in which they report a degenerate Todani Ia choledochal cyst in a patient with a pancreas divisum. However, patients with a choledochal cyst might benefit from per oral cholangioscopy for malignancy detection and extension evaluation.

Clinical Features and Surgical Management of Bile Duct Cyst in Adults

Objectives

Bile duct cyst (BDC) is a rare congenital biliary malformation with 20% of cases initially diagnosed during adulthood. Although the incidence of BDC in adults is increasing worldwide, the clinical features of adult BDC remain unclear. The present study was aimed at characterizing the demographic and clinical features of this rare disease.

Methods

We constructed a retrospective database and analyzed records of 106 patients (mean age, 41.0 ± 14.8 years; 18 men (17.0%)) with BDC treated at our institution from May 2012 to October 2018. Data collected included demographic characteristics, clinical manifestations, surgical patterns, and prognoses. We compared the characteristics of patients undergoing their primary BDC resection against those of patients undergoing reoperation. Risk factors for bile duct infection (BDI), a common complication of BDC, were identified using univariate and multivariate analyses.

Results

Abdominal pain was the most common preoperative symptom, but 12 patients (11.3%) were asymptomatic. Ninety-nine patients underwent their primary BDC resection, and 7 patients received reoperation at our hospital. There was no significant difference in the postoperative complication rate between the two groups. Ninety-four patients were followed up for 37.8 ± 23.8 months, and BDI occurred in 33 patients (35.1%). Hilar anastomosis was an independent risk factor for BDI (odds ratio = 3.561; 95%confidence interval = 1.101, 11.517; and p = 0.034).

Conclusion

BDC was more frequent in women and abdominal pain was the most common preoperative symptom. The primary reason for reoperation was anastomotic stenosis. Reoperation had similar outcomes to primary resection and may be considered safe and acceptable if performed by a skillful surgeon. BDI was the most frequent postoperative complication with hilar anastomosis being the only independent risk factor. This highlights the importance of proper bile duct flow for surgical outcomes of BDC.

Epidemiology of gallbladder cancer

According to GLOBOCAN 2018 data, gallbladder cancer (GBC) accounts for 1.2% of all global cancer diagnoses, but 1.7% of all cancer deaths. Only 1 in 5 GBC cases in the United States is diagnosed at an early stage, and median survival for advanced stage cancer is no more than about a year. The incidence of the disease is increasing in the developed world. Gallstones, biliary cysts, carcinogen exposure, typhoid, and Helicobacter pylori infection, and abnormal pancreaticobiliary duct junctions are all risk factors, many of which account for its geographical, ethnic and sex distribution. Genetics also plays a strong role, as about a quarter of GBC cases are considered familial, and certain ethnicities, such as Native Americans, are at far higher risk for the neoplasm. Prevention includes weight loss, vaccination against and treatment of bacterial infections, early detection and elimination of polyps and cysts, and avoidance of oral estrogen replacement therapy.

Giant choledochal cyst presenting during third trimester of pregnancy

Biliary cystic disease is a rare entity. Twenty-five per cent of cases are diagnosed during adulthood and only a few reports have described this condition during pregnancy, where it represents a therapeutic challenge for both obstetricians and surgeons with regard to the risks it entails for the patient and the fetus.Definitive management is surgical resection, as cysts may progress to malignancy if untreated. During pregnancy, resection is generally deferred to after delivery, especially in the context of suspected cholangitis.A 19-year-old young woman with no previous prenatal control, presented to the emergency department on her 32nd week of gestation with abdominal pain and jaundice. A giant Todani I biliary cyst was observed on imaging along with dilation of the proximal biliary tree suggesting acute cholangitis. Fetal compromise prompted immediate delivery after which percutaneous biliary drainage was performed. Following recovery, the cyst was surgically resected.

Biliary Anomalies in Patients With HNF1B Diabetes

CONTEXT

The clinical spectrum of organogenetic anomalies associated with HNF1B mutations is heterogeneous. Besides cystic kidney disease, diabetes, and various other manifestations, odd cases of mainly neonatal and posttransplantation cholestasis have been described. The biliary phenotype is incompletely defined.

OBJECTIVE

To systematically characterize HNF1B-related anomalies in the bile ducts by imaging with magnetic resonance imaging (MRI) or magnetic resonance cholangiopancreatography (MRCP).

SETTING AND PATIENTS

Fourteen patients with HNF1B mutations in the catchment area of the Helsinki University Hospital were evaluated with upper abdominal MRI and MRCP. Blood samples and clinical history provided supplemental data on the individual phenotype.

MAIN OUTCOME MEASURE(S)

Structural anomalies in the biliary system, medical history of cholestasis, other findings in abdominal organs, diabetes and antihyperglycemic treatment, hypomagnesemia, and hyperuricemia.

RESULTS

Structural anomalies of the bile ducts were found in seven of 14 patients (50%). Six patients had choledochal cysts, which are generally considered premalignant.

CONCLUSIONS

Structural anomalies of the biliary system were common in HNF1B mutation carriers. The malignant potential of HNF1B-associated choledochal cysts warrants further studies.

Contrast-Enhanced Magnetic Resonance Cholangiography: Practical Tips and Clinical Indications for Biliary Disease Management

Since its introduction, MRCP has been improved over the years due to the introduction of several technical advances and innovations. It consists of a noninvasive method for biliary tree representation, based on heavily T2-weighted images. Conventionally, its protocol includes two-dimensional single-shot fast spin-echo images, acquired with thin sections or with multiple thick slabs. In recent years, three-dimensional T2-weighted fast-recovery fast spin-echo images have been added to the conventional protocol, increasing the possibility of biliary anatomy demonstration and leading to a significant benefit over conventional 2D imaging. A significant innovation has been reached with the introduction of hepatobiliary contrasts, represented by gadoxetic acid and gadobenate dimeglumine: they are excreted into the bile canaliculi, allowing the opacification of the biliary tree. Recently, 3D interpolated T1-weighted spoiled gradient echo images have been proposed for the evaluation of the biliary tree, obtaining images after hepatobiliary contrast agent administration. Thus, the acquisition of these excretory phases improves the diagnostic capability of conventional MRCP—based on T2 acquisitions. In this paper, technical features of contrast-enhanced magnetic resonance cholangiography are briefly discussed; main diagnostic tips of hepatobiliary phase are showed, emphasizing the benefit of enhanced cholangiography in comparison with conventional MRCP.

Two Cases of Plug or Stone in Remnant Intrapancreatic Choledochal Cysts Treated with Endoscopic Retrograde Cholangiopancreatography

Incomplete resection of choledochal cysts (CCs) that extend deep into the pancreas can lead to protein plug or stone formation, pancreatitis, and cholangiocarcinoma. We encountered two cases of choledocholithiasis in remnant intrapancreatic CCs, in which the patients exhibited symptoms after 3 and 21 years of cyst excision. A 21-year-old woman who had undergone excision of a CC, as a neonate, presented with epigastric pain. Abdominal computed tomography (CT) revealed stones inside the remnant pancreatic cyst, which were removed by endoscopic retrograde cholangiopancreatography (ERCP), and her symptoms improved. A 33-year-old woman, who underwent cyst excision 3 years ago, presented with pancreatitis. Abdominal CT showed a radiolucent plug inside the remnant pancreatic cyst. The soft, whitish plug was removed by ERCP, and the pancreatitis improved. These cases indicate that plugs and stones in CCs have the same pathogenetic mechanism, and their form depends on the time since the incomplete excision surgery.

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.

Characterizing the activation of the Wnt signaling pathway in hilar cholangiocarcinoma using a tissue microarray approach

Hilar cholangiocarcinoma (HCCA) is an invasive hepatic malignancy that is difficult to biopsy; therefore, novel markers of HCCA prognosis are needed. Here, the level of canonical Wnt activation in patients with HCCA, intrahepatic cholangiocarcinoma (IHCC), and congenital choledochal cysts (CCC) was compared to understand the role of Wnt signaling in HCCA. Pathology specimens from HCCA (n=129), IHCC (n=31), and CCC (n=45) patients were used to construct tissue microarrays. Wnt2, Wnt3, β-catenin, TCF4, c-Myc, and cyclin D1 were detected by immunohistochemistry. Parallel correlation analysis was used to analyze differences in protein levels between the HCCA, IHCC, and CCC groups. Univariate and multivariate analyses were used to determine independent predictors of successful resection and prognosis in the HCCA group. The protein levels of Wnt2, β-catenin, TCF4, c-Myc, and cyclin D1 were significantly higher in HCCA compared to IHHC or CCC. Wnt signaling activation (Wnt2+, Wnt3+, nuclear β-catenin+, nuclear TCF4+) was significantly greater in HCCA tissues than CCC tissues. Univariable analyses indicated that expression of cyclin D1 as well as Wnt signaling activation, and partial Wnt activation (Wnt2+ or Wnt3+ and nuclear β-catenin+ or nuclear TCF4+) predicted successful resection, but only cyclin D1 expression remained significant in multivariable analyses. Only partial Wnt activation was an independent predictor of survival time. Proteins in the canonical Wnt signaling pathway were present at higher levels in HCCA and correlated with tumor resecility and patient prognosis. These results suggest that Wnt pathway analysis may be a useful marker for clinical outcome in HCCA.

Another Type of Choledochal Cyst Beyond the Todani Classification

The classification of choledochal cyst has changed from 3 types described by Alonso-Lej to 5 types described by Todani, but these classifications do not include dilatation of the cystic duct. The sixth type of choledochal cyst has been described by some authors for the cystic dilatation of the cystic duct. It is so rare that accurate diagnosis is difficult before operation. We present a 15-month-old girl with a type VI choledochal cyst that was misidentified preoperatively as a type I choledochal cyst. Besides the gall bladder and the cystic duct cyst, we also excised the distal part of the common bile duct and performed reconstruction with Roux-en-Y hepaticojejunostomy. From a review of the literature, we have determined that there is a more direct route to adequate diagnosis and management of the sixth type of choledochal cyst.

Cholangiocarcinoma Arising from a Type VI Biliary Cyst: A Case Report and Review of the Literature

Cystic dilatations of the cystic duct which are suggested as type VI biliary cysts are very rare and many of them go unrecognized or are confused with other cysts until the operation although they are obvious on imaging studies. They can present with fusiform or saccular dilatations and can be accompanied by common bile duct dilatations. It is important to identify these cysts as they share the same characteristics as the other biliary cyst types and can be complicated with malignancy. We herein present a very unusual case of a cholangiocarcinoma arising from a type VI biliary cyst in a 58-year-old female patient and review the literature. The patient presented with jaundice, weight loss, and abdominal pain. On imaging, the cystic duct and common bile duct were fusiformly dilated and had a wide communication. There was a mass filling the distal parts of both ducts. The patient was urgently operated on after perforation following ERCP. Histopathology was compatible with a type VI biliary cyst and an associated cholangiocarcinoma.

MRI Findings of Intrinsic and Extrinsic Duodenal Abnormalities and Variations

This pictorial review aims to illustrate the magnetic resonance imaging (MRI) findings and presentation patterns of anatomical variations and various benign and malignant pathologies of the duodenum, including sphincter contraction, major papilla variation, prominent papilla, diverticulum, annular pancreas, duplication cysts, choledochocele, duodenal wall thickening secondary to acute pancreatitis, postbulbar stenosis, celiac disease, fistula, choledochoduodenostomy, external compression, polyps, Peutz-Jeghers syndrome, ampullary carcinoma and adenocarcinoma. MRI is a useful imaging tool for demonstrating duodenal pathology and its anatomic relationships with adjacent organs, which is critical for establishing correct diagnosis and planning appropriate treatment, especially for surgery.

Predictive and prognostic molecular markers for cholangiocarcinoma in Han Chinese population

Cholangiocarcinoma (CCA) is the most common malignant heterogeneous polygenetic carcinoma with a high incidence in Asia. Most patients would die within 1 year after diagnosis and the 5 year survival rate is less than 10-20% worldwide. Single nucleotide polymorphisms (SNPs) in genes regulate telomere maintenance, mitosis, and inflammation, and may help predict individual susceptibility to certain drugs, environmental factor, and risks to particular diseases. The gene-gene interaction and the regulation of SNPs have not been assessed extensively in CCA. According to our previous study, the GRB2-associated-binding protein (Gab1) gene rs3805246 (X(2) =5.015, P=0.025, OR=0.531, 95% CI 0.304-0.928) and epidermal growth factor receptor (EGFR) gene rs2007000 (X(2) =7.934, P=0.005, OR=2.148, 95% CI 1.255-3.675) presented significant difference between CCA patients and controls. This study conducted a population-based analysis using 225 CCA cases (153 biliary tract cancer patients and 72 gall bladder cancer patients) to assess the association between SNPs and progression of CCA patients, including the overall survival and the prognosis analysis. Results showed that an increased susceptibility of BTC was significantly associated with SNP loci distribution frequency in EGFR rs2107000 (X(2) =7.934, P=0.005, OR=2.148, 95% CI 1.255-3.675). Furthermore, multivariate factor regression analysis represented cholelithiasis medical history of BTC patients can be an effective evaluation criteria of BTC susceptibility in early stage. This study also assessed the relationship between these genotypic polymorphisms and clinicopathologic data, including tumor differentiation stage and overall survival. This is the first study identifying that EGFR polymorphisms are associated with BTC and EGFR rs2017000 polymorphisms may be an important survival predictor in BTC patients.

Choledochal Cyst in Adults: Etiopathogenesis, Presentation, Management, and Outcome-Case Series and Review

Background. Choledochal cyst, a rare congenital cystic dilatation of biliary tree, is uncommon in adults. Their presentations differ from children and surgical management has evolved. Methods. A retrospective review of the records of all the patients above 15 years, who underwent therapeutic intervention in our hospital, was carried out. Results. Ten cases of choledochal cyst were found; 8 female, with mean age 31 years. These included 8 cases of Todani type I and one case each of type II and type III. The predominant symptoms were abdominal pain and jaundice. Abdominal mass and past history of cholangitis and pancreatitis were seen in 2 patients. Investigations included ultrasound in 8 patients, CT in 7, ERCP in 3, and MRCP in 5. Surgical intervention included complete excision of the cyst with hepaticojejunostomy and cholecystectomy (type I), excision of the diverticulum (type II), and ERCP sphincterotomy (type III). Malignancy was not seen in any patients. The long-term postoperative complications included cholangitis in two patients. Conclusion. Choledochal cyst is rare in adults. The typical triad of abdominal pain, jaundice, and mass is uncommon in adults. The surgical strategy aims for single stage complete excision of the cyst with hepaticojejunostomy.

Clinical value of ultrasound in diagnosing pediatric choledochal cyst perforation

OBJECTIVE. The objective of our study was to evaluate ultrasound images of pediatric patients with choledochal cyst perforation and establish imaging findings that can be used as the basis for timely surgical intervention. MATERIALS AND METHODS. Our study group was composed of 23 pediatric patients who presented with various symptoms of acute abdomen and were admitted to our institution between 1996 and 2013. All had undergone preoperative ultrasound examination and had a final diagnosis of choledochal cyst perforation that was confirmed at exploratory laparotomy. The imaging and surgical data were reviewed and analyzed retrospectively. RESULTS. The 23 patients included nine males and 14 females with a mean age of 2.55 years and mean disease duration of 12.48 days. The most common initial diagnoses were intestinal obstruction and peritonitis. Real-time ultrasound imaging with multislice views revealed characteristics of choledochal cyst perforation, including changes in the shape of the bile duct, loss of local gallbladder tension, thickened gallbladder wall, changes in the morphology of the gallbladder, and peritoneal effusion. The inability to visualize the gallbladder, gallbladder enlargement, the presence of gallbladder sludge and of pebblelike stones, and dilatation of the intrahepatic ducts were also noted on ultrasound. Choledochectasia was present in a majority of the patients (17/23), and ascites was seen in all 23 patients. The ultrasound signs corresponded to the surgical findings, thus showing the high clinical diagnostic value of ultrasound in this setting. CONCLUSION. Real-time ultrasound imaging-with its multislice views and good reproducibility-allows definitive preoperative diagnosis of pediatric choledochal cyst perforation.

Ruptured choledochal cyst: a rare presentation and unique approach to management

We present the rare case of a ruptured choledochal cyst (CC) in a young woman presenting with a two-day history of worsening upper abdominal pain. Imaging revealed a contracted gallbladder, dilated common bile duct (CBD), and a large amount of peritoneal fluid. Percutaneous paracentesis was performed, obtaining bilious fluid. Further imaging revealed cystic dilatation of the CBD and the diagnosis of rupture CC type I was made. The patient was initially managed conservatively with percutaneous drains, IV antibiotic therapy, and sphincterotomy through an ERCP. Elective cyst resection and Roux-en-Y hepatojejunostomy was performed 8 weeks later. It is important to differentiate a ruptured CC from other surgical emergencies without exploratory laparotomy. Initial conservative management could be considered, followed by elective resection once inflammation, infection, and other complications have resolved, avoiding the increased risk associated with an emergency operation or two-stage laparotomy.