Choledochal cyst of the cystic duct: Report of imaging findings in three cases and review of literature

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.

A new variant of Choledochal cyst-type VI: a rare case presentation and review of the literature

A 53-year-old male patient with a previous diagnosis of dilatation of the common bile duct was admitted to the hospital due to recurrent episodes of vague epigastric pain over a 4-month period. After undergoing abdominal CT, MRI, MRCP, ERCP examinations, together with joint diagnosis by the radiology department and the gastroscopy unit, the diagnosis of a cystic dilatation of the common bile duct was excluded, and to preliminarily diagnose as cystic lesion at the hepatoduodenum ligament. A nasobiliary tube was preset before the surgery, and it was found that the gallbladder, the cyst, and the common bile duct were connected in sequence during the surgery, leading to the definitive diagnosis of biliary cyst of the cystic duct. During the surgery, the anatomical position of the common bile duct was accurately identified, avoiding iatrogenic biliary injury and preserving the integrity of the common bile duct structure. The patient recovered and was discharged from the hospital on the 14th postoperative day. Cystic duct cysts are a relatively new and rare condition. This case demonstrates that clinical decision-making by a multidisciplinary team is of great significance for such diseases, and preoperative assessment of the anatomical relationship between cystic dilation lesions in the hepatic portal region and the biliary system and gallbladder is also crucial.

Cystic duct cyst in adults: a systematic review of the sixth entity

Over the past two decades, there have been an increasing number of reports describing a sixth type of choledochal cyst (cystic duct cyst) in adults that was not included in Todani's classification. This sixth entity has not yet been systematically reviewed in the literature. We therefore explored this condition in adults from the perspective of the clinical presentation, diagnosis and treatment through a systematic review of the evidence. The final analysis included 33 reported cases, with 55% of them reported in Asia. The mean age was 39.3 years old, with a female-to-male ratio of 1.5:1. Magnetic resonance cholangiopancreatography was accurate in establishing the diagnosis in 69% of cases. Where reported, standard laparoscopic/open cholecystectomy was performed in about 74% of patients, while around 25% of them needed extensive surgery. Associated malignancy was reported in 6.1% of cases, while 28% of patients had co-existent gallstone-related disease. No significant post-operative morbidity or mortality was reported. In this era of emergency laparoscopic cholecystectomy, surgeons should be aware of this rare condition, with the particular understanding that it is associated with gallstone-related disease in a significant number of reported cases.

Imaging in ductal plate malformations

Ductal plate malformations are a heterogenous group of congenital fibrocystic liver diseases resulting from insult to the ductal plate at various stages of embryogenesis. As a result various biliary malformations, cysts, hamartomas and congenital hepatic fibrosis may be seen. We present a radiological pictorial of ductal plate malformations, accurate diagnosis of which is important for clinical management.

Type VI Choledochal Cysts-Case Report and Review of Literature

Choledochal cysts (CDC), are rare congenital dilations involving the extra hepatic biliary apparatus with or without dilation of the intrahepatic bile ducts. They are conventionally classified into five types. A new type, type VI, causing dilation of the cystic duct between the neck of the gall bladder and the common hepatic duct (CHD) has been described in medical literature which is the rarest of all these subtypes. They are commonly observed in middle aged females and are mostly symptomatic. Most of these cysts need magnetic resonance cholangiopancreatography (MRCP) for accurate diagnosis. Treatment options for these lesions are not well defined but range from simple cholecystectomy to complete excision of the entire bile duct and biliary reconstruction, as there is a concern of malignant transformation in these cysts. Hence, these rare cysts, though rare, must be borne in mind when dealing with suspicious cystic lesions in the biliary tract. Here, we present an interesting case of such a rare cyst and its management in a middle aged woman.

Embryonal rhabdomyosarcoma of the biliary tree: A rare cause of obstructive jaundice in children which can mimic choledochal cysts

Jaundice in children is more often due to hepatic disease than obstruction. Differential considerations for obstructive jaundice in children include choledocholithiasis, choledochal cysts and rare neoplasms. Rhabdomyosarcoma, the most common soft tissue sarcoma in pediatric patients, typically involves the head and neck, genitourinary system and extremities. Embryonal rhabdomyosarcoma of the biliary tree is a rare entity. We present a 3-year-old boy with abrupt onset obstructive jaundice. Although initial imaging suggested a dilated biliary system with fusiform common bile duct, sludge, and possible cholelithiasis, endoscopic retrograde cholangiopancreatogram (ERCP) diagnosed a common bile duct embryonal rhabdomyosarcoma and further imaging showed involvement of the cystic duct. This case illustrates the importance of considering malignant etiologies in cases of obstructive jaundice, particularly when imaging is not classic for common causes.

Pediatric types I and VI choledochal cysts complicated with acute pancreatitis and spontaneous perforation: A case report and literature review

RATIONALE

Choledochal cysts are a congenital disorder of the common bile duct that can cause progressive biliary obstruction and biliary cirrhosis. They were classified by Todani into five types. Of these, type VI choledochal cysts are rarely reported in the literature.

PATIENT CONCERNS

A 22-month-old girl presented with intermittent epigastralgia for approximately 10 days and fever for three days. Fasting and total parenteral nutrition were administered after admission. However, sudden onset of severe epigastric pain occurred. An abdominal sonogram showed turbid ascites and peritonitis was impressed.

DIAGNOSES

An emergent exploratory laparotomy was performed, and perforation of the posterior wall of types I and VI choledochal cysts was observed.

INTERVENTIONS

Intraoperative cholangiography revealed concomitant types I and VI choledochal cysts with stricture of the distal common bile duct. Definite surgery for resection of the choledochal cysts and gallbladder was performed with Roux-en-Y choledochojejunostomy.

OUTCOMES

The patient had no evidence of ascending cholangitis at three years after the operation.

LESSONS

Type VI choledochal cysts are rarely reported in the literature. To our knowledge, this is the first reported pediatric case of concomitant types I and VI choledochal cysts complicated with acute pancreatitis and spontaneous perforation.

Anatomical Variations of Cystic Ducts in Magnetic Resonance Cholangiopancreatography and Clinical Implications

Background. Anatomical variations of cystic duct (CD) are frequently unrecognized. It is important to be aware of these variations prior to any surgical, percutaneous, or endoscopic intervention procedures. Objectives. The purpose of our study was to demonstrate the imaging features of CD and its variants using magnetic resonance cholangiopancreatography (MRCP) and document their prevalence in our population. Materials and Methods. This study included 198 patients who underwent MRCP due to different indications. Images were evaluated in picture archiving communication system (PACS) and variations of CD were documented. Results. Normal lateral insertion of CD at middle third of common hepatic duct was seen in 51% of cases. Medial insertion was seen in 16% of cases, of which 4% were low medial insertions. Low insertion of CD was noted in 9% of cases. Parallel course of CD was present in 7.5% of cases. High insertion was noted in 6% and short CD in 1% of cases. In 1 case, CD was draining into right hepatic duct. Congenital cystic dilation of CD was noted in one case with evidence of type IV choledochal cyst. Conclusion. Cystic duct variations are common and MRCP is an optimal imaging modality for demonstration of cystic duct anatomy.