Giant choledochal cyst and infantile polycystic kidneys as prenatal sonographic features of Caroli syndrome

Caroli syndrome is a developmental disorder caused by complete or partial arrest of ductal plate remodeling, leading to dilated bile ducts along with fibrosis surrounding the portal tracts. It is most commonly associated with autosomal recessive polycystic kidney (ARPKD). We report a unique case of Caroli syndrome, diagnosed prenatally at 24 weeks of gestation in a 29-year-old Thai woman. Ultrasound findings revealed the association of a fetal giant choledochal cyst with ARPKD. Autopsy findings showed ductal plate malformation, typical of Caroli syndrome, associated with giant choledocal cyst and ARPKD.

Role of laparoscopy during surgery at the porta hepatis

Minimally invasive surgery in children has evolved to the extent that complex procedures can be performed with safety, with comparable outcomes to open surgery and with the advantages of minimal scarring and less pain. In this article, we describe the latest laparoscopic techniques used at Juntendo University Hospital in Japan, for treating conditions affecting the porta hepatis, focusing on biliary atresia and choledochal cysts. We also summarise our postoperative management protocols and discuss preliminary outcomes.

Biliary cysts: a review and simplified classification scheme

Biliary cystic disease has been known of for centuries. It has traditionally been classified as 5 major types of disease, each with different clinical profiles and attributes. In this article, the basis for the existing classification schemes is reviewed and a simplified classification scheme and treatment regimen are suggested.

Delayed presentation of complete pancreatic ductal transection in children: management of two cases without resection

Pancreatic ductal injuries in children are rare, and ductal transections presenting in a delayed or subacute fashion are seldom reported. We describe two cases of traumatic pancreatic ductal transection secondary to physical abuse, both of which presented late to medical care. Both were managed successfully without pancreatic resection. Judicious application of non-resectional management can yield favorable outcomes in this subset of pediatric patients.

Congenital choledochal malformation: not just a problem for children

Choledochal cysts remain relatively uncommon in Western Europe and the US, although they are appreciably more common in Asia. Their aetiology remains obscure although abnormalities of the pancreaticobiliary junction may be the primary pathology in some, with biliary dilatation following reflux of activated pancreatic secretions. Most anomalies will present in childhood with obstructive jaundice or abdominal pain; a proportion may only present for the first time during adulthood, and some of these will show malignant transformation. The classical triad of pain, jaundice and a palpable mass is, however, not common. Complete cyst excision, where possible, and biliary reconstruction remain the aims for most types although there is still some controversy about the type of reconstruction. Laparoscopic reconstruction is possible but is still very much an advanced technique. The risk of long-term problems post-surgery is significant. Whether this is due to recurrent pancreatitis secondary to the retained common channel and/or a distal stump, or due to the development of biliary tract malignancy is still a cause for concern and indicates the need for adequate, prolonged follow-up.

Proteomic analysis of protein plugs: causative agent of symptoms in patients with choledochal cyst

Symptoms of choledochal cysts are caused by protein plugs. We performed proteomic analysis of protein plugs to elucidate formation mechanism. Protein plugs were obtained from three pediatric patients with choledochal cyst. Proteins were separated using sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Gel bands common to the samples were excised for mass spectrometry. Mass spectra were compared with the NCBI database for protein identification. Gel bands of protein plug samples were predominant at 14 kilodaltons (kDa), followed by 29 kDa. Four other thin bands were common to the plug samples. Four bands (including 14 and 29 kDa) were identified as lithostathine, and one band as serum albumin. Plugs consisted mostly of lithostathine, a protein secreted by pancreatic acinar cells into pancreatic juice. The mechanism involves trypsinogen and lithostathine regurgitating into the cyst through an aberrant union of pancreaticobiliary ducts. Activated trypsin cleaves soluble lithostathine into insoluble forms that aggregate to form plugs.

The role of sphincteroplasty in adverse effect of anomalous pancreaticobiliary duct union in an animal model

Anomalous union between the pancreatic and biliary systems (APBDU) has been reported to produce choledochal cyst. The aim of this experiment was to evaluate the role of sphincteroplasty to adverse effect of APBDU in an animal model. Twelve mongrel puppies were randomly divided into a control group (n = 5) and an experimental group (n = 7). A well-established model of APBDU was produced in both groups. Transduodenal sphincteroplasty was performed only on the experimental group. For all animals, serial chemical analyses of serum were performed, and biliary tree sizes were measured by magnetic resonance cholangiography 2.5 months after the experimental surgery. At the time of animal sacrifice, 3 months after the experimental surgery, operative cholangiography was performed, and bile juice and tissues were obtained for chemical analysis and histologic examination. Dilatation of the bile duct and thickening of the wall of the bile duct were observed less frequently in the experimental group than in the control group. There were no significant differences found in pancreatic enzyme activity in the bile juice between the two groups. Denudation of the mucosa was the predominant mucosal change seen in the experimental group, while epithelial hyperplasia was the predominant mucosal change found in the control group. Our experiment shows that sphincteroplasty is not effective to prevent the pancreaticobiliary reflux, but may be effective to reduce the degree of both bile duct dilatation and mural thickening in the APBDU puppy model.

Congenital dilatation of extrahepatic bile ducts in children. Experience in the central hospital of Hue, Vietnam

BACKGROUND/PURPOSE

The authors present a study of a series of cases in children with congenital dilatation of the extrahepatic bile ducts (CDEBD).

METHODS

Between November 1998 and October 2002, 38 children aged between 50 days and 15 years suffering from CDEBD, admitted to the Central Hospital in Hue, Vietnam, were treated surgically with a minimum follow-up of one year.

RESULTS

Diagnosis was based only on ultrasonography which was 100% accurate. According to Miyano's classification, 26 cases presented as cystic dilatation of the main bile duct (MBD) associated with dilatation of the intrahepatic bile ducts, while in the other 12 cases the dilatation of the MBD was of the fusiform type. The surgical treatment of choice was extensive excision of the dilatated extrahepatic bile ducts and biliary drainage according to the Roux-en-Y method in 36/38 patients. The other two patients underwent surgery for internal biliary drainage without removing the cysts. During follow-up we observed one case of pancreatitis out of the 36 patients who underwent excision of the dilatated extrahepatic bile ducts, while the two patients who had internal biliary drainage without removal of the cysts suffered from numerous attacks of cholangitis.

CONCLUSIONS

The reflux of bile in the dilated biliary tree plays an important role in the etiopathogenesis of CDEBD. Excision of the extrahepatic bile ducts and internal biliary drainage by Roux-en-Y has proved a satisfactory surgical method.

Bile duct cysts in adults

BACKGROUND

Bile duct cysts are rare and of uncertain origin. Most have been reported in young females of Asian descent, but an increasing number have occurred in Western adults.

METHODS

A Medline literature search was performed to locate articles on the pathophysiological concepts, clinical behaviour and management controversies pertaining to bile duct cysts in adults. Emphasis was placed on reports from the past two decades.

RESULTS AND CONCLUSION

An increasing rate of occurrence of bile duct cyst is reported in adults. Type IV cysts are more frequent in adults than children. Presentation tends to be non-specific abdominal discomfort. Related hepatobiliary or pancreatic disease frequently precedes recognition, and may complicate the postoperative course. Surgical treatment aims to relieve complications deriving from the cysts and to reduce the significant risk of malignant change within the biliary tree. Complete cyst resection, cholecystectomy and Roux-en-Y hepaticojejunostomy reconstruction is standard. Controversy exists about the role of hepatic resection in type IV and V cysts, and the role of minimally invasive and laparoscopic treatment. In general, the outcome is good and a near-zero mortality rate has been reported in institutional series over the past decade.

Surgical treatment of choledochal cysts

Biliary cystic disease is uncommon in Asia and very rare in Europe and the Americas. Patients with biliary cysts may present as infants, children, or adults. When patients present as adults, they are more likely to have stones in the gallbladder, common duct, or intrahepatic ducts and to present with biliary colic, acute cholecystitis, cholangitis, or gallstone pancreatitis. With increasing age at presentation, the risks of intrahepatic strictures and stones, segmented hepatic atrophy/hypertrophy, secondary biliary cirrhosis, portal hypertension, and biliary malignancy all increase significantly. Factors to be considered when performing surgery on patients with biliary cystic disease include: (1) age, (2) presenting symptoms, (3) cyst type, (4) associated biliary stones, (5) prior biliary surgery, (6) intrahepatic strictures, (7) hepatic atrophy/hypertrophy, (8) biliary cirrhosis, (9) portal hypertension, and (10) associated biliary malignancy. In general, regardless of age, presenting symptoms, biliary stones, prior surgery or other secondary problems, surgery should include cholecystectomy and excision of extrahepatic cyst(s). With respect to the distal bile duct, the surgical principle should be excision of a portion of the intrapancreatic bile duct with care to not injure the pancreatic duct or a long common channel. Resection of the pancreatic head should be reserved for patients with an established malignancy. With respect to the intrahepatic ducts, surgery should be individualized depending on whether (1) both lobes are involved, (2) strictures and stones are present, (3) cirrhosis has developed, or (4) an associated malignancy is localized or metastatic. When the liver is not cirrhotic, hepatic parenchyma should be preserved even when strictures and stones are present. If cirrhosis is advanced, hepatic transplantation may be indicated, but this sequence of events is unusual. If a malignancy has developed, oncologic principles should be followed. Whenever possible, resection of a localized tumor including adjacent hepatic parenchyma and regional lymph nodes should be performed.

Choledochal cyst due to anomalous pancreatobiliary junction in the adult: sonographic findings

BACKGROUND

Adult cases of choledochal cyst due to anomalous pancreaticobiliary duct junction have been rarely reported. At present, sonography (US) is the first tool for diagnosing biliary disorders. The aim of this study was to reevaluate the US findings of choledochal cysts due to anomalous pancreaticobiliary duct junction in adults.

METHODS

We reviewed the clinical manifestations and US findings of 12 such adult cases confirmed by endoscopic retrograde cholangiopancreatic ductography (ERCP). Patients were assigned to three groups: (a) associated with biliary carcinoma (two cases), (b) associated with choledocholithiasis (one case), and (c) not associated with other abdominal diseases (nine cases).

RESULTS

Patients in group c were asymptomatic, and the lesions were detected incidentally detected by US. In contrast, patients in group a sought medical care because of symptoms such as jaundice and those in group b sought medical attention because of abdominal pain. The diameter of a dilated bile duct on US was considerably less than that of ERCP (ERCP: 26-58 mm, mean = 37.6 mm; US: 13-32 mm, mean = 21.8 mm). Its diameter changed significantly under probe compression when the dilated bile duct took a purely cystic form but changed very little when it took a tubular form.

CONCLUSION

Unlike cases in children, adult cases of choledochal cyst are generally asymptomatic. Careful US observation of the bile duct is thus expected to detect asymptomatic adult choledochal cysts cases. Cyst diameter can change significantly under probe compression, so it is important not to compress the bile duct during routine US examination.

Sphincter of Oddi dysfunction associated with choledochal cyst

The pathophysiology of choledochal cysts remains unclear, although an association with anomalous pancreato-biliary junction and the reflux of pancreatic enzymes into the biliary tree is known. Sphincter of Oddi (SO) manometry was performed in three patients with choledochal cysts. All patients exhibited an elevated basal pressure diagnostic of sphincter of Oddi dysfunction. Two patients exhibited anomalous pancreato-biliary junction. This report suggests an association between the choledochal cyst and sphincter of Oddi dysfunction, and may suggest that SO dysfunction plays a role in choledochal cyst formation.

Management of liver hydatid cysts with a large biliocystic fistula: multicenter retrospective study. Tunisian Surgical Association

The large biliocystic fistula (> 5 mm) encountered with hydatic cyst of the liver produces clinical manifestations only when it allows the hydatic cyst content to pass into the common bile duct. Various therapeutic problems occur. The aim of this study was to evaluate the results of the therapeutic methods used by 14 Tunisian centers to treat this specific aspect of the hydatic cyst of the liver associated with a large biliocystic fistula. This study concerned a period of 5 years between January 1988 and December 1992, and it included 244 cases associated with hydatic content in the common bile duct (158 cases) and with cholelithiasis and choledocholithiasis (2 cases); 127 patients underwent an emergency operation (52%). The surgical procedures performed consisted in radical procedures (24 cases, 9.8%) and conservative procedures (220 cases, 90.2%). The latter included 52 cases of internal transfistulary drainage, 140 unroofing procedures associated in 20 cases with the fistula, in 93 cases with suture of the fistula, and in 27 cases with direct fistulization. In the 28 remaining cases, through the choledoctomy evacuation of the parasite was performed. The common bile duct was approached in 180 cases (73.7%). The postoperative course was uneventful in 57% of the cases and complicated in 38.5% others. The mortality rate was 4.5%. In conclusion, the presence (or not) of hydatic material in the common bile duct did not seem to be a determinant of the surgical procedure choice and did not influence the results. The only difficulty with treatment was the large biliocystic fistula itself. The internal transfistulary drainage on one part, and the unroofing procedure associated with suturing healthy fistula tissue and to omentoplasty or capitonnage of the remaining cavity on the other part, were easily performed and constituted efficient methods. Radical methods constituted operations that had excellent results, but they were feasible in only 10% of the cases.

Heterotopic pancreatic tissue associated with intra- and extrahepatic choledochal cysts

A case report of heterotopic pancreas in intra- and extrahepatic biliary tracts in a 36-year-old female who suffered from intra- and extrahepatic choledochal cysts with an anomalous pancreatobiliary duct system. Histologic examination of the resected specimen showed pancreatic tissues located along the wall of the biliary tract with choledochal cysts. The pancreatic tissue consisted of acinar cells and duct elements without Langerhans' islets; the acinar cells were positive immunohistochemically for alpha-amylase and negative for endocrine hormones. Ultrastructural study revealed zymogen granules in the acinar cells. In the present case the heterotopic exocrine pancreatic tissue seems to be etiologically related to choledochal cysts as well as to the anomalous arrangement of the pancreatobiliary duct.

Different types of congenital biliary dilatation in dizygotic twins

A pair of dizygotic twins who were both found to have congenital biliary dilatation, but of different types, is reported. This case is of academic interest from an etiologic point of view.

A contribution to the casuistics of choledochal cysts

Choledochal cyst is a rare cystic anomaly of bile ducts, primarily affecting the choledochus. The etiology of the disease is unknown, while the symptoms predominated by cholangitis usually occur by the age of thirty. The complications of untreated disease include septic complications, biliary cirrhosis, formation of concrements in cystically dilated bile ducts, and a potential risk of cholangiocarcinoma. Two patients with choledochal cysts type III and IV are presented. The patient with type III choledochal cyst underwent radical treatment, whereas in the patient with type IV choledochal cyst only a palliative procedure could be used. Both patients were men older than 40, and were free from the disease associated sequels for two and five years after the surgery.

Virtual intraluminal endoscopy: a new method for evaluation and management of choledochal cyst

A 12-year-old girl who suffered from cholangitis was treated successfully with appropriate antibiotics. She had undergone an operation in mainland China, the exact nature of which was unknown. After an ultrasound study, she underwent a helical computed tomography (CT) cholangiogram using intravenous meglumine iodoxamine. The volume data were transferred to a workstation and virtual endoscopy rendering reconstruction of bile ducts was performed. Findings of this study showed that she had cyst excision with hepaticojejunostomy (HJ), and her intrahepatic ducts were packed with stones. Virtual endoscopy gave the impression that the examiner was flying inside the lumen and showed the stricture at the HJ anastomosis, the inner surface of the bile ducts, areas of dilated intrahepatic ducts, and the intrahepatic stones. The study overcame the need for an invasive study such as a percutaneous transhepatic cholangiography (PTC) and also facilitated appropriate surgical treatment in a timely fashion. It is believed that virtual intraluminal endoscopy (VIE) is helpful in the evaluation and management of selected cases of choledochal cyst.

Acquired choledochal cyst from anomalous pancreatobiliary duct union

The high incidence of anomalous pancreatobiliary duct union (APBDU) in children who have a choledochal cyst has been well documented. Additionally, cylindrical dilatation of the bile duct has been reproduced in animal models by anastomosing the pancreatic duct to the bile duct. In recent years, APBDU has been considered a possible etiologic factor in the formation of a choledochal cyst. The authors observed a progressive cylindrical dilatation of the common bile duct in a 6-year-old boy over an 18-month period. An operative cholangiogram showed a type Ic choledochal cyst and a type B APBDU (Todani classification). This clinical experience suggests that a normal common bile duct in children can be progressively dilated and become an acquired choledochal cyst arising as a complication of the preexisting APBDU.

Protein plugs cause symptoms in patients with choledochal cysts

OBJECTIVES

Symptoms in patients with choledochal cysts are believed to be caused by pancreaticobiliary maljunction. However, this anomaly alone cannot explain the occurrence of symptoms. The aim of this study was to elucidate the etiology of the symptomatology in patients with choledochal cysts.

METHODS

Clinical data and preoperative and operative cholangiopancreatography were reviewed in 55 consecutive patients with choledochal cysts seen between 1980 and 1996.

RESULTS

The bile duct was significantly larger in the symptomatic phase than in the asymptomatic phase. External biliary drainage resulted in rapid resolution of symptoms in 11 patients. A radiolucent filling defect in the pancreaticobiliary duct was found in 22 patients (40.0%). The defects were in the common channel in 15 patients and near the common channel in 7 patients. Filling defects disappeared spontaneously or after irrigation in 19 patients. In three patients, the material in the common channel removed during surgery was fragile and consisted of more than 98% protein.

CONCLUSION

The filling defects were protein plugs. The simultaneous occurrence of symptoms and signs may be explained by disturbances in bile and pancreatic secretory flow caused by a protein plug in the common channel.

Choledochal cysts

Choledochal cysts are a relatively rare abnormality in the West but are more common in the East. The etiology of choledochal cysts remains unknown. Recently, the incidence in neonates and young infants has been increasing due to advances in diagnostic imaging, including antenatal diagnosis. Choledochal cysts can present at any age, but the clinical manifestation differs according to the age of onset. Early diagnosis followed by cyst excision is the treatment of choice, even in asymptomatic children. Recently, attention has been paid to the treatment of intrahepatic and intrapancreatic ductal diseases such as intrahepatic duct dilatation, debris in the intrahepatic ducts, and protein plugs in the common channel. Intraoperative cyst endoscopy is strongly recommended as a valuable adjunct to cyst excision for the prevention of postoperative complications due to intrahepatic or intrapancreatic ductal diseases.

Anomalous pancreatico-biliary junction--report of a new experimental model and review of the literature

A model of anomalous pancreatico-biliary junction was developed and used to investigate a possible role in the development of choledochal cyst and tumors of the biliary tract. An anastomosis was constructed between an isolated pancreas-duodenal segment and the gallbladder in 20 minipigs, but the results did not show any subsequent dilatation of the biliary tract, although intestinal metaplasia was observed in 20% of the animals. The severity of the epithelial changes was proportional to the duration of the experiment and may represent a premalignant change. A critical review of all reported animal models of anomalous pancreaticobiliary junction also is provided.

Choledochal cyst: an atypical presentation of Caroli's disease

An unusual case of a four month old baby girl with obstructive jaundice due to a choledochal cyst is reported. Pertinent clinical history, ultrasound and computerized tomography allowed accurate pre-operative diagnosis.

[Carcinoma of the gallbladder in anomalous pancreaticoliliary ductal junction]

Anomalous pancreaticobiliary ductal junction (APBDJ) can be defined as the junction between the choledochus and the pancreatic duct outside of the duodenalwall and beyond the influence of the sphincter of Oddi. The frequency of APDBJ has been reported to be 2-3% of patients examined with ERCP. The significance of APBDJ has been recognized as an etiological factor developing congenital choledochal dilatation (CCD) and biliary tarct carcinoma because most patients with CCD present with APBDJ and 23% of patients with APBDJ have biliary tract carcinoma in the Japanese nationwide study. Of the patients with APBDJ, approximately 80% are associated with CCD and the remaining 20% are not. The occurrence rate of biliary tract carcinoma has been reported to be 3-18% (9% in ours) in the former group, while it reaches 33-54% or even more in the latter. The origin of biliary tract carcinoma is either the gallbladder or extrehepatic bile duct in most patients with CCD, whereas the gallbladder is in patients without CCD. We advocate the excision of the extrahepatic dilated bile duct together with the gallbladder in patients with CCD and cholecystectomy for patients with APBDJ without CCD at the time of diagnosis. The necessity of prophylatic hepatectomy in patients with type IVA CCD and of prophylactic resection of the extrahepatic bile duct in patients without CCD need further analyses to draw the final conclusion. Careful follow-up is recommended against the liver, biliary tract and pancreas even after surgery.

Spontaneous perforation of choledochal cyst

BACKGROUND

Spontaneous perforation of the common bile duct in children is very rare and its etiology is unknown. We describe herein five patients treated for the spontaneous perforation of choledochal cyst and suggest the important factors leading to perforation.

STUDY DESIGN

All patients were initially treated with T-tube drainage through the perforated site. Cholangiography through the T tube was performed intraoperatively and the important factors leading to perforation were examined. Furthermore, histological examination of the perforated wall of the common bile duct was performed.

RESULTS

Cholangiography through a T tube revealed the presence of a pancreaticobiliary junction malformation and filling defects (protein plugs) in the common channel in all patients. Postoperatively, the T tube was gently irrigated with a physiological salt solution until the free flow of bile into the duodenum was established. Histological examination showed that the wall near the perforation was covered with a granulation tissue that was present only at the limited area.

CONCLUSIONS

Perforation of the common bile duct was related to the abrupt increase in intraluminal pressure due to obstruction by protein plugs at the common channel.

How great is the incidence of truly congenital common bile duct dilatation?

In an attempt to investigate the causes of common bile duct dilatation (CBDD), activity of the pancreatic enzymes in bile aspirated from the dilated duct during laparotomy was measured in 24 children with CBDD. The reasoning behind this is the fact that the existence of activated pancreatic enzymes, namely raised activity of all enzymes accompanied by trypsin activation, can be regarded as an acquired result of an anomalous choledochopancreaticoductal junction (ACP-DJ). All of the pancreatic enzymes measured were activated in 14 cases (58.3%) but no evidence of activation of enzymes, such as trypsin or others except for amylase and lipase, was observed in the remaining 10 cases (41.7%), whether an ACPDJ was present or absent. Eight of the 10 patients with no enzyme activation (33.3% of the total) were less than 2 months old. The findings in these eight infants, which included cystic dilation or hypoplasia of the intrahepatic duct, provide strong suggestive evidence of the congenital nature of these cases. These results suggest that at least one third of CBDD cases are congenital and the remaining cases are either acquired or a combination of congenital and acquired, or both.

Long common channel syndrome as etiology of choledochal cysts and pancreatitis--two instructive cases

The aetiology of choledochal cysts is controversial. The authors report two cases of Type I C and Type IV B choledochal cysts; both showing axial dilatation of the common bile duct and common hepatic ducts, single fusiform (Type IC) and multiple cysts of extrahepatic ducts only (Type IVB). Both had anomalous junction of the pancreaticobiliary ductal system as delineated on ERCP leading to the formation of a long common channel. Both these female patients presented in the third decade of life with 7-8 years history of repeated episodes of right upper abdominal and epigastric pain suggestive of pancreatitis. Similar pain was precipitated in both patients following ERCP with raised serum amylase. Hepatico-enterostomy gave lasting relief in both these patients.

[Choledochal cysts. Review and presentation of 2 girls with perforated cyst]

The clinical record is reported of two female girls, 4 1/2 and 5 1/2 years old, who were reported in 1988 at the Children's Hospital in this City with diagnosis of perforated Cholodochal supurated cyst and who were asymptomatic when they left the hospital. It is mentioned that another four patients had been operated in the same hospital, between 1981 and 1987, with choledochal cyst diagnosis.

Choledochal cyst

Since 1959 when Alonzo-Lej and colleagues introduced the modern era of treatment of choledochal cysts, much information has come to light, particularly from Japan where the incidence of choledochal cyst is much higher than in occidental countries. While the original classification of Alonzo-Lej is still in use, additional forms of the anomaly have been identified by modern imaging techniques. Antenatal ultrasound studies and accurate cholangiography have made it possible not only to better define these anomalies but also to provide information regarding etiology. It seems most likely that choledochal cysts are the result of pancreatic reflux into the biliary tree from an anomalous junction of the main pancreatic duct with the common bile duct. Ultrasound, radioscintigraphic studies, and various forms of cholangiography have made the diagnosis straightforward. Although many approaches to treatment have been tried over the years, the most successful approach is total cyst excision with Roux-en-Y hepaticojejunostomy. This provides excellent long-term results with minimal complications. Nonetheless, lifelong follow-up is necessary to avoid potential problems such as biliary cirrhosis. Other forms of choledochal cysts, such as choledochocele and Caroli's disease, are treated as the anatomy dictates and these individuals must be followed long term as well. The overall results are most gratifying.

Spontaneous rupture of a choledochal cyst: clues to diagnosis and etiology

A healthy 3-year-old black girl had acute onset of abdominal pain, vomiting, and elevated aminotransferase, amylase, and lipase levels. Sonographic evaluation suggested a choledochal cyst, but hepatobiliary scintigraphy clearly showed an extrahepatic biliary leak. Exploratory laparotomy confirmed bile peritonitis and a ruptured choledochal cyst. Other cases with this unusual presentation is reviewed in the literature. An anomalous insertion of the pancreatic duct into the common duct appears to facilitate reflux of pancreatic secretions into the biliary tree and may contribute to formation and even perforation of a choledochal cyst.

ERCP in the evaluation of choledochal cyst due to anomalous pancreatobiliary junction

With the application of endoscopic retrograde cholangio pancreatography (ERCP), the association of anomalous pancreatobiliary junction and choledochal cyst is being increasingly recognized. We describe here the ERCP findings in three patients who had this anomaly in association with fusiform (Type I) choledochal cyst. Two of our patients also had evidence of pancreatitis. The importance of ERCP in the preoperative assessment of such patients is highlighted.

[Cystic anomalies of the external bile ducts in children]

Observations of 44 patients aged from 20 days to 15 years were used for making a classification of cystic anomalies of bile ducts. The method of choice for the operative intervention is creation of cystoduodenoanastomosis with resection of the gallbladder. A stable effect in remote terms of treatment can be obtained by endoscopic sanitation of the zone of cystoduodenoanastomosis.