External Drainage of Giant Infantile Choledochal Cyst before Definitive Repair: Is it Worth?

Abstract

Infantile Choledochal Cysts (IFCC) usually present with jaundice, acholic stool and abdominal lump or abdominal distension. If the surgical intervention is delayed, they rapidly progress to liver fibrosis which is considered to be irreversible if progressed to cirrhosis. We present the data of four cases (aged one month to seven months) of IFCC presented with cholangitis managed in one surgical unit in last two years. In one case, cholangitis was treated with prolonged antibiotic course before definitive repair whereas in rest, external drainage of cyst was done in addition to intravenous antibiotic to treat cholangitis. All the infants had features of cholangitis at time of presentation. Total leucocyte count ranged from 18x1000/UL to 30.6x1000/UL. Total bilirubin level at presentation ranged from 8.2 mg/dl to 18 mg/dl and Prothrombin time (INR) ranged from 1.33 to 1.9. Hepatic fibrosis was observed in all cases but cirrhosis was observed in only one case. There was no mortality but one patient had postoperative complication with prolonged hospital stay. External drainage helps in early recovery from cholangitis and better optimization of liver function. It also delays further progression to liver fibrosis by relieving the biliary outflow obstruction while waiting for definitive repair.

Management of Complicated Choledochal Cyst in Children: Ultrasound-Guided Percutaneous External Drainage and Subsequent Definitive Operation

“…For complicated choledochal cyst, US-PED can ensure minimally invasive treatment of the entire process. The giant choledochal cyst was conventionally treated by laparotomy, but in our study, except for Case 2, all subsequent patients underwent minimally invasive operations [17,19]. This suggests that minimally invasive operation after US-PED is safe and feasible for complicated choledochal cyst.…”

“…Moreover, with the improvement of perioperative management and surgical techniques, most patients can undergo one-stage de nitive operation [28,29]. However, some patients still have severe common bile duct (CBD) dilatation, liver dysfunction or coagulopathy due to complete biliary obstruction, even are treated by conservative treatments, which poses a major risk for operation [11,17]. Severe CBD dilatation often suggests the presence of CBD stenosis.…”

“…For patients with complicated choledochal cyst, US-PED is minimally invasive and effective in quickly relieving the symptoms of biliary obstruction, but it also has risks of electrolyte disturbance and infection [10,15,17]. It has been reported that the coagulation function of patients with choledochal cyst improved signi cantly 7 days after external drainage [11].…”

“…The methods of external drainage mainly included biliary drainage of extrahepatic cyst or intrahepatic bile duct, and gallbladder drainage or cholecystostomy [10,[14][15][16]. In most pediatric cases, traditional external drainage was accomplished by laparotomy or laparoscopic-assisted [10,11,17]. Percutaneous external drainage of choledochal cyst in children has been rarely reported in the literature, and ultrasound-guided percutaneous external drainage (US-PED) is even rarer [10,14].…”