Surgical treatment of choledochal cysts

Abstract

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: Their clinical presentation, diagnosis and treatment in central Nepal: a retrospective study

“…However, in our study none of the patients presented with classical triad of choledochal cystic disease. Lipsett et al 16 and Jesudason SR 17 mentioned abdominal pain is most common symptom among pediatric and adult patients. According to Singham 18, abdominal pain in pediatric and adult patients has an incidence ranging from 78% to 90%, jaundice and cholangitis being in 40 to 50%.…”

“…Lipsett et al 16 reported the classic triad of pain abdomen, jaundice and palpable abdominal mass is seen in less than 20% of the cases. However, in our study none of the patients presented with classical triad of choledochal cystic disease.…”

What is the Right Therapeutic Approach to Biliary Choledochal Cyst?

“…protrusion of a focally dilated, intramural segment of the distal common bile duct into the duodenum; IVacombination of intra-and extrahepatic cysts; IVbmultiple extrahepatic biliary cysts; and V -multiple intrahepatic cysts (Caroli disease) 7 . Even though our patient had a biliary type II cyst which, like type III, has a low malignant alteration potential and does not require complete excision 2,3 , in this case optimal approach as in case of type I cysts, i.e. timely radical excision, would reduce further complications 3,4 .…”

Choledochal Cyst: A Report of 3 Cases and a Review of its Treatment and Outcome

“…This technique avoids injury to vital structures. Sometimes by injection of normal saline into the cyst wall dissection can be made easy [64]. Finally, before establishing choledochoduodenostomy or choledochojejunostomy the hepatic hilum can be flushed of biliary sludge with normal saline as was done in one of the patients; this will reduce risk of forming hepatobilairy stones from biliary sludge.…”