The distal classification and management of choledochal cyst in adults

Abstract

Todani classification is extensively used to guide the surgical strategy of choledochal cysts, but no systematic investigations on the distal management of intrapancreatic choledochal cysts have been conducted. This study reports the distal classification and management of choledochal cysts in adults based on the relation between the cyst and pancreatic duct. Patients with choledochal cyst who underwent operation, including distal management, in our department from January 2009 to December 2014 were retrospectively reviewed. Patients presenting symptoms, coexisting diseases, surgical treatment, perioperative complications, and long-term follow-up according to the distal classification of choledochal cyst were analyzed. A total of 54 patients with choledochal cyst were included in the present retrospective study. Based on the distal classification of choledochal cyst, 39 patients (72.22%) were type 1, 13 patients (24.07%) were type 2, and 2 patients (3.70%) were type 3. Thirty-nine type 1 patients and 10 type 2 patients underwent excision of intrapancreatic choledochal cyst or bile duct. Three type 2 patients received excision of distal cylindrical cyst and papilla, followed by pancreatic duct plasty with duodenum mucosa. One type 3 patient underwent endoscopic sphincteroplasty, and another type 3 patient underwent transduodenal sphincteroplasty. After the operation, 11 patients (20.37%, 11/54) had short-term perioperative complications. The long-term follow-up results showed that the satisfactory rate (excellent and good outcomes) was 95.83%. Current distal classification of choledochal cysts could provide a more targeted strategy for complete excision to eliminate potential dead space within the pancreas, protect the pancreatic duct, and prevent reoperation.

Transitional care for patients with surgical pediatric hepatobiliary disease: Choledochal cysts and biliary atresia

“…19 Long-term postoperative complications occur between 5% and 30% of cases. [20][21][22][23][24][25][26] The most common complications include anastomotic stricture, bile duct stenosis, bile duct stones, intrahepatic calculus formation, cholangitis, pancreatitis, and malignant transformation of remnant cystic tissue. Formation of intrahepatic stones and cholangitis is thought to arise due to bile stasis.…”

“…As these patients age into adulthood (around ages [18][19][20][21], their care will need to be transitioned to adult-focused providers ( Table 1). Planning for the transition will need to be carried out on a case by case basis due to variability in patient complications.…”

Successful Management of a Post-Choledochal Cyst Excision Pancreatic Fistula in an Adult Patient: A Case Report and Literature Review on Risk Factors

“…Liu et al proposed a distal classification system based on the morphology of the relation of pancreatic duct to distal end of the cyst and the common channel and advocated excision of ampulla of Vater with pancreatic duct plasty along with CEHE for cysts without distal stenotic stump. 8 …”

“…Liu et al proposed a distal classification system based on the morphology of the relation of pancreatic duct to distal end of the cyst and the common channel and advocated excision of ampulla of Vater with pancreatic duct plasty along with CEHE for cysts without distal stenotic stump. 8 Distal dissection of intrapancreatic portion of the cyst is technically tedious in the setting of recurrent cholangitis due to scarring and neovascularization. At the distal end, dissection external to epicholedochal plexus is recommended to avoid pancreatic injury.…”

“…Most of these have been managed conservatively with significant associated morbidity. [4][5][6][7][8] Herein, we report our experience in managing POPF in a Todani type IV-A choledochal cyst in a 23-year-old male with operative intervention and a successful outcome. We have also reviewed available literature regarding this unique postoperative complication.…”