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1
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Ciccioli C, Mazza S, Sorge A, Torello Viera F, Mauro A, Vanoli A, Bardone M, Scalvini D, Rovedatti L, Pozzi L, Strada E, Agazzi S, Veronese L, Barteselli C, Sgarlata C, Ravetta V, Anderloni A. Diagnosis and Treatment of Choledochal Cysts: A Comprehensive Review with a Focus on Choledochocele. Dig Dis Sci 2025; 70:39-48. [PMID: 39589463 DOI: 10.1007/s10620-024-08708-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 10/21/2024] [Indexed: 11/27/2024]
Abstract
Choledochal cysts (CCs) are cystic dilations of intrahepatic and/or extrahepatic bile ducts. Around 80% of CCs are diagnosed within the first decade of life. These complex clinical entities are extremely rare, especially in the Western population. CCs are frequently classified according to the Todani classification. CCs may be asymptomatic or present as acute pancreatitis and/or cholangitis, biliary obstruction, or malignancy. Therefore, the diagnosis relies primarily on abdominal imaging modalities, mainly magnetic resonance cholangiopancreatography. Management is tailored based on the cyst morphology and the patient's clinical characteristics, with surveillance, surgery, and interventional endoscopy being the most frequent management options. While the surgical approach is the most frequently employed, type III CCs (also known as choledochocele) are frequently managed endoscopically, and novel endoscopic, minimally invasive treatment options are rapidly emerging.
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Affiliation(s)
- Carlo Ciccioli
- Section of Gastroenterology and Hepatology, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza (PROMISE), University of Palermo, 90127, Palermo, Italy
| | - Stefano Mazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy.
| | - Andrea Sorge
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Francesca Torello Viera
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Alessandro Vanoli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia, 27100, Pavia, Italy
- Unit of Anatomic Pathology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Marco Bardone
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Davide Scalvini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
- PhD in Experimental Medicine, Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
| | - Laura Rovedatti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Lodovica Pozzi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Elena Strada
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Simona Agazzi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Letizia Veronese
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Chiara Barteselli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Carmelo Sgarlata
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Valentina Ravetta
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
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Myrthong AL, C G A, Rashid R, Venu V, Kb V. Navigating the Nexus: A Rare Case of Choledochal Cyst With Concomitant Pancreas Divisum. Cureus 2024; 16:e63964. [PMID: 39104986 PMCID: PMC11299473 DOI: 10.7759/cureus.63964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/07/2024] Open
Abstract
Choledochal cysts (CCs) are quite rare and are characterized by anomalous dilations of the biliary tree, mostly due to anomalous pancreaticobiliary junction (APBJ). A less frequent congenital anomaly due to incomplete fusion of pancreatic ducts, pancreas divisum (PD) can complicate the clinical course of CC. Although rare, the coexistence of CC and PD presents significant clinical challenges. With very few documented cases globally, our experience with this case adds to our understanding of this unique condition. This report aims to highlight the complex relationship between these anomalies and underscores the need for heightened clinical awareness and comprehensive management strategies to improve patient outcomes. We present the case of a 27-year-old female patient who was diagnosed with type 1 CC with concomitant PD after recurrent pancreatitis and multiple biliary interventions. Her choledochal cyst was excised with Roux-en-Y hepaticojejunostomy (RYHJ). Histopathological examination confirmed CC with evidence of chronic inflammatory changes but no malignancy. The preoperative hospital stay was three days with an operative duration of 150 minutes and intraoperative blood loss of 210 mL. Postoperatively, the patient was discharged on day 5. The pain score as per the Visual Analog Scale (VAS) was 2 on the day of discharge. The patient was started on diet on postoperative day (POD) 3. The abdominal drains were removed on POD 4 (subhepatic) and POD 5 (pelvic). Sutures were removed on POD 10, with follow-up for two years with no recurrence of similar complaints. This case illustrates the diagnostic challenge of synchronous CC and PD and elaborates on the role of extensive imaging modalities in guiding management decisions. The surgical approach remains the foremost for CC; preventing complications in the form of cholangitis and malignancy is the mainstay of treatment. The present report is an addition to the existing literature on the management of complex biliary anomalies and places special emphasis on the need for a multidisciplinary approach with individualized treatment strategies in such rare clinical scenarios. Further studies are required to clarify pathophysiological mechanisms linking CC and PD, with the need for better therapeutic strategies toward the optimization of patient outcomes. More studies with robust data are necessary to draw better conclusions.
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Affiliation(s)
- Aldrin L Myrthong
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
| | - Abhinav C G
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
| | - Rihan Rashid
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
| | - Vinayak Venu
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
| | - Vismaya Kb
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
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3
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Brown ZJ, Baghdadi A, Kamel I, Labiner HE, Hewitt DB, Pawlik TM. Diagnosis and management of choledochal cysts. HPB (Oxford) 2023; 25:14-25. [PMID: 36257874 DOI: 10.1016/j.hpb.2022.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 08/31/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Choledochal cysts (CCs) are rare cystic dilatations of the intrahepatic and/or extrahepatic bile ducts. We review the pathophysiology, diagnosis, and management of CCs. METHODS MEDLINE/PubMed and Web of Science databases were queried for "choledochal cyst", "bile duct cyst", "choledochocele", and "Caroli disease". Data were synthesized and systematically reviewed. RESULTS Classified according to the Todani Classification, CCs are generally believed to arise secondary to reflux of pancreatic enzymes into the biliary tree due to anomalous pancreaticobiliary duct union. Complications of CCs include abdominal pain, jaundice, cystolithiasis, cholecystitis, pancreatitis, liver abscess, liver cirrhosis and malignant transformation (3-7.5%). Radiological and endoscopic imaging is the cornerstone of CC diagnosis and full delineation of cyst anatomy is imperative for proper management. Management is generally guided by cyst classification with complete cyst excision necessary for CCs with high potential of malignant transformation such as types I and IV. 5-year overall survival after choledochal cyst excision is 95.5%. CONCLUSION Most CCs should undergo surgical intervention to mitigate the risk of cyst related complications such as cholangitis and malignant transformation.
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Affiliation(s)
- Zachary J Brown
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Ihab Kamel
- Department of Radiology, John Hopkins University, Baltimore, MD, USA
| | - Hanna E Labiner
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - D Brock Hewitt
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Wu GZ, Wu QY, Zhao ZH, Wang M. Diagnosis and minimally invasive treatment of type III choledochal cysts. BMC Surg 2022; 22:272. [PMID: 35836224 PMCID: PMC9284719 DOI: 10.1186/s12893-022-01713-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 06/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background Type III choledochal cysts (CCs) are the rarest and least well-characterized of the five variants of biliary cysts. Only a few relevant studies have been conducted and a gold standard treatment for type III CCs is still lacking because of their scarcity. An unusual case of type III CC with choledochocele at the end of the distal common bile duct (CBD) with no bulging of the duodenum is presented here. Case presentation A 61-year-old woman presented to our department with repeated upper abdominal pain for one year. Laboratory examination revealed abnormal liver function and a slight increase in the white blood cell (WBC) count and proportion of neutrophils. In an MRCP of the patient, the distal CBD was found to have a cystic structure indicative of a type III CC. Endoscopic retrograde cholangiopancreatograpy (ERCP) revealed cystic findings compatible with Todani type III CCs. However, duodenoscopy did not show a bulge in the duodenum so laparoscopic cholecystectomy and Roux-en-Y hepaticojejunostomy were performed. In her 6-month follow-up, the patient reported that recovery from the operation was uneventful. Conclusions ERCP has become the gold standard for diagnosing type III CCs. Type III CCs can be treated minimally invasively with laparoscopic cholecystectomy and Roux-en-Y hepaticojejunostomy.
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Affiliation(s)
- Guang-Zhen Wu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun City, Jilin Province, China
| | - Qing-Yuan Wu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun City, Jilin Province, China
| | - Zhi-Hao Zhao
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun City, Jilin Province, China
| | - Meng Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun City, Jilin Province, China.
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Chan TK, Luk WH, Ng FH, Chan RL, Hui YH, Chan CYJ, Cheung WH. The diagnostic value of hepatobiliary scintigraphy for choledochal cysts in the era of magnetic resonance imaging with cholangiopancreatography and contrast-enhanced hepatobiliary phase: a case report and review. BJR Case Rep 2022; 7:20210123. [PMID: 35300230 PMCID: PMC8906148 DOI: 10.1259/bjrcr.20210123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/08/2021] [Accepted: 08/11/2021] [Indexed: 11/18/2022] Open
Abstract
Objective Choledochal cysts (CCs) represent cystic dilatations of the intra- or extrahepatic biliary tract. The diagnosis of CCs may not always be straightforward particularly for the intrahepatic subtype. Whereas the gold standard for diagnosing CCs is endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) is commonly used as primary diagnostic tool for delineation of biliary pathologies including CCs. Methods We report a case of cystic hepatic lesion near the confluence of bilateral intrahepatic ducts. MRCP shows direct anatomical communication between the lesion and the biliary tract, raising suspicion of a CC. Endoscopic ultrasound shows no communication between the lesion and biliary system. 99mTc-hepatic iminodiacetic acid scintigraphy (hepatobiliary scintigraphy) was subsequently performed, showing no tracer uptake in the concerned cystic hepatic lesion despite visualisation of gallbladder and transit of tracer into the intestine. Overall scintigraphic findings speak against a CC. Conclusion The case showed conflicting anatomical findings of a CC on MRCP and endoscopic ultrasound. Hepatobiliary scintigraphy and hepatobiliary contrast MRI may both functionally demonstrate communication of a hepatic lesion with the biliary tract. But hepatobiliary scintigraphy offers the advantage of much higher hepatic extraction and hence higher resistance to competition from plasma bilirubin compared with hepatobiliary contrast MRI. The better pharmacokinetics of HIDA confer superior lesion contrast that may offset inferior image spatial resolution, in particular for large lesions and patients with hyperbilirubinaemia. Hepatobiliary scintigraphy should be considered a suitable functional diagnostic modality for CCs even in the era of magnetic resonance imaging with cholangiopancreatography and contrast-enhanced hepatobiliary phase.
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Affiliation(s)
- Tak Kwong Chan
- Nuclear
Medicine Unit, Queen Elizabeth Hospital, Yau Ma
Tei, Hong Kong
| | - Wing Hang Luk
- Department
of Radiology, Princess Margaret Hospital, Yau Ma
Tei, Hong Kong
| | - Fung Him Ng
- Department
of Radiology, Princess Margaret Hospital, Yau Ma
Tei, Hong Kong
| | - Rois L.S. Chan
- Department
of Radiology, Princess Margaret Hospital, Yau Ma
Tei, Hong Kong
| | - Yan Ho Hui
- Nuclear
Medicine Unit, Queen Elizabeth Hospital, Yau Ma
Tei, Hong Kong
| | | | - Wai Hung Cheung
- Department
of Surgery, Princess Margaret Hospital, Yau Ma
Tei, Hong Kong
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Huang Y, Yang C, Gu G, Wan Y. Endoscopic retrograde cholangiopancreatography for type III choledochal cyst: A case report. Asian J Surg 2021; 44:1240-1241. [PMID: 34362625 DOI: 10.1016/j.asjsur.2021.07.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/23/2021] [Indexed: 02/05/2023] Open
Affiliation(s)
- Yi Huang
- North Sichuan Medical College of China, PR China.
| | - Chuang Yang
- West China Hospital of Sichuan University, PR China; The Third Hospital of Mianyang, Sichuan Mental Health Center, PR China.
| | - Guangqiang Gu
- The Third Hospital of Mianyang, Sichuan Mental Health Center, PR China.
| | - Yi Wan
- The Third Hospital of Mianyang, Sichuan Mental Health Center, PR China
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7
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Ando H, Takada T. Cystic Disorders of the Bile Ducts. SHACKELFORD'S SURGERY OF THE ALIMENTARY TRACT, 2 VOLUME SET 2019:1367-1377. [DOI: 10.1016/b978-0-323-40232-3.00116-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Yang J, Xiao GF, Li YX. Open surgical treatment of choledochocele: A case report and review of literature. World J Clin Cases 2018; 6:842-846. [PMID: 30510953 PMCID: PMC6264990 DOI: 10.12998/wjcc.v6.i14.842] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/16/2018] [Accepted: 10/23/2018] [Indexed: 02/05/2023] Open
Abstract
Choledochocele (also known as type III choledochal cyst according to Todani’s classification) is a cystic dilation of the distal segment of the common bile duct protruding into the duodenal lumen. Cases are rare and the etiology remains unclear. It is usually misdiagnosed as peptic ulcer, as in the patient whose case is described here. Multislice spiral computed tomography and magnetic resonance cholangiopancreatography may be comparable to endoscopic retrograde cholangiography for diagnosis of choledochocele. Both endoscopic therapy and open surgical management are safe options, and size of the cyst plays a role in the decision-making for which approach to apply. A 50-year-old woman admitted to our hospital with upper abdominal pain caused by choledochocele with large size was successfully treated by open surgical management. We present the details of her case in this case report and discuss the recent literature on such cases and their therapeutic management.
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Affiliation(s)
- Jie Yang
- Department of Biliopancreatic Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Guang-Fa Xiao
- Department of Biliopancreatic Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Yi-Xiong Li
- Department of Biliopancreatic Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
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Serradj NB, Tabeti B, Tidjane A, Benmaarouf N. [Choledochocele: a rare variety of congenital cystic dilation of the bile ducts]. Pan Afr Med J 2018; 29:156. [PMID: 30050620 PMCID: PMC6057592 DOI: 10.11604/pamj.2018.29.156.12084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 03/01/2018] [Indexed: 11/11/2022] Open
Abstract
La dilatation kystique des voies biliaires (DKVB) est une pathologie rare, elle touche principalement les jeunes femmes, avec la douleur comme maitre symptôme. Son principal risque est la cancérisation. L'exérèse chirurgicale complète demeure le traitement de choix. La classification de TODANI établi cinq groupes de dilatations kystiques congénitales des voies biliaires. Le cholédococèle représente le type III et se définit comme une dilatation kystique isolée de l'ampoule de Vater. La rareté de cette variété de DKVB et la multitude de présentations cliniques de cette pathologie avaient conduit à un nombre réduit de publications dans la littérature médicale, et l'absence de référence concernant la prise en charge thérapeutique entre traitement endoscopique en plein progrès ,mais conservateur et un traitement chirurgical radical mais difficile à réaliser. Notre présentation porte sur le cas d'une jeune patiente âgée de 32 ans, consultant pour des douleurs épigastriques itératives et dont les examens morpho-cliniques conclut à un cholédococèle .Nous avions réalisé chez cette patiente une résection complète du kyste à travers une duodénotomie, avec réimplantation du canal cholédoque et du canal de Wirsung, associée à une cholécystectomie.
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Affiliation(s)
- Nabil Boudjenan Serradj
- Service de Chirurgie Hépatobiliaire et Greffe du Foie, Etablissement Hospitalo-Universitaire d'Oran, Algérie
| | - Benali Tabeti
- Service de Chirurgie Hépatobiliaire et Greffe du Foie, Etablissement Hospitalo-Universitaire d'Oran, Algérie
| | - Anisse Tidjane
- Service de Chirurgie Hépatobiliaire et Greffe du Foie, Etablissement Hospitalo-Universitaire d'Oran, Algérie
| | - Noureddine Benmaarouf
- Service de Chirurgie Hépatobiliaire et Greffe du Foie, Etablissement Hospitalo-Universitaire d'Oran, Algérie
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10
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Ray-Offor E, Elenwo SN, Igwe PO, Ngeribara C. Ulcerated choledochocele: A case report. Int J Surg Case Rep 2016; 28:42-44. [PMID: 27677116 PMCID: PMC5037116 DOI: 10.1016/j.ijscr.2016.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 08/11/2016] [Indexed: 02/07/2023] Open
Abstract
Upper gastro-intestinal endoscopy is part of diagnostic work-up for massive bleeding per rectum. A positive ‘pillow sign’ in a mass in the region of the ampulla of Vater may be a choledochocele. Cyst excision and marsupialization is the definitive treatment for a choledochocele. Laparoscopic adhesiolysis is useful in adhesive small bowel obstruction. Background The cystic dilatation of the biliary tract is an uncommon anomaly. Choledochocele, a cystic dilatation of the distal common bile duct, rarely presents clinically as massive gastrointestinal bleeding. Aim This is to report a very rare disease condition and highlight minimal access options in surgical care. Case summary A 13 year-old boy was referred with a day history of sudden onset of passage of bright red blood per rectum with a fainting episode. There was no anal protrusion, jaundice, recurrent epigastric pain nor bleeding from any other orifice. An initial endoscopic assessment of the upper digestive tract showed profuse bleeding from a sub-mucosal mass in the region of ampulla of Vater. Emergency laparotomy revealed small intestine filled with blood from duodenum to ileum. A duodenotomy showed a cystic mass with an ulcerated mucosa at the dome containing bilious fluid in the second part of the duodenum. The cyst was de-roofed and marsupialized. Post-operative recovery was complicated by features of adhesive small bowel obstruction on the 9th post op day and treated by laparoscopic adhesiolysis. He was discharged home in good clinical state. Conclusion Choledochocele is a differential diagnosis in the endoscopic finding of a submucosal mass in the second part of the duodenum. An initial oesophagogastroduodenoscopy endoscopy is necessary in the evaluation of massive lower gastrointestinal bleeding.
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Affiliation(s)
- E Ray-Offor
- Department of Surgery, University of Port-Harcourt Teaching Hospital, Rivers State, Nigeria.
| | - S N Elenwo
- Department of Surgery, University of Port-Harcourt Teaching Hospital, Rivers State, Nigeria
| | - P O Igwe
- Department of Surgery, University of Port-Harcourt Teaching Hospital, Rivers State, Nigeria
| | - C Ngeribara
- Total E & P Clinic, Port Harcourt, Rivers State, Nigeria
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11
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Kwak TY, Park CH, Eom SH, Hwang HS, Chung DW, Seo JY, Kim YS, Kwak DH. Choledochocele containing a stone mistaken as a distal common bile duct stone. Yeungnam Univ J Med 2015. [DOI: 10.12701/yujm.2015.32.1.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Tae Young Kwak
- Department of Internal Medicine, Kwak's Hospital, Daegu, Korea
| | - Chang Hwan Park
- Department of Internal Medicine, Kwak's Hospital, Daegu, Korea
| | - Seok Hyeon Eom
- Department of Internal Medicine, Kwak's Hospital, Daegu, Korea
| | - Hong Suk Hwang
- Department of Internal Medicine, Kwak's Hospital, Daegu, Korea
| | - Duk Won Chung
- Department of Internal Medicine, Kwak's Hospital, Daegu, Korea
| | - Ji Young Seo
- Department of Internal Medicine, Kwak's Hospital, Daegu, Korea
| | - Yeong Sung Kim
- Department of Internal Medicine, Kwak's Hospital, Daegu, Korea
| | - Dong Hyup Kwak
- Department of Internal Medicine, Kwak's Hospital, Daegu, Korea
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McNeeley MF, Lalwani N, Dhakshina Moorthy G, Maki J, Dighe MK, Lehnert B, Prasad SR. Multimodality imaging of diseases of the duodenum. ABDOMINAL IMAGING 2014; 39:1330-1349. [PMID: 24811767 DOI: 10.1007/s00261-014-0157-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The duodenum is a unique segment of intestine, occupying both intra and extra-peritoneal locations. There is a wide spectrum of abnormalities of the duodenum that range from congenital anomalies to traumatic, inflammatory, and neoplastic entities. The duodenum may be overlooked on cross-sectional imaging due to its location and small size. Duodenal pathologies may, therefore, be missed or wrongly diagnosed. Knowledge about duodenal pathologies and optimal imaging techniques can increase diagnostic yield and permit optimal patient management. Conventionally, the duodenum was evaluated with upper GI studies on fluoroscopy; however, endoluminal evaluation is better performed with endoscopy. Additionally, a broad array of cross-sectional imaging modalities permits comprehensive assessment of the duodenum and surrounding viscera. While endoscopic sonography is increasingly used to locally stage duodenal malignancies, MDCT remains the primary modality widely used in the detection and characterization of duodenal abnormalities. MRI is used as a "problem solving" modality in select conditions. We present a comprehensive review of duodenal abnormalities with an emphasis on accurate diagnosis and management.
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Choledochal cysts: presentation, clinical differentiation, and management. J Am Coll Surg 2014; 219:1167-80. [PMID: 25442379 DOI: 10.1016/j.jamcollsurg.2014.04.023] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/29/2014] [Accepted: 04/30/2014] [Indexed: 02/08/2023]
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Law R, Topazian M. Diagnosis and treatment of choledochoceles. Clin Gastroenterol Hepatol 2014; 12:196-203. [PMID: 23660418 DOI: 10.1016/j.cgh.2013.04.037] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 04/15/2013] [Accepted: 04/16/2013] [Indexed: 02/07/2023]
Abstract
Choledochoceles are cystic dilatations of the intraduodenal portion of the common bile duct. Although often classified as Type III biliary cysts, choledochoceles have distinctive demographic and anatomic features and a lower risk of malignancy than other types of choledochal cysts. Type A choledochoceles are cystic dilatations of a segment of the intra-ampullary bile duct and are located proximal to the ampullary orifice. Type B choledochoceles are diverticula of the intra-ampullary common channel and are located distal to the ampullary orifice; they can be distinguished from duodenal duplication cysts both anatomically and histologically. Both types of choledochocele may present with pancreatitis, biliary obstruction, or nonspecific gastrointestinal symptoms. Cross-sectional imaging, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are useful for diagnosis. Choledochoceles may be drained or resected endoscopically. Surveillance for dysplasia should be considered for lesions that are not resected.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Ando H, Takada T. Cystic Disorders of the Bile Ducts. SHACKELFORD'S SURGERY OF THE ALIMENTARY TRACT 2013:1397-1404. [DOI: 10.1016/b978-1-4377-2206-2.00111-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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16
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Mane S, Arlikar J, Dhende N. Choledochocele: An unusual presentation in a premature neonate. J Indian Assoc Pediatr Surg 2012; 17:28-30. [PMID: 22279362 PMCID: PMC3263036 DOI: 10.4103/0971-9261.91084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Choledochocele in a premature neonate who presented with obstructive jaundice and was managed surgically is reported. At 1-year follow-up, the child is asymptomatic.
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Affiliation(s)
- Shivaji Mane
- Department of Pediatric Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India
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17
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Cakmakci E, Ugurlar OY, Erturk SM, Ozel A, Basak M. Sonographic diagnosis of choledochocele. JOURNAL OF CLINICAL ULTRASOUND : JCU 2012; 40:448-450. [PMID: 21953240 DOI: 10.1002/jcu.20877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 08/16/2011] [Indexed: 05/31/2023]
Abstract
We present a case of a 48-year-old female with a history of cholecystectomy and recurrent attacks of pancreatitis whose initial abdominal sonography (US) revealed multiple conglomerated stones in the descending part of the duodenum. Abdominal CT, MRI, and magnetic resonance cholangiopancreatography showed the same findings. The distended sacciform distal intramural segment of the common bile duct was protruding into the duodenum. The imaging findings explained the etiology of the patient's recurrent attacks of pancreatitis and led to surgical excision of the choledococele.
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Affiliation(s)
- Emin Cakmakci
- Department of Radiology, Sisli Etfal Training and Research Hospital, Etfal Sokak, Istanbul 34360, Turkey
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18
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Abstract
The classification of choledochoceles as a type of choledochal cyst stems from the 1959 article by Alonso-Lej and colleagues describing 94 choledochal cysts, only 4 of which were choledochoceles. Even then, Alonso-Lej questioned the propriety of including the choledochocele, stating it was unclear "as to whether or not it originates from the same etiologic factors [as other choledochal cysts]". In 1971, Trout and Longmire also questioned the validity of classifying choledochoceles as choledochal cysts, noting the anatomic position article and variant mucosa of the choledochocele. Wearn and Wiot, in an article titled "Choledochocele: not a form of choledochal cyst", cite the differences in clinical presentation, demographics, and histology as reasons why choledochoceles represent separate entities from choledochal cysts. Over the ensuing decades, numerous investigators have questioned the legitimacy of classifying choledochoceles as choledochal cysts. In our recent series (the only one to our knowledge directly comparing patients with choledochocele and other [type I, II, IV, and V] choledochal cysts), patients with choledochoceles differed from patients with choledochal cysts in their age, gender, presenting symptoms, history of previous cholecystectomy, pancreatobiliary ductal anatomy, management, and most importantly, propensity to developing biliary malignancy. Based on the available cases of choledochoceles found in the literature, combined with the recent series from our institution, we conclude that choledochoceles seem to be distinct entities from choledochal cysts.
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Affiliation(s)
- Kathryn M Ziegler
- Department of Surgery, Indiana University, 545 Barnhill Drive, EH 202, Indianapolis, IN 46202, USA
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19
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Nawara C, Wolkersdörfer G, Öfner-Velano D, Emmanuel K. Recent developments in the diagnosis and treatment of bile duct cysts: a review. Eur Surg 2011. [DOI: 10.1007/s10353-011-0006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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20
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Abstract
OBJECTIVE The aim of this analysis was to report a multidisciplinary series comparing choledochoceles to Todani Types I, II, IV, and V choledochal cysts. SUMMARY BACKGROUND DATA Choledochoceles have been classified as Todani Type III choledochal cysts. However, most surgical series of choledochal cysts have reported few choledochoceles because they are managed primarily by endoscopists. METHODS Surgical, endoscopic, and radiologic records were reviewed at the Riley Children's Hospital and the Indiana University Hospitals to identify patients with choledochal cysts. Patient demographics, presenting symptoms, radiologic studies, associated abnormalities, surgical and endoscopic procedures as well as outcomes were reviewed. RESULTS A total of 146 patients with "choledochal cysts" including 45 children (31%) and 28 with choledochoceles (18%) were identified, which represents the largest Western series. Patients with choledochoceles were older (50.7 vs. 29.0 years, P < 0.05) and more likely to be male (43% vs. 19%, P < 0.05), to present with pancreatitis (48% vs. 24%, P < 0.05) rather than jaundice (11% vs. 30%, P < 0.05) or cholangitis (0% vs. 21%, P < 0.05), to have pancreas divisum (38% vs. 10%, P < 0.01), and to be managed with endoscopic therapy (79% vs. 17%, P < 0.01). Two patients with choledochoceles (7%) had pancreatic neoplasms. CONCLUSIONS Patients with choledochoceles differ from patients with choledochal cysts with respect to age, gender, presentation, pancreatic ductal anatomy, and their management. The association between choledochoceles and pancreas divisum is a new observation. Therefore, we conclude that classifications of choledochal cysts should not include choledochoceles.
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21
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Endoscopic retrograde cholangiopancreatography in the diagnosis and treatment of a case of choledochocoele. Arab J Gastroenterol 2010. [DOI: 10.1016/j.ajg.2010.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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22
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Abstract
PURPOSE OF REVIEW Surgical treatment of bile duct cysts remains the mainstay to reduce cyst-related complications and risk of malignancy. Optimizing treatment outcomes is dependent upon a thorough preoperative evaluation and selecting the appropriate intervention. This review summarizes the recent progress in the evaluation and treatment of bile duct cysts, particularly in relation to contemporary operative approaches. RECENT FINDINGS Ongoing efforts continue in optimizing the evaluation, classification and management of bile duct cysts. The risk of cholangiocarcinoma is not limited to the bile duct cyst itself and appropriate management and surveillance is paramount. Recent advances in laparoscopic and endoscopic equipment have paralleled an increasing interest in minimally invasive approaches in the management of patients with bile duct cysts. Favorable results of laparoscopic approaches are increasingly reported and suggest the feasibility of this technique in select patients. SUMMARY Although the surgical premise of resection has not changed for the treatment of bile duct cysts, there has been an increasing utilization of minimally invasive approaches. Results thus far are promising, but long-term, controlled data is needed before this approach can be considered standard.
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Shimamura K, Kurosaki I, Sato D, Takano K, Yokoyama N, Sato Y, Hatakeyama K, Nakadaira K, Yagi M. Intrahepatic cholangiocarcinoma arising 34 years after excision of a type IV-A congenital choledochal cyst: report of a case. Surg Today 2009; 39:247-51. [PMID: 19280286 DOI: 10.1007/s00595-008-3825-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 05/28/2008] [Indexed: 12/22/2022]
Abstract
We report a rare case of intrahepatic cholangiocarcinoma (IHCC) arising many years after excision of a type IV-A congenital choledochal cyst. A 44-year-old man was transferred to our hospital with acute cholangitis more than 34 years after several operations for congenital biliary dilatation. Imaging showed a huge tumor in the left medial section of the liver, extending to the porta hepatis. Although he had no jaundice, the intrahepatic bile ducts showed cylinder-like dilatation with narrowing of the hilar bile duct. At surgery, the tumor was found to arise from the dilated intrahepatic bile duct just above the narrow portion. He underwent a left hepatic trisectionectomy with a vascular procedure. Microscopically, the tumor was confirmed to be moderate-to-well-differentiated tubular adenocarcinoma. Thus, when the narrow segment is left untouched, careful long-term follow-up is important to detect new lesions at an early stage.
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Affiliation(s)
- Kazuhiko Shimamura
- Division of Digestive and General Surgery, Department of Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
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24
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Berger A, Douard R, Landi B, Poupardin E, Canard JM, Cellier C, Cugnenc PH. Endoscopic management of a large choledochocele associated with choledocholithiasis. ACTA ACUST UNITED AC 2007; 31:200-3. [PMID: 17347632 DOI: 10.1016/s0399-8320(07)89356-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Choledochocele or type III choledochal cyst is a very rare lesion, defined as a cystic dilatation of the distal common bile duct protruding into the duodenal lumen. Abdominal pain, biliary disorders, and acute pancreatitis are frequently observed but malignant degeneration is rare. A 70-year-old man had a history of epigastralgia associated with abnormal liver function tests suggesting gallstones. During laparoscopic cholecystectomy, intraoperative cholangiography showed a 40-mm-diameter choledochocele associated with choledocholithiasis. A transcystic drain was placed after cholecystectomy had been completed. Endoscopic retrograde cholangiopancreatography confirmed the diagnosis and a 45-mm-long endoscopic sphincterotomy successfully treated both lesions as confirmed by a transcystic cholangiogram showing a thin-walled common bile duct with no residual stones. This case illustrates that the diagnosis of choledochocele remains difficult in clinical practice and confirms that endoscopic retrograde cholangiopancreatography is the best available diagnostic tool. Coexistent choledocholithiasis is observed in about 20% of choledochocele. Endoscopic sphincterotomy is feasible and effectively treats both lesions even in larger choledochoceles.
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Affiliation(s)
- Anne Berger
- General and Digestive Surgery Unit, AP-HP European Georges Pompidou University Hospital, Paris, France
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Izumiya M, Tamada K, Tomiyama T, Hanatsuka K, Ohashi A, Sugano K. A case of choledochocele mimicking choledocholithiasis on MR cholangiography: A new differential diagnosis of pseudo-filling defect. J Magn Reson Imaging 2007; 26:1097-100. [PMID: 17896387 DOI: 10.1002/jmri.21114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We present the case of a 79-year-old female with acute cholangitis and cholecystitis who presented with right upper quadrant pain. Thin-collimation MR cholangiogram showed a filling defect measuring 1 cm, which was less prominent on single-slab images. Endoscopy showed dynamic ballooning and collapsing of the ampulla of Vater, and a cholangiogram showed characteristic bulging at the distal common bile duct, which led to the diagnosis of choledochocele. It is important to differentiate choledochocele as a cause of filling defect of the lower common bile duct on the MR cholangiogram.
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Affiliation(s)
- Masashi Izumiya
- Department of Gastroenterology, Jichi Medical School, Tochigi, Japan.
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26
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Kishino T, Haradome H, Mori H, Takahashi S, Ishida H, Watanabe T. Choledochocele demonstrated on conventional sonography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2006; 34:199-202. [PMID: 16615054 DOI: 10.1002/jcu.20191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Choledochocele is the least common form of choledochal cyst. We report a rare bile duct cyst diagnosed in a 63-year-old woman via CT cholangiography. Although conventional sonography initially failed to reveal abnormal findings, a subsequent detailed study clearly depicted the lesion. To the best of our knowledge, this is the first report of choledochocele unambiguously demonstrated on transabdominal sonography.
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Affiliation(s)
- Tomonori Kishino
- Department of Laboratory Medicine, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan
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27
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Abstract
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.
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Affiliation(s)
- K Söreide
- Department of Surgery, University of Bergen, Stavanger, Norway
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28
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Abstract
Cystic diseases of the biliary tract encompass a complex group of congenital disorders. Some of the disorders, such as Caroli disease and the hepatobiliary cysts of autosomal-dominant polycystic kidney disease, share common embryologic origins, whereas others, such as choledochal cysts, biliary diverticula, and choledochoceles, have unclear origins. This article reviews the embryologic, clinical, pathologic, and imaging features of biliary cystic disease.
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Affiliation(s)
- Angela D Levy
- Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington, DC 20306, USA.
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Groebli Y, Meyer JL, Tschantz P. Choledochocele demonstrated by computed tomographic cholangiography: report of a case. Surg Today 2001; 30:272-6. [PMID: 10752782 DOI: 10.1007/s005950050058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Choledochocele is a rare cystic congenital malformation of the distal common bile duct, the precise pathogenesis of which remains unclear. It is usually diagnosed in adulthood after many examinations for unclear digestive symptoms, as in the patient whose case is described herein. Of all the diagnostic techniques available, endoscopic retrograde cholangiography (ERCP) seems to be the best; however, it is an invasive procedure associated with some morbidity. Spiral computed tomographic cholangiography with three-dimensional reconstruction is also an interesting screening technique. Malignant transformation of a choledochocele occurs very rarely, compared with other cystic malformations of the biliary tract. If a choledochocele is small and symptomatic, the lesion can be treated by endoscopic sphincterotomy, but larger cysts are more effectively removed by a surgical cystoduodenostomy. We present herein the case of a 25-year-old woman admitted to our hospital in March 1998 with upper right quadrant abdominal pain caused by a choledochocele, who was successfully treated by a cystoduodenostomy.
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Affiliation(s)
- Y Groebli
- Department of Surgery, Hôpital des Cadolles, Neuchâtel, Switzerland
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30
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Abstract
Choledochal cysts are rare developmental malformations of the biliary tree. Percutaneous and endoscopic ultrasound, as well as endoscopic retrograde cholangiopancreatography, are recommended diagnostic tools. Magnetic resonance cholangiography may also contribute to the workup and treatment plan of patients with choledochal cysts. We report a 25-yr-old white woman with episodic nausea and moderate epigastric discomfort. Magnetic resonance cholangiography showed a rather spherical, cyst-like, fluid-filled structure in continuity with the prepapillary segment of the common bile duct, thus making a choledochocele (type III choledochal cyst) likely. The patient was treated by endoscopic sphincterotomy and, after a 6-month follow-up, is without complaints.
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Affiliation(s)
- H E Adamek
- Department of Internal Medicine C, Klinikum Ludwigshafen, Academic Teaching Hospital of the University of Mainz, Germany
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31
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