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Ray S, Saha H, Sen S, Das S, Lahiri S, Das S, Mandal TS, Biswas J, Khamrui S. Presentation and outcomes of surgery for choledochal cyst in children and adults: an experience of 329 cases. Updates Surg 2025; 77:459-470. [PMID: 40035920 DOI: 10.1007/s13304-025-02138-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Accepted: 02/24/2025] [Indexed: 03/06/2025]
Abstract
The purpose of this study is to report our experience in patients with choledochal cyst (CDC) and to evaluate whether there is any difference in the clinical presentation, cyst -related complications, and long-term biliary outcomes after surgery among children and adults. All the patients who underwent CDC excision between January 2008 and December 2023 were retrospectively reviewed. The patients were divided into two groups: children (< 18 years) and adults (≥ 18 years). There were 329 patients with CDC excision (77.5% were female, adult/children = 251/78). Abdominal pain was the predominant presenting symptom in both groups. Abdominal lump (10.3% vs 3.2%; p = 0.011) and the triad of CDC (9% vs 2.4%; p = 0.009) were more common in children. But, the preoperative biliary intervention (37.8% vs 15.4%; p = < 0.001), previous biliary surgery (32.7% vs 3.8%; p = < 0.001), and prevalence of gallstones (36.7% vs 3.8%; p = < 0.001), cystolithiasis (56.6% vs 38.5%; p = 0.005), and intrahepatic stones (7.6% vs 1.3%; p = 0.054) were more common in adults. Most patients were presented with type I CDC (71.4%). Extrahepatic bile duct excision with Roux en-Y hepaticojejunostomy was performed in all the patients. Although overall postoperative complications were comparable between adults and children (31.1% vs 26.9%; p = 0.485), wound infection was more common in adults (19.9% vs 6.4%; p = 0.005) and bile leak was more common in children (12.8% vs 5.2%; p = 0.021). There was no operative mortality. Over a mean follow-up of 59 (40) months, 2 patients (0.78%) developed malignancy. Excellent or good Long-term biliary outcome was significantly better in children than adults (98.1% vs 90.5%; p = 0.010). Independent predictors for unsatisfactory biliary outcomes were type IVA cysts, postoperative bile leak, adult patients, and longer duration of follow-up. In conclusion, presentation and cyst-related complications differ between adults and children. Surgery offers excellent results in the vast majority of patients. Long-term biliary complications were more in adults. Long-term follow-up is recommended for the possibility of future development of hepato-biliary-pancreatic malignancy and delayed biliary complications.
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Affiliation(s)
- Sukanta Ray
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, West Bengal, 700020, India.
| | - Hemabha Saha
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Swapnil Sen
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Suman Das
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Somdatta Lahiri
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Somak Das
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Tuhin Subhra Mandal
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Jayanta Biswas
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Sujan Khamrui
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, West Bengal, 700020, India
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Alghamdi TH. Intrahepatic Class VII Choledochal Cyst: Radiological Insights and Surgical Approach. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e945049. [PMID: 39616438 PMCID: PMC11622327 DOI: 10.12659/ajcr.945049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 10/16/2024] [Accepted: 09/27/2024] [Indexed: 12/08/2024]
Abstract
BACKGROUND Choledochal cysts are congenital cystic dilatation of any section of the bile ducts. They have been divided into 5 primary categories. This is the case of an intrahepatic variant of bile duct cysts originating from the main lobar bile ducts at the confluence, initially radiologically identified as biliary cystadenoma in segments 4b and 5. CASE REPORT A 35-year-old woman presented with right upper quadrant pain and palpable mass during examination. History and laboratory results were normal. Magnetic resonance cholangiopancreatography revealed a complicated cystic lesion compressing right and left proximal hepatic ducts, diagnosed radiologically as biliary cyst adenoma in segments 4b and 5. Intraoperatively, large cyst found in liver segment 4b and 5, extending infra-hepatic, included the confluence of the common hepatic duct and extended to the gallbladder. It was easily separable from the gallbladder, and total cholecystectomy was done; however, the cyst was inseparable from the confluence of common hepatic duct. The peritoneum over the cyst, containing the right and left hepatic duct and in the area of confluence, was dissected and pushed down to avoid injury; enucleation of the lower border was successfully done. Upper border was transected through liver parenchyma; many small ductules connected with the cyst were ligated. Resection should be done to decrease possibility of malignant transformation and prevent recurrent cholangitis. CONCLUSIONS Class VII choledochal cyst is rare, and surgery is the preferred choice, after proper evaluation of the cyst and surrounding structure. Magnetic resonance cholangiopancreatography still has a high overall accuracy for choledochal cyst diagnosis and classification.
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Bloomfield GC, Nigam A, Calvo IG, Dorris CS, Fishbein TM, Radkani P, Winslow ER. Characteristics and malignancy rates of adult patients diagnosed with choledochal cyst in the West: a systematic review. J Gastrointest Surg 2024; 28:77-87. [PMID: 38353080 DOI: 10.1016/j.gassur.2023.11.007] [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: 07/03/2023] [Revised: 10/14/2023] [Accepted: 10/25/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND The approach to patients with choledochal cysts (CCs) remains varied and subject to institutional practices. Owing to the rarity of the disease, the optimal treatment remains poorly defined, particularly in the adult population. This study aimed to review the literature on adult patients with CCs to evaluate trends of diagnosis and management in Western countries. METHODS A literature search of 3 electronic databases was performed on adult patients diagnosed with CCs in Western institutions. A review of published literature was completed with comprehensive screening by 2 independent reviewers. Studies were analyzed, and data on surgical approach, malignancies, and follow-up were collected. Findings are presented in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. RESULTS Of the 3488 articles retrieved, 21 studies evaluated Western adults with CCs for a combined population of 1337 patients. The most common Todani subtypes included types I (64%) and IV (22%). Symptoms at presentation included abdominal pain and jaundice, although many were asymptomatic. Ultrasound was used most frequently for diagnosis, followed by computed tomography and endoscopic cholangiopancreatography. The combined malignancy rate was 10.9%, with cholangiocarcinoma being the most prevalent. Complete extrahepatic cyst resection was standard for type I and IV CCs. Among malignancies, 18.5% and 16.4% were observed in patients with prior resection and internal drainage, respectively. CONCLUSIONS A significant proportion of patients who undergo resection of CC disease harbor malignancy. Cancer risk seems reduced but not eliminated with complete resection, which remains the standard treatment. Additional studies are needed to standardize guidelines for the diagnosis and postoperative care of patients in Western countries.
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Affiliation(s)
- Grace C Bloomfield
- Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Aradhya Nigam
- Department of Surgery, Medstar Georgetown University Hospital, Washington, District of Columbia, United States
| | - Inochi Gonzalez Calvo
- Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - C Scott Dorris
- Dahlgren Memorial Library, Georgetown University Medical Center, Washington, District of Columbia, United States
| | - Thomas M Fishbein
- MedStar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, United States
| | - Pejman Radkani
- MedStar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, United States
| | - Emily R Winslow
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Ray S, Dhali A, Khamrui S, Mandal TS, Das S, Dhali GK. Surgical outcomes after re-operation for excision of choledochal cyst with delayed biliary complications: A retrospective study on 40 patients. Am J Surg 2023; 226:93-98. [PMID: 36792452 DOI: 10.1016/j.amjsurg.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/18/2023] [Accepted: 02/04/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE The purpose of this study is to review our experience in patients who underwent re-operation for delayed biliary complications after choledochal cyst (CDC) excision. METHODS All the patients who underwent re-operation. for delayed biliary complications after CDC excision between August 2007 and July 2020 were included in this retrospective study. The outcomes of these patients were compared with those who underwent primary surgery (CDC excision) at our institution. RESULTS Of the total 40 patients with delayed biliary complications, 25 (62.5%) were female. Thirty-seven (92.5%) patients had a history of cholangitis. The median interval between CDC excision and the reoperation was 70 (4-216) months. The median duration of symptoms before reoperation was 12 (2.5-84) months. Re-do hepaticojejunostomy and direct hepaticojejunostomy were performed in 34 and in 6 patients respectively. Median operative time and blood losses were 219 min and 150 ml respectively. The median postoperative stay was 9 days. Postoperative complications developed in 10 (25%) patients. There was no operative mortality. Over a median follow-up of 71 months, a satisfactory outcome was achieved in 86% of patients. Restricture and intrahepatic stones developed in three and two patients respectively. Incidence of type IV cyst, cholangitis before operation, and operative blood loss were significantly more in the re-operative group. Clinical outcomes like the incidence of recurrent cholangitis, re-stricture, and postoperative hospital stay were comparable between the two groups. CONCLUSION Surgery affords excellent results for majority of the patients with delayed biliary complications after CDC excision. Type IV cysts are more commonly associated with the development of delayed biliary complications.
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Affiliation(s)
- Sukanta Ray
- Department of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India.
| | - Arkadeep Dhali
- Department of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India.
| | - Sujan Khamrui
- Department of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Tuhin Subhra Mandal
- Department of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Somak Das
- Department of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Gopal Krishna Dhali
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate sMedical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
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PICCINO M, GROSSI U, PALUMBO R, PIROZZOLO G, D’ALIMONTE L, RECORDARE AG. Bile duct cysts in adults: is it time to think about a tailored treatment? Chirurgia (Bucur) 2023; 36. [DOI: 10.23736/s0394-9508.22.05453-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Manekar AA, Tripathy BB, Sahoo SK, Sable MN, Naik S, Janjala N, Mohanty MK. Prevalence of Pancreato-Biliary Maljunction in Children with Choledochal Cyst - A Prospective Observational Study. J Indian Assoc Pediatr Surg 2023; 28:137-143. [PMID: 37197231 PMCID: PMC10185032 DOI: 10.4103/jiaps.jiaps_104_22] [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] [Received: 07/29/2022] [Revised: 10/13/2022] [Accepted: 10/26/2022] [Indexed: 05/19/2023] Open
Abstract
Background Pancreatico-biliary maljunction (PBM) is often found to be associated with choledochal cysts (CCs). According to a European multicenter study, the prevalence of PBM in cases of CC is found to be 72.2%, however, there is no Indian study depicting the prevalence of PBM in Indian children with CCs, which is one of the main postulated factors in the etiopathogenesis of CC. In this study, we have attempted to observe prospectively the prevalence of PBM in children with CC and correlate this to its morphological and biochemical parameters. The association between the presence of PBM and histopathological findings such as epithelial changes of the mucosa of the CC, inflammation, metaplasia or dysplasia, and histopathology of the liver has also been evaluated. Materials and Methods We carried out a single center, prospective observational study with a single arm study group. We prospectively selected all patients of CC admitted for surgery from November 2018 to October 2020. Data on biochemical, radiological, and histopathological parameters were collected and analyzed. Results We included a total of 20 patients in our study. The mean age of the participants was 6.22 ± 4.32 years. Among them, 11 (55.0%) were male and 9 (45%) were female. Abdominal pain was the most common presenting complaint among our patients (75.0%) and had a significant association with the presence of a PBM (P = 0.001). In symptomatic children, the mean duration of symptoms was 4.50 ± 2.26 months for jaundice, 4.50 ± 1.98 months for abdominal distension, and 5.07 ± 2.02 months for abdominal pain. Among the 3 children with cholangitis, the mean number of episodes was 3.33 ± 2.08, with a median of four episodes. Fourteen (70.0%) of the children had type I a CC, 1 (5.0%) participant each for types I b, I c, II and IV a and 2 (10.0%) of them had type IV b cyst. The mean size of the cyst (cm) was 7.41 ± 3.03 with a median of 6.85 cm. Among the children, 9 (45%) showed the presence of PBM on magnetic resonance cholangiopancreatography (MRCP), with 7 (77.8%) showing Komi's C-P type and 2 (22.2%) showing Komi's PC type. The mean common channel length (mm) on MRCP was 8.11 ± 2.47 with a median length of 8.00 mm. The biochemical analysis of a bile fluid amylase and lipase is the functional indicator of the presence of a PBM. Histopathological examination showed the presence of ulceration in the walls of the CC in 10 (50.0%) of the specimens. There was a significant association of the presence of PBM and ulceration in the mucosa of the CC (P ≤ 0.001), with the median levels being the highest in the PBM present group. Conclusion Abdominal pain is the most common complaint in a child with CC, and when present, it is significantly associated with the presence of a PBM. MRCP is the gold standard tool to detect CCs and find out the morphology of PBM. The prevalence of PBM in children with CC of 45% with a mean common channel length of 8.11 mm. The biochemical analysis of a bile amylase and lipase is the functional indicator of the presence of a PBM and there is a significant association of their higher levels and presence of PBM. The presence of chronic inflammation and microscopic ulcers is significant histologic parameters depicting the presence of a PBM.
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Affiliation(s)
- Aditya Arvind Manekar
- Department of Paediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Bikasha Bihary Tripathy
- Department of Paediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Subrat Kumar Sahoo
- Department of Paediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Mukund Namdev Sable
- Department of Pathology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Suprava Naik
- Department of Radiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Narahari Janjala
- Department of Paediatric Surgery, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| | - Manoj Kumar Mohanty
- Department of Paediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Yaghi M, Jaafar R, Kanso M, Khalife M, Faraj W. Choledochal anomalies in adults: A 20-year single-center retrospective cohort experience in the Middle East. Arab J Gastroenterol 2022; 23:235-240. [PMID: 36371373 DOI: 10.1016/j.ajg.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 03/31/2022] [Accepted: 10/14/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Choledochal cysts are rare congenital cystic dilatations of the bile ducts that occur in fewer than 1% of individuals. The disease is common in East Asia, and most of the literature concerns those populations, but some data about Western populations have been published recently. Long-term reports about the disease in Middle Eastern populations, however, are currently lacking. We report a single-center 20-year experience in diagnosing and managing choledochal anomalies. PATIENTS AND METHODS Participants were adult patients in whom choledochal cysts were diagnosed over a 20-year (2000-2019) period at a single tertiary academic care center. Clinical data, including radiologic imaging findings, were retrieved from the patients' medical records. To describe the baseline characteristics of the population, we calculated descriptive statistics. RESULTS Choledochal anomalies were diagnosed in 19 adult patients, whose median age was 30 years (interquartile range [IQR], 23-67 years). Of the choledochal cysts 13 (68.4%) were classified as Todani type I, 4 (21.1%) as Todani type IV, and 3 (15.8%) as Todani type V (Caroli's disease). No patient had underlying chronic liver disease, and liver synthetic function was preserved in all. Eighteen patients (94.7%) underwent surgery: cyst excision with Roux-en-Y hepaticojejunostomy in 17 and liver transplantation in 1. All 18 survived surgery, and the median postoperative hospital stay was 11 days (IQR, 5-34 days). All 18 were alive 90 days after surgery, and the median follow-up period was 40 months (IQR, 12-140 months). Seven patients (36.8%) developed postoperative surgical complications; 2 patients required rehospitalization, and 1 required reoperation. CONCLUSION This description of adults with choledochal cysts is the latest long-term report about this disease in the Middle East. In our 20-year experience, the disease characteristics in our patients were moderately consistent with those described previously.
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Affiliation(s)
- Marita Yaghi
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Rola Jaafar
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Mariam Kanso
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Mohamed Khalife
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Walid Faraj
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon.
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Wu X, Li BL, Zheng CJ, He XD. Risk factors for preoperative carcinogenesis of bile duct cysts in adults. World J Clin Cases 2021; 9:6278-6286. [PMID: 34434994 PMCID: PMC8362564 DOI: 10.12998/wjcc.v9.i22.6278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/06/2021] [Accepted: 05/19/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bile duct cyst (BDC) is a rare congenital bile duct malformation. The incidence of bile duct malignancy in BDC patients is markedly higher than that in the general population. However, few studies have been conducted on the risk factors for preoperative carcinogenesis in BDC patients. AIM To analyze the risk factors associated with preoperative carcinogenesis in BDC patients. METHODS The medical records of BDC patients treated at our hospital between January 2012 and December 2018 were retrospectively reviewed. We constructed a database and compared the characteristics of BDC patients with dysplasia and carcinoma against those with benign cysts. The risk factors for preoperative carcinogenesis were identified using univariate and multivariate analyses. RESULTS The cohort comprised 109 BDC patients. Ten patients had preoperative dysplasia or adenocarcinoma. Univariate and multivariate analyses showed that gallbladder wall thickness > 0.3 cm [odds ratio (OR), 6.551; 95% confidence interval (CI), 1.351 to 31.763; P = 0.020] and Todani type IV (OR, 7.675; 95%CI, 1.584 to 37.192; P = 0.011) were independent factors associated with preoperative carcinogenesis. CONCLUSION BDC is a premalignant condition. Our findings show that gallbladder wall thickness > 0.3 cm and Todani type IV are independent risk factors for preoperative carcinogenesis of BDC. They are therefore useful for deciding on the appropriate treatment strategy, especially in asymptomatic patients.
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Affiliation(s)
- Xin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Bing-Lu Li
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Chao-Ji Zheng
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiao-Dong He
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Ming G, Guo W, Cheng Y, Wang J. Identification and evaluation of fructose-bisphosphate aldolase B as a potential diagnostic biomarker in choledochal cysts patients: a quantitative proteomic analysis. Transl Pediatr 2021; 10:2083-2094. [PMID: 34584879 PMCID: PMC8429877 DOI: 10.21037/tp-21-336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/16/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Choledochal cyst (CC) is a congenital bile duct malformation, with a higher incidence in minors. Patients with CCs are at risk of pancreatitis and ascending cholangitis. The main forms of treatments aim to avoid any possible hepatic, pancreatic, or biliary complications. Since early diagnosis is of great importance for CC treatment and prognosis, this investigation was designed to screen and identify potential biomarkers from the serum samples of CC patients for CC early diagnosis. METHODS Quantitative label free proteomic analysis was used to identify differentially expressed proteins in serum samples from CC patients and normal healthy children. The expression levels of biomarker candidates were further confirmed using quantitative polymerase chain reaction (Q-PCR), Western blot analysis, and immunohistochemistry in the choledochal tissues. RESULTS The quantitative label free proteomic analysis identified 47 differentially expressed proteins in the serum samples from the CC patients and the normal children, including 14 up-regulated proteins and 33 down-regulated proteins. The expression profile of eight biomarker candidates in CC patients, namely, insulin-like growth factor binding protein 2 (IGFBP2), tropomyosin (TPM3), fructose-bisphosphate aldolase B (ALDOB), fumarylacetoacetate hydrolase (FAH), superoxide dismutase 3 (SOD3), secreted protein acidic and cysteine rich (SPARC), apolipoprotein E (APOE), and retinol binding protein 4 (RBP4), were selected for further examination in choledochal tissues, showing that ALDOB was significantly increased. CONCLUSIONS The results demonstrated that the ALDOB protein increased significantly in choledochal tissues and the serum samples of CC patients, which may serve as an effective predictor for early diagnosis of CC.
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Affiliation(s)
- Gedong Ming
- Department of Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, China
| | - Wanliang Guo
- Department of Radiology, Children's Hospital of Soochow University, Suzhou, China
| | - Yuan Cheng
- Department of Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, China.,Department of Radiology, Children's Hospital of Soochow University, Suzhou, China
| | - Jian Wang
- Department of Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, China
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Ndoye NA, Wellé IB, Cissé L, Guèye D, Diouf C, Mbaye PA, Lo FB, Seck NF, Sagna A, Ndour O, Ngom G. Choledochal cyst in children in dakar: Diagnostic and therapeutic aspects. Afr J Paediatr Surg 2021; 18:168-170. [PMID: 34341203 PMCID: PMC8362915 DOI: 10.4103/ajps.ajps_4_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Choledochal cyst is a rare malformation that mainly affects girls. AIMS The aim of this work is to report the diagnostic, therapeutic and evolutionary aspects of bile duct cyst in children in Dakar. SUBJECTS AND METHODS we conducted a prospective monocentre descriptive study from 1 July, 2016, to 30 June, 2019, in the Pediatric Surgery Department of Albert Royer Children's Hospital in Dakar. The studied parameters featured clinical, biological, radiological, therapeutic and evolutionary data. Overall, ten patients, including eight girls and two boys, were selected. RESULTS Two patients presented the classic triple-syndrome complex featuring an abdominal pain, an abdominal mass and jaundice. Most of the patients presented a symptomatology associating abdominal pain and vomiting. Biological cholestasis syndrome was present in six cases and biological cytolysis syndrome in five cases. The abdominal ultrasound-computed tomography (CT) scan confirmed the diagnosis and helped to set the Todani classification with a predominance of Types 1 and 4. Surgical treatment by laparotomy consisted of total excision of the cyst followed by a Y-en-Roux hepatico-jejunal anastomosis in nine cases, whereas we performed a drainage of the cyst in one case. Two patients presented a morbidity of anastomotic suture release and evisceration and had a good outcome after surgical repair. There was no mortality. CONCLUSIONS The diagnosis of choledochal cyst dilatation (CCD) can be suspected in the postnatal period on the basis of a gastro-intestinal symptomatology with or without associated to jaundice. The combination ultrasound-abdominal CT-scan helps set the diagnosis. The laparatomic approach always has its place for the management of CCD, especially in our context.
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Affiliation(s)
- Ndeye Aby Ndoye
- Department of Pediatric Surgery, Albert Royer Children's Hospital; Cheikh Anta Diop University, Dakar, Senegal
| | - Ibrahima Bocar Wellé
- Department of Pediatric Surgery, Albert Royer Children's Hospital, Dakar, Senegal
| | - Lissoune Cissé
- Department of Pediatric Surgery, Albert Royer Children's Hospital, Dakar, Senegal
| | - Doudou Guèye
- Department of Pediatric Surgery, Albert Royer Children's Hospital, Dakar, Senegal
| | - Cheikh Diouf
- Department of Pediatric Surgery, Regional Hospital of Ziguinchor Assane Seck University, Dakar, Senegal
| | - Pape Alassane Mbaye
- Department of Pediatric Surgery, Albert Royer Children's Hospital; Cheikh Anta Diop University, Dakar, Senegal
| | - Faty Balla Lo
- Department of Pediatric Surgery, Albert Royer Children's Hospital, Dakar, Senegal
| | - Ndèye Fatou Seck
- Department of Pediatric Surgery, Albert Royer Children's Hospital, Dakar, Senegal
| | - Aloïse Sagna
- Department of Pediatric Surgery, Albert Royer Children's Hospital; Cheikh Anta Diop University, Dakar, Senegal
| | - Oumar Ndour
- Cheikh Anta Diop University; Department of Pediatric Surgery, Aristide Ledantec Hospital, Dakar, Senegal
| | - Gabriel Ngom
- Department of Pediatric Surgery, Albert Royer Children's Hospital; Cheikh Anta Diop University, Dakar, Senegal
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11
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de Kleine RH, Ten Hove A, Hulscher JBF. Long-term morbidity and follow-up after choledochal malformation surgery; A plea for a quality of life study. Semin Pediatr Surg 2020; 29:150942. [PMID: 32861446 DOI: 10.1016/j.sempedsurg.2020.150942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Much about the aetiology, pathophysiology, natural course and optimal treatment of choledochal malformation remains under debate. Surgeons continuously strive to optimize their roles in the management of choledochal malformation. Nowadays the standard treatment is complete cyst excision followed by Roux-en-Y hepaticojejunostomy, be it via a laparotomy, laparoscopy or robot-assisted procedure. Whatever surgical endeavor is undertaken, it will be a major operation, with significant morbidity. It is important to realize that especially in asymptomatic cases, this is considered prophylactic surgery, aimed at preventing symptoms but even more important the development of malignancy later in life. A clear overview of long-term outcomes is therefore necessary. This paper aims to review the long-term outcomes after surgery for choledochal malformation. We will focus on biliary complications such as cholangitis, the development of malignancy and quality of life. We will try and identify factors related to a worse outcome. Finally, we make a plea for a large scale study into quality and course of life after resection of a choledochal malformation, to help patients, parents and their treating physicians to come to a well-balanced decision regarding the treatment of a choledochal malformation.
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Affiliation(s)
- R H de Kleine
- Department of Surgery, Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, the Netherlands.
| | - A Ten Hove
- Department of Surgery, Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, the Netherlands; Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, the Netherlands
| | - J B F Hulscher
- Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, the Netherlands
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Management of Choledochal Cysts at a Tertiary Care Centre: A Nine-Year Experience from India. Surg Res Pract 2020; 2020:8017460. [PMID: 32373713 PMCID: PMC7191366 DOI: 10.1155/2020/8017460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 02/07/2023] Open
Abstract
Background Although choledochal cyst disease is seen predominantly in childhood, it is becomingly increasingly diagnosed in adult patients. Methods Data of 36 patients with choledochal cysts managed in our institute between January 2010 and December 2018 were retrospectively analyzed. Results Median age at presentation was 37 years (range: 13–72 years). Female-to-male ratio was 3.5 : 1. All patients were symptomatic, and abdominal pain was the most common symptom. 72.2% had other associated conditions. There was a considerable delay from the onset of symptoms to referral, median duration being 348 days. There were 28 cases of type I (77.8%), 5 cases of type IVA (13.9%), and 3 cases of type IVB (8.3%). Cyst excision with Roux-en-Y hepaticojejunostomy was performed in 29 (80.55%) cases. This procedure was combined with a left lateral sectionectomy, left hepatectomy, and radical cholecystectomy in 1, 2, and 1 cases, respectively. Lilly's technique was used in 2 cases, and cyst excision with hepaticoduodenostomy was performed in 1 case. Early complications were seen in 21 patients (58.3%), and late complications were seen in 5 patients (13.8%). 2 patients were found to have associated malignancies. One patient was detected to have cholangiocarcinoma in the resected liver incidentally, and another patient was diagnosed to have gall bladder cancer intraoperatively. Conclusion Choledochal cysts should be considered in the differential diagnosis of adults presenting with epigastric or right hypochondrium pain or jaundice. A thorough preoperative evaluation is required. Cyst excision with Roux-en-Y hepaticojejunostomy forms the standard treatment in most cases. Long-term follow-up is essential for management of complications and early detection of malignant change.
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13
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Azahouani A, Zaari N, Aissaoui FE, Hida M, Fitri M, Benradi L, Benhaddou H. [Cyst of the broken common bile duct: literature review]. Pan Afr Med J 2019; 33:276. [PMID: 31692842 PMCID: PMC6815484 DOI: 10.11604/pamj.2019.33.276.14372] [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: 11/11/2017] [Accepted: 02/27/2018] [Indexed: 12/04/2022] Open
Abstract
Les malformations kystiques des voies biliaires sont des affections congénitales rares évaluées à environ 1/2 000 000 naissances. C'est une affection qui peut se révéler gravement par une complication notamment l'angiocholite, la pancréatite chronique, cirrhose biliaire progressive, l'hypertension portale ou les lithiases biliaires. Sa perforation spontanée est l'une des rares complications, décrite pour la première fois en 1934 par Weber. Nous rapportant le cas d'un garçon de 18 mois admis pour syndrome sub-occlusif avec une péritonite biliaire. Une échographie a été réalisée montrant un épanchement abdominal avec formation kystique communicante des voies biliaires associée à un épanchement sous capsulaire du foie confirmé par scanner. L'intervention a consisté en une toilette péritonéale avec mise en place d'un drain de redon au niveau de la perforation et un drain sous hépatique sans excision du kyste. Le patient a été réadmis 6 mois après cet incident pour sa cure définitive.
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Affiliation(s)
- Ahmed Azahouani
- Service de Chirurgie Pédiatrique, CHU Mohamed VI, Oujda, Maroc
| | - Najlae Zaari
- Service de Chirurgie Pédiatrique, CHU Mohamed VI, Oujda, Maroc
| | | | - Mohamed Hida
- Service de Chirurgie Pédiatrique, CHU Mohamed VI, Oujda, Maroc
| | - Mohamed Fitri
- Service de Chirurgie Pédiatrique, CHU Mohamed VI, Oujda, Maroc
| | - Larbi Benradi
- Service de Chirurgie Pédiatrique, CHU Mohamed VI, Oujda, Maroc
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Morales-Maza J, Rodríguez-Quintero JH, Cortés-Vázquez S, Cruz-Benítez L. Giant choledochal cyst presenting during third trimester of pregnancy. BMJ Case Rep 2018; 2018:bcr-2018-224891. [PMID: 29898912 DOI: 10.1136/bcr-2018-224891] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Biliary cystic disease is a rare entity. Twenty-five per cent of cases are diagnosed during adulthood and only a few reports have described this condition during pregnancy, where it represents a therapeutic challenge for both obstetricians and surgeons with regard to the risks it entails for the patient and the fetus.Definitive management is surgical resection, as cysts may progress to malignancy if untreated. During pregnancy, resection is generally deferred to after delivery, especially in the context of suspected cholangitis.A 19-year-old young woman with no previous prenatal control, presented to the emergency department on her 32nd week of gestation with abdominal pain and jaundice. A giant Todani I biliary cyst was observed on imaging along with dilation of the proximal biliary tree suggesting acute cholangitis. Fetal compromise prompted immediate delivery after which percutaneous biliary drainage was performed. Following recovery, the cyst was surgically resected.
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Affiliation(s)
- Jesus Morales-Maza
- General Surgery, Instituto Nacional de Ciencias Medicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | | | - Sonia Cortés-Vázquez
- General Surgery, Hospital Regional de Alta Especialidad de Ixtapaluca, Ixtapaluca, Mexico
| | - Luis Cruz-Benítez
- General Surgery, Hospital Regional de Alta Especialidad de Ixtapaluca, Ixtapaluca, Mexico
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ten Hove A, de Meijer VE, Hulscher JBF, de Kleine RHJ. Meta-analysis of risk of developing malignancy in congenital choledochal malformation. Br J Surg 2018; 105:482-490. [PMID: 29480528 PMCID: PMC5900735 DOI: 10.1002/bjs.10798] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/20/2017] [Accepted: 11/22/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Choledochal malformations comprise various congenital cystic dilatations of the extrahepatic and/or intrahepatic biliary tree. Choledochal malformation is generally considered a premalignant condition, but reliable data on the risk of malignancy and optimal surgical treatment are lacking. The objective of this systematic review was to assess the prevalence of malignancy in patients with choledochal malformation and to differentiate between subtypes. In addition, the risk of malignancy following cystic drainage versus complete cyst excision was assessed. METHODS A systematic review of PubMed and Embase databases was performed in accordance with the PRISMA statement. A meta-analysis of the risk of malignancy following cystic drainage versus complete cyst excision was undertaken in line with MOOSE guidelines. Prevalence of malignancy was defined as the rate of biliary cancer before resection, and malignant transformation as new-onset biliary cancer after surgery. RESULTS Eighteen observational studies were included, reporting a total of 2904 patients with a median age of 36 years. Of these, 312 in total developed a malignancy (10·7 per cent); the prevalence of malignancy was 7·3 per cent and the rate of malignant transformation was 3·4 per cent. Patients with types I and IV choledochal malformation had an increased risk of malignancy (P = 0·016). Patients who underwent cystic drainage had an increased risk of developing biliary malignancy compared with those who had complete cyst excision, with an odds ratio of 3·97 (95 per cent c.i. 2·40 to 6·55). CONCLUSION The risk of developing malignancy among patients with choledochal malformation was almost 11 per cent. The malignancy risk following cystic drainage surgery was four times higher than that after complete cyst excision. Complete surgical resection is recommended in patients with choledochal malformation.
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Affiliation(s)
- A. ten Hove
- Division of Hepato‐Pancreato‐Biliary Surgery and Liver TransplantationUniversity of Groningen and University Medical Centre GroningenGroningenThe Netherlands
| | - V. E. de Meijer
- Division of Hepato‐Pancreato‐Biliary Surgery and Liver TransplantationUniversity of Groningen and University Medical Centre GroningenGroningenThe Netherlands
| | - J. B. F. Hulscher
- Division of Paediatric Surgery, Department of SurgeryUniversity of Groningen and University Medical Centre GroningenGroningenThe Netherlands
| | - R. H. J. de Kleine
- Division of Hepato‐Pancreato‐Biliary Surgery and Liver TransplantationUniversity of Groningen and University Medical Centre GroningenGroningenThe Netherlands
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Fan F, Xu DP, Xiong ZX, Li HJ, Xin HB, Zhao H, Zhang JW. Clinical significance of intrapancreatic choledochal cyst excision in surgical management of type I choledochal cyst. J Int Med Res 2018; 46:1221-1229. [PMID: 29322850 PMCID: PMC5972235 DOI: 10.1177/0300060517728598] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/07/2017] [Indexed: 01/29/2023] Open
Abstract
Objective To investigate the effectiveness of intrapancreatic choledochal cyst excision in treating type I choledochal cyst, and increase understanding of the need for thorough surgical management of the disease. Methods Primary and secondary (including multiple) surgical cases, treated between 2005 and 2015, were retrospectively analysed, and follow-up data of post-treatment effectiveness to date were reviewed. Differences in curative effects were compared between whole and partial excision of the choledochal cyst. Results Out of 350 cases, patients with whole excision of the choledochal cyst ( n = 272) experienced no associated symptoms in the long-term (3/272 [1.1%] experienced stomach ache or fever). Patients with partial resection of the choledochal cyst ( n = 78) developed associated symptoms, including new cyst, calculus of the bile duct (51/78 [65.4%]), and carcinogenesis (11/78 [14.1%]) in the residual intrapancreatic biliary duct. Post-treatment clinical manifestations were significantly different between patients with partial resection versus whole excision of the choledochal cyst ( P<0.05). Conclusion Surgical re-excision should be considered in patients with a residual intrapancreatic portion of the choledochal cyst due to prior incomplete surgery, regardless of clinical symptoms.
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Affiliation(s)
- Fei Fan
- Department of Special Treatment II, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Da-Peng Xu
- Department of General Surgery, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Zheng-Xiang Xiong
- Department of Special Treatment II, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Hai-Jia Li
- Department of General Surgery, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Hai-Bei Xin
- Department of General Surgery, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Huan Zhao
- Department of General Surgery, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Jin-Wei Zhang
- Department of General Surgery, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China
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Kim YN, Song JS. Cystic metastasis from a mucinous adenocarcinoma of duodenum mimicking type II choledochal cyst: A case report. World J Gastrointest Oncol 2017; 9:492-496. [PMID: 29290919 PMCID: PMC5740089 DOI: 10.4251/wjgo.v9.i12.492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 08/31/2017] [Accepted: 09/14/2017] [Indexed: 02/05/2023] Open
Abstract
A 51-year-old male patient was referred to our hospital because of an incidentally detected cystic mass near the common bile duct (CBD). Imaging studies demonstrated a cystic mass that was suspected to communicate with the CBD. Gastroscopy showed irregular mucosal thickening with hyperemic change in the second portion of the duodenum. A type II choledochal cyst combined with duodenal malignancy was suspected. The patient underwent surgical resection and the histological diagnosis was mucinous adenocarcinoma of the duodenum with cystic metastasis. Although its incidence is extremely rare, care should be taken to check for other sites of malignancy when a pericholedochal cystic mass is detected.
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Affiliation(s)
- Yo Na Kim
- Department of Pathology, Chonbuk National University Medical School, Research Institute for Endocrine Sciences, Jeonju 54907, South Korea
| | - Ji Soo Song
- Department of Radiology, Chonbuk National University Medical School and Hospital, Jeonju 54907, South Korea
- Research Institute of Clinical Medicine of Chonbuk National University, Jeonju 54907, South Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju 54907, South Korea
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18
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Ransom-Rodríguez A, Blachman-Braun R, Sánchez-García Ramos E, Varela-Prieto J, Rosas-Lezama E, Mercado MÁ. A rare case of choledochal cyst with pancreas divisum: case presentation and literature review. Ann Hepatobiliary Pancreat Surg 2017; 21:52-56. [PMID: 28317046 PMCID: PMC5353911 DOI: 10.14701/ahbps.2017.21.1.52] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/13/2016] [Accepted: 11/17/2016] [Indexed: 01/12/2023] Open
Abstract
Choledochal cysts are rare congenital malformations of the bile duct characterized by dilatations of the intrahepatic and/or extrahepatic portion of the biliary tree, they are associated to an anomalous arrangement of the pancreaticobiliary duct. Pancreas divisum results from a fusion failure of the pancreatic buds. The coexistence of pancreas divisum and choledochal cyst in adults has been reported in less than 10 well documented cases. This article presents a case of a 42-year-old Peruvian man with intermittent episodes of abdominal pain, initially diagnosed with choledocholithiasis, who underwent open cholecystectomy. During surgery, a diagnosis of choledochal cyst and pancreas divisum was made, and therefore a hepaticoduodenostomy was performed. The patient was referred to our hospital due to persistence of abdominal pain. After admission, a papillectomy was achieved without further complications. A cyst resection and dismantling of hepaticoduodenostomy with Roux-en-Y was performed 8 years later. During the subsequent 18-month follow-up, the patient remains asymptomatic.
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Affiliation(s)
- Adrián Ransom-Rodríguez
- Department of Hepatopancreatobiliary Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.; Facultad Mexicana de Medicina de la Universidad La Salle, Mexico City, Mexico
| | - Ruben Blachman-Braun
- Facultad de Ciencias de la Salud, Universidad Anáhuac México Norte, Edo. de Mexico, Mexico
| | - Emilio Sánchez-García Ramos
- Department of Hepatopancreatobiliary Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.; Facultad Mexicana de Medicina de la Universidad La Salle, Mexico City, Mexico
| | - Jesús Varela-Prieto
- Department of Hepatopancreatobiliary Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Erick Rosas-Lezama
- Department of Hepatopancreatobiliary Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Miguel Ángel Mercado
- Department of Hepatopancreatobiliary Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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19
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Robert O’Neill J, Parks RW. Surgical Resection of a Type IVa Choledochal Cyst. CASE-BASED LESSONS IN THE MANAGEMENT OF COMPLEX HEPATO-PANCREATO-BILIARY SURGERY 2017:215-225. [DOI: 10.1007/978-3-319-50868-9_16] [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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Ahmed B, Sharma P, Leaphart CL. Laparoscopic resection of choledochal cyst with Roux-en-Y hepaticojejunostomy: a case report and review of the literature. Surg Endosc 2016; 31:3370-3375. [PMID: 27873011 DOI: 10.1007/s00464-016-5346-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/09/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Choledochal cysts are associated with ductal strictures, stone formation, cholangitis, rupture, secondary biliary cirrhosis and increased incidence of cholangiocarcinoma. The surgical approach to choledochal cysts has evolved from the cyst-enterostomy to a complete excision with more recent use of minimally invasive approaches. We report a complete minimally invasive approach to a Type 1 choledochal cyst and summarize the literature containing large case series of similar approaches. METHODS AND OPERATIVE TECHNIQUE A 38-year-old female with a history of vague epigastric pain for multiple years was diagnosed with a Type 1 choledochal cyst on MRCP. The operative approach was an elective laparoscopic resection of choledochal cyst and Roux-en-Y hepaticojejunostomy. There were no intraoperative complications and discharge occurred on postoperative day three. Approximately 1 month after resection, she was diagnosed with a small retrohepatic fluid collection which was treated percutaneously and was diagnosed as a hematoma. A PubMed literature review focusing on surgical approaches to Type 1 choledochal cysts methods of repair and postoperative complications was performed and summarized. RESULTS AND DISCUSSION The literature search performed on the subject of choledochal cyst management in adults and laparoscopic approaches resulted in a review of twenty-one articles. Ten of the articles were review articles regarding surgical approach and management of the disease. An additional two were case reviews, and eight reported on laparoscopic approaches to management of choledochal cysts. In this paper, we summarize the eight articles that provide information on the laparoscopic management and outcomes for choledochal cysts. While operative times were longer on the laparoscopic procedures, hospital stay was shorter and there was no increase in complication rates. The most common complications reported were postoperative bile leak followed by anastomotic stricture. CONCLUSION This case highlights the management of laparoscopic resection of choledochal cyst as a viable, safe and feasible approach based on this case and a literature review.
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Affiliation(s)
- Bestoun Ahmed
- Department of Surgery, UPMC-University of Pittsburgh School of Medicine, 3380 Blvd of the Allies, Suite 305, Pittsburgh, PA, 15213, USA.
| | - Priya Sharma
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Cynthia L Leaphart
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
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21
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Hwang S, Choi JW, Ha TY, Song GW, Jung DH. Cosmetic selection of skin incision for resection of choledochal cyst in young female patients. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:127-32. [PMID: 27621750 PMCID: PMC5018951 DOI: 10.14701/kjhbps.2016.20.3.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 05/30/2016] [Accepted: 06/05/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUNDS/AIMS Open surgery for choledochal cyst has a disadvantage of skin incision scar from operative wound, which can be a definite disadvantage especially in young female patients. This study focused on the cosmetic aspect of skin incision for resection of choledochal cyst in young female patients. METHODS During a 2-year study period, 11 adult female patients aged less than 40 years underwent primary resection of choledochal cyst by a single surgeon. The cosmetic effect of two types of skin incision was evaluated. RESULTS The patients underwent mini-laparotomy through either a right subcostal incision (n=8) or an upper midline incision (n=3). The mean length of skin incision was 10 cm for right subcostal incisions and 9 cm for upper midline incisions. It took approximately 1 hour to repair the operative wound meticulously in both groups. At the 6 month to 1 year follow-up, a slight bulge on the skin scar was observed in 3 (37.5%) patients of the right subcostal incision group and 1 (33.3%) patient of the upper midline incision group. CONCLUSIONS The results of this preliminary study support the claim that cosmetic effect of the upper midline incision for CCD surgery appears to be non-inferior to that of the right subcostal incision if the incision is placed accurately and repaired very meticulously.
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Affiliation(s)
- Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong-Woo Choi
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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22
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Moslim MA, Takahashi H, Seifarth FG, Walsh RM, Morris-Stiff G. Choledochal Cyst Disease in a Western Center: A 30-Year Experience. J Gastrointest Surg 2016; 20:1453-63. [PMID: 27260526 DOI: 10.1007/s11605-016-3181-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 05/27/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to report a Western experience in the diagnosis and management of choledochal cyst disease. RESULTS Sixty-seven patients were identified including 15 children and 52 adults; 76.1 % were females. The median age at diagnosis was 3 [inter-quartile range (IQR) = 6.0-0.7] years for children, and 46 [IQR = 55.6-34.3] years for adults. Forty-eight patients (72 %) were symptomatic. Types of choledochal cyst included: I (n = 49, 73.1 %), II (n = 1, 1.5 %), IV (n = 9, 13.4 %), and V (n = 8, 12 %). The median diameter of the type I choledochal cyst was 35 [IQR = 47-25] mm. All 48 patients underwent excision of cyst with Roux-en-Y hepaticojejunostomy, and eight underwent resection with hepaticoduodenostomy. Six patients underwent liver resection, and five patients underwent orthotopic liver transplantation. Malignancy was concomitant in five adult patients, being identified on preoperative imaging in three cases; and atypia was seen in three additional patients. Early morbidity included Clavien-Dindo classification grades III (n = 7) and II (n = 5), while long-term complications consisted of Clavien-Dindo grades V (n = 5), IV (n = 2), III (n = 18), and II (n = 1). CONCLUSIONS Presentation and management of choledochal cyst is varied. Malignant transformation is often detected incidentally, and so should be the driving source for resection when a choledochal cyst is diagnosed.
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Affiliation(s)
- Maitham A Moslim
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Hideo Takahashi
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Federico G Seifarth
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - R Matthew Walsh
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Gareth Morris-Stiff
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Laparoscopic Management of Choledochal Cyst-Technical Modifications and Outcome Analysis. World J Surg 2016; 39:2550-6. [PMID: 26067634 DOI: 10.1007/s00268-015-3111-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Choledochal cyst (CDC) is a well described albeit rare clinical entity. Complete cyst excision with biliary-enteric reconstruction is the recommended treatment for Todani type I, II, and IVA cysts to prevent complications. The aim of this study is to evaluate outcomes of laparoscopic CDC excision from a tertiary care center. METHODS This is a retrospective analysis of prospectively collected data of 110 patients who underwent laparoscopic cyst excision and biliary-enteric reconstruction for CDC type I and IVA from 1998 to 2013. RESULTS Out of 110 patients, 55 were children (<16 years) and 55 were adults (>16 years) with mean age 21.19 ± 17.75 years and male:female ratio of 1:2.14. Abdominal pain was the most common presenting symptom (59.09 %). Surprisingly, 32.73 % of adults presented with incidentally detected cyst. Type I cyst was the most common (71.82 %) with mean size of 4.67 ± 1.59 cm. Blood loss (56.0 ± 16.62 vs. 76.55 ± 26.61 ml) and operative time (199.8 ± 44.66 vs. 251.6 ± 54.25 min) were significantly low in pediatric group. Three adults required conversion. Overall complication rate was 10 %. Re-exploration rate was 1.81 % with one patient died post-operatively. Mean hospital stay was significantly low in children (5.9 ± 1.39 vs. 7.0 ± 2.66 days). Median follow-up was 60 months (8-110). Cholangitis developed in six patients with three having anastomotic stricture requiring intervention. CONCLUSION Laparoscopic excision of CDC is safe and feasible. Surgery should be performed early as outcomes are better in pediatric age as compared to adults.
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Sastry AV, Abbadessa B, Wayne MG, Steele JG, Cooperman AM. What is the incidence of biliary carcinoma in choledochal cysts, when do they develop, and how should it affect management? World J Surg 2015; 39:487-92. [PMID: 25322698 DOI: 10.1007/s00268-014-2831-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of cancer in choledochal cysts (CCs) in adults was calculated to determine the timing and need for surgery. In 78 publications (1996-2010), 434 of 5780 reported CCs patients had cancer. Cholangiocarcinoma (70.4 %) and gallbladder cancer (23.5 %) were the most common malignancies. Only nine malignancies were reported before age 18 (0.42 %). In contrast, the incidence of malignancy in adults was 11.4 %. The median age for diagnosis of cancer was 42 years, and the incidence increased with each decade.
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Affiliation(s)
- Amit V Sastry
- Department of Surgery, Beth Israel Medical Center, New York, NY, USA,
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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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Surgical treatment of type IV-A choledochal cyst in a single institution: children vs. adults. J Pediatr Surg 2013; 48:2061-6. [PMID: 24094958 DOI: 10.1016/j.jpedsurg.2013.05.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 04/23/2013] [Accepted: 05/25/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND The treatment of type IV-A choledochal cyst is particularly difficult and remains a challenge because of the rareness and the various presentations of the disease involving not only the extrahepatic but also the intrahepatic biliary tract. The purpose of this study is to analyze our clinical experience for surgical treatment of type IV-A choledochal cyst, and compare between children and adults. METHODS During a 10-year period of time (2000-2010), clinical data of 81 consecutive patients with type IV-A choledochal cyst were retrospectively analyzed. We divided these patients into two groups, the child group (age ≤ 18 years) and the adult group (age >18 years). According to whether the patient received additional liver resection, patients were divided into a extrahepatic cystectomy (EHC) group and an additional liver resection (LR) group. The long-term outcomes after surgery were evaluated in two groups. RESULTS Of all 81 patients, there were 17 children and 64 adults; 16 children and 35 adults belonged to EHC group, one child and 29 adults belonged to LR group. The morbidity of biliary stricture and/or lithiasis in the adults was significantly higher than that in the children (p = 0.041 < 0.05). In the EHC group, the reoperation rate of adults was significantly higher than that of children (p = 0.019 < 0.05). For adult patients, the morbidity of biliary stricture and/or lithiasis and the reoperation rate in EHC group was significantly higher than that in LR group (p = 0.037 < 0.05 and p = 0.026 < 0.05 respectively). Five adults were found to have cholangiocarcinoma within a follow-up period, while no child was found to. However, for adult patients, no significant discrepancy was observed between EHC group and LR group (p = 0.366 > 0.05). CONCLUSIONS The present study suggests that the children have better outcomes than adults for patients with type IV-A choledochal cyst after EHC, while LR brings better outcomes than EHC for adult patients.
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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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Hung MH, Lin LH, Chen DF, Huang CS. Choledochal cysts in infants and children: experiences over a 20-year period at a single institution. Eur J Pediatr 2011; 170:1179-85. [PMID: 21350805 DOI: 10.1007/s00431-011-1429-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 02/10/2011] [Indexed: 02/07/2023]
Abstract
This analysis was undertaken to compare the clinicopathological features of infants with choledochal cysts to those of older children with these entities and to evaluate the surgical outcomes for both subject groups. The medical records of all children admitted to the Cathay General Hospital with choledochal cysts over a 20-year period were retrospectively reviewed. Twenty-five subjects were included and divided into the infant (<1 year at presentation; 8 subjects) and classical pediatric (1-18 years at presentation; 17 subjects) groups. Anatomical subtypes were: IA (16), IC (6), and IVA (3). The median biliary amylase value was markedly elevated for the pediatric group but not for the infant group. Most (82.4%) patients in the pediatric group, but none in the infant group, presented with abdominal pain. Jaundice and clay-colored stool were present in all patients in the infant group but only 35% of those in the pediatric group. All patients underwent choledochocystectomy and Roux-en-Y hepaticojejunostomy with good outcomes. Neonates/infants with choledochal cysts present differently from older children with these entities. Amylase measurements may serve to distinguish biliary atresia with cystic dilatation from choledochal cyst in neonates/infants. Prognosis following radical cyst excision and reconstruction with Roux-en-Y hepaticojejunostomy is excellent.
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Affiliation(s)
- Min-Hsuan Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
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Cho MJ, Hwang S, Lee YJ, Kim KH, Ahn CS, Moon DB, Lee SK, Kim MH, Lee SS, Park DH, Lee SG. Surgical experience of 204 cases of adult choledochal cyst disease over 14 years. World J Surg 2011; 35:1094-102. [PMID: 21360306 DOI: 10.1007/s00268-011-1009-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study presents our 14-year surgical experience with adult choledochal cyst disease (CCD), focusing on the clinical outcomes after surgical treatment. METHODS Medical records of 204 adult patients who had undergone surgery for CCD were reviewed retrospectively. RESULTS Median patient age was 40.2 years, and 157 (77%) of the patients were female. Todani classification was type I in 116 patients (56.9%), type II in 1 patient (0.5%), type IVa in 86 patients (42.2%), and type V in 1 patient (0.5%). Extrahepatic cyst excision and hepaticojejunostomy were performed in 185 patients (90.7%). Major perioperative complications occurred in 5 patients (2.5%), resulting in no mortality. Late complications occurred in 48 patients (23.6%). Concurrent cancer was diagnosed in 20 patients (9.8%). Mean age of patients with or without biliary cancer was 48.1±13.2 years and 39.1±11.8 years, respectively (P=0.001). Anomalous union of the pancreaticobiliary duct was more frequently associated with gallbladder cancer than with bile duct cancer. De novo malignancy at the cyst remnant occurred in 2 patients (1%). The survival outcomes in CCD patients with concurrent biliary cancer were comparable to those in cancer patients without CCD. CONCLUSIONS As a result of diverse features of adult CCD, various clinical problems occurred after surgical excision. Surgical treatment for adult patients with CCDs having complex features should be individualized to maintain a balance between risk of surgery and potential risk of late complications.
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Affiliation(s)
- Min-Jeong Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 138-736, Korea
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Part 2: CT characterisation of pancreatic neoplasm: tumour mimics. Insights Imaging 2011; 2:389-397. [PMID: 22347960 PMCID: PMC3259386 DOI: 10.1007/s13244-011-0103-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 02/28/2011] [Accepted: 05/04/2011] [Indexed: 12/18/2022] Open
Abstract
There are numerous pancreatic and peripancreatic conditions that can mimic pancreatic neoplasms. Many of these can be confidently diagnosed on computed tomography (CT), while others will require further imaging. Knowledge of these tumour mimics is important to avoid misclassification of benign conditions as malignant and to avoid unnecessary surgery. Mimics can be grouped as parenchymal, vascular, biliary and peripancreatic. These are discussed and illustrated in this review.
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Periampullary choledochal diverticula are not choledochal cysts. Gastrointest Endosc 2011; 73:994-1001. [PMID: 21439566 DOI: 10.1016/j.gie.2011.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 01/04/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Choledochal cysts (CC) are rare, congenital anomalies of the biliary tree, associated with the development of biliary malignancies. Small periampullary choledochal diverticula (PCD) are a previously unreported type of biliary anomaly found primarily at ERCP. OBJECTIVE The aim of this study was to assess whether PCD are congenital or acquired lesions by comparing the clinical presentation, management, and risk of malignancy between patients with PCD and CC. DESIGN Retrospective analysis of a medical center database. SETTING Academic tertiary referral center. PATIENTS Over the study period, data regarding 16 patients with PCD were identified and compared with that of 118 patients with CC. INTERVENTION Retrospective review of ERCP, surgical pathology, billings, and a diagnostic imaging database from our institution from 1985 to 2009 was done. MAIN OUTCOME MEASUREMENTS Clinical presentation, investigations, management strategies, complication rates, and long-term outcomes were compared in patients with classic CC and PCD over the same time period. RESULTS Patients with PCD were less likely to be female (50% vs 81%), older aged (mean 68 vs 28 years), to complain of abdominal pain (88% vs 68%), and were less likely to present with jaundice (0% vs 32%) (P<.05 for all pairs). Patients with PCD also were noted to have lower frequency of anomalous pancreatobiliary junction (0% vs 83%) and biliary neoplasia (0% vs 5%) and more likely to have sphincter of Oddi dysfunction (63% vs 1%). Management of PCD was done with ERCP in 87% of cases and with surgery in 0% of cases, whereas management of CC was done with ERCP in 20% of cases and surgery in 80% of cases (P<.001). Long-term complications at a mean follow-up of 3.7 years after therapy were more common in CC (40% vs 6%, P=.02). LIMITATIONS Retrospective study. Lack of structured follow up. CONCLUSION Small, periampullary, choledochal diverticula are a newly reported, likely acquired anomaly of the biliary tract that are frequently associated with sphincter of Oddi dysfunction and may be secondary to biliary hypertension. These acquired lesions should not be classified as CC.
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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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