Our Experience with Cyst Excision and Hepaticoenterostomy for Choledocal Cyst: A Single Center Case Review of 16 Patients

Abstract

Background and Objectives: Choledocal cyst is a rare congenital disease of the biliary tree defined by dilatation of the extrahepatic and/or intrahepatic biliary ducts. Untreated, it leads to complications such as cholangitis, stone formation and malignant degeneration. The standard treatment for choledocal cyst is complete excision and subsequent biliary reconstruction via hepaticojejunostomy or hepatiocoduodenostomy. Materials and Methods: We report our experience with 16 pediatric cases of choledocal cyst over a 10-year period. Results: The predominant symptoms were nausea and jaundice, both at 62.5% (n = 10), followed by abdominal pain at 56.3% (n = 9). Ultrasonography was the diagnostic method used in all patients. Computed tomography was used in 75% (n = 12) and magnetic resonance imaging in 25% (n = 4) of cases. Age at the time of intervention ranged from 2 months to 17 years with a mean of 4 years and 5 months. The open approach was used in nine patients and the laparoscopic approach was used in seven patients, with one conversion to open surgery. Complete excision of the choledocal cyst was performed in 15 cases (93.7%), and partial excision with mucosectomy was performed in one case (6.2%). Eight patients (50%) underwent hepaticoduodenostomy and eight (50%) underwent hepaticojejunostomy, out of which one was attempted laparoscopically but was converted. We had a postoperative complication rate of 12.5% (n = 2) represented by anastomotic leak and pancreatitis. Conclusions: From our experience with these cases, we concluded that a wide hepaticoduodenostomy constitutes a favorable choice over the traditional hepaticojejunostomy, being more physiological and less time consuming.

Preliminary Experience with Continuous Submucosal Anastomosis in Small-Diameter Hepaticojejunostomy during Single-Port Laparoscopic Choledochal Cyst Surgery in Children

“…Choledochal cysts are congenital biliary diseases characterized by the dilation of both intrahepatic and extrahepatic bile ducts..The most common type is type I, which involves the dilatation of the extrahepatic bile duct [7] , and the incidence of choledochal cysts is lower in Europe and North America [8] .They are more common in Asia, with a hospitalization rate of up to 1:1000. According to international literature, the male-to-female ratio of choledochal cysts is approximately 3-4:1, although this ratio varies in different regions [9] .Approximately 60% of choledochal cysts are diagnosed within the first year after birth, The main clinical manifestations include the triad of abdominal pain, abdominal mass, and jaundice.…”

“…The most common type is type I, which involves the dilatation of the extrahepatic bile duct, 7 and the incidence of CDCs is lower in Europe and North America. 8 They are more common in Asia, with a hospitalization rate of up to 1:1000. According to international literature, the male-to-female ratio of CDCs is approximately 3 to 4:1, although this ratio varies in different regions.…”

Contemporary trends in choledochal cyst excision: An analysis of the pediatric national surgical quality improvement program

“…[4][5][6][7][8][9][10][11][12][13] RNYHJ reconstruction has been associated with malabsorption; therefore, some surgeons prefer HD for a more physiologic reconstruction. 8,12,14 Yet, HD has been associated with increased rates of postoperative reflux, gastritis, and pancreatitis. 13,[15][16][17][18] Although controversy remains regarding the difference in long-term complications between these reconstructions, studies have shown HD and RNYHJ to have similar short-term outcomes.…”

“…The most common management approach historically has been resection with Roux‐en‐Y hepaticojejunostomy (RNYHJ); however, this practice has been challenged recently, with increasing use of hepaticoduodenostomy (HD) 4–13 . RNYHJ reconstruction has been associated with malabsorption; therefore, some surgeons prefer HD for a more physiologic reconstruction 8,12,14 . Yet, HD has been associated with increased rates of postoperative reflux, gastritis, and pancreatitis 13,15–18 .…”

“…Prior studies have examined outcomes of HD versus RNYHJ reconstruction, although many have been limited to meta‐analyses, small institutional studies, or international cohorts 4–12,14,15,20,21,24,33,38 . Very few utilize large national databases 13 .…”