Surgical Treatment of Coledochal Cyst Associated with an Aberrant Posterior Hepatic Duct: Report of a Case and Brief Literature Review

Abstract

Choledochal cysts (CCs) are rare congenital cystic or fusiform dilatations of the biliary tree that can involve the extrahepatic and/or intrahepatic biliary tree. We report a case of huge type I CC associated with an aberrant posterior hepatic duct. A 52-year-old man presented with a 3-week history of upper right abdominal pain and jaundice and serologic sign of obstructive jaundice. Ultrasonography (US), magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography were performed with the diagnosis of CC type I according to the classification of Alonso-Lej and Todani-Watanabe. The indication for surgical resection was posed. The cyst was completely resected and the biliary tract was reconstructed with a double hepatico-jejunostomy using the same Roux limb, since during the surgical dissection a before unrecognized anatomical variation of the right biliary tree (aberrant posterior hepatic duct at VI–VII segment) was identified. The diagnosis of CC is often difficult and US and magnetic resonance cholangiopancreatography are necessary to definite biliary dilatation. Endoscopic retrograde cholangiopancreatography should be the most definitive and reliable procedure for the diagnosis and treatment of bilio-pancreatic disorders. Gold standard treatment is surgery (bilio-jejunostomy) and frozen-section histology should be performed to rule out the presence of cancer. In conclusion, surgery is the gold standard for the treatment of CC type I and does not depend on the age of patients, based on a substantial lifetime risk of developing cholangiocarcinoma. Preoperative study is mandatory to assess the biliary tree morphology and to research any anatomical variation.

Cystic duct cyst: Report of one case

“…Clinical symptoms are nonspecific. Asymptomatic or right upper quadrant pain may be observed in adults (6,9). Surgery is performed in approximately 50% of the patients before diagnosis.…”

“…While icterus is rarely seen in adults, cholecystitis, cholangitis and pancreatitis are observed more frequently. A palpable abdominal mass is seen rarely (6,10). Diagnosis of bile duct anomalies is difficult and radiological examination is required.…”

“…Diagnosis of bile duct anomalies is difficult and radiological examination is required. USG, MRCP, and endoscopic retrograde cholangiopancreatography (ERCP) are the frequently used examinations for this purpose (3,6). ERCP is one of the methods that may be chosen for both diagnosis and treatment (11).…”

Choledochal Cyst with Aberrant Right Posterior Sectoral Duct

“…On literature review, only nine cases of the right posterior sectoral duct opening into the choledochal cyst are reported [1][2][3][4][5][6][7][8]. AHD is not easily detected on cholangiography as it may be displaced by the choledochal cyst or may be overshadowed by the denser image of the choledochal cyst …”

“…AHD is not easily detected on cholangiography as it may be displaced by the choledochal cyst or may be overshadowed by the denser image of the choledochal cyst [2,6]. In earlier case reports, AHD was diagnosed during or after cyst excision, on repeated ERCP, intra-operative cholangiography, intra-operative endoscopy or on 3D MRCP [2,[6][7][8]. Ligation or missed AHD during surgery may lead to complications like cholangitis, liver abscess, liver atrophy, cirrhosis, biliary fistula or biliary peritonitis.…”