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Koo DC, Scalise PN, Ostertag-Hill CA, Naus AE, Durgin JM, Chiu MZ, Mejia Bautista M, Moskowitzova K, Staffa SJ, Gonzalez GR, Al-Ibraheemi A, Lee EJ, Demehri FR, Kim HB. Polyvinyl Alcohol Sponges Reduce Intraperitoneal Adhesions After Abdominal Surgery. J Surg Res 2025; 308:183-192. [PMID: 40090054 DOI: 10.1016/j.jss.2025.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 12/31/2024] [Accepted: 02/09/2025] [Indexed: 03/18/2025]
Abstract
INTRODUCTION The use of cotton sponges in the operating room has been linked to intraperitoneal adhesion formation. Inert, nonlinting polyvinyl alcohol (PVA) sponges have been used as an alternative to reduce intraoperative tissue trauma and particle remnants in other surgical fields. We investigate the effect of PVA sponges on reducing postoperative intraperitoneal adhesions in a murine model. METHODS AND METHODS In total, 189 C57BL/6 mice were randomly divided into three groups by abdominal packing intervention. Following laparotomy on day 0, the abdominal cavity was packed with cotton gauze (n = 53), PVA wipe (n = 54), or no packing (sham; n = 58) for three rounds of 10 min each before packing was removed. Mice were euthanized, and necropsies were performed between postoperative days 13-15. Adhesions were graded by two blinded observers using a validated system composed of adhesion extent, tenacity, and density. Adhesion scores were compared between the three groups. RESULTS Compared to adhesions in gauze-packed mice, adhesions in PVA-packed mice were significantly less extensive, less tenacious, and less dense (P < 0.001 for all), which equated to lower total adhesion scores in PVA-packed mice (0 [0, 3] versus 5 [2, 7], P < 0.001). The adhesion scores for sham group mice were significantly lower than PVA and gauze mice in all categories. CONCLUSIONS This is the first study to directly compare postoperative intra-abdominal adhesion formation following the use of gauze and PVA sponges in an animal model. PVA sponges significantly reduce postoperative adhesions when compared to standard cotton gauze sponges. PVA should be further explored as a useful alternative to reduce postoperative adhesion-related morbidity.
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Affiliation(s)
- Donna C Koo
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts.
| | - P Nina Scalise
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | | | - Abbie E Naus
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan M Durgin
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Megan Z Chiu
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Steven J Staffa
- Division of Anesthesiology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Alyaa Al-Ibraheemi
- Division of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | - Eliza J Lee
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts.
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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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Pakkala AK, Nekarakanti PK, Nagari B, Bansal AK, Thumma V, Gunturi SV. An audit of Complicated Choledochal Cysts- 15-years' experience at a tertiary care center. Langenbecks Arch Surg 2023; 408:212. [PMID: 37247085 DOI: 10.1007/s00423-023-02952-y] [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: 02/21/2022] [Accepted: 05/21/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE Complicated choledochal cysts (CDC) have a variable presentation, and their management differs from an uncomplicated CDC. They are infrequently reported. We present our 15 years of experience in the management of complicated CDC. METHODOLOGY We reviewed the data of patients with CDCs managed at a tertiary level center from 2005 to 2020 from a prospectively maintained database. RESULTS Of 215 patients with CDC, 123 patients presented with complicated CDC. The median age of complicated CDC was 31 years with a female preponderance (62.6%). The most common type of CDC associated with complications was type I (69.1%), followed by type IVA (29.3%). The Complicated CDC was presented as cholangitis with or without cystolithiasis (n = 45), cystolithiasis and hepatolithiasis(n = 44), malignancy(n = 10), complications associated with incomplete cyst excision (n = 10), acute pancreatitis (n = 8), chronic pancreatitis(n = 8), portal hypertension (n = 6), spontaneous rupture (n = 4), gastric outlet obstruction (n = 1). These patients were managed as a one-stage approach (52.03%) and a two-stage approach (47.96%). On univariate and multivariate analysis, increasing age, prolonged duration of symptoms, and presence of abnormal pancreaticobiliary ductal junction (APBDJ) were significantly associated with complicated CDC. CONCLUSION The management of complicated CDC varied depending on the associated pathology, many of them required a staged approach. Increasing age, prolonged duration of symptoms, and presence of APBDJ were significantly associated with complicated CDC.
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Affiliation(s)
- Amith Kumar Pakkala
- Department of Surgical Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Phani Kumar Nekarakanti
- Department of Surgical Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Bheerappa Nagari
- Department of Surgical Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India.
| | - Ashish Kumar Bansal
- Department of Surgical Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - VenuMadhav Thumma
- Department of Surgical Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 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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Koea J, O'Grady M, Agraval J, Srinivasa S. Defining an optimal surveillance strategy for patients following choledochal cyst resection: results of a systematic review. ANZ J Surg 2022; 92:1356-1364. [PMID: 35579057 DOI: 10.1111/ans.17775] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Choledochal cysts should be treated with complete surgical resection, or, rarely liver transplantation. Treated patients can remain at risk of developing metachronous cholangiocarcinomas and lifelong follow up is indicated. However, there is no agreement on what constitutes an acceptable follow up strategy. This review was undertaken to develop an evidenced based surveillance strategy. METHODS A systematic review of MEDLINE, EMBASE, PubMed, Web of Science, and Google Scholar was undertaken for reports (published up to 10 September 2021) describing late biliary complications and development of metachronous cholangiocarcinoma following choledochal cyst resection. RESULTS Twenty-five publications described 74 metachronous cholangiocarcinomas occurring in 3911 patients (overall incidence 2%). Cancers developed commonly at the hepatic hilus and were diagnosed after a median interval of 92 months (range 9-249 months) after the initial resection. While reporting is incomplete, the majority of cholangiocarcinomas developed following resection of type I and type IV cysts with few metachronous cancers recorded after treatment of type II or III cysts. Peak age range for presentation with metachronous cholangiocarcinoma is in the twenties following cyst resection in childhood suggesting that patients are at greatest risk for metachronous tumour development for up to 20 years (240 months). CONCLUSION A surveillance strategy is proposed for patients treated primarily for cyst types I and IV and unresected type V using annual liver function tests, Ca 19-9 measurement and biannual ultrasound assessment for 20 years post cyst resection, with biannual liver function testing, Ca 19-9 measurement and three yearly ultrasound assessment thereafter.
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Affiliation(s)
- Jonathan Koea
- Department of Surgery, North Shore Hospital, Auckland, New Zealand
| | - Michael O'Grady
- Department of Surgery, Whanganui Hospital, Whanganui, New Zealand
| | - Jash Agraval
- Department of Radiology, North Shore Hospital, Auckland, New Zealand
| | - Sanket Srinivasa
- Department of Surgery, North Shore Hospital, Auckland, New Zealand
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Meng Y, Guo K, Jiang Y, Wei S. Todani type III: like biliary dilatation with duodenal prolapse-a case report. BMC Gastroenterol 2022; 22:220. [PMID: 35508976 PMCID: PMC9066763 DOI: 10.1186/s12876-022-02278-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/13/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Biliary dilatation is a rare disease involving intrahepatic and extrahepatic biliary tract abnormalities. With the development of imaging technology, an increasing number of special cases have been diagnosed, which poses a challenge to the traditional classification method. CASE PRESENTATION A 50-year-old woman was admitted to the hospital due to right upper quadrant pain for more than 10 days. The patient had previous episodes of similar symptoms, which were relieved after symptomatic treatment at a local community hospital. After the symptoms developed, she underwent a computed tomography scan at the local hospital, which showed biliary dilatation; thus, she was referred to our hospital for further treatment. After admission, her magnetic resonance imaging examination also suggested biliary dilatation, but abnormal signals were found in her duodenum. First, a duodenal diverticulum was considered. Later, endoscopic ultrasonography was conducted, and the results suggested that the dilated biliary tract had herniated into the duodenum. This type of lesion is most closely classified as a Todani type III lesion. The patient finally underwent choledochectomy and Roux‑en‑Y hepaticojejunostomy, and the postoperative pathology was consistent with our preoperative diagnosis. The patient was followed up for approximately 2 years, and no obvious postoperative complications were found. CONCLUSIONS The manifestations of this case are relatively rare and involve one of the undiscussed categories of the Todani classification system; therefore, this case has certain clinical value. Moreover, there is no report similar to this experience in the previous literature.
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Affiliation(s)
- Yunpeng Meng
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Kangli Guo
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yu Jiang
- Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Shaohua Wei
- The Second Affiliated Hospital of Soochow University, Suzhou, China.
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Hakimi T, Esmat HA, Karimi R. Choledochal cyst: A challenging diagnostic and therapeutic entity in low-resource settings. Int J Surg Case Rep 2022; 90:106729. [PMID: 34991049 PMCID: PMC8741487 DOI: 10.1016/j.ijscr.2021.106729] [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: 11/26/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 02/07/2023] Open
Abstract
Background Choledochal cyst is an uncommon congenital biliary tract abnormality of unknown etiology. Its classical symptoms are jaundice, abdominal pain, and right upper quadrant mass. However, the disease may present with a vague and non-specific chronic abdominal discomfort. Delay in diagnosis and management may increase the risk of complications particularly the malignancy, which can directly affect the prognosis and outcome. Complete excision of the extra-hepatic duct, cholecystectomy, and Roux-en-Y hepaticojejeunostomy through the open surgical intervention or laparoscopic procedure is the mainstay of treatment. Case Presentation A 14-year-old male was presented to our hospital complaining of vague abdominal pain for 5 years. The radiologic imaging showed the features of a type IVa choledochal cyst. He underwent complete excision of the extra-hepatic duct, cholecystectomy, and Roux-en-Y hepaticojejeunostomy. Although the bile leakage occurred as a complication of the procedure, our team best managed the patient in the post-operative period until full recovery. Discussion The Choledochal cyst was first described by Vater, which is a congenital anomaly that sometimes may remain asymptomatic till adulthood. Surgical intervention is the mainstay of treatment. However, postoperative complications including bile leakage need a close follow-up of the patient. Conclusion Diagnostic delay (antenatal and postnatal) and non-specific symptoms will mask the real feature of the disease, especially in low-resource settings. Technical facilities and professional care of the patient may preclude complications.
The choledochal cyst is an uncommon congenital biliary tract anomaly. Early diagnosis and management can directly affect the prognosis and outcome. Low-resource settings and less symptomatic cases may lead to diagnostic delay. Open surgery or laparoscopic intervention is the mainstay of treatment.
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Wu H, Tian J, Li H, Liu H, Liu Y, Lu L, Chen X, Zhang X, Xu W. Accuracy of Magnetic Resonance Imaging in Prenatal Diagnosis of Choledochal Cysts: A Single-Center Retrospective Analysis. Int J Clin Pract 2022; 2022:3268797. [PMID: 36238902 PMCID: PMC9529511 DOI: 10.1155/2022/3268797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the accuracy of prenatal MRI in diagnosing choledochal cysts (CDC), evaluate the sensitivity and specificity of MRI signs in the diagnosis of fetal CDC, and first compare the trend of size of CC between prenatal and postpartum. METHODS A total of 18 fetal who were diagnosed with CDCs through prenatal MRI were enrolled in the study. We summarized and analyzed the prenatal clinical data and prognosis information of prenatal and postpartum surgery, then compared the sensitivity, specificity, and diagnostic accuracy of various signs of MRI and postpartum MRCP diagnosis of CC. Finally, we tried to compare the earliest prenatal detection of common bile duct cysts with the size of surgery, and calculated the growth rate of common bile duct cysts for the first time. RESULTS All 18 patients were delivered in our institution. Among these patients, 14 were confirmed with CDCs after postpartum surgery, two patients had CDCs that disappeared, and two patients were confirmed with cystic biliary atresia (CBA) through the Kasai operation. Furthermore, 13 patients with CDCs and two patients with CBA underwent MRCP before the operation, and one patient with CDCs ruptured at birth and underwent ultrasound diagnosis. The sensitivity and diagnostic compliance of prenatal MRI signs for the location were higher when compared to postnatal MRCP (100% vs. 76.9% and 83.3% vs. 66.7%): the cyst was located at the porta hepatis, which was higher than the lowest edge of the liver, and parallel to the hepatoduodenal ligament. CONCLUSION Prenatal MRI is higher than that of US for diagnosing CDCs, specifically in identifying the location of the cyst and confirming the origin of the cyst. The length, width, and size of the CDC become slightly bigger in our study.
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Affiliation(s)
- Huiying Wu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou 510623, China
| | - Jinsheng Tian
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou 510623, China
| | - Hehong Li
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou 510623, China
| | - Hongsheng Liu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou 510623, China
| | - Yutao Liu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou 510623, China
| | - Lianwei Lu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou 510623, China
| | - Xiwen Chen
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou 510623, China
| | - Xiaochun Zhang
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou 510623, China
| | - Wenbiao Xu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou 510623, China
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Uecker M, Lehmann U, Braubach P, Schukfeh N, Madadi-Sanjani O, Ure BM, Petersen C, Kuebler JF. Choledochal Cysts Resected during Childhood Show No Mutations of KRAS and BRAF as Early Markers of Malignancy in Cholangiocytes. Eur J Pediatr Surg 2021; 31:20-24. [PMID: 32820496 DOI: 10.1055/s-0040-1715610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION In patients with choledochal cysts (CDC), a hyperplasia-dysplasia-carcinoma sequence can lead to biliary tract malignancy. The limited data available suggest that the risk decreases considerably after excision in childhood. We analyzed samples of resected CDC from pediatric patients histologically and performed mutational analysis of the proto-oncogenes KRAS and BRAF as early markers of malignant alteration in cholangiocytes. MATERIALS AND METHODS After institutional review board approval, patients undergoing resection for CDC in our center from 2011 to 2019 were retrospectively identified. Histopathological reports were searched for inflammation and endothelial alteration. Cases with sufficient tissue specimen were tested for KRAS codon 12/13 and BRAF codon 600 mutations by pyrosequencing. RESULTS In total, 42 patients underwent resection for choledochal cyst in the study period. Median age at surgery was 2.4 years (range = 18 days-18 years). Histopathological analysis showed no malignancy, but various degrees of inflammation or fibrosis in approximately 50% of the patients and in all age groups. Sufficient tissue for mutation analysis was available for 22 cases, all of which tested negative for KRAS or BRAF mutation. CONCLUSION In our series, chronic inflammatory changes were frequently present in CDC of infants and children. However, the lack of KRAS and BRAF mutations suggests that no malignant changes have been initiated in this group of European patients undergoing early resection.
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Affiliation(s)
- Marie Uecker
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Ulrich Lehmann
- Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Peter Braubach
- Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | | | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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An Unusual Type of Choledochal Cyst with Huge Dilation of Extrahepatic Bile Duct from Hilum to Ampulla of Vater; a Case Report and Literature Review. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2019. [DOI: 10.5812/ijcm.92136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Baison GN, Bonds MM, Helton WS, Kozarek RA. Choledochal cysts: Similarities and differences between Asian and Western countries. World J Gastroenterol 2019; 25:3334-3343. [PMID: 31341359 PMCID: PMC6639560 DOI: 10.3748/wjg.v25.i26.3334] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/05/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
Choledochal cysts (CCs) are rare bile duct dilatations, intra-and/or extrahepatic, and have higher prevalence in the Asian population compared to Western populations. Most of the current literature on CC disease originates from Asia where these entities are most prevalent. They are thought to arise from an anomalous pancreaticobiliary junction, which are congenital anomalies between pancreatic and bile ducts. Some similarities in presentation between Eastern and Western patients exist such as female predominance, however, contemporary studies suggest that Asian patients may be more symptomatic on presentation. Even though CC disease presents with an increased malignant risk reported to be more than 10% after the second decade of life in Asian patients, this risk may be overstated in Western populations. Despite this difference in cancer risk, management guidelines for all patients with CC are based predominantly on observations reported from Asia where it is recommended that all CCs should be excised out of concern for the presence or development of biliary tract cancer.
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Affiliation(s)
- George N Baison
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Morgan M Bonds
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - William S Helton
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
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Chang X, Zhang X, Xiong M, Yang L, Li S, Cao G, Zhou Y, Yang D, Tang ST. Laparoscopic-assisted cyst excision and ductoplasty plus widened portoenterostomy for choledochal cysts with a narrow portal bile duct. Surg Endosc 2019; 33:1998-2007. [PMID: 30604269 PMCID: PMC6505504 DOI: 10.1007/s00464-018-06635-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/19/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Complete cyst excision with Roux-en-Y hepaticojejunostomy is the standard procedure for choledochal cysts (CCs). In recent years, neonates have been increasingly diagnosed with CCs prenatally. Earlier treatment has been recommended to avoid complications. For type IVa malformation without extensive intrahepatic bile duct dilatation, laparoscopic hepaticojejunostomy is technically challenging, and anastomotic stricture is a concern. Therefore, we propose laparoscopic synthetical techniques-laparoscopic excision of cyst and ductoplasty plus widened portoenterostomy to avoid stricture in CCs with a narrow hilar duct. METHODS An anastomosis was created around the transected end of the common bile duct in 12 minipigs (Group A), and another 12 minipigs (Group B) received conventional cholangiojejunostomy. Anastomotic diameter measurements and cholangiography were conducted at different times. Histological findings of inflammation and scarring were compared. The expression levels of TGF-β1 and type I collagen were detected by real-time quantitative PCR. Between January 2012 and January 2016, laparoscopic excision of cyst and ductoplasty plus widened portoenterostomy were performed on 29 children with confirmed CCs with a narrow portal bile duct who were followed up for 12-48 months. RESULTS Group A survived well without obstruction. Slight inflammation and fibrotic tissue were confined to the bile duct periphery. In Group B, five pigs developed stricture. Severe inflammation and diffuse fibrosis affected the whole layer of the anastomosis. Fibrotic biomarkers were significantly higher postoperatively in Group B. Clinically, 29 patients exhibited satisfactory outcomes. No anastomotic stricture has been observed to date. CONCLUSIONS Laparoscopic synthetical techniques may be a superior option to prevent anastomotic stricture in treating CCs with a narrow portal bile duct.
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Affiliation(s)
- Xiaopan Chang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xi Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Meng Xiong
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Li Yang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Guoqing Cao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ying Zhou
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Dehua Yang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shao-Tao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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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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Ma W, Tan Y, Shrestha A, Li F, Zhou R, Wang J, Hu H, Yang Q. Comparative analysis of different hepatico-jejunostomy techniques for treating adult type I choledochal cyst. Gastroenterol Rep (Oxf) 2018; 6:54-60. [PMID: 29479444 PMCID: PMC5806402 DOI: 10.1093/gastro/gox025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/21/2017] [Accepted: 04/27/2017] [Indexed: 02/05/2023] Open
Abstract
Objective To compare Roux-en-Y hepatico-jejunostomy with complete resection of the cyst or incomplete resection with 1-cm remnant proximal cyst wall in treating adult type I choledochal cyst (CC). Methods The medical records of 267 adult patients with type I CC from January 1998 to December 2015 were reviewed retrospectively. Among them, 171 underwent Roux-en-Y hepatico-jejunostomy with complete resection (PBD 0-cm group) and 96 underwent Roux-en-Y hepatico-jejunostomy with 1-cm proximal cyst wall left (PBD 1-cm group). The short- and long-term post-operative complications were compared between the two groups. Results No significant difference was observed in operative time or anastomotic diameter between the two groups. The incidence of perioperative complications was significantly higher in the PBD 1-cm group than that in the PBD 0-cm group (28.1% vs 14.0%, p=0.005), especially post-operative cholangitis (7.3% vs 1.2%, p=0.021). The incidence of long-term post-operative complications was not significantly different, including anastomotic stricture, reflux cholangitis, intra-hepatic bile duct stones and bile leak (all p >0.05). Post-operative intra-pancreatic biliary malignancy occurred in one patient in the PBD 0-cm group at 25 months and one patient in the PBD 1-cm group at 5 month, respectively. Anatomical site malignancy was observed in one patient in the PBD 1-cm group at 10 months. Conclusion Ease of performing anastomosis does not justify retaining a segment of choledochal cyst in type I CC due to its higher risk of post-operative complication and malignancy. A complete excision of the CC with anastomosis to the healthy proximal bile duct is necessary in treatment of type I CC.
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Affiliation(s)
- Wenjie Ma
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Yongqiong Tan
- Operation Room, West China Hospital of Sichuan University, Chengdu, China
| | - Anuj Shrestha
- Department of General Surgery, Andaki Medical College, Pokhara, Nepal
| | - Fuyu Li
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Rongxing Zhou
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Junke Wang
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Haijie Hu
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Qin Yang
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
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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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Totally laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy for choledochal cyst in adults: a single-institute experience of 5 years. Surg Laparosc Endosc Percutan Tech 2016; 25:e65-8. [PMID: 25122485 DOI: 10.1097/sle.0000000000000091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE The present study aimed to describe the authors' experience and the intermediate-term outcome for totally laparoscopic choledochal cyst excision and Roux-en-Y hepatoenterostomy at a single center in a 5-year period. METHODS We retrospectively analyzed the clinical data of totally laparoscopic choledochal cyst excision and Roux-en-Y hepatoenterostomy on 31 adult patients from January 2009 to November 2013. RESULTS Thirty-one cases successfully underwent totally laparoscopic choledochal cyst excision laparoscopy and Roux-en-Y hepatoenterostomy. The operation time varied from 200 to 360 minutes. The intraoperative blood loss was 50 to 210 mL. The patients passed flatus in 3.0 ± 1.3 days. The mean time interval to resume oral intake from the time of surgery was 3.8 ± 1.4 days. The duration of postoperative intravenous fluids was 4 to 11 days. Postoperative ambulation varied from 2 to 4 days. The duration of hospital stay was 4 to 13 days. Follow-up observations lasted 3 to 59 months and complications were noted in 4 patients. Of these patients, 1 patient suffered postoperative respiratory tract infection, 1 patient had an episode of adhesive small bowel obstruction, biliary leakage occurred in 1 patient, and 1 patient developed an anastomotic stoma stricture and cholangitis. There were no perioperative deaths. CONCLUSIONS Totally laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy is a safe, efficacious, and minimally invasive procedure for the most instances of adult choledochal cyst. The key of success is skilled laparoscopic skills, good team cooperation, and stapler anastomosis.
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How to treat a neonate with duodenal atresia and intrapancreatic choledochocele causing persistent hyperbilirubinemia: A case report. Int J Surg Case Rep 2015; 19:11-3. [PMID: 26701845 PMCID: PMC4756091 DOI: 10.1016/j.ijscr.2015.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/01/2015] [Accepted: 12/06/2015] [Indexed: 12/02/2022] Open
Abstract
We report the first case of duodenal atresia and choledochocele requiring surgical treatment in the neonatal period. The patient received a classical duodeno-duodenostomy on day 2 of life. The choledochocele was treated with transduodenal marsupialization at the age of three months. A life-long observation seems mandatory to examine the potential risk of metaplasia in the cystic remnant. Introduction The congenital combination of duodenal atresia and choledochal cyst has only been reported in a few children. None of these patients had an intrapancreatic choledochocele causing persistent hyperbilirubinemia in the newborn period. Presentation of case A female newborn presented with duodenal atresia and received a duodeno–duodenostomy on day two of life. The postoperative course was uneventful except for progressive hyperbilirubinemia and elevation of liver enzymes. No evidence for surgical obstruction, malformations of the hepatobiliary system, or infectious diseases were found. At three months of age and persistent hyperbilirubinemia an intrapancreatic choledochocele type III according to Todani was confirmed by ultrasound and MRI. Upon laparotomy no lesion was visible or palpable within the pancreas. Even after duodenotomy distally of the duodeno–duodenostomy only a normal papilla Vateri could be identified. Transduodenal ultrasound allowed for localization and saline distension to outline the borders of the choledochocele. A transduodenal marsupialization provided immediate biliary drainage and postoperatively bilirubin levels returned to normal limits. Discussion We present a case of duodenal atresia and choledochocele requiring surgical treatment in the neonatal period. Transduodenal marsupialization prompted adequate biliary drainage without inflicting the potential complications of biliary and pancreatic diversion at this early age. A life-long endoscopic observation seems mandatory to examine the potential risk of metaplasia of the cystic remnant. Conclusion Early transduodenal marsupialization of an intrapancreatic choledochocele in a case of duodenal atresia is safe and feasible to prevent secondary liver cirrhosis.
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Weng R, Hu W, Cai S, Guo X, Luo Q. Prenatal diagnosis and prognosis assessment of congenital choledochal cyst in 21 cases. J OBSTET GYNAECOL 2015; 36:324-7. [DOI: 10.3109/01443615.2015.1050648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Xia HT, Dong JH, Yang T, Zeng JP, Liang B. Extrahepatic cyst excision and partial hepatectomy for Todani type IV-A cysts. Dig Liver Dis 2014; 46:1025-30. [PMID: 25190435 DOI: 10.1016/j.dld.2014.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 06/12/2014] [Accepted: 07/04/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extrahepatic cyst excision and Roux-en-Y hepaticojejunostomy is not satisfactory in many patients with complex Todani type IV-A choledochal cysts. AIMS To report the results of combined extrahepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy for type IV-A choledochal cysts. METHODS The records of patients who received extrahepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy for type IV-A choledochal cysts from January 2002 to December 2011 were retrospectively reviewed, and surgical outcomes analysed. RESULTS 59 patients (30.5% males; mean age, 43.2 ± 18.4 years) were included. Radical excision of cystically dilated bile ducts was achieved in 53 patients (89.8%). Bile leakage, delayed wound healing, and abdominal infection occurred in 5 (8.47%), 7 (11.86%), and 3 (5.08%) patients, respectively. Forty-nine patients (83.1%) were followed for an average of 42.6 ± 15.3 months. During the follow-up, 6 patients (12.2%) experienced recurrent cholangitis. Long-term biliary function was excellent in 33 (67.4%), good in 9 (18.4%), fair in 5 (10.2%), and poor in 2 (4.1%) patients. CONCLUSION Combined extra-hepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy is effective for the treatment of complex Todani type IV-A choledochal cysts with substantial intrahepatic bile duct involvement and hilar bile duct stenosis.
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Affiliation(s)
- Hong-Tian Xia
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing 100853, China.
| | - Jia-Hong Dong
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing 100853, China
| | - Tao Yang
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing 100853, China
| | - Jian-Ping Zeng
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing 100853, China
| | - Bin Liang
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing 100853, China
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Katabi N, Pillarisetty VG, DeMatteo R, Klimstra DS. Choledochal cysts: a clinicopathologic study of 36 cases with emphasis on the morphologic and the immunohistochemical features of premalignant and malignant alterations. Hum Pathol 2014; 45:2107-14. [PMID: 25123074 DOI: 10.1016/j.humpath.2014.06.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/10/2014] [Accepted: 06/19/2014] [Indexed: 02/08/2023]
Abstract
Choledochal cysts (CDCs) are believed to represent a risk factor for the development of neoplasia. However, the frequency and morphology of neoplastic changes have not been systematically studied, especially in North America. Our aims were to study the frequency and morphology of preneoplastic/neoplastic changes of CDCs. Thirty-six cysts were subjected to clinicopathological analyses. Metaplasia was found in 14 of 35, of which 9 had biliary intraepithelial neoplasia (BilIN). Of the 14 with metaplasia, 13 showed pyloric gland; 5, intestinal; and 2, squamous. BilINs included 6 BilIN-1, 2 BilIN-2, and 2 BilIN-3. Carcinoma was identified in 5 cases of which 3 were associated with metaplasia and BilIN. Only 1 of 18 cases without metaplasia had BilIN, and none had carcinoma (P = .0008). There was a trend toward more BilIN and carcinoma with intestinal rather than with pyloric gland metaplasia. All cases with metaplasia or/and BilIN were negative for MUC1. All cases with intestinal metaplasia were positive for CK20, CDX2, and MUC2, whereas cases with pyloric gland were positive for MUC6. MUC1, CEA, and B72.3 were positive only in carcinoma. There was a trend toward increasing p53 and Ki-67 from metaplasia to BilIN to carcinoma. Four of 5 patients with carcinoma died, and one was alive with disease. All others were free of disease except for one who developed new cysts. CDCs are associated with a high rate of BilIN (28.5%) and carcinoma (14.3%). CDCs show a sequence of tumor progression from metaplasia to BilIN and carcinoma.
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Affiliation(s)
- Nora Katabi
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065.
| | - Venu G Pillarisetty
- Department of Surgery, University of Washington School of Medicine, Seattle, WA 98109-1023
| | - Ronald DeMatteo
- Hepatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - David S Klimstra
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065
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MRI manifestations of adult choledochal cysts associated with biliary malignancy: a report of ten cases. ACTA ACUST UNITED AC 2012; 38:1061-70. [DOI: 10.1007/s00261-012-9942-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Steinbrück K, Enne M, Fernandes R, Martinho JM, Pacheco-Moreira LF. Living Donor Liver Transplantation for Caroli's Disease: A Report of Two Cases. ISRN SURGERY 2011; 2011:106487. [PMID: 22084740 PMCID: PMC3195350 DOI: 10.5402/2011/106487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 03/24/2011] [Indexed: 12/21/2022]
Abstract
Caroli's disease (CD) is a rare autosomal recessive disorder characterized by intrahepatic cystic dilatation of the bile ducts. Patients with bilobar or progressive disease may require orthotopic liver transplantation (OLT). In the MELD era, living donor liver transplantation (LDLT) raised as the ultimate treatment option for these patients, once their MELD score is usually low. Herein, we describe 2 cases of patients (a 2-year-old girl and a 19-year-old teenager) that successfully underwent LDLT as a treatment for diffuse CD. The good postoperative courses of the two cases indicate that LDLT is a feasible option in the treatment of this disorder, even in complicated or early age patients.
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Affiliation(s)
- Klaus Steinbrück
- Liver Transplantation Unit, Bonsucesso Federal Hospital, Health Ministry, Rio de Janeiro, 21041-030, RJ, Brazil
| | - Marcelo Enne
- Liver Transplantation Unit, Bonsucesso Federal Hospital, Health Ministry, Rio de Janeiro, 21041-030, RJ, Brazil
| | - Reinaldo Fernandes
- Liver Transplantation Unit, Bonsucesso Federal Hospital, Health Ministry, Rio de Janeiro, 21041-030, RJ, Brazil
| | - Jose M. Martinho
- Liver Transplantation Unit, Bonsucesso Federal Hospital, Health Ministry, Rio de Janeiro, 21041-030, RJ, Brazil
| | - Lúcio F. Pacheco-Moreira
- Liver Transplantation Unit, Bonsucesso Federal Hospital, Health Ministry, Rio de Janeiro, 21041-030, RJ, Brazil
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Lee HK, Park SJ, Yi BH, Lee AL, Moon JH, Chang YW. Imaging features of adult choledochal cysts: a pictorial review. Korean J Radiol 2009; 10:71-80. [PMID: 19182506 PMCID: PMC2647175 DOI: 10.3348/kjr.2009.10.1.71] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Choledochal cysts are rare congenital anomalies which are principally diagnosed by disproportional dilatation of the extrahepatic bile ducts. In addition, choledochal cysts are believed to arise from the anomalous union of the common bile duct and pancreatic duct outside the duodenal wall which is also proximal to the sphincter of the Oddi mechanism. The various types of choledochal cysts have been classified on the basis of these anomalous unions (Komi classification) and their anatomical locations (Todani classification). The multidetector computed tomography with reformatted imaging, magnetic resonance cholangiopancreatography, and an endoscopic retrograde cholangiography represent the important techniques providing the anatomical resolution and detail required to properly diagnose and classify choledochal cysts and their associated abnormal features of the biliary tree, as well as their pancreaticobile duct union. This study describes the various imaging features of a choledochal cyst in adults according to the various types of anomalous unions of the pancreaticobile duct according to Komi's classification and anatomic location according to Todani's classification. Lastly, we also review and discuss the associated abnormal findings developed in biliary systems.
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Affiliation(s)
- Hae Kyung Lee
- Department of Radiology, College of Medicine, Soonchunhyang University Bucheon Hospital, Gyunggi-do, Korea.
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