AUDIT OF MANAGEMENT OF ADULT CHOLEDOCHAL CYSTS

Objective: To analyze the complexity and diversity of type, surgical management and complications in adult choledochal cysts presenting to a Hepatobiliary unit of a tertiary care hospital. Study Design: Case series. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from Jan 2017 to Dec 2019. Methodology: All the patients diagnosed with choledochal cyst and underwent surgical procedure between Jan 2017 to June 2019 were analyzed. The clinical features, types, operative procedure and outcomes of the patients in terms of post-operative morbidity and mortality were assessed. Calvin Dindo classification was used to assess complications. Results: A total of 17 patients were studied, out of which, 13 were females (76.5%) and 4 were males (23.5%) with mean age of 37.41 ± 16.96 years. There were 13 type I (76.5%), 2 type IVa (11.8%) and 1 type II (5.9%) choledochal cysts according to Todani’s classification. Extrahepatic cyst excision with a Roux-en-Y hepatico-jejunostomy was performed on all 17 patients. There was no mortality in the series. Post-operative complications occurred in 4 (23.5%) patients, 2 were grade II, 1 was grade I and 1 grade III according to Clavin Dindo scale. Long-term follow up revealed recurrent cholangitis in 3 (17.6%) patients which settled on antibiotic regime. The median follow up time was 1.5 years. Conclusion: The total extra-hepatic excision with Roux-en-Y hepaticojejunostomy is the treatment of choice for adult choledochal cyst. The procedure has low morbidity and very low mortality.

A Unique and Rare Presentation of Obstructed Choledochal Cyst in an Adult: A Case Report

Choledochal cysts in adults are rare congenital abnormalities. Approximately 80% are found in childhood. Thus, their presentation in adults is always associated with complications, such as stone formation, inflammation and malignancies. The pathophysiology of this disease is yet uncertain. There are different types of choledochal cysts. Diagnosis can be challenging clinically; however, imaging techniques, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT), can be helpful. We found several procedures performed in the extant literature, such as choledochoduodenostomy and choledochojejunostomy submucosal excision of the cyst; however, the best surgical option is excision with hepaticojejunostomy. We discuss the unusual presentation of a 33-year-old female patient with an obstructed choledochal cyst, despite having undergone a drainage procedure in childhood.

The role in the decision-making of the surgeon in choledochal cysts during pregnancy

The diagnosis and management of bile duct diseases during pregnancy are highly controversial because preserving both the fetus and pregnancy often required surgical intervention. In this manuscript we reported three cases of pregnant patients referred to our hospital with choledochal cyst. Medical management was implemented until fetal well-being was compromise with moderate cholangitis and oligohydramnios. A C-section prior induction with lung ripeness was performed, four weeks later cyst resection and biliodigestive derivation was performed prior preoperative parenteral total nutrition was implemented. All patients and products survived without complications.

Apixaban Causing Hepatic Cystic Bleeding: A Rare but a Life-Threatening Complication

Cystic lesions of the liver are a heterogeneous group of disorders with varied etiology, prevalence, and clinical manifestations. Fibropolycystic liver disease encompasses a spectrum of related liver and biliary tract lesions caused by abnormal embryologic development of the ductal plates. These disorders include congenital hepatic fibrosis, biliary hamartomas, polycystic liver disease (PCLD), choledochal cysts, and Carolis disease. PCLD is arbitrarily defined as a liver that contains >20 cysts. Most liver cysts are incidentally found on imaging studies, and the majority of the patients with liver cysts are asymptomatic. Rarely, complications such as compression, infection, and bleeding within the cyst can occur. Under the effect of the increased pressure, the epithelial lining of the cyst undergoes necrosis and sloughing, causing injury of the fragile blood vessels, leading to intracystic bleeding. The bleeding within or from the cyst can be precipitated by anticoagulation. We present a patient with PCLD who developed intracystic bleeding after he was started on apixaban for the prevention of thromboembolism.

Preliminary Experiences With Robot-Assisted Choledochal Cyst Excision Using the Da Vinci Surgical System in Children Below the Age of One

The purpose of this study is to introduce our preliminary experiences with using the da Vinci surgical system to treat choledochal cysts in children under 1 year old and discuss the application of this robot-assisted surgery. We retrospectively analyzed all available clinical data of children below the age of 1 who underwent surgery for choledochal cysts using the da Vinci robotic surgical system between January 2015 and December 2020. Data collection mainly included demographic information, imaging data, perioperative details, and postoperative outcomes. Ten patients were included in this study. The average patient age was 8.5 months, and the average weight was 9.11 kg. Half of these patients suffered from abdominal pain, while 30% exhibited vomiting and 10% jaundice. Eight of them were type Ia, and two were Ic. The average operation time among the patients was 219.5 min. None of the 10 patients had to receive a blood transfusion or conversion. The average time of the patients' subsequent fluid diet was 3.28 days, and the solid diet was 3.76 days. Meanwhile, the average length of hospital stay was 7.6 days. All 10 patients recovered and were eventually discharged. We believe that the da Vinci surgical system is a safe and feasible form of treatment for choledochal cysts in children <1 year old.

The diagnostic value of hepatobiliary scintigraphy for choledochal cysts in the era of magnetic resonance imaging with cholangiopancreatography and contrast-enhanced hepatobiliary phase: a case report and review

Objective: Choledochal cysts (CCs) represent cystic dilatations of the intra- or extrahepatic biliary tract. The diagnosis of CCs may not always be straightforward particularly for the intrahepatic subtype. Whereas the gold standard for diagnosing CCs is endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) is commonly used as primary diagnostic tool for delineation of biliary pathologies including CCs. Methods: We report a case of cystic hepatic lesion near the confluence of bilateral intrahepatic ducts. MRCP shows direct anatomical communication between the lesion and the biliary tract, raising suspicion of a CC. Endoscopic ultrasound shows no communication between the lesion and biliary system. 99mTc-hepatic iminodiacetic acid scintigraphy (hepatobiliary scintigraphy) was subsequently performed, showing no tracer uptake in the concerned cystic hepatic lesion despite visualisation of gallbladder and transit of tracer into the intestine. Overall scintigraphic findings speak against a CC. Conclusion: The case showed conflicting anatomical findings of a CC on MRCP and endoscopic ultrasound. Hepatobiliary scintigraphy and hepatobiliary contrast MRI may both functionally demonstrate communication of a hepatic lesion with the biliary tract. But hepatobiliary scintigraphy offers the advantage of much higher hepatic extraction and hence higher resistance to competition from plasma bilirubin compared with hepatobiliary contrast MRI. The better pharmacokinetics of HIDA confer superior lesion contrast that may offset inferior image spatial resolution, in particular for large lesions and patients with hyperbilirubinaemia. Hepatobiliary scintigraphy should be considered a suitable functional diagnostic modality for CCs even in the era of magnetic resonance imaging with cholangiopancreatography and contrast-enhanced hepatobiliary phase.