What are the surgical treatments for choledochal cysts?

Updated: Jul 01, 2020
  • Author: Emily Tommolino, MD; Chief Editor: BS Anand, MD  more...
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Answer

Surgery

The treatment of choice for choledochal cysts is complete excision with construction of a biliary-enteric anastomosis to restore continuity with the gastrointestinal tract. [5, 6]

The surgical management for each choledochal cyst type is described as follows:

  • Type I: Treatment of choice is complete excision of the involved portion of the extrahepatic bile duct; a Roux-en-Y hepaticojejunostomy is performed to restore the biliary-enteric continuity [7, 8]

  • Type II: Complete excision of the dilated diverticulum comprising a type II choledochal cyst; the resultant defect in the common bile duct is closed over a T-tube

  • Type III (choledochocele): Therapeutic choice depends on the size of the cyst; choledochoceles measuring 3 cm or less can be treated effectively with endoscopic sphincterotomy, whereas lesions larger than 3 cm (which typically produce some degree of duodenal obstruction) are excised surgically via a transduodenal approach—if the pancreatic duct enters the choledochocele, reimplantation into the duodenum may be required following excision of the cyst

  • Type IV: Complete excision of the dilated extrahepatic duct, followed by a Roux-en-Y hepaticojejunostomy to restore continuity; intrahepatic ductal disease does not require dedicated therapy unless hepatolithiasis, intrahepatic ductal strictures, and hepatic abscesses are present (in such instances, resection of the affected hepatic segment or lobe is performed)

  • Type V (Caroli disease): Hepatic lobectomy for disease limited to one hepatic lobe (left lobe usually affected); however, one should carefully examine the hepatic functional reserve before committing to such therapy; patients with bilobar disease manifesting signs of liver failure, biliary cirrhosis, or portal hypertension may require liver transplantation

  • Lilly technique: When the cyst adheres densely to the portal vein secondary to long-standing inflammatory reaction, it may not be possible to perform a complete, full-thickness excision of the cyst; the Lilly technique allows the serosal surface of the duct to be left adhering to the portal vein, while the mucosa of the cyst wall is obliterated by curettage or cautery—theoretically, this removes the risk of malignant transformation in that segment of the duct


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