Type 1C Choledochal Cyst With Recurrent CBD Dilation After Roux-en-Y Hepaticojejunostomy

Author Type(s)

Student

Document Type

Abstract

Publication Date

10-2024

DOI

10.14309/01.ajg.0001045848.31418.42

Journal Title

American Journal of Gastroenterology

Abstract

Introduction:

Choledochal cysts are rare, with an incidence of 1 in 150,000 individuals, most common in Asia. Due to very high risk of malignant transformation, they require early total surgical resection of the biliary structures, with either Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy. In this case report we describe a young female with a rare, large 4.2 cm remnant CBD dilatation with fluid collection 2 years after open choledochal cyst resection and Roux-en-Y hepaticojejunostomy, managed with fine-needle aspiration, and biliary stent placement.

Case Description/Methods:

A 22-year-old woman with history of type 1c choledochal cyst s/p biliary stenting and subsequent open cholecystectomy, choledochal cyst resection and Roux-en-Y hepaticojejunostomy 2 years prior presented with severe RUQ abdominal pain without fevers, with nausea and vomiting. Patient had leukocytosis of 17,900, imaging revealed a dramatic 4.2 cm CBD dilation. Repeat ERCP revealed a dilated CBD remnant with fluid collection and stenotic major papilla. Patient underwent ventral pancreatic duct sphincterotomy and stent placement, CBD remnant stent placement, and fine-needle aspiration of fluid collection without acute complication. Her symptoms resolved and she was discharged home.

Discussion:

The reported risk of malignancy in type 1 choledochal cyst ranges from 2.5-2.8% and guidelines are to perform early resection and hepaticojejunostomy as in our patient. Post hepaticojejunostomy related complications are poorly described in literature and here we describe a large CBD dilation 2 years post-operation of 4.2 cm. The etiology of this massive dilation appears unclear, possible causes include post-op stricture, malignancy, biloma, abscess, or retained segment of primary choledochal cyst due to incomplete resection. Here, dilation was complicated by fluid collection, which was aspirated and ruled out malignancy based on cytologic studies. In this case, symptomatic relief was achieved with biliary stents and bile flow was appreciated without evidence of obstruction. Sufficient guidelines do not exist to guide decisions on timing and frequency of endoscopic follow-up, patient symptoms and expert opinion are the guiding factor in this decision. Surgical consult should be obtained to assess the need for revision procedure (see Figure 1).

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