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Endoscopic Management Postcholedochoduodenostomy for Choledochal Cysts

Shah, Kevin P.; Ramachandran, Vignesh; Lee, Frances C.∗,†; Keith, Brent‡,§; Mazziotti, Mark V.||,¶; Fishman, Douglas S.∗,†

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Journal of Pediatric Gastroenterology and Nutrition: August 2018 - Volume 67 - Issue 2 - p e36
doi: 10.1097/MPG.0000000000001928

Treatment of choledochal cysts (CC) includes Roux-en-Y hepaticojejunostomy or choledochoduodenostomy. Postoperative adverse events include stenosis, obstruction, and cholangitis (1). We report 2 CC cases postcholedochoduodenostomy managed by endoscopic retrograde cholangiopancreatography (ERCP) and intraductal endoscopy (Video 1, Supplemental Digital Content, http://links.lww.com/MPG/B286).

Case 1: A 4-year-old girl, 15 months postcholedochoduodenostomy for type I CC presents with intermittent epigastric pain. Laboratory reports notable for alanine aminotransferase (ALT) of 174U/L and gamma-glutamyl transferase (GGT) of 170U/L. Hepatobiliary iminodiacetic acid scan was abnormal and magnetic resonance cholangiopancreatography was suggestive of obstruction. Biliary access was obtained via dilating catheters and ERCP-guided balloon dilation with subsequent stent placement. The stent was removed 2 months later with normal labs at 6 months.

Case 2: A 15-year-old male 4 years post-choledochoduodenostomy for type IVA CC presents with RUQ pain, and history of recurrent cholangitis and residual cyst with stenosis. Laboratory reports were notable for ALT of 215U/L, GGT of 431U/L, and conjugated bilirubin of 0.8 mg/dL. ERCP with intraductal endoscopy was used to remove stones from the biliary tree (Fig. 1). Laboratory reports normalized within 6 weeks with a plan for surgical revision.

FIGURE 1
FIGURE 1:
Endoscopic view within the intrahepatic bile ducts and corresponding cholangiogram.

Despite similar stenosis rates between Roux-en-Y hepaticojejunostomy and choledochoduodenostomy (2), choledochoduodenostomy may be preferred due to maintenance of bowel integrity and easier endoscopic access. Further research is needed to evaluate differences in the role of each operation and postoperative endoscopic management.

REFERENCES

1. Singham J, Yoshida EM, Scudamore CH. Choledochal cysts: Part 1 of 3: classification and pathogenesis. Can J Surg 2009; 52:434–440.
2. Narayanan SK, Chen Y, Narasimham KL, et al. Hepaticoduodenostomy versus hepaticojejunostomy after resection of choledochal cyst: a systematic review and meta-analysis. J Pediatr Surg 2013; 48:2336–2342.

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Copyright © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition