A large stone detected in Roux-en-Y jejunal limb 20 years after excision of congenital choledochal cyst

Abstract

A 30-YEAR-OLDWOMAN was transferred to our hospital with pain in the right hypochondriac region. The patient had undergone excision of an extrahepatic cyst and Roux-en-Y reconstruction for a congenital choledochal cyst (Todani type IVA) at 10 years of age. A magnetic resonance imaging scan demonstrated scattered tiny stones in the dilated intrahepatic bile duct. In addition, a huge low-intensity, oval-shaped mass approximately 8 cm in diameter was also detected in the dilated jejunal limb (Fig 1). Percutaneous transhepatic biliary drainage was performed for cholangitis; bile cultures were positive for Klebsiella. Serum tumor markers were within normal limits. During surgical exploration, a huge stone measuring 8.0 cm in diameter in the jejunal limb (Fig 2), and 92 intrahepatic stones were found. Because the jejunal limb above the level of transverse mesocolon was slack and long, we performed a resection of the jejunal limb including the previous hepaticojejunal anastomosis, removal of the stones, and re-hepaticojejunostomy. No jejunal obstruction was found during the operation. Biliary stenosis was present in the remnant hilar bile duct, which presented inflammation and fibrosis histologically. The stones both in the intrahepatic bile duct and the jejunal limb were calcium bilirubinate stones. The postoperative course was uneventful.