Delay in Resection of Choledochal Cysts Highlights the Significance of Malignancy Potential: A Case Report

Abstract

Risks of choledochal cysts include obstructive jaundice, cholangitis, and malignancy. Therefore, cysts are typically resected especially if symptomatic. A 69 year old female who presented with cholangitis due to a common bile duct stone. Past medical history significant for type III choledochal cyst and recurrent cholangitis. Previous surgical interventions included biliary bypass at age 10 and revision in early 20s; choledochal cyst was not resected at either surgery. Imaging suggested hepaticojejunostomy stricture leading to recurrent cholangitis. Initially patient was very hesitant to undergo any further surgical intervention and opted for close surveillance. Shortly after patient develop rigors and while still reluctant to undergo large procedure did consent to choledochal cyst resection and hepaticojejunostomy revision. During the operation, choledochal cyst identified, mobilized and approximately 80% of it was excised. Hepaticojejunostomy appeared to incorporate remnant gallbladder based on intraoperative evaluation. Cholangiogram was attempted through duct of Luschka but was not completed due to difficult angle and subsequently ligated. New hepaticojejunostomy was created using original roux limb and good biliary drainage of right and left hepatic lobes demonstrated on completion cholangiogram. Final pathology significant for poorly differentiated adenocarcinoma, biliary type in choledochal cyst and remnant gallbladder; additionally bile duct margin showed invasive adenocarcinoma. Patient then underwent a completion pancreaticoduodenectomy with partial hepatectomy for complete oncologic resection. In adults presenting with a symptomatic choledochal cyst, excision should be recommended treatment. Risk of malignancy is present in biliary tree despite resection. Thus, the entire biliary tree should be inspected for multiple areas of neoplasm.