Todani Classification Research Articles

Construction of nomogram based on clinical factors for the risk prediction of postoperative complications in children with choledochal cyst.

The aim of the study was to develop a prediction nomogram based on clinical factors to assess the risk of postoperative complications in children with congenital choledochal cyst. The clinical data from 131 children who underwent choledochal cyst resection and Roux-en-Y hepaticojejunostomy in our hospital between January 2016 and December 2022 were retrospectively analyzed. The general information, clinical symptoms, procedure, biochemical indicators, and imaging data were recorded. A prolonged hospital stay induced by postoperative complications or a follow-up over 6 months was assessed as the event outcome. A logistics regression analysis was performed to screen for risk factors with statistical significance in inducing postoperative complications. Then, with the dataset split into the training group and internal validation group, the nomogram for the prediction of postoperative complications was developed based on a computer algorithm. In addition, the receiver operating characteristic (ROC) curve and calibration curve were performed for nomogram verification. Of 131 children, the multivariate logistics regression analysis suggested that age ≤2 years [odds ratio (OR) 0.93; 95% confidence interval (CI) 0.15-5.65; p = 0.938], Todani classification type 1 (OR 36.58; 95% CI 4.14-871.74; p = 0.005), cyst wall thickness >0.4 cm (OR 10.82; 95% CI 2.88-49.13; p < 0.001), with chronic cholecystitis (OR 7.01; 95% CI 1.62-38.52; p = 0.014), and choledochal cyst diameter (OR 1.01; 95% CI 0.99-1.03; p = 0.370) were predictors associated with the postoperative complications of choledochal cysts. The data were randomly divided into the training group (n = 92) and internal validation group (n = 39) to build the prediction nomogram including the appeal factors. The accuracy and discrimination of the model were evaluated using a ROC curve and calibration curve. The results showed that the nomogram area under the ROC curve [area under the curve (AUC) = 0.894; 95% CI 0.822-0.966; p < 0.001], validation (AUC = 0.844; 95% CI 0.804-0.952; p < 0.001), and Brier = 0.120 (95% CI 0.077-0.163p; p < 0.001) were indicative of the good stability and calibration of the predictive nomogram. The prognosis of congenital choledochal cysts was associated with multiple aspects of clinical factors. Combined with the internal validation, the novel prediction nomogram was suitable for evaluating the individualized risk of postoperative complications of choledochal cysts. The prediction nomogram could provide a more accurate strategy of procedure and postoperative follow-up for children with choledochal cysts.

A "C" triad: cirrhosis and cholangitis due to Caroli disease.

Abstract Caroli disease (CD) is a rare congenital pathology of probable autosomal recessive inheritance, it is part of the fibrocystic liver diseases and is included in group V of the Todani classification. It is characterized by saccular or cystic dilations of the intrahepatic bile ducts, sometimes associated with congenital liver fibrosis, and is then called Caroli syndrome (CS). The usual clinical manifestation is recurrent abdominal pain secondary to intrahepatic or vesicular stones, and acute cholangitis crises with the consequent formation of intrahepatic abscesses.

Biliary cysts in adults: Cerrahpaşa experience.

Biliary cysts are biliary duct dilatations, with 20% of the cysts being diagnosed in adulthood. Abdominal pain, jaundice and palpable abdominal mass are defined as the classical triad. However, nausea, vomiting, fever, itching and weight loss are frequent complaints. There are several treatment options depending on the type of the cyst. This study aimed to share our experience with biliary cysts and contribute to the literature on this subject. Thirty patients, who received treatment for biliary cyst from January 1981 to December 2018 at our clinic, were studied retrospectively. The patients were analyzed based on age, sex, type of the cyst, diagnosis and treatment methods, post-op follow up and complications. Twenty-seven of the patients were females, and three were males. The patients were aged between 16 and 76 years, and the median age was 41.9 years. All patients presented with abdominal pain, which was accompanied by cholangitis in nine patients, nausea and vomiting in four patients, dyspepsia in three patients and palpable mass in one patient. According to the Todani classification, biliary cyst findings were consistent with Type I in 23 patients, Type V in three patients, Type IV in two patients, Type II in one patient and Type III in one patient. Diagnosis and treatment are complex in biliary cysts due to anatomical proximity and variations. Therefore, it would be beneficial to refer them to referral centers. Choice of treatment should be based on the type of the cyst.

Management of Biliary Cysts in Adults: A Single-Center 10-Year Experience.

A choledochal cyst is a cystic dilatation of the biliary tree, also termed abiliary cyst, including an intrahepatic cyst as well. Magnetic resonance cholangiopancreatography (MRCP) is the gold standard investigation of choice for this pathology. Todani classification is most commonly used to classify choledochal cysts. A total of 30 adult patients with choledochal cysts presenting at our center from December 1, 2009, to October 31, 2019, were studied retrospectively. The mean age was 35.13 years ranging from 18 to 62 years with a male-to-female ratio of 1:3.29. Of the patients, 86.6% presented with abdominal pain. Total serum bilirubin was raised in six patients with a mean of 1.84 mg/dL. MRCP was done in all patients, which had almost 100% sensitivity. Two cases had anomalous pancreaticobiliary duct union. In our study, we found only type I and type IVA cysts according to the Todani classification (type IA = 56.3%, IB = 11%, 1C = 16%, and IVA = 17%). The mean size of the cyst was 2.37 cm. Complete cyst excision with Roux-en-Y hepaticojejunostomy was performed in all patients. Four patients had surgical site infections and two had bile leaks. One patient developed hepatic artery thrombosis. All complications were eventually managed conservatively. Mortality was nil in our study with the mean postoperative stay being 7.97 days. Adult presentation of biliary cysts is not an uncommon entity in the Indian population and should be considered as a differential diagnosis of biliary pathology in adult patients. Complete excision of cysts with bilioenteric anastomosis is the current treatment of choice.

Curative effect and technical key points of laparoscopic surgery for choledochal cysts in children.

The purpose of this study was to investigate the curative effect of and experience with laparoscopic surgery for congenital choledochal cysts in children. This is a retrospective analysis of 33 children diagnosed with congenital choledochal cyst in the pediatric surgery department of the Affiliated Hospital of Southwest Medical University between January 2019 and December 2021. The cohort included 8 males and 25 females aged 0.25-13.7 years (median age, 3.2 years), including 21 cases of type I and 12 cases of type IV choledochal cyst (Todani classification). Laparoscopic choledochal cyst resection and hepaticojejunostomy with Roux-en-Y anastomosis were performed in all the patients. Laparoscopy without transit opening was successfully performed in the 33 cases. The duration of the procedure was 235-460 min (mean ± SD, 316 ± 61 min), and intraoperative blood loss volume was 15-40 ml (23 ± 7.6 ml). Postoperative hospital stay was 7-14 days (9 ± 1.8 days). Postoperative biliary fistula and pancreatitis occurred in two cases each, and all four patients were successfully treated with conservative treatment. No anastomotic stenosis, delayed bleeding, cholangitis, intestinal obstruction, or other complications occurred. All the children were followed up for 2-36 months (median period, 17.2 months). The clinical symptoms disappeared, and no obvious hepatic dysfunction was found on abdominal color ultrasound and liver function examination. Laparoscopic surgery for congenital choledochal cyst in children is safe and effective, as it is a minimally invasive surgery that is associated with a low degree of trauma and bleeding, rapid postoperative recovery, and satisfactory aesthetic appearance.

Choledochal cyst with a twist: Type 1 choledochal cyst and dilated cystic duct with aberrant accessory right hepatic drainage

Choledochal cysts are rare cystic dilations of the biliary tree that typically involve the extrahepatic bile duct and more infrequently, the intrahepatic bile ducts. Todani's classification of choledochal cysts is the most referenced system in which five types of choledochal cysts are described. Several new variants have been reported including dilations of the cystic duct and a double common bile duct. We describe a never reported variant involving dilation of the common bile duct, dilation of the cystic duct and an accessory right hepatic duct.

Postoperative anastomotic stricture following excision of choledochal cyst: a systematic review and meta-analysis.

Postoperative anastomotic stricture (PAS) is a well-known complication after correcting choledochal cyst (CC). Although the exact cause of PAS is unknown, various risk factors, such as Todani classification type IV-A, hepaticoduodenostomy, and narrow anastomosis have been reported to be associated with PAS. As far as we know, there is no report with a cumulative analysis of such risk factors of PAS. This systematic review and meta-analysis aimed to investigate the risk factors of PAS following surgical correction of CC in children. A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms "Congenital biliary dilatation", "Congenital choledochal cyst", "Choledochal cyst", "Stenosis", "Stricture", and "Complication" for studies published between 1973 and 2022. The relevant cohorts of PAS were systematically searched for clinical presentation and outcomes. The search strategy identified 795 reports. Seventy studies met the defined inclusion criteria, reporting a total of 206 patients with PAS. There is no prospective study in this search. The incidence of PAS was 2.1%. The proportion of Todani classification of the patient with PAS was higher in type IV-A with significant difference (2.0% in type I and 10.1% in type IV-A (p = 0.001)). Fourteen studies reported a comparison between hepaticojejunostomy and hepaticoduodenostomy. There was no significant difference between the two groups (p = 0.36). Four studies reported the diameter of the anastomosis at the primary surgery. The mean diameter was 12.5mm. Nine studies reported a comparison between laparoscopic surgery and open surgery. Pooled odds ratio of PAS did not show a statistical difference (p = 0.29). This study suggests that close careful follow-up is important in the patients with type IV-A of CC who underwent excision surgery, considering the possibility of PAS.

Type II choledochal cyst of the cystic duct in a 3 Month old

Type II choledochal cysts are rare, representing approximately 2% of cases [1-3]. Even fewer cases of type II cysts involving the cystic duct have been reported. Excision is necessary to prevent future ascending cholangitis, liver fibrosis, and malignancy [1-3, 5]. We present a case of a 3 month old male born premature who presented with persistent conjugated hyperbilirubinemia. Imaging workup demonstrated a cystic structure at the neck of the cystic duct, measuring 0.9 cm × 1.6 cm x 0.9 cm. Delayed biliary excretion was noted on HIDA. Decision was made to take the patient to the operating room for a cholecystectomy and intraoperative cholangiogram to delineate the anatomy. Intraoperatively, the patient was found to have a small cystic structure arising from the cystic duct. A cholecystectomy was performed and the patient recovered well. Choledochal cysts of the cystic duct are considered type II cysts based on the original Todani Classification. Due to their location, cholecystectomy is required during excision [1-3,5]. Wide-based cysts involving the common bile duct additionally require hepaticojejunostomy [1-3,5]. • Type II choledochal cysts represent 2% of cases. Even fewer involve the cystic duct. • Choledochal cysts of the cystic duct are type II cysts based on Todani classification. • Excision is indicated to prevent cholangitis, liver fibrosis, and malignancy. • Surgical management involves cholecystectomy with or without hepaticojejunostomy.

Todani type III: like biliary dilatation with duodenal prolapse—a case report

BackgroundBiliary dilatation is a rare disease involving intrahepatic and extrahepatic biliary tract abnormalities. With the development of imaging technology, an increasing number of special cases have been diagnosed, which poses a challenge to the traditional classification method.Case presentationA 50-year-old woman was admitted to the hospital due to right upper quadrant pain for more than 10 days. The patient had previous episodes of similar symptoms, which were relieved after symptomatic treatment at a local community hospital. After the symptoms developed, she underwent a computed tomography scan at the local hospital, which showed biliary dilatation; thus, she was referred to our hospital for further treatment. After admission, her magnetic resonance imaging examination also suggested biliary dilatation, but abnormal signals were found in her duodenum. First, a duodenal diverticulum was considered. Later, endoscopic ultrasonography was conducted, and the results suggested that the dilated biliary tract had herniated into the duodenum. This type of lesion is most closely classified as a Todani type III lesion. The patient finally underwent choledochectomy and Roux‑en‑Y hepaticojejunostomy, and the postoperative pathology was consistent with our preoperative diagnosis. The patient was followed up for approximately 2 years, and no obvious postoperative complications were found.ConclusionsThe manifestations of this case are relatively rare and involve one of the undiscussed categories of the Todani classification system; therefore, this case has certain clinical value. Moreover, there is no report similar to this experience in the previous literature.

Cystic duct cyst in adults: a systematic review of the sixth entity.

Over the past two decades, there have been an increasing number of reports describing a sixth type of choledochal cyst (cystic duct cyst) in adults that was not included in Todani's classification. This sixth entity has not yet been systematically reviewed in the literature. We therefore explored this condition in adults from the perspective of the clinical presentation, diagnosis and treatment through a systematic review of the evidence. The final analysis included 33 reported cases, with 55% of them reported in Asia. The mean age was 39.3years old, with a female-to-male ratio of 1.5:1. Magnetic resonance cholangiopancreatography was accurate in establishing the diagnosis in 69% of cases. Where reported, standard laparoscopic/open cholecystectomy was performed in about 74% of patients, while around 25% of them needed extensive surgery. Associated malignancy was reported in 6.1% of cases, while 28% of patients had co-existent gallstone-related disease. No significant post-operative morbidity or mortality was reported. In this era of emergency laparoscopic cholecystectomy, surgeons should be aware of this rare condition, with the particular understanding that it is associated with gallstone-related disease in a significant number of reported cases.

Surgical Management and Prognosis of Congenital Choledochal Cysts in Adults: A Single Asian Center Cohort of 69 Cases.

Background The choledochal cyst (CC) is a rare cystic dilatory condition with malignant tendency, which is more frequently reported in children. Surgical resection of cysts can significantly decrease the risk of malignancy and reduce associated complications. However, CC has been paid lesser attention in adults, and its surgical parameters have been frequently reported to be in dispute. This study aimed to report experience associated with the treatment of an adult with CC and to suggest the appropriate parameters for the surgery, including the extent of excision (complete or not), the length of the Y limb, the diameter of the cholangio-intestinal anastomosis (CIA), and different operative approaches (open, laparoscopic, and laparoscopic converted to open) by comparing the various indicators, including postoperative bile leakage, cholangitis, choledocholithiasis, carcinogenesis, and surgical re-excision. Methods We conducted a single-center noninterventional retrospective study of 69 different congenital choledochal cyst patients who were admitted to our hospital between July 2010 and July 2020. We collected and analyzed their demographic data, clinical presentations, underlying complications, imaging tests, endoscopic interventions, and parameters for the surgery, histological data, and prognostic indicators over a mean 77-month follow-up period. Results We found that out of the 69 cases, the median age at diagnosis was 32 (IQR = 22–45) years. Seven (10.1%) patients were asymptomatic before the diagnosis, with abdominal pain as the primary complaint in 62 (89.9%) patients, whereas nausea/vomiting was observed in 29 (42.0%) patients. CCs were mainly evaluated by using magnetic resonance cholangiopancreatography (MRCP) (n = 47, 68.1%). It was observed that surgery, cholecystectomy, choledochal cysts excision, and Roux-en-Y hepaticojejunostomy (n = 65, 94.2%), and laparotomy (n = 58, 84.1%) were the dominant therapeutic modalities employed. However, seventeen (24.6%) patients were treated with incomplete cyst resection, while 52 (75.4%) patients received complete cyst resection. We also conducted regular follow-ups after the surgery for a mean duration of 77 months. Postoperative complications were found to be experienced by 35 (50.7%) patients, and a further two patients (2.9%) developed malignancy during the follow-up. Moreover, increasing the diameter of cholangio-intestinal anastomosis served as a potential protective factor for postoperative choledocholithiasis (p = 0.040) and a risk factor for cholangitis (p = 0.002). Conclusions Among the 69 CC participants, abdominal pain was their major symptom. Those with an abnormal pancreaticobiliary junction were more likely to have choledocholithiasis and pancreatitis. The diagnosis was found to be highly dependent on the Todani classification scheme and MRCP. Surgical resection remains the key to CC treatment. The results suggested that the complete resection, the length of the Y limb of 40 cm–60 cm, and the diameter of the CIA of 1.0 cm–1.5 cm were appropriate values for predicting the lower risk of postoperative complications.

Laparoscopic repositioning of an aberrant right hepatic artery and hepaticojejunostomy for pediatric choledochal cyst: A case report.

IntroductionThe right hepatic artery crossing the ventral side of the common hepatic duct is a relatively frequent abnormality. This aberrant right hepatic artery not only interferes with dissection of the common bile duct and hepaticojejunostomy for choledochal cyst but can also cause postoperative anastomotic stenosis.Case presentationA 14-year-old patient presented with upper abdominal pain and was diagnosed with a choledochal cyst (Type IVA in Todani Classification) and pancreaticobiliary maljunction. Abdominal enhanced computed tomography showed aberrant right hepatic artery located at the ventral side of the common hepatic duct. Laparoscopic choledochal cyst resection and hepaticojejunostomy were planned. Intraoperative findings also showed the aberrant right hepatic artery crossing the common hepatic duct ventrally as detected on preoperative computed tomography. Laparoscopic dorsal side repositioning of the aberrant right hepatic artery was performed because it appeared to compress the common hepatic duct and risked causing postoperative anastomotic stenosis. We performed laparoscopic hepaticojejunostomy by replacing the aberrant right hepatic artery dorsally to facilitate suturing and prevent postoperative anastomotic stenosis. The postoperative course was uneventful, with no findings suggestive of anastomotic stenosis.DiscussionThe abnormality of the right hepatic artery is reported to be a primary cause of anastomotic stenosis after hepaticojejunostomy. Once anastomotic stenosis or stricture develops, it is often difficult to treat. The prevention of the stenosis is important.ConclusionsIn choledochal cyst with aberrant right hepatic artery, dorsal repositioning is effective for preventing postoperative anastomotic stenosis and cholestasis.

Biliary Tract Malignancies Related to Gallbladder Polyps, Primary Sclerosing Cholangitis, and Choledochal Cysts.

Biliary Tract Malignancies Related to Gallbladder Polyps, Primary Sclerosing Cholangitis, and Choledochal Cysts.

Long-term outcome of 18 years single-center study of surgical treatment of choledochal cyst patients

There are not many reports of postoperative long-term malignant risk or postoperative sequelae after surgery on choledochal cyst (CC). The purpose of this study was to report the long-term results of operated CC. The patients who underwent surgical treatments for CC between 2003 and 2020 at the Seoul National University Hospital were enrolled. Clinicopathologic factors and pre/postoperative CT or MRI were reviewed. Of the 153 patients, the female was 85%, and the mean age was 41 years old. The most common symptom was abdominal pain. According to the Todani classification, the most common type was 1c (36.6%). APBDU was 85.6% and C-P type, P-C type APBDU were observed at 43.8%, 41.8% respectively. Fourteen patients (9.2%) had biliary tract cancer including 8 cholangiocarcinomas and 8 gallbladder cancer. Two patients had both cancers. A comparison of patients with and without malignancy showed that age, operative time, EBL were significantly higher in the malignant group, while the diameter of the cyst is significantly smaller in the malignant group. There was no significant difference in APBDU type and Todani classification type between the two groups. The incidence of long-term complication was 14.3% and the median time interval was 30 months. The two most common complication was cholangitis or stricture (5.9%). There were 2 cases (1.3%) of new cancer near the intrapancreatic remnant bile duct. The 9.2% of resected CCs had combined malignancy on biliary tracts. Long-term complications such as cholangitis, anastomosis stricture, and new cancer may occur. Therefore continuous surveillance is required.

Biliary Tree Cysts and Surgical Treatment: Outcomes in a Multicentric Study.

Background: Biliary tree cysts (BTCs) represent an either localized or multifocal abnormal dilatation of the biliary tree, which entails an increased risk of acute cholangitis and cholangiocarcinoma (2.5%-16%). Its incidence in Western countries is ∼1/100.000-1/150.000, being more frequent in Asia (1/1.000). These cysts are usually classified according to Todani classification, which is based on site and morphology of cysts. Patients and Methods: This is a retrospective multicentric descriptive study of patients surgically treated for BTCs. From 2005 to 2018, 25 cases were collected between Hospital de la Santa Creu i Sant Pau (Barcelona, Spain) and Ospedale San Paolo (Savona, Italy). Clinical presentation was characterized by abdominal pain, jaundice, fever, and sometimes weight loss. Eight patients presented Todani type I, 1 patient Todani type II, 3 patients Todani III, 1 patient Todani type IV, and 12 patients Todani type V. Results: Among the 25 surgically treated patients, 12 patients underwent liver resection, 7 patients underwent resection of the extrahepatic biliary tree, 3 patients underwent BTC removal through a duodenotomy, 1 patient underwent resection of the extrahepatic biliary tree and liver resection, and 2 patients underwent pancreatoduodenectomy. Overall 30-day morbidity rate was 20%, and 90-day mortality was 0%. Pathologic examination confirmed diagnosis of cholangiocarcinoma in 5 patients (20%). After a median follow-up of 59 months, 20 patients are alive and in good conditions, whereas 50% of patients with cholangiocarcinoma died for disease progression. Conclusions: Surgical treatment for BTCs is associated with acceptable postoperative outcomes, with moderate morbidity and null mortality rates. Moreover, the risk of developing cholangiocarcinoma is still high that prompts surgical treatment once diagnosis is made.

Three-dimensional visualization technique compared with magnetic resonance cholangiopancreatography for evaluation of anatomic variants of pediatric congenital choledochal cysts.

The aim of this study was to compare the application of a three-dimensional (3D) visualization technique and magnetic resonance cholangiopancreatography (MRCP) for diagnosis of pediatric congenital choledochal cysts. Thin slices of coronal heavily T2-weighted pulse sequences of MRI pertaining to 35 patients were retrospectively used to reconstruct 3D models. Diagnoses and variants of the biliary system were evaluated based on the 3D models and MRCP imaging. The quality of delineation of the biliary duct system and the Todani classification were evaluated. Wilcoxon and Chi-squared tests were used for statistical analysis. Two cases that were diagnosed as type II congenital choledochal cysts using the 3D model were diagnosed as type I using MRCP imaging. Significant differences were observed between the two modalities with respect to the delineation of the right anterior bile duct, right posterior bile duct, and left hepatic duct. The excellent and good rates obtained with the 3D model (65.7%) were much better than that obtained with MRCP (37.1%) imaging. Two cases with accessory hepatic ducts (5.7%), one case with an accessory pancreatic duct (2.8%), and two cases with biliary strictures at the hepatic hilum (5.7%) were detected using the 3D models. In contrast, only one case with an accessory hepatic duct and one case with a biliary stricture at the hepatic hilum were detected using MRCP. The 3D visualization technique facilitated more precise morphological evaluation of congenital choledochal cysts and provided comprehensive spatial anatomic information for diagnosis.

Clinical characteristics of patients with malignancy and long-term outcomes of surgical treatment of patients with choledochal cyst

PurposeThere are few reports of postoperative long-term malignant risk or postoperative sequelae after surgery for choledochal cysts (CCs). This study aimed to analyze the clinical characteristics of patients with malignancy and the long-term results of operated CC.MethodsThe patients who underwent surgical treatments for CC between 2003 and 2020 at Seoul National University Hospital were enrolled. Clinicopathologic factors and pre-/postoperative computed tomography or magnetic resonance imaging were reviewed.ResultsOf the 153 patients, Todani classification Ic (36.6%), C-P type (43.8%) anomalous pancreaticobiliary duct union were the most common type respectively. Fourteen patients (9.2%) had biliary tract cancer and a comparison of patients with and without malignancy showed that the diameter of cyst was significantly lower in malignant patients and malignancy was observed to be significantly higher in P-C type. The incidence of long-term complications was 9.8%, and the median time interval was 30 months. The 2 most common complications were cholangitis and stricture (60.0%). There was one case of new cancer near the intrapancreatic remnant bile duct.ConclusionOf the resected CCs, 9.2% had a combined malignancy on the biliary tracts. Long-term complications such as cholangitis, anastomotic stricture, and new cancers may occur. Therefore, continuous surveillance is required.

Choledochal cyst in children in dakar: Diagnostic and therapeutic aspects.

Context:Choledochal cyst is a rare malformation that mainly affects girls.Aims:The aim of this work is to report the diagnostic, therapeutic and evolutionary aspects of bile duct cyst in children in Dakar.Subjects and Methods:we conducted a prospective monocentre descriptive study from 1 July, 2016, to 30 June, 2019, in the Pediatric Surgery Department of Albert Royer Children's Hospital in Dakar. The studied parameters featured clinical, biological, radiological, therapeutic and evolutionary data. Overall, ten patients, including eight girls and two boys, were selected.Results:Two patients presented the classic triple-syndrome complex featuring an abdominal pain, an abdominal mass and jaundice. Most of the patients presented a symptomatology associating abdominal pain and vomiting. Biological cholestasis syndrome was present in six cases and biological cytolysis syndrome in five cases. The abdominal ultrasound-computed tomography (CT) scan confirmed the diagnosis and helped to set the Todani classification with a predominance of Types 1 and 4. Surgical treatment by laparotomy consisted of total excision of the cyst followed by a Y-en-Roux hepatico-jejunal anastomosis in nine cases, whereas we performed a drainage of the cyst in one case. Two patients presented a morbidity of anastomotic suture release and evisceration and had a good outcome after surgical repair. There was no mortality.Conclusions:The diagnosis of choledochal cyst dilatation (CCD) can be suspected in the postnatal period on the basis of a gastro-intestinal symptomatology with or without associated to jaundice. The combination ultrasound-abdominal CT-scan helps set the diagnosis. The laparatomic approach always has its place for the management of CCD, especially in our context.

Laparoscopic Type IV Choledochal Cyst Excision with Roux-En-Y Hepaticojejunostomy

Introduction: Choledochаl cysts represent а rare congenital cystic dilation of the biliary tract. Nearly 25% are diagnosed in the first year of life with and incidence of approximately 1/200 000 live births in western countries, although these numbers are significantly higher in East Аsiаn populations. Presentation typically occurs in childhood, with jaundice, fever or an abdominal mass. Although benign, choledochаl cysts cаn be аssociаted with various complications including malignant transformation. In western countries, the incidence of cholangiocarcinoma has been reported to reach 12% in some series, with higher reports in Asian countries. Other hurdles include cholangitis, pancreatitis, and cholelithiаsis. The modified Todani classification is employed to describe the various types of choledocal cysts (I-V). Type I, a fusiform dilation of the common bile duct, is the most common. Type IV is the second most prevalent, with extension of the cysts into the intrahepatic ducts. Types II, II and V are less frequent. This video intends to present the laparoscopic excision of a type IV choledocal cyst with intracorporeal Roux-en-Y hepaticojejunostomy with a specific attention on technical detail and education. Methods: A 49 year old female with no relevant prior medical history presented with a history of abdominal comfort. Results: An abdominal CT scan showed common biliary duct dilation and an MRi revealed the existence of a type IVa choledochаl cyst. Laparoscopic cyst excision was proposed and accepted. The patient was submitted to surgery on January 2021, initiated oral intake on day 2 and was discharged at day 7 without any hurdles. Conclusion: Laparoscopic choledochal cyst excision is a safe procedure with decreased morbidity and in-hospital stay days compared with an open approach. The authors consider that the video quality and surgical procedure can successfully contribute to the education and training of surgery residents and also contribute to share expertise and consolidate knowledge to surgeons.

Multiple cholangiogenic liver abscesses with cystic transformation of bile ducts

In the present paper we show a rare case of choledocal cyst type IVa according to T. Todani classification in a 46-yearold patient. Four years after cystoenterostomy without cyst excision, a severe cholangitis developed. Multiple small abscesses of the right lobe of the liver were identified. Puncture-drainage and antibacterial treatment was started, diagnostic laparotomy was performed, but the patient's condition progressively worsened. So the patient was admitted to the Vishnevsky National Medical Surgery Research Center, where the diagnosis was confirmed. According to vital indications, a right hepatectomy was performed, a large cyst was removed, and Roux-en-Y hepaticojejunostomy was formed with the left lobar duct. In early postoperative period the patient developed biliary leakage. Late complications include anastomotic stricture with obstructive jaundice and episode of cholangitis, which was resolved by percutaneous transhepatic cholangiography and external-internal biliary drainage. The analysis of literature data, etiology, classification, pathogenesis of cystic transformations of extra- and intrahepatic bile ducts is presented. An assessment of the methods of surgical treatment of the disease and its complications is given. Surgical treatments of choledochal cysts and its complications were evaluated.