Ammiel Arra, Dr, N Bascombe, Dr, M Bartholomew, Dr, D Dan, Prof. San Fernando General Hospital
Objective: Due to the risk of malignancy, the established management of choledochal cysts mandates bile duct excision and biliary reconstruction. While the reconstructive procedure of choice for most surgeons has traditionally been hepatico-jejunostomy, this may not be feasible in selected cases due to immobility or inadequacy of the jejunum. Hepatico-duodenostomy, while traditionally thought to be associated with a higher risk of complications, may be the only alternative for such patients. The following case will outline the management of a 32-year-old woman with short bowel syndrome, who was diagnosed with choledocholithiasis and a type 1 choledochal cyst.
Method and Materials: As a child, our patient suffered midgut volvulus secondary to malrotation which resulted in extensive bowel resection. She was left with 100cm of small bowel anastamosed to the transverse colon and subsequently developed short bowel syndrome. She compensated very well but developed cholelithiasis and extensive choledocholithiasis, which was further complicated by recurrent bouts of cholangitis. Imaging of her biliary tree confirmed common duct stones extending into the branched hepatic ducts, as well as a fusiform dilatation of the common bile duct, that appeared consistent with a type 1 choledochal cyst. Laparoscopic clearance of the biliary tree and excision of the cyst with reconstruction using a hepatico-duodenostomy was planned.
Results: The patient underwent successful laparoscopic Cholecystectomy, CBD clearance with excision of the bile duct and reconstruction with hepatico-duodenostomy. A short video is presented to demonstrate the technique used. The procedure took 4 hours and she was discharged on day 3. The patient had an uneventful recovery and remains asymptomatic on subsequent follow-up. Histology is consistent with a markedly dilated bile duct rather than choledochal cysts.
Conclusions: This case illustrates the dilemma of diagnosis and treatment of choledochal cysts in a patient with short bowel syndrome and the feasibility of laparoscopic bile duct excision and reconstruction, while demonstrating that hepaticoduodenostomy may be a safe alternative in selected cases with limited material for conduit.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92325
Program Number: V299
Presentation Session: Video Loop Day 3
Presentation Type: VideoLoop