Page 69 - World Journal of Laparoscopic Surgery

CASE REPORT
Type VI Choledochal Cyst: A Rare Case Presenting with Acute

Pancreatitis

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Ambuj Agarwal , Divij Jayant , Kailash Chand Kurdia , Arunanshu Behera 4
Received on: 29 June 2021; Accepted on: 06 September 2022; Published on: 07 December 2022
AbstrAct
Choledochal cyst (CDC) of cystic duct, i.e., choledochal cyst type VI is an extremely rare clinical entity, with few case reports only. Even the Todani
classification of choledochal cyst does not include as a separate entity. Most of choledochal cyst VI is asymptomatic. For an accurate diagnosis,
magnetic resonance cholangiopancreatography (MRCP) is required. There is no consensus regarding the management of the cystic duct cyst
due to the rarity of the disease, but treatment alternatives extend from laparoscopic cholecystectomy to complete excision of the biliary duct
with bilio-enteric reconstruction. We present a case of middle-aged woman who presented with biliary pancreatitis and managed with interval
laparoscopic cholecystectomy. Choledochal cyst type VI had been identified intraoperatively.
Keywords: Acute pancreatitis, Intraoperative diagnosis, Type VI choledochal cyst.
World Journal of Laparoscopic Surgery (2022): 10.5005/jp-journals-10033-1512

bAckground 1–4 Department of General Surgery, Postgraduate Institute of Medical
Choledochal cysts are focal or diffuse dilatations of a biliary tree Education and Research, Chandigarh, India
that are believed to be congenital. They may occur as single or Corresponding Author: Kailash Chand Kurdia, Department of General
multiple cysts involving an extrahepatic or intrahepatic biliary Surgery, Postgraduate Institute of Medical Education and Research,
tree. The incidence of 1 in 1000 persons is seen in Asia, with higher Chandigarh, India, Phone: +91 6394358323, e-mail: drkurdia@gmail.
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rates seen in Japan. Cystic malformations of cystic ducts i.e. CDC com
type VI are uncommon with few cases reported in the literature. How to cite this article: Agarwal A, Jayant D, Kurdia KC, et al. Type VI
These are often misdiagnosed or undiagnosed preoperatively. Choledochal Cyst: A Rare Case Presenting with Acute Pancreatitis.
Preoperative diagnosis and appropriate management require World J Lap Surg 2022;15(3):255–257.
awareness of CDC type VI. In this case report, we report an instance Source of support: Nil
of a 45-year-old lady presenting with acute gallstone-induced Conflict of interest: None
pancreatitis managed conservatively. No cystic malformation was
identified preoperatively but the cystic duct cyst was identified
intraoperatively and managed with laparoscopic cholecystectomy. Four weeks later, she underwent laparoscopic cholecystectomy.
On laparoscopy, the gallbladder was distended and mildly
cAse description inflamed, Calot’s triangle dissected, and critical view of safety was
demonstrated. After dissection, we found that there was focal
A 45-year-old lady presented to the emergency department dilatation around a 10-mm cystic duct present, and proximal and
with acute onset severe pain abdomen in the epigastric region, distal to dilation, there was waisting present (Fig. 1). The cystic
radiating to back for the last 5 days, associated with recurrent duct was completely dissected till junction to the common hepatic
bilious vomiting. No history of jaundice, fever, obstipation, and duct (CHD). Laparoscopic cholecystectomy was completed with an
abdomen distension. On assessment, the patient had a pulse rate application of hemolock clip just adjacent to the junction of the
of 100 per minute, BP of 130/80 mm of Hg, respiratory rate of 20 cystic duct and CHD. On the cut section of the specimen, there
per minute, and afebrile. Per-abdominal examination, the patient was no evidence of any mucosal irregularities in the gall bladder
had tenderness in the epigastric region. and CDC.

investigAtion
outcome And Follow-up
Blood workup showed an elevated serum amylase level of 1265 U/L.
Ultrasound of the abdomen reported cholelithiasis with multiple The postoperative course was uneventful. Magnetic resonance
calculi and choledocholithiasis, but the pancreas appears normal. cholangiopancreatography done after 9 months of surgery showed
Contrast-enhanced CT reported grossly distended gallbladder no extrahepatic biliary cystic dilation. It showed normal intrahepatic
with multiple calculi and no wall edema. Common bile duct (CBD) and extrahepatic biliary systems (Fig. 2).
dilated, with a diameter of 14 mm and multiple stones in the lumen.
discussion
treAtment Choledochal cyst is traditionally classified by Alonso-Lej and
She underwent ERCP and CBD clearance and stenting. The patient associates, which was later modified by Todani and colleagues
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was treated with IV fluid and analgesics. After satisfactory clinical in 1977 into five types to include intrahepatic cystic dilatation.
improvement, the patient was discharged. Choledochal cyst type VI was first identified by Bode and Aust in
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