Abstract
Introduction Choledochal cyst is a premalignant condition and surgical excision with biliary enteric
anastomosis is the standard of care. Surgical treatment in adults may be difficult
due to associated biliary pathology and high incidence of postoperative complications
is reported. Postoperative pancreatic fistula (POPF) is a rare early complication
following choledochal cyst excision.
Material and Methods A 23-year-old male patient was operated for a Todani type IV-A choledochal cyst with
anomalous pancreaticobiliary junction. Cyst excision with hepaticojejunostomy was
performed. Distal stump closure was technically challenging due to extreme thickening
of the cyst wall with neovascularization. On postoperative day 2, patient developed
tachycardia and progressive tachypnea with 200 mL of pancreatic fluid in the drain.
Endoscopic pancreatic stenting was attempted but was technically not possible. At
reexploration, leak from oversewn distal cyst stump was identified and the suture
line was reinforced. After the second surgery the patient was hemodynamically stable
but continued to have a low output pancreatic fistula for few days which was managed
conservatively successfully. We conducted a review of English literature with an aim
to identify the risk factors and predictors of pancreatic fistula following cyst excision.
An electronic search was performed in Medline and Google Scholar during September
2020 and available literature since January 2000 were reviewed. The keywords used
were “pancreatic fistula” and “choledochal cyst.”
Results Preoperative cholangiography (magnetic resonance cholangiopancreotography/endoscopic
retrograde cholangiopancreatography) is essential to know the extent of cyst and delineate
biliary pancreatic junction. Literature review including our case revealed that Todani
type I-c, type IV, and forme fruste type of choledochal cyst are at high risk of pancreatic
injury and POPF. Recurrent cholangitis makes excision technically more challenging
and complete removal is not always possible.
Conclusion Postoperative pancreatic fistula can be anticipated in select group of patients with
high-risk preoperative findings. Chronic inflammation due to recurrent cholangitis
promotes scarring and neovascularization which adds to surgical complexity. Operative
technique in these high-risk patients needs further refinement.
Keywords
postoperative pancreatic fistula - choledochal cyst
