Endoscopic resection of a choledochocele

Choledochal cysts are uncommon congenital dilatations of the extrahepatic and/or intrahepatic biliary system. Several serious complications of choledochal cysts have been described, including malignancy. According to Todani et al., choledochal cysts are classified into five types [1]. Type III, or choledochocele, is a cystic dilatation of the intra-ampullary portion of the common bile duct (CBD). Compared with other choledochal cysts, the choledochocele has a very low rate of malignant transformation [2]. Therefore, the choledochocele can be treated with sphincterotomy or endoscopic papillectomy [3] [4]. Here we report a case of a 17-year-old man admitted to our hospital with acute mild pancreatitis.

A preliminary magnetic resonance cholangiopancreatography showed an isolated cystic-like dilatation of the distal portion of the CBD. Duodenoscopy revealed a 25 – 30-mm subepithelial swelling proximal to the major papilla and protruding into the duodenum ([Fig. 1]). Endoscopic ultrasound confirmed cystic dilation of the intra-ampullary portion of the CBD and three biliary stones. Choledochocele was diagnosed and the patient was referred for endoscopic treatment ([Video 1]).

Fig. 1 Subepithelial swelling proximal to the major papilla.

Video 1 Choledochocele was diagnosed by duodenoscopy and endoscopic ultrasound. A complete en bloc resection with hot snare papillectomy was performed. At the 2-month follow-up duodenoscopy, no residual lesions were seen.

The lesion was resected en bloc by hot snare papillectomy ([Fig. 2]) and the stones were also removed ([Fig. 3]). Endoscopic retrograde cholangiopancreatography was then performed and no further biliary alterations were seen. Pancreatic and biliary sphincterotomies were performed and a plastic stent was placed in the pancreatic duct to prevent post-procedural acute pancreatitis and papillary stenosis. Two through‐the‐scope clips were deployed to close the mucosal defect. No post-procedural complications were observed. Pathological examination showed hyperplasia of the biliary epithelium and inflammatory infiltration without dysplasia.

Fig. 2 Complete en bloc resection of the lesion by hot snare papillectomy.

Fig. 3 Choledochocele with stones.

At the 2-month follow-up, duodenoscopy showed no residual lesions in the ampullary area and spontaneous pancreatic stent migration ([Fig. 4]). In our opinion, this case confirms that endoscopic papillectomy may be a good option for the treatment of patients with choledochocele.

Fig. 4 2-month follow-up duodenoscopy.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Todani T, Watanabe Y, Narusue M. et al. Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst. Am J Surg 1977; 134: 263-269
• 2 Ten Hove A, de Meijer VE, Hulscher JBF. et al. Meta-analysis of risk of developing malignancy in congenital choledochal malformation. Br J Surg 2018; 105: 482-490
• 3 Law R, Topazian M. Diagnosis and treatment of choledochoceles. Clin Gastroenterol Hepatol 2014; 12: 196-203
• 4 Ohtsuka T, Inoue K, Ohuchida J. et al. Carcinoma arising in choledochocele. Endoscopy 2001; 33: 614-619

Publication History

Article published online:
17 December 2020