Discussion:
Choledochal cysts are infrequent congenital malformations characterized
by cystic dilatations of the biliary
tree(1). These dilatations can be
extra-hepatic, intrahepatic or both. The incidence of choledochal cysts
in Asian population is 1 in 1000 live births with predominance in
females. In western countries, the incidence ranges from 1:100,000 to
1:150,000 in the United States, 1 in 2 million in the United
Kingdom(12). In Uganda, so far this is
the second case of giant choledochal cyst in a young female adult that
has been managed successful at Mbarara Regional Referral Hospital
(13). A study done in Uganda by Odongo et
al., shows that choledochal cysts account for 1.4% of the causes of
extra-hepatic obstructive jaundice which is very low hence making it
rare case(14)
Giant choledochal cyst refer to the huge cysts with a diameter of
greater than 10 cm(15). For our case,
intra-operatively, the cyst was measuring 30cm x 25cm x 25cm which is
big.
The primary diagnostic modality is by abdominal ultrasound scan followed
by CT scan and the MRI(16). The
associated anomalies are biliary atresia, gallbladder atresia, hepatic
fibrosis and those of pancreatico-biliary ductal system. MRI and MRCP
have a conclusive role in confirming ultrasound scan
diagnosis(5). This is also done to
evaluate anatomy and identify complications related to the
cyst(5). In our case, only imaging
modalities available were abdominal ultrasound scan and the CT-scan. The
abdominal ultrasound sound scan was used to screen the patient and
identify the choledocal cyst. The CT-Scan was used to confirm our
diagnosis and classify our cyst under Tonadi classification and it was
type IA choledochal cyst.
Although studies have documented the use of ERCP in certain centers of
Uganda in the management of hepatobiliary conditions, in our center
(MRRH), there is absence of these modern invasive machines that can help
us in both diagnosis and treatment of choledochal cysts. Therefore we
rely on open surgery for everything which in some instances increases
the chances of complications for example along hospital
stay(17).
The treatment of choledochal cyst is an initial control of complications
then followed by the primary surgery of the cause. Presently the most
popular and accepted surgical intervention is by total excision of the
choledochal cyst and restore the biliary enteric drainage into the
duodenum either via Roux-en-Y hepatico-jejunostomy or Braun
hepatico-jejunostomy(18). The later
approach was used in our patient to reconstruct a connection between
common hepatic duct and a loop of jejunum 40 cm from the ligament of
treitz(10).