What is the surgical treatment of choice for a type III choledochal cyst?

Surgical Treatment for Type III Choledochal Cyst

The surgical treatment of choice for type III choledochal cyst (choledochocele) is endoscopic sphincterotomy. 1, 2

Understanding Type III Choledochal Cysts

• Type III choledochal cysts, also known as choledochoceles, are rare abnormalities consisting of cystic or diverticular dilatation of the terminal intramural portion of the common bile duct protruding into the duodenum 1
• They represent the rarest variant among the five types of choledochal cysts according to the Todani classification 3
• Unlike other types of choledochal cysts, type III cysts are frequently managed endoscopically rather than with traditional surgical excision 3

Diagnostic Approach

• Magnetic resonance cholangiopancreatography (MRCP) is the primary imaging modality for diagnosis 3
• Endoscopic retrograde cholangiopancreatography (ERCP) has become the gold standard for diagnosing type III choledochal cysts 4
• An intraluminal duodenal filling defect on barium study that opacifies during cholangiography or ERCP is diagnostic 1

Treatment Options and Rationale

First-line Treatment: Endoscopic Sphincterotomy

• Endoscopic sphincterotomy is the treatment of choice for type III choledochal cysts 2
• This approach is less invasive than surgical excision and provides effective drainage of the cyst 1
• ERCP with sphincterotomy allows for direct visualization and treatment in a single procedure 2

Alternative Surgical Approaches

• For cases where endoscopic management is not feasible or fails, surgical options include:
  • Partial excision of the cyst 1
  • Laparoscopic cholecystectomy with Roux-en-Y hepaticojejunostomy for complex cases 4

Management Considerations

• Treatment is tailored based on cyst morphology and the patient's clinical characteristics 3
• The presence or absence of duodenal bulging may influence the treatment approach 4
• Long-term follow-up is essential as complications like cholangitis can occur post-treatment 5

Comparison with Other Types of Choledochal Cysts

• Type I and IV choledochal cysts typically require complete excision with hepaticojejunostomy 2
• Type II cysts are managed with excision of the diverticulum 2
• Type III cysts uniquely benefit from endoscopic management rather than surgical excision 3, 2

Potential Complications

• Inadequate treatment may lead to recurrent symptoms including cholangitis and pancreatitis 5
• Long-term complications after treatment include cholangitis in some patients 2
• Unlike other types of choledochal cysts, type III cysts have a lower risk of malignant transformation 2

Based on the available evidence, the answer to the question is D. Sphincterotomy, as this represents the surgical treatment of choice for type III choledochal cysts.