Hepaticoduodenostomy is NOT Recommended for Choledochal Cyst Management
Complete cyst excision with Roux-en-Y hepaticojejunostomy is the standard of care for choledochal cyst treatment, and hepaticoduodenostomy should be avoided due to increased risk of reflux cholangitis and malignant transformation. 1, 2
Why Hepaticojejunostomy is Superior
Malignancy Prevention
- The primary goal of choledochal cyst surgery is complete cyst excision to prevent malignant transformation within residual cyst tissue 1
- Even after complete excision, patients remain at slightly elevated risk for biliary malignancy, making any technique that leaves residual tissue or allows reflux particularly dangerous 1
- Incomplete cyst excision can result in recurrent symptoms and malignant transformation within the cyst remnant 1
Standard Surgical Approach
- The definitive treatment consists of: complete excision of the cyst + cholecystectomy + Roux-en-Y hepaticojejunostomy 2, 3
- This approach has been validated across multiple studies with acceptable morbidity and mortality 1
- The Roux-en-Y configuration prevents reflux of intestinal contents into the biliary tree 2
Problems with Hepaticoduodenostomy
Reflux Cholangitis Risk
- Direct anastomosis to the duodenum allows reflux of duodenal contents (including pancreatic enzymes and bacteria) into the biliary tree 2
- This creates ongoing inflammation and increases risk of recurrent cholangitis 2
- The Roux-en-Y configuration specifically prevents this complication by creating a defunctionalized limb 3
Historical Evidence Against Direct Drainage
- Traditional internal drainage procedures (cystoenterostomy) have been abandoned due to high incidence of late complications 3
- These complications led to the need for reoperation in multiple patients, with four patients in one series requiring cyst excision specifically due to complications from earlier internal drainage 3
- Internal drainage should be reserved only for highly specific indications such as severe liver disease 3
Technical Considerations
Surgical Technique
- Resection should be performed from inside the cyst when possible to minimize danger of injury to neighboring vascular structures 3
- The anastomosis should be created to the common hepatic duct below the confluence of right and left hepatic ducts 4
- The lower end of the common bile duct should be closed 4
Special Populations
- In infants, liver biopsy may show findings consistent with biliary atresia, and extrahepatic bile ducts proximal to the cyst may be obliterated 3
- These patients should be evaluated and treated at high-volume hepatopancreaticobiliary centers 1
Long-term Outcomes
Post-operative Complications
- Cholangitis can occur in approximately 20% of patients even after proper Roux-en-Y reconstruction 2
- This rate would be expected to be significantly higher with hepaticoduodenostomy due to reflux 2
- Long-term follow-up is essential as malignancy risk persists even after complete excision 1