Advertisement

Diagnosis and management of choledochal cysts

Published:October 04, 2022DOI:https://doi.org/10.1016/j.hpb.2022.09.010

      Abstract

      Background

      Choledochal cysts (CCs) are rare cystic dilatations of the intrahepatic and/or extrahepatic bile ducts. We review the pathophysiology, diagnosis, and management of CCs.

      Methods

      MEDLINE/PubMed and Web of Science databases were queried for “choledochal cyst”, “bile duct cyst”, “choledochocele”, and “Caroli disease”. Data were synthesized and systematically reviewed.

      Results

      Classified according to the Todani Classification, CCs are generally believed to arise secondary to reflux of pancreatic enzymes into the biliary tree due to anomalous pancreaticobiliary duct union. Complications of CCs include abdominal pain, jaundice, cystolithiasis, cholecystitis, pancreatitis, liver abscess, liver cirrhosis and malignant transformation (3–7.5%). Radiological and endoscopic imaging is the cornerstone of CC diagnosis and full delineation of cyst anatomy is imperative for proper management. Management is generally guided by cyst classification with complete cyst excision necessary for CCs with high potential of malignant transformation such as types I and IV. 5-year overall survival after choledochal cyst excision is 95.5%.

      Conclusion

      Most CCs should undergo surgical intervention to mitigate the risk of cyst related complications such as cholangitis and malignant transformation.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to HPB
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Soares K.C.
        • Kim Y.
        • Spolverato G.
        • Maithel S.
        • Bauer T.W.
        • Marques H.
        • et al.
        Presentation and clinical outcomes of choledochal cysts in children and adults: a multi-institutional analysis.
        JAMA Surg. 2015; 150: 577-584https://doi.org/10.1001/jamasurg.2015.0226
        • Sastry A.V.
        • Abbadessa B.
        • Wayne M.G.
        • Steele J.G.
        • Cooperman A.M.
        What is the incidence of biliary carcinoma in choledochal cysts, when do they develop, and how should it affect management?.
        World J Surg. 2015; 39: 487-492https://doi.org/10.1007/s00268-014-2831-5
        • Edil B.H.
        • Cameron J.L.
        • Reddy S.
        • Lum Y.
        • Lipsett P.A.
        • Nathan H.
        • et al.
        Choledochal cyst disease in children and adults: a 30-year single-institution experience.
        J Am Coll Surg. 2008; 206 (discussion 5-8): 1000-1005https://doi.org/10.1016/j.jamcollsurg.2007.12.045
        • de Vries J.S.
        • de Vries S.
        • Aronson D.C.
        • Bosman D.K.
        • Rauws E.A.
        • Bosma A.
        • et al.
        Choledochal cysts: age of presentation, symptoms, and late complications related to Todani's classification.
        J Pediatr Surg. 2002; 37: 1568-1573https://doi.org/10.1053/jpsu.2002.36186
        • Stringer M.D.
        • Dhawan A.
        • Davenport M.
        • Mieli-Vergani G.
        • Mowat A.P.
        • Howard E.R.
        Choledochal cysts: lessons from a 20 year experience.
        Arch Dis Child. 1995; 73: 528-531https://doi.org/10.1136/adc.73.6.528
        • Xia H.T.
        • Yang T.
        • Liu Y.
        • Liang B.
        • Wang J.
        • Dong J.H.
        Proper bile duct flow, rather than radical excision, is the most critical factor determining treatment outcomes of bile duct cysts.
        BMC Gastroenterol. 2018; 18: 129https://doi.org/10.1186/s12876-018-0862-3
        • Soares K.C.
        • Arnaoutakis D.J.
        • Kamel I.
        • Rastegar N.
        • Anders R.
        • Maithel S.
        • et al.
        Choledochal cysts: presentation, clinical differentiation, and management.
        J Am Coll Surg. 2014; 219: 1167-1180https://doi.org/10.1016/j.jamcollsurg.2014.04.023
        • Alonso-Lej F.
        • Rever Jr., W.B.
        • Pessagno D.J.
        Congenital choledochal cyst, with a report of 2, and an analysis of 94, cases.
        Int Abstr Surg. 1959; 108: 1-30
        • Todani T.
        • Watanabe Y.
        • Narusue M.
        • Tabuchi K.
        • Okajima K.
        Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst.
        Am J Surg. 1977; 134: 263-269https://doi.org/10.1016/0002-9610(77)90359-2
        • Tyson G.L.
        • El-Serag H.B.
        Risk factors for cholangiocarcinoma.
        Hepatology (Baltimore, Md). 2011; 54: 173-184https://doi.org/10.1002/hep.24351
        • Søreide K.
        • Søreide J.A.
        Bile duct cyst as precursor to biliary tract cancer.
        Ann Surg Oncol. 2007; 14: 1200-1211https://doi.org/10.1245/s10434-006-9294-3
        • Chang J.
        • Jang J.Y.
        • Kang M.J.
        • Jung W.
        • Shin Y.C.
        • Kim S.W.
        Clinicopathologic differences in patients with gallbladder cancer according to the presence of anomalous biliopancreatic junction.
        World J Surg. 2016; 40: 1211-1217https://doi.org/10.1007/s00268-015-3359-z
        • Sugiyama M.
        • Atomi Y.
        Endoscopic ultrasonography for diagnosing anomalous pancreaticobiliary junction.
        Gastrointest Endosc. 1997; 45: 261-267https://doi.org/10.1016/s0016-5107(97)70268-2
        • Iwai N.
        • Yanagihara J.
        • Tokiwa K.
        • Shimotake T.
        • Nakamura K.
        Congenital choledochal dilatation with emphasis on pathophysiology of the biliary tract.
        Ann Surg. 1992; 215: 27-30https://doi.org/10.1097/00000658-199201000-00003
        • Iwai N.
        • Tokiwa K.
        • Tsuto T.
        • Yanagihara J.
        • Takahashi T.
        Biliary manometry in choledochal cyst with abnormal choledochopancreatico ductal junction.
        J Pediatr Surg. 1986; 21: 873-876https://doi.org/10.1016/s0022-3468(86)80011-2
        • Park S.W.
        • Koh H.
        • Oh J.T.
        • Han S.J.
        • Kim S.
        Relationship between anomalous pancreaticobiliary ductal union and pathologic inflammation of bile duct in choledochal cyst.
        Pediatr Gastroenterol Hepatol Nutr. 2014; 17: 170-177https://doi.org/10.5223/pghn.2014.17.3.170
        • Lee H.K.
        • Park S.J.
        • Yi B.H.
        • Lee A.L.
        • Moon J.H.
        • Chang Y.W.
        Imaging features of adult choledochal cysts: a pictorial review.
        Korean J Radiol. 2009; 10: 71-80https://doi.org/10.3348/kjr.2009.10.1.71
        • Funabiki T.
        • Matsubara T.
        • Miyakawa S.
        • Ishihara S.
        Pancreaticobiliary maljunction and carcinogenesis to biliary and pancreatic malignancy.
        Langenbeck's Arch Surg. 2009; 394: 159-169https://doi.org/10.1007/s00423-008-0336-0
        • Horaguchi J.
        • Fujita N.
        • Kobayashi G.
        • Noda Y.
        • Ito K.
        • Takasawa O.
        Clinical study of choledochocele: is it a risk factor for biliary malignancies?.
        J Gastroenterol. 2005; 40: 396-401https://doi.org/10.1007/s00535-005-1554-7
        • Iwasaki J.
        • Ogura Y.
        • Nakagawa S.
        • Kato K.
        • Kondo A.
        • Shiraki K.
        Familial occurrence of congenital bile duct dilatation.
        World J Gastroenterol. 2008; 14: 941-943https://doi.org/10.3748/wjg.14.941
        • Kusunoki M.
        • Saitoh N.
        • Yamamura T.
        • Fujita S.
        • Takahashi T.
        • Utsunomiya J.
        Choledochal cysts. Oligoganglionosis in the narrow portion of the choledochus.
        Arch Surg. 1988; 123 (Chicago, Ill : 1960): 984-986https://doi.org/10.1001/archsurg.1988.01400320070014
        • Kendrick M.L.
        • Nagorney D.M.
        Bile duct cysts: contemporary surgical management.
        Curr Opin Gastroenterol. 2009; 25: 240-244https://doi.org/10.1097/mog.0b013e328329887c
        • Nagorney D.M.
        • McIlrath D.C.
        • Adson M.A.
        Choledochal cysts in adults: clinical management.
        Surgery. 1984; 96: 656-663
        • Ono J.
        • Sakoda K.
        • Akita H.
        Surgical aspect ot cystic dilatation of the bile duct. An anomalous junction of the pancreaticobiliary tract in adults.
        Ann Surg. 1982; 195: 203-208https://doi.org/10.1097/00000658-198202000-00014
        • Lipsett P.A.
        • Pitt H.A.
        • Colombani P.M.
        • Boitnott J.K.
        • Cameron J.L.
        Choledochal cyst disease. A changing pattern of presentation.
        Ann Surg. 1994; 220: 644-652https://doi.org/10.1097/00000658-199411000-00007
        • Okada A.
        • Nakamura T.
        • Higaki J.
        • Okumura K.
        • Kamata S.
        • Oguchi Y.
        Congenital dilatation of the bile duct in 100 instances and its relationship with anomalous junction.
        Surg Gynecol Obstetr. 1990; 171: 291-298
        • Rattner D.W.
        • Schapiro R.H.
        • Warshaw A.L.
        Abnormalities of the pancreatic and biliary ducts in adult patients with choledochal cysts.
        Arch Surg. 1983; 118 (Chicago, Ill : 1960): 1068-1073https://doi.org/10.1001/archsurg.1983.01390090052012
        • Swisher S.G.
        • Cates J.A.
        • Hunt K.K.
        • Robert M.E.
        • Bennion R.S.
        • Thompson J.E.
        • et al.
        Pancreatitis associated with adult choledochal cysts.
        Pancreas. 1994; 9: 633-637
        • Okada A.
        • Oguchi Y.
        • Kamata S.
        • Ikeda Y.
        • Kawashima Y.
        • Saito R.
        Common channel syndrome--diagnosis with endoscopic retrograde cholangiopancreatography and surgical management.
        Surgery. 1983; 93: 634-642
        • Ando H.
        • Ito T.
        • Kaneko K.
        • Seo T.
        Congenital stenosis of the intrahepatic bile duct associated with choledochal cysts.
        J Am Coll Surg. 1995; 181: 426-430
        • Ramond M.J.
        • Huguet C.
        • Danan G.
        • Rueff B.
        • Benhamou J.P.
        Partial hepatectomy in the treatment of Caroli's disease. Report of a case and review of the literature.
        Dig Dis Sci. 1984; 29: 367-370https://doi.org/10.1007/bf01318526
        • Mercadier M.
        • Chigot J.P.
        • Clot J.P.
        • Langlois P.
        • Lansiaux P.
        Caroli's disease.
        World J Surg. 1984; 8: 22-29https://doi.org/10.1007/bf01658359
        • Martin L.W.
        • Rowe G.A.
        Portal hypertension secondary to choledochal cyst.
        Ann Surg. 1979; 190: 638-639https://doi.org/10.1097/00000658-197911000-00013
        • Martin R.F.
        Biliary cysts: a review and simplified classification scheme.
        Surg Clin. 2014; 94: 219-232https://doi.org/10.1016/j.suc.2014.01.011
        • Machado N.O.
        • Chopra P.J.
        • Al-Zadjali A.
        • Younas S.
        Choledochal cyst in adults: etiopathogenesis, presentation, management, and outcome-case series and review.
        Gastroenterol Res Pract. 2015; 2015602591https://doi.org/10.1155/2015/602591
        • Anderson M.A.
        • Bhati C.S.
        • Ganeshan D.
        • Itani M.
        Hepatobiliary mucinous cystic neoplasms and mimics.
        Abdominal radiology, New York2021https://doi.org/10.1007/s00261-021-03303-5
        • Mortelé K.J.
        • Ros P.R.
        Cystic focal liver lesions in the adult: differential CT and MR imaging features.
        Radiographics. 2001; 21: 895-910https://doi.org/10.1148/radiographics.21.4.g01jl16895
        • Lewis V.A.
        • Adam S.Z.
        • Nikolaidis P.
        • Wood C.
        • Wu J.G.
        • Yaghmai V.
        • et al.
        Imaging of choledochal cysts.
        Abdom Imag. 2015; 40: 1567-1580https://doi.org/10.1007/s00261-015-0381-4
        • Park D.H.
        • Kim M.H.
        • Lee S.K.
        • Lee S.S.
        • Choi J.S.
        • Lee Y.S.
        • et al.
        Can MRCP replace the diagnostic role of ERCP for patients with choledochal cysts?.
        Gastrointest Endosc. 2005; 62: 360-366https://doi.org/10.1016/j.gie.2005.04.026
        • Kim S.H.
        • Lim J.H.
        • Yoon H.K.
        • Han B.K.
        • Lee S.K.
        • Kim Y.I.
        Choledochal cyst: comparison of MR and conventional cholangiography.
        Clin Radiol. 2000; 55: 378-383https://doi.org/10.1053/crad.2000.0438
        • Hung M.H.
        • Lin L.H.
        • Chen D.F.
        • Huang C.S.
        Choledochal cysts in infants and children: experiences over a 20-year period at a single institution.
        Eur J Pediatr. 2011; 170: 1179-1185https://doi.org/10.1007/s00431-011-1429-2
        • Sacher V.Y.
        • Davis J.S.
        • Sleeman D.
        • Casillas J.
        Role of magnetic resonance cholangiopancreatography in diagnosing choledochal cysts: case series and review.
        World J Radiol. 2013; 5: 304-312https://doi.org/10.4329/wjr.v5.i8.304
        • Anbarasu A.
        • Deshpande A.
        Successful management of a post-choledochal cyst excision pancreatic fistula in an adult patient: a case report and literature review on risk factors.
        Surg J. 2022; 8: e41-e45https://doi.org/10.1055/s-0041-1742175
        • Ronnekleiv-Kelly S.M.
        • Soares K.C.
        • Ejaz A.
        • Pawlik T.M.
        Management of choledochal cysts.
        Curr Opin Gastroenterol. 2016; 32: 225-231https://doi.org/10.1097/mog.0000000000000256
        • Todani T.
        • Watanabe Y.
        • Toki A.
        • Ogura K.
        • Wang Z.Q.
        Co-existing biliary anomalies and anatomical variants in choledochal cyst.
        Br J Surg. 1998; 85: 760-763https://doi.org/10.1046/j.1365-2168.1998.00697.x
        • Takeshita N.
        • Ota T.
        • Yamamoto M.
        Forty-year experience with flow-diversion surgery for patients with congenital choledochal cysts with pancreaticobiliary maljunction at a single institution.
        Ann Surg. 2011; 254: 1050-1053https://doi.org/10.1097/SLA.0b013e3182243550
        • Lilly J.R.
        The surgical treatment of choledochal cyst. Surgery.
        Gynecol Obstet. 1979; 149: 36-42
        • Benhidjeb T.
        • Münster B.
        • Ridwelski K.
        • Rudolph B.
        • Mau H.
        • Lippert H.
        Cystic dilatation of the common bile duct: surgical treatment and long-term results.
        Br J Surg. 1994; 81: 433-436https://doi.org/10.1002/bjs.1800810337
        • Ouaïssi M.
        • Kianmanesh R.
        • Belghiti J.
        • Ragot E.
        • Mentha G.
        • Adham M.
        • et al.
        Todani type II congenital bile duct cyst: European multicenter study of the French surgical association and literature review.
        Ann Surg. 2015; 262: 130-138https://doi.org/10.1097/sla.0000000000000761
        • Ladas S.D.
        • Katsogridakis I.
        • Tassios P.
        • Tastemiroglou T.
        • Vrachliotis T.
        • Raptis S.A.
        Choledochocele, an overlooked diagnosis: report of 15 cases and review of 56 published reports from 1984 to 1992.
        Endoscopy. 1995; 27: 233-239https://doi.org/10.1055/s-2007-1005677
        • Martin R.F.
        • Biber B.P.
        • Bosco J.J.
        • Howell D.A.
        Symptomatic choledochoceles in adults. Endoscopic retrograde cholangiopancreatography recognition and management.
        Arch Surg. 1992; 127 (Chicago, Ill : 1960) (discussion 8-9): 536-538https://doi.org/10.1001/archsurg.1992.01420050056007
        • Masetti R.
        • Antinori A.
        • Coppola R.
        • Coco C.
        • Mattana C.
        • Crucitti A.
        • et al.
        Choledochocele: changing trends in diagnosis and management.
        Surg Today. 1996; 26: 281-285https://doi.org/10.1007/bf00311589
        • Han M.
        • Yang N.
        • Zhang H.
        • Ran X.
        Endoscopic management of a type III choledochal cyst (choledochocele) using snare resection without balloon-catheter assistance.
        VideoGIE. 2021; 6: 134-135https://doi.org/10.1016/j.vgie.2020.11.015
        • Katabathina V.S.
        • Kapalczynski W.
        • Dasyam A.K.
        • Anaya-Baez V.
        • Menias C.O.
        Adult choledochal cysts: current update on classification, pathogenesis, and cross-sectional imaging findings.
        Abdom Imag. 2015; 40: 1971-1981https://doi.org/10.1007/s00261-014-0344-1
        • Powell C.S.
        • Sawyers J.L.
        • Reynolds V.H.
        Management of adult choledochal cysts.
        Ann Surg. 1981; 193: 666-676https://doi.org/10.1097/00000658-198105000-00018
        • Komi N.
        • Takehara H.
        • Kunitomo K.
        Choledochal cyst: anomalous arrangement of the pancreaticobiliary ductal system and biliary malignancy.
        J Gastroenterol Hepatol. 1989; 4: 63-74https://doi.org/10.1111/j.1440-1746.1989.tb00808.x
        • Komi N.
        • Takehara H.
        • Kunitomo K.
        • Miyoshi Y.
        • Yagi T.
        Does the type of anomalous arrangement of pancreaticobiliary ducts influence the surgery and prognosis of choledochal cyst?.
        J Pediatr Surg. 1992; 27: 728-731https://doi.org/10.1016/s0022-3468(05)80102-2
        • Lobeck I.N.
        • Dupree P.
        • Falcone Jr., R.A.
        • Lin T.K.
        • Trout A.T.
        • Nathan J.D.
        • et al.
        The presentation and management of choledochocele (type III choledochal cyst): a 40-year systematic review of the literature.
        J Pediatr Surg. 2017; 52: 644-649https://doi.org/10.1016/j.jpedsurg.2016.10.008
        • Lee S.E.
        • Jang J.Y.
        • Lee Y.J.
        • Choi D.W.
        • Lee W.J.
        • Cho B.H.
        • et al.
        Choledochal cyst and associated malignant tumors in adults: a multicenter survey in South Korea.
        Arch Surg. 2011; 146 (Chicago, Ill : 1960): 1178-1184https://doi.org/10.1001/archsurg.2011.243
        • Xia H.T.
        • Dong J.H.
        • Yang T.
        • Zeng J.P.
        • Liang B.
        Extrahepatic cyst excision and partial hepatectomy for Todani type IV-A cysts.
        Dig Liver Dis. 2014; 46: 1025-1030https://doi.org/10.1016/j.dld.2014.07.007
        • Ando H.
        • Kaneko K.
        • Ito F.
        • Seo T.
        • Ito T.
        Operative treatment of congenital stenoses of the intrahepatic bile ducts in patients with choledochal cysts.
        Am J Surg. 1997; 173: 491-494https://doi.org/10.1016/s0002-9610(97)00013-5
        • Chijiiwa K.
        • Tanaka M.
        Late complications after excisional operation in patients with choledochal cyst.
        J Am Coll Surg. 1994; 179: 139-144
        • Uno K.
        • Tsuchida Y.
        • Kawarasaki H.
        • Ohmiya H.
        • Honna T.
        Development of intrahepatic cholelithiasis long after primary excision of choledochal cysts.
        J Am Coll Surg. 1996; 183: 583-588
        • Davenport M.
        • Stringer M.D.
        • Howard E.R.
        Biliary amylase and congenital choledochal dilatation.
        J Pediatr Surg. 1995; 30: 474-477https://doi.org/10.1016/0022-3468(95)90059-4
        • Davenport M.
        • Basu R.
        Under pressure: choledochal malformation manometry.
        J Pediatr Surg. 2005; 40: 331-335https://doi.org/10.1016/j.jpedsurg.2004.10.015
        • Turowski C.
        • Knisely A.S.
        • Davenport M.
        Role of pressure and pancreatic reflux in the aetiology of choledochal malformation.
        Br J Surg. 2011; 98: 1319-1326https://doi.org/10.1002/bjs.7588
        • Kronfli R.
        • Davenport M.
        Insights into the pathophysiology and classification of type 4 choledochal malformation.
        J Pediatr Surg. 2020; 55: 2642-2646https://doi.org/10.1016/j.jpedsurg.2020.05.017
        • Zheng X.
        • Gu W.
        • Xia H.
        • Huang X.
        • Liang B.
        • Yang T.
        • et al.
        Surgical treatment of type IV-A choledochal cyst in a single institution: children vs. adults.
        J Pediatr Surg. 2013; 48: 2061-2066https://doi.org/10.1016/j.jpedsurg.2013.05.022
        • Mabrut J.Y.
        • Kianmanesh R.
        • Nuzzo G.
        • Castaing D.
        • Boudjema K.
        • Létoublon C.
        • et al.
        Surgical management of congenital intrahepatic bile duct dilatation, Caroli's disease and syndrome: long-term results of the French Association of Surgery Multicenter Study.
        Ann Surg. 2013; 258 (discussion 21): 713-721https://doi.org/10.1097/sla.0000000000000269
        • De Kerckhove L.
        • De Meyer M.
        • Verbaandert C.
        • Mourad M.
        • Sokal E.
        • Goffette P.
        • et al.
        The place of liver transplantation in Caroli's disease and syndrome.
        Transpl Int. 2006; 19: 381-388https://doi.org/10.1111/j.1432-2277.2006.00292.x
        • Habib S.
        • Shakil O.
        • Couto O.F.
        • Demetris A.J.
        • Fung J.J.
        • Marcos A.
        • et al.
        Caroli's disease and orthotopic liver transplantation. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the.
        Int Liver Transpl Soc. 2006; 12: 416-421https://doi.org/10.1002/lt.20719
        • Harring T.R.
        • Nguyen N.T.
        • Liu H.
        • Goss J.A.
        • O'Mahony C.A.
        Caroli disease patients have excellent survival after liver transplant.
        J Surg Res. 2012; 177: 365-372https://doi.org/10.1016/j.jss.2012.04.022
        • Scharschmidt B.F.
        Human liver transplantation: analysis of data on 540 patients from four centers.
        Hepatology (Baltimore, Md). 1984; 4: 95s-101shttps://doi.org/10.1002/hep.1840040723
        • Witlin L.T.
        • Gadacz T.R.
        • Zuidema G.D.
        • Kridelbaugh W.W.
        Transhepatic decompression of the biliary tree in Caroli's disease.
        Surgery. 1982; 91: 205-209
        • Fahrner R.
        • Dennler S.G.C.
        • Dondorf F.
        • Ardelt M.
        • Rauchfuss F.
        • Settmacher U.
        Liver resection and transplantation in Caroli disease and syndrome.
        J Visc Surg. 2019; 156: 91-95https://doi.org/10.1016/j.jviscsurg.2018.06.001
        • Kassahun W.T.
        • Kahn T.
        • Wittekind C.
        • Mössner J.
        • Caca K.
        • Hauss J.
        • et al.
        Caroli's disease: liver resection and liver transplantation. Experience in 33 patients.
        Surgery. 2005; 138: 888-898https://doi.org/10.1016/j.surg.2005.05.002
        • Ulrich F.
        • Pratschke J.
        • Pascher A.
        • Neumann U.P.
        • Lopez-Hänninen E.
        • Jonas S.
        • et al.
        Long-term outcome of liver resection and transplantation for Caroli disease and syndrome.
        Ann Surg. 2008; 247: 357-364https://doi.org/10.1097/SLA.0b013e31815cca88
        • Liem N.T.
        • Pham H.D.
        • Dung le A.
        • Son T.N.
        • Vu H.M.
        Early and intermediate outcomes of laparoscopic surgery for choledochal cysts with 400 patients.
        J Laparoendosc Adv Surg Tech Part A. 2012; 22: 599-603https://doi.org/10.1089/lap.2012.0018
        • Margonis G.A.
        • Spolverato G.
        • Kim Y.
        • Marques H.
        • Poultsides G.
        • Maithel S.
        • et al.
        Minimally invasive resection of choledochal cyst: a feasible and safe surgical option.
        J Gastrointest Surg. 2015; 19: 858-865https://doi.org/10.1007/s11605-014-2722-y
        • Liu Y.
        • Yao X.
        • Li S.
        • Liu W.
        • Liu L.
        • Liu J.
        Comparison of therapeutic effects of laparoscopic and open operation for congenital choledochal cysts in adults.
        Gastroenterol Res Pract. 2014; 2014670260https://doi.org/10.1155/2014/670260
        • Tian Y.
        • Wu S.D.
        • Zhu A.D.
        • Chen D.X.
        Management of type I choledochal cyst in adult: totally laparoscopic resection and Roux-en-Y hepaticoenterostomy.
        J Gastrointest Surg. 2010; 14: 1381-1388https://doi.org/10.1007/s11605-010-1263-2
        • Duan X.
        • Mao X.
        • Jiang B.
        • Wu J.
        Totally laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy for choledochal cyst in adults: a single-institute experience of 5 years.
        Surg Laparosc Endosc Percutan Tech. 2015; 25: e65-e68https://doi.org/10.1097/sle.0000000000000091
        • Revathi G.
        • Singh B.K.
        • Rathore Y.S.
        • Chumber S.
        Laparoscopic management of type VI choledochal cyst with common bile duct stone: report of a case and review of literature.
        BMJ Case Rep. 2021; 14https://doi.org/10.1136/bcr-2021-244393
        • Varshney V.K.
        • Swami A.
        Total robotic choledochal cyst excision with Roux-en-Y hepaticojejunostomy in adults.
        Langenbeck's Arch Surg. 2022; https://doi.org/10.1007/s00423-021-02395-3
        • Lee C.
        • Byun J.
        • Ko D.
        • Yang H.B.
        • Youn J.K.
        • Kim H.Y.
        Comparison of long-term biliary complications between open and laparoscopic choledochal cyst excision in children.
        Annals of surgical treatment and research. 2021; 100: 186-192https://doi.org/10.4174/astr.2021.100.3.186
        • Morikawa T.
        • Ohtsuka H.
        • Takadate T.
        • Ishida M.
        • Miura T.
        • Mizuma M.
        • et al.
        Laparoscopic and robot-assisted surgery for adult congenital biliary dilatation achieves favorable short-term outcomes without increasing the risk of late complications.
        Surg Today. 2022; https://doi.org/10.1007/s00595-021-02438-8
        • Xie X.
        • Wu Y.
        • Li K.
        • Ai C.
        • Wang Q.
        • Wang C.
        • et al.
        Preliminary experiences with robot-assisted choledochal cyst excision using the da vinci surgical system in children below the age of one.
        Front Pediatr. 2021; 9741098https://doi.org/10.3389/fped.2021.741098
        • Ihn K.
        • Ho I.G.
        • Hong Y.J.
        • Jeon H.J.
        • Lee D.
        • Han S.J.
        Changes in outcomes and operative trends with pediatric robot-assisted resection of choledochal cyst.
        Surg Endosc. 2021; https://doi.org/10.1007/s00464-021-08844-w
        • Ming G.
        • Guo W.
        • Cheng Y.
        • Wang J.
        Identification and evaluation of fructose-bisphosphate aldolase B as a potential diagnostic biomarker in choledochal cysts patients: a quantitative proteomic analysis.
        Transl Pediatr. 2021; 10: 2083-2094https://doi.org/10.21037/tp-21-336