Surgical Science, 2011, 2, 5-7
doi:10.4236/ss.2011.21002 Published Online January 2011 (http://www.SciRP.org/journal/ss)
Can Mucosectomy be Always Performed in Complicated
Cases of Choledochal Cysts
Sezen Özkisacik1, Mesut Yazici1, Canten Tataroglu2, Yelda Ozsunar3, Harun Gürsoy1
1Adnan Menderes University, Medical Faculty, Department of Pediatric Su rgery, Aydin, Turkey
2Adnan Menderes University, Medical Faculty, Depart me nt of Pat h ol o gy, Aydin , T urkey
3Adnan Menderes University, Medical Faculty, Department of Radiodiagnostic, Aydin, Turkey
Received September 9, 2010; September 18, 201 0; September 25, 2010
Abstract
Introduction: If the surgical dissection is too risky in choledochal cyst, mucosectomy is defined as a benefi-
cial technical method in the literature. To discuss in this manner, we present this case. Case: 9 y ears old girl
was referred to our clinic due to multipl stones in the gallbladder. History and physicial examination could
not be performed effectively because of her cerebral palsy. Ultrasonography showed choledochal cyst con-
taining multipl stones. MR cholangiography showed multipl stones in the dilated choledochus. During the
dissection, the cyst appeared extremely adherent to the adjacent structures and cyst wall was so thin and
transparent. The mucosectomy was not thought to be a good option to carry out for this case. For this reason,
cyst was totally excised. Discussion: The preferred method for choledochal cyst is total cyst excision and
Roux-en Y hepaticoenterostomy. When the dissection is unsafe to perform, posterior wall mucosectomy may
be performed. However, like in our case, when the diagnosis is delayed, the cyst wall may become too thin
and may be attached very strongly to the adjacent structures. So, mucosectomy is impossible and full layer
total cyst excision remains as the only alternative in spite of its high risks.
Keywords: Mucosectomy, Choledoch, Cyst
1. Introduction
Choledochal cysts are rare congenital anomalies of the
biliary tree [1]. Since every piece of unresected remains
of the cystic wall is associated with malignan cies [2], the
method of choice for the treatment of choledochal cysts
in children is total resection and Roux-en-Y (RY) hepa-
ticoenterostomy to prevent carcinogenesis of biliary
duckts [3]. If there is inflammation in the cystic wall, if
the cyst is excessively inflated and if it is adhered to sur-
rounding tissue excessively, total resection may not be
possible. Since surgical resection of the posterior wall
may cause excessive risk in such cases, excision of the
cyst mucosa (mucosectomy), a technique which facili-
tates the operation and renders excision more successful,
has been descri bed [4,5].
We will present a case of choledochal cyst found to
have no specific findings, but difficulty in orientation
due to cerebral palsy on history and physical examina-
tion and treated with full thickness total resection.
2. Case
A nine-year-old girl was referred to our center for
multiple calculi in her gallb ladder detected o n abdo minal
ultrasonography (USG) and computed tomography (CT).
On history, she frequently presented with restlessness to
several health centers; however, it turned out that effec-
tive examination could not be performed and that history
could not be taken because she had cerebral palsy since
she was two years old.
In our emergency department, physical examination
could not be carried out properly. Direct abdominal x-ray
taken when the patient was standing showed two
air-fluid levels on the right upper quadrant. Therefore,
abdominal USG was repeated and then magnetic reso-
nance (MR) cholangiography was performed. USG and
MR cholangiography demonstrated a choledochal cyst
containing multiple calculi (Figure 1). The patient un-
derwent operation. On intraoperative USG and cholan-
giography, the cyst was about 7-8 cm in length and 5 cm
in width and connected to the pancreas via 1.5 cm-

S.ÖZKISACIK ET AL. 6
common bile duct and intrahepatic bile ducts were di-
lated (Figure 2). While we were removing the cyst, the
cyst wall was quite thin and so much adhered to the sur-
rounding tissue that surgical dissection was impossible
(Figure 3). We thought that dissection of the cyst wall is
riskier in such cases and decided to perform mucosec-
tomy. However, the cyst wall was too thin to allow mu-
cosectomy and cystic fluid became apparent. Due to all
these complexities, we had to perform a total removal of
the gallbladder and the cyst: we carried out total cyst
excision and Roux-en Y cholechojejunostomy. On day
14 after the operation, no complications developed and
the patient was discharged. Pathological examination
revealed that the cyst wall was 1 mm in thic kness and its
mucosa was occasionally shed (Figure 4).
3. Discussion
Many treatment alternatives have been described for
choledochal cysts and the alternative of choice at present
is total excision of the cyst and extrahepatic bile ducts
and Roux-en Y choledochojejunostomy [6]. Although
such complications as recurrent cholangitis, intrahepatic
bile duct stones, pancreatitis, intrahepatic calculi and
malignancy may appear [3], no complications occurred
during one year fo llow-up of this patient.
If there is excessive adhesion between a cyst and sur-
rounding tissues at the time of total excision of the cyst
and bile ducts, dissection can be very difficult. Actually,
if the diagnosis is delayed, there may be an increase in
adhesions. Cyst mucosectomy is recommended for the
treatment of such cases in order to decrease surgical risk
and complications. It is claimed that this method pre-
vents postoperative pancreatitis and/or stone formation
due to residual cyst [5].
However, as in the case presented here, when the cyst
wall became too thin and its mucosa was shed, muco-
sectomy can be technically impossible. Therefore, full
Figure 1. MR cholangiography demonstrated a choledochal
cyst containing multi p le ca l c uli.
Figure 2. Intraoperative cholangiography, the cyst was
about 7-8 cm in length and 5 cm in width and connected to
the pancreas via 1.5 cm-common bile duct.
Figure 3. The cyst wall so much adhered to the surrounding
tissue.
Figure 4. Pathological image, the cyst wall was 1mm in
thickness and its mucosa was occ a sionally she d.

S.ÖZKISACIK ET AL. 7
thickness total excision can be the only alternative left
despite high surgical risk.
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