Type IVA Choledochal Cyst: Is Hepatic Resection Necessary?

Background: This study concerns patients who have choledochal cyst with intrahepatic and extrahepatic involvement (type IVA cyst). The extent of excision and the necessity of hepatectomy, including the intrahepatic cyst in these patients have not been clarified. Study design: We have performed excision of the extrahepatic cyst with hepaticojejunostomy upon 13 patients with type IVA cyst during a 16 year period. The present study was done to examine the size of the anastomotic opening by direct cholangiography two weeks postoperatively. The long-term results were assessed to find the appropriate operative management for patients with type IVA cysts. Results: Intrahepatic cysts were present in both hepatic lobes in 11 patients (85 percent). None of the patients had carcinoma after excision of extrahepatic cyst during the follow-up period, which ranged from two months to 16 years. Postoperative late complications occurred in three patients (23 percent), hepatolithiasis in two and cholangitis in one. The anastomotic opening of hepaticojejunostomy was 13.3±4.5 mm in diameter two weeks postoperatively, which was not significantly different when compared with that in ten patients without late complications (13.4±4.9 mm). The late complications were successfully treated with either antibiotics or percutaneous transhepatic cholangioscopy, and none required a reoperation. Conclusions: The results suggest that additional hepatectomy is not required because carcinoma has rarely occurred from the intrahepatic cyst. Excision of an extrahepatic cyst with a wide hepaticojejunostomy is an acceptable operative management for patients with type IVA cysts.