A Study of MRCP and intraoperative correlation of anatomy of choledochal cysts.

Vijay Ganesh, S (2011) A Study of MRCP and intraoperative correlation of anatomy of choledochal cysts. Masters thesis, Madras Medical College, Chennai.

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Abstract

INTRODUCTION : The liver develops from an endodermal bud in the ventral floor of the foregut at about 22 days' gestation. One type of endodermal cell in the cranial portion of the liver diverticulum serves as a common precursor for both hepatocytes and the intrahepatic and hilar bile ducts. Immature hepatocytes, or hepatoblasts, are derived from these early cells and retain the potential to differentiate into either hepatocytes or intrahepatic ducts. These cells may persist as a facultative stem cell and can be stimulated to proliferate and differentiate under certain pathologic conditions. At about 2 months' gestation, primitive intrahepatic bile ducts can be distinguished from early hepatocytes by their tendency to form a sleeve around portal venous branches and associated mesenchyme. This sleeve is termed the ductal plate. Portions of the sleeve are duplicated, forming small linear tubules that differentiate into bile ducts. This process begins at the liver hilum and extends peripherally into the segmental distribution of the developing liver. At the hilum, connection is made to the extra hepatic bile ducts. Formation of the major branches of the biliary tree is completed by 10 to 12 weeks' gestation, but the peripheral branches continue developing throughout gestation. The development of the distal common bile duct and pancreaticobiliary junction is particularly relevant to pediatric surgeons. During the fifth week of gestation, the dorsal and ventral pancreatic buds appear. The dorsal bud forms the body of the pancreas and empties through what will become the accessory pancreatic duct (Santorini) into the duodenum. The ventral bud arises from the distal common bile duct, rotates dorsally to join the body of the pancreas as the uncinate process, and empties through the main pancreatic duct (Wirsung) into the common bile duct. During normal development, the junction between the main pancreatic duct and the common bile duct migrates distally through the duodenal wall to unite within the sphincter of Oddi at the ampulla. Abnormalities in this process account for a variety of anatomically based biliary disorders of childhood. AIMS : 1. To analyze the epidemiology of choledochal cyst related to age, sex and type. 2. To analyze various clinical presentations of choledochal cyst. 3. To discuss the role of ultra-sonogram in the diagnosis and follow up of patients. 4. To analyze the length of common channel by a preoperative MRCP. 5. To correlate intraoperative biliary amylase levels with the type of choledochal cyst. 6. To discuss various complications of choledochal cyst after operative treatment. PATIENTS AND METHODS : All patients presenting to the paediatric surgical department between Jan 2008 to Jan 2011 treated at Institute of child health, Egmore were included in the study. The median age was 5 years (range: 4months to 12 years). The male to female ratio is 1:2. All patients underwent surgery after complete investigations and evaluation. The study was designed as a case cohort report. Data were registered using patient’s files, operative reports and office notes. The following data were collected: presenting symptoms, complications of disease, diagnostic strategy and treatment of choledochal cysts. CONCLUSION : Choledochal cysts are resected more often in childhood. Presenting symptoms are age dependent with abdomen pain predominating in all age groups with male to female ratio of 1:2. Biliary amylase levels are a sensitive marker in detecting type 4 cysts (100%) but not in other types (table7). Ultra sonogram is the major diagnostic tool and a highly sensitive investigation in picking up choledochal cysts and its accuracy is increased when accompanied by MRCP. MRCP appears to offer diagnostic information that is equivalent to that of ERCP. It is a first choice imaging technique for examination of pediatric patients with choledochal cysts. A preoperative finding of pancreatitis with a long common channel by MRCP correlates well with an elevated cyst amylase in my study and is 100% diagnostic in supporting the theory of long common channel proposed by Babbitt et al. Total excision of the cyst with hepaticojejunostomy is the preferred surgical treatment and is well tolerated with minimal complications and there was no mortality in the group. Whereas post-operative pancreatitis is more common with the hepaticojejunostomy group, adhesive obstruction and biliary leak is more common with the hepaticoduodenostomy group. 8. In view of high risk of cholangiocarcinoma, complete resection and not internal drainage is the appropriate treatment of type1, 2 and the extra hepatic part of type 4 biliary cysts.

Item Type: Thesis (Masters)
Uncontrolled Keywords: MRCP ; intraoperative correlation ; anatomy of choledochal cysts.
Subjects: MEDICAL > Paediatric Surgery
Depositing User: Kambaraman B
Date Deposited: 28 Jul 2017 03:03
Last Modified: 28 Jul 2017 03:03
URI: http://repository-tnmgrmu.ac.in/id/eprint/2295

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