19/02/2026
🌟Choledochal Cysts – Types and Management
📌Choledochal cysts are congenital cystic dilatations of the biliary tree. They are associated with an abnormal pancreaticobiliary junction and carry a significant lifetime risk of malignancy (especially cholangiocarcinoma).
Classification (Todani Classification)
📌The most widely used system is the Todani classification, which divides choledochal cysts into five main types:
Type I – Extrahepatic bile duct dilatation (most common, 50–80%)
🔘Ia – Diffuse cystic dilatation of CBD
⏺️Ib – Focal segmental dilatation
🔘Ic – Fusiform dilatation of CBD
Management:
➡️ Complete excision of extrahepatic bile duct + Roux-en-Y hepaticojejunostomy
Type II – True diverticulum of CBD
🔘Saccular outpouching from extrahepatic bile duct.
▶️Management:
➡️Diverticulectomy ± primary closure of CBD
Type III – Choledochocele
⏺️Intraduodenal dilatation of distal CBD (within ampulla)
▶️Management:
➡️Endoscopic sphincterotomy (often sufficient)
➡️Surgical excision if large/symptomatic
Type IV – Multiple cysts
⏺️IVa – Both intrahepatic and extrahepatic involvement
🔘IVb – Multiple extrahepatic cysts only
Management:
➡️ Excision of extrahepatic bile duct + Roux-en-Y hepaticojejunostomy
➡️ Liver resection if localized intrahepatic disease
➡️Liver transplant if diffuse severe intrahepatic disease
Type V – Caroli Disease
• Multiple intrahepatic cystic dilatations only
Associated with congenital hepatic fibrosis.
▶️Management:
➡️ Segmental liver resection (localized)
➡️ Liver transplantation (diffuse disease)
▶️Clinical Presentation:
▶️Children: classic triad (rarely complete)
🔘Abdominal pain
⏺️Jaundice
🔘Palpable mass
▶️Adults:
🔘Recurrent cholangitis
⏺️Pancreatitis
🔘Biliary colic
⏺️Incidental finding
▶️Investigations:
🔘Ultrasound – initial test
⏺️MRCP – investigation of choice
🔘CT if malignancy suspected
⏺️LFTs
▶️ERCP mainly therapeutic (type III).
▶️Complications:
🔘Cholangitis
⏺️Pancreatitis
🔘Stones
⏺️Strictures
🔘Rupture (rare)
⏺️Cholangiocarcinoma (10–30% lifetime risk if untreated)
▶️Principles of Management (Important for Practice)
☀️ Complete cyst excision whenever possible
☀️Avoid drainage procedures (obsolete due to cancer risk)
☀️Long-term follow-up due to residual malignancy risk
☀️Early surgery in children once diagnosed
✔️Surgical Standard Operation🌟
👩⚕️Cyst excision + Roux-en-Y hepaticojejunostomy
→ Gold standard for Type I and IV
