Successful Open Bile Duct Excision with Roux-en-Y Hepaticojejunostomy for Choledochal Cyst

Chief Complaints

A 12-year-old female patient with a body mass index (BMI) of 19 presented to the Surgical Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of intermittent abdominal pain in the right upper quadrant and epigastric region for the past four years. The last episode of pain occurred four days prior to admission. There was no history of fever, jaundice, right upper abdominal lump, altered bowel habits, or weight loss.

The patient was a newly diagnosed case of primary hypothyroidism with no other known comorbidities and no history of prior abdominal surgery. There was a history of similar intermittent complaints over the past four years. The patient had a documented allergy to a cephalosporin-class antibiotic.

On examination, the patient was conscious, alert, and well-oriented, with stable vital signs and no evidence of fever or respiratory distress. General physical examination revealed no pallor, icterus, lymphadenopathy, or edema. Per abdominal examination showed a soft, non-tender abdomen with no palpable masses or organomegaly, and no signs of guarding or rigidity; bowel sounds were normal. Other systemic examinations were unremarkable.

Upon admission to PACE Hospitals, following the clinical assessment, the Surgical Gastroenterology team conducted a comprehensive evaluation based on the patient’s complaints of recurrent right upper quadrant and epigastric abdominal pain with a history of similar episodes over four years. A detailed medical history, physical examination, and preoperative assessment were performed to evaluate overall fitness for surgery and to identify associated comorbid conditions, including primary hypothyroidism and iron deficiency anemia.

Baseline investigations, including complete blood picture, renal function tests, liver function tests, serum electrolytes, coagulation profile, inflammatory markers, thyroid profile, iron studies, vitamin levels, viral screening, blood and urine cultures, chest X-ray, electrocardiography, ultrasonography of the abdomen and pelvis, computed tomography (CT) abdomen, magnetic resonance cholangiopancreatography (MRCP), and other relevant biochemical and imaging studies were carried out. Imaging revealed a Type I choledochal cyst with dilatation of the extrahepatic biliary tree, while other investigations were largely within acceptable limits for surgical intervention.

Based on the confirmed diagnosis, the patient was advised to undergo Type 1 Choledochal Cyst Treatment in Hyderabad, India, under the expert care of the Surgical Gastroenterology Department.

After a detailed consultation with the surgical gastroenterologist Dr. CH. Madhusudhan, along with the Gastroenterology consultants Dr. Govind Verma, Dr. M Sudhir, and Dr. Padma Priya, and the Endocrinologist Dr. Tripti Sharma, a comprehensive clinical, biochemical, endocrinological, and radiological evaluation was carried out to determine the most appropriate management plan for the patient. Based on the patient’s history of chronic intermittent right upper quadrant and epigastric abdominal pain and imaging findings from USG abdomen, CECT abdomen, and MRCP showing dilatation of the extrahepatic biliary tree with smooth distal tapering, a diagnosis of Type I choledochal cyst was established. Associated iron deficiency anemia and primary hypothyroidism were also identified and medically optimized prior to surgery.

A detailed review of investigations, including complete blood picture, liver function tests, renal function tests, serum electrolytes, coagulation profile, iron studies, vitamin levels, thyroid profile, inflammatory markers, infection screening tests, cultures, and radiological imaging, was performed by the multidisciplinary team to assess surgical fitness and define disease extent. Based on the collective evaluation and multidisciplinary consensus, and considering the risk of recurrent biliary infection, pancreatitis, cholangitis, and long-term malignant transformation associated with choledochal cysts, surgical management was planned.

It was determined that open extrahepatic bile duct excision with Roux-en-Y hepaticojejunostomy was the most appropriate definitive treatment to remove the diseased biliary segment and restore normal biliary drainage. The patient was optimized preoperatively with correction of anemia, and supportive care.

The patient and her family members were counselled in detail regarding the diagnosis, surgical procedure, expected outcomes, and possible complications, including bile leak, anastomotic stricture, infection, and need for long-term follow-up, along with postoperative care instructions.

Following the decision, the patient was scheduled to undergo Open Extrahepatic Bile duct excision with Roux-en-Y Hepaticojejunostomy in Hyderabad at PACE Hospitals under the expert care of the Surgical Gastroenterology Department. 

The procedure involved the following steps:

• Surgical Access and Exposure: Right-sided subcostal (Kocher’s) incision was given. Abdomen was opened in layers and adequate exposure of the hepatobiliary region was achieved. Intraoperatively, dilated common bile duct (CBD), common hepatic duct (CHD), and cystic duct were identified.

• Bile Duct Dissection and Hilar Anatomy Identification: Circumferential dissection of the CBD was performed carefully. Hepatic arterial anatomy was delineated, including common hepatic artery (CHA), right hepatic artery (RHA), and left hepatic artery (LHA). It was noted that the RHA had an early origin from CHA and was coursing posterior to the CBD.

• Excision of Diseased Bile Duct: Distal CBD was dissected up to the pancreatic head, then divided, and the distal stump was securely sutured. The CBD was further dissected off the portal vein (PV) and RHA and divided near the hepatic hilum, completing extrahepatic bile duct excision.

• Reconstruction – Roux-en-Y Hepaticojejunostomy Formation: A Roux limb was created and brought in a retrocolic fashion through the transverse mesocolon. End-to-side hepaticojejunostomy was performed with posterior layer continuous suturing using PDS 5-0, and anterior layer interrupted suturing using PDS 5-0. Jejunojejunostomy was completed in two layers using outer 4-0 silk and inner 4-0 Vicryl.

• Completion, Hemostasis, and Closure: Mesenteric rent was closed, and meticulous hemostasis was achieved. The hepaticojejunostomy site was checked for leak using gauze. A Jackson-Pratt drain was placed, and the incision was closed in layers after confirming stability of the operative field.

During the postoperative period, the patient had an uneventful recovery after surgery. She was managed with intravenous fluids to maintain hydration, treatment to prevent postoperative infection, and acid suppression therapy to protect the stomach lining and support gastrointestinal healing. Supportive care included close monitoring of vital signs, adequate pain control, and maintenance of overall clinical stability.

The patient was closely observed for possible complications such as bile leakage, intra-abdominal fluid collection, and wound infection, with regular clinical assessment and imaging when required. A screening ultrasound confirmed satisfactory postoperative recovery, following which the drain was safely removed. Oral feeding was introduced gradually and advanced stepwise as tolerated until a normal diet was achieved. At discharge, she was stable, ambulatory, and advised regular follow-up along with proper wound care.

Upon discharge, the patient was advised a short course of treatment to prevent and manage postoperative infection and support recovery after surgery. Medications were given for the protection of the stomach and upper gastrointestinal tract, along with relief of post-surgical pain and discomfort. Ongoing therapy was continued to manage hypothyroidism and maintain hormonal balance. Additional supportive treatment was prescribed to promote bile flow and aid liver recovery following biliary reconstruction. Nutritional supplementation was also recommended to support wound healing and overall recovery, with clear instructions on regular intake and adherence.

The patient was advised to follow an iron-rich diet to support correction of anemia and promote postoperative recovery. Discharge advice included proper wound care with maintenance of cleanliness and dryness of the surgical site, along with alternate-day dressing changes under aseptic precautions to ensure optimal healing and prevent infection.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as abdominal pain, fever, or vomiting.

The patient was advised to follow up with the Surgical Gastroenterologist in Hyderabad at PACE Hospitals, after 1 week, and to also review with the Gastroenterologist after 1 week for further evaluation and management.

This case highlights a Type I choledochal cyst in a pediatric patient presenting with chronic right upper abdominal pain, confirmed on imaging and managed surgically. The patient underwent successful open extrahepatic bile duct excision with Roux-en-Y hepaticojejunostomy without complications. Postoperative recovery was uneventful with clinical improvement, drain removal, and stable condition at discharge.