Regarding the Article “Mixed Choledochal Cyst (Type i and ii) Associated With a Malformation of the Pancreatobiliary Junction. A Case Report and Review of the Literature”. Can We Improve the Diagnosis?

Dear Editor:

We have read with interest the article by Dr. Zacarías-Ezzat et al., published in Cirugía Española.¹ The article describes a case of choledochal cyst and reviews the related literature. We feel it is necessary to make some comments on this article.

In the case reported, after a computed tomography (CT) scan of the abdomen showed dilatation of the intra- and extrahepatic bile duct up to the ampullary region, surgical treatment was carried out. The procedure included diverticulectomy, but afterwards a second surgery was required for the necessary bile duct resection. We consider it a very illustrative case that demonstrates once more the need for a correct diagnosis of patients with jaundice to avoid unnecessary or inappropriate surgery. As reported by several studies,^1,2 when there is cystic dilatation of the bile duct suspected by CT, the diagnosis of choledochal cyst, its type and any possible associated pancreaticobiliary junction anomaly can be confirmed by magnetic resonance cholangiopancreatography (MRCP), which has a high sensitivity (90%–100%) and specificity (73%–100%). Thus, the management described in the article does not seem to be the most adequate. Furthermore, the authors do not describe the role of MRCP in this situation. Even though MRCP is not available at all hospitals, we believe that this diagnostic method should be mentioned as it is optimal for avoiding invasive procedures.

We would also like to emphasise that the indication for bile duct resection is considered the gold standard treatment for all type i cysts, and exeresis of the cyst is reserved for type ii.^3,4 Types iii to v cysts require a personalised approach, as we have described in our experience with 18 cases published in Cirugía Española in 2008.⁴

Last of all, as the article reports including a review of the literature, we find that both the review and bibliographic references lack the articles we have mentioned,^2–4 two of which are the most complete reviews published, and our own experience is one of the most extensive national reports.

Funding

The authors have received no funding for this paper.

Conflict of Interests

The authors have no conflict of interests to declare.