Presentation and outcomes of surgery for choledochal cyst in children and adults: an experience of 329 cases

The purpose of this study is to report our experience in patients with choledochal cyst (CDC) and to evaluate whether there is any difference in the clinical presentation, cyst -related complications, and long-term biliary outcomes after surgery among children and adults. All the patients who underwent CDC excision between January 2008 and December 2023 were retrospectively reviewed. The patients were divided into two groups: children (< 18 years) and adults (>= 18 years). There were 329 patients with CDC excision (77.5% were female, adult/children = 251/78). Abdominal pain was the predominant presenting symptom in both groups. Abdominal lump (10.3% vs 3.2%; p = 0.011) and the triad of CDC (9% vs 2.4%; p = 0.009) were more common in children. But, the preoperative biliary intervention (37.8% vs 15.4%; p = < 0.001), previous biliary surgery (32.7% vs 3.8%; p = < 0.001), and prevalence of gallstones (36.7% vs 3.8%; p = < 0.001), cystolithiasis (56.6% vs 38.5%; p = 0.005), and intrahepatic stones (7.6% vs 1.3%; p = 0.054) were more common in adults. Most patients were presented with type I CDC (71.4%). Extrahepatic bile duct excision with Roux en-Y hepaticojejunostomy was performed in all the patients. Although overall postoperative complications were comparable between adults and children (31.1% vs 26.9%; p = 0.485), wound infection was more common in adults (19.9% vs 6.4%; p = 0.005) and bile leak was more common in children (12.8% vs 5.2%; p = 0.021). There was no operative mortality. Over a mean follow-up of 59 (40) months, 2 patients (0.78%) developed malignancy. Excellent or good Long-term biliary outcome was significantly better in children than adults (98.1% vs 90.5%; p = 0.010). Independent predictors for unsatisfactory biliary outcomes were type IVA cysts, postoperative bile leak, adult patients, and longer duration of follow-up. In conclusion, presentation and cyst-related complications differ between adults and children. Surgery offers excellent results in the vast majority of patients. Long-term biliary complications were more in adults. Long-term follow-up is recommended for the possibility of future development of hepato-biliary-pancreatic malignancy and delayed biliary complications.