title: Forty-year experience with flow-diversion surgery for patients with congenital choledochal cysts with pancreaticobiliary maljunction at a single institution.
abstract: BACKGROUND
  Congenital choledochal cyst with pancreaticobiliary maljunction (PBM) is known as a high-risk factor for various complications such as cholangitis, pancreatitis, and carcinogenesis of the biliary system by mutual refluxes of bile and pancreatic juice. Furthermore, it is not rare to suffer from postoperative complications if the wrong operative procedure is chosen. Therefore, we sought to review the relationship between operative procedure for types I and IV-A (Todani's classification) congenital choledochal cyst with PBM, and long-term treatment outcome.
  
  
  METHODS
  A retrospective review was carried out of 144 patients who underwent flow diversion surgery in our institution during the 40-year period from 1968 to 2008 and who did not have a coexisting malignant tumor at the time of surgery.
  
  
  RESULTS
  Of these 144 patients, 137 underwent complete cyst excision and 7 underwent pancreas head resection as flow diversion surgery. The follow-up periods ranged from 1 to 345 months and from 1 to 271 months (average, 100.2 and 94.1) in patients with type I and type IV-A cysts, respectively. Regarding surgical treatment outcome, postoperative progress was good in 130 (90.3%) of the 144 patients. Fourteen patients required hospitalization for long-term postoperative complications such as cholangitis, pancreatitis, intrahepatic calculi, pancreatic calculus, and carcinogenesis during postoperative follow-up. Of these, 2 patients who underwent surgery for type IV-A cysts died because of secondary biliary cirrhosis with liver failure and advanced intrahepatic cholangiocarcinoma, respectively.
  
  
  CONCLUSIONS
  The present study shows that flow diversion surgery for congenital choledochal cysts with PBM significantly reduces the risk of subsequent development of malignancy in the biliary tract, and it is vital to choose the appropriate operative procedure to prevent occurrence of these postoperative complications.
authors.affiliation: Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan. takeshita@ige.twmu.ac.jp
authors.forename: Nobuhiro
authors.initials: N
authors.lastname: Takeshita
authors.forename: Takehiro
authors.initials: T
authors.lastname: Ota
authors.forename: Masakazu
authors.initials: M
authors.lastname: Yamamoto
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001650:Bile Duct Neoplasms / Q000209:etiology / Q000401:mortality; D017734:Bile Ducts, Extrahepatic / Q000002:abnormalities* / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic; D015904:Biliopancreatic Diversion / Q000379:methods* / Q000401:mortality; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D018281:Cholangiocarcinoma / Q000209:etiology / Q000401:mortality; D015529:Choledochal Cyst / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008105:Liver Cirrhosis, Biliary / Q000209:etiology / Q000401:mortality; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods; D010183:Pancreatic Ducts / Q000002:abnormalities* / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology* / Q000401:mortality; D012189:Retrospective Studies; D015996:Survival Rate; D055815:Young Adult