Parikh and Lillemoe2 have emphasized the association between type I and type IV choledochal cysts and cholangiocarcinoma and the importance of complete cyst excision and reconstruction with a Roux-en-Y hepaticojejunostomy. The association with type II and type III (choledochoceles) is less clear, but adult patients still often present with jaundice, cholangitis, or pancreatitis and these cysts should also be resected. An important diagnostic tool in patients with choledochal cysts is biliary cytology, but the authors do not describe the potential screening value of the tumor-associated antigen CA19-9,11 that has also been shown to be useful in patients with primary sclerosing cholangitis who are at risk for developing cholangiocarcinoma. The fluorescence in situ hybridization (FISH) cytological test is a new screening tool that holds additional promise for early identification of cholangiocarcinoma.12 The authors note that unilobar Caroli's disease (type V) should be managed with hepatic resection because of the risk of cholangiocarcinoma and this has been pointed out to be true in children as well where they are often seen in association with type I or type IV choledochal cysts and concomitant cyst excision and lobectomy should be performed.
In the authors' discussion of bile leaks after laparoscopic cholecystectomy, they note that hepatobiliary iminodiacetic acid (HIDA) scans are not sensitive enough to identify the source of the leak. However, in a patient with a suspected bile duct injury, the HIDA scan can help in determining whether the patient should undergo an ERCP or PTC. If the HIDA scan shows the radionuclide passing into the duodenum, then an ERCP would be the appropriate initial diagnostic test, whereas if no radionuclide passes into the duodenum the most appropriate initial study would be a PTC since the ERCP would likely only show an obstructed, clipped, or transected duct. The role of injecting a subhepatic drain, placed to drain a biloma, in diagnosing the source of leak cannot be overemphasized if the PTC or ERCP do not show the source of the leak. Drain injection can demonstrate a transected right posterior duct that is not in communication with the CBD. Finally, the authors suggest for waiting 6–8 weeks after drainage to proceed with repair. My practice has been to wait about 2 weeks after drainage from above (PTC) and below (CT or ultrasound-guided drainage) before proceeding with Roux-en-Y hepaticojejunostomy which provides more than adequate time for the inflammatory process to abate and permits safe repair. I also leave the transhepatic catheter in place for 3 months, obtaining a cholangiogram at 5 days, 1 month, and 3 months.
The authors argue that the management of recurrent pyogenic cholangitis involves primarily treating biliary strictures with biliary drainage utilizing a Roux-en-Y hepaticojejunostomy. However, just as with percutaneous or endoscopic management, drainage procedures are associated with a high risk of recurrence and hepatic resection of unilobar disease is curative and is the treatment of choice.10