Endosonographically confirmed type III choledochal cyst managed with endoscopic needle-knife division

Type III choledochal cysts consist of a cystic dilatation of the intraduodenal portion of the common bile duct and represent the rarest subtype, with a low risk of malignancy. Traditionally, choledochoceles are treated with surgical resection or endoscopic choledochal cyst fenestration with cannulation of the cyst via the native papilla and marsupialization using a sphincterotome. We describe a novel approach to management of a type IIIA choledochal cyst with endoscopic needle-knife division and marsupialization of a type IIIA choledochal cyst.

A 19-year-old male nonsmoker with a 5-year history of intermittent, colicky epigastric pain was referred to our tertiary center for management of a large (69 × 53 × 89 mm) type IIIA choledochal cyst confirmed on MRCP. Duodenoscopy revealed a large pendulous mass, with significant medial displacement of the duodenum and intermittent gastric outlet obstruction, that prevented clear visualization of the distally located papilla. After careful multidisciplinary team discussion, it was decided that endoscopic needle-knife division and marsupialization would be undertaken to reduce biliary stasis and the chance of further ductal stone formation.

Needle-knife division was performed using a freehand technique using ENDO CUT I (30 W, 3d 3i). To decompress the cyst, a large incision was made from the inferior to superior position on the luminal aspect of the cyst. Further incisions were made to marsupialize the cyst cavity and allow complete drainage of the cystic content into the duodenum. The patient tolerated the procedure well, with no bleeding postprocedure. Serial imaging demonstrated complete resolution of the large choledochal cyst, with no adverse events at last follow-up (12 months after the procedure).

Endoscopic needle-knife division and marsupialization is an effective novel approach for the treatment of symptomatic choledochoceles; however, more data are required to evaluate the long-term safety of this approach.