American Board of Surgery Qualifying Exam (ABS QE) Practice Test

What is the advisable treatment for a Type 4 choledochal cyst?

1. Excise cyst

2. Liver resection if possible or liver transplant

3. Transduodenal excision of cyst

4. Roux-en-Y hepaticojejunostomy

The correct answer is: Liver resection if possible or liver transplant

In the case of a Type 4 choledochal cyst, the advisable treatment is to perform a liver resection when feasible or to consider liver transplantation. Type 4 choledochal cysts are characterized as being cystic dilatations of the intrahepatic and/or extrahepatic bile ducts. Given this alteration in the bile duct anatomy and the associated risk of complications, including cholangiocarcinoma, aggressive management is required. Surgical interventions aim to eliminate the cystic structures to reduce complications like malignancy formation and recurrent cholangitis. While cyst excision and reconstruction techniques, such as Roux-en-Y hepaticojejunostomy, might be considered in other types of choledochal cysts, Type 4 typically necessitates liver resection or transplantation due to the extent of disease involvement. When liver tissue shows significant pathology or if extensive resection would be necessary, liver transplantation becomes the preferred option to restore biliary anatomy and function effectively. This approach reduces the presence of potentially malignant cysts while addressing the functional aspects of the liver, thereby ensuring a better prognosis for the patient.