A 16-year-old girl has recurrent episodes of jaundice with abdominal pain and a palpable right upper quadrant mass. MRCP shows fusiform dilatation of the entire extrahepatic bile duct extending to involve both right and left intrahepatic ducts. According to the Todani classification and management principles, the correct statement is:
- A This is a type II cyst, treated by diverticulectomy
- B This is a type IVA cyst, treated by complete cyst excision with Roux-en-Y hepaticojejunostomy ✓
- C Internal drainage by cystoduodenostomy is the procedure of choice
- D This is a type V cyst, best managed by liver transplantation in all cases
Correct answer: B. This is a type IVA cyst, treated by complete cyst excision with Roux-en-Y hepaticojejunostomy
Explanation
Fusiform dilatation of the whole extrahepatic duct with intrahepatic involvement defines Todani type IVA. Definitive treatment is complete excision of the cyst with Roux-en-Y hepaticojejunostomy, because retained cyst mucosa carries a high lifetime risk of cholangiocarcinoma. Internal drainage procedures such as cystoduodenostomy are obsolete for this reason, leaving malignant epithelium behind.
Reference: Bailey and Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.