PANCREATITIS ASSOCIATED WITH ADULT CHOLEDOCHAL CYSTS

We reviewed the records of 32 adult patients with choledochal cysts (C DC) to determine the characteristics of the associated pancreatic dise ase. Eighteen patients (56%) had 30 documented episodes of pancreatiti s with epigastric pain and elevated serum amylase levels. Three patien ts developed a prolonged course with a pancreatic phlegmon and one pat ient died secondary to a pancreatic abscess after endoscopic retrograd e cholangiopancreatography (ERCP). Pancreatitis occurred in all types of CDC and was not related to the age, gender, or race of the patient. There was an association with the size of the CDC: 90% of patients wi th CDC greater than or equal to 5 cm developed pancreatitis compared w ith only 9% of patients with CDC < 5 cm (p < 0.0004). In addition, ERC P was performed in 14 patients and demonstrated an abnormal pancreatic obiliary duct junction in eight (57%). All eight patients with an abno rmal pancreaticobiliary junction developed pancreatitis compared with only 2 out of 6 patients with normal pancreatic duct anatomy (p < 0.00 6). Patients undergoing surgical bypass rather than resection also ten ded to have higher rates of pancreatitis (80 vs. 50%). One patient wit h a Type I CDC and chronic pancreatitis was treated with surgical rese ction of the CDC and pancreatic head; this combined procedure relieved the pain. Microscopic examination of the CDC and the abnormal ''commo n channel'' within the pancreas revealed identical fibrous thickening of the duct walls with focal chronic inflammation and loss of surface epithelium. In conclusion, these data stress the previously unrecogniz ed high incidence of symptomatic pancreatic inflammatory disease that accompanies adult CDC. Diagnostic ERCP and surgical manipulations of t he pancreas should be done with care to avoid precipitating pancreatit is. CDC resection is preferred to surgical bypass to avoid anastomotic stricture with cholangitis and to minimize the chance for ongoing pan creatitis.