Endoscopic Unroofing of a Choledochocele

Abstract

A 42-year-old man with previous laparoscopic cholecystectomy was referred for further evaluation of recurrent acute pancreatitis. Secretin-enhanced magnetic resonance cholangiopancreatography showed a 16 mm × 11 mm T2 hyperintense cystic lesion at the major papilla (Figure 1). Upper endoscopic ultrasound (EUS) showed a 15 mm × 10 mm oval, intramural, subepithelial lesion at the major papilla (Figure 2). Endoscopic retrograde cholangiopancreatography (ERCP) showed an 18-mm bulging lesion at the major papilla with normal overlying mucosa (Figure 3); injected contrast collected into a 16-mm cystic cavity (Figure 4). Findings were suggestive of type A choledochocele. A 10–12-mm freehand precut papillotomy was made with a monofilament needle-knife (Huibregtse Single-Lumen Needle Knife, Cook Medical, Bloomington, IN) using an ERBE VIO electrocautery system (ERBE USA; Marietta, GA). The incision was made as long as safely possible in an attempt to open the choledochocele completely and thus expose its walls and contents. We used a standard pull sphincterotome and ERBE electrocautery to perform the pancreatic sphincterotomy, followed by placement of a pancreatic stent. Biliary sphincterotomy was performed using the same technique (settings for needle-knife and pull sphincterotomies: Endocut I, blend current, effect 2/duration 2/interval 3). Biopsies of the inverted choledochocele showed biliary mucosa and duodenal columnar epithelium with inflammation and fibrosis, and no dysplasia. Follow-up ERCP at 4 weeks showed adequate unroofing of the choledochocele (Figure 5); the pancreatic stent was subsequently removed. The patient reported no recurrence of acute pancreatitis at 6-, 12-, and 18-month follow-up intervals.