{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 27, Ep 4 of 4: Cysts, Leaks, Strictures, and Sphincter Dysfunction","html":"","width":"100%","height":180,"duration":773,"description":"Episode four turns to the duct that is structurally abnormal from birth or made abnormal by an operation, where the recurring move is to read the anatomy and let it dictate whether an endoscopic fix can work at all. Choledochal cysts drive cholangiocarcinoma through decades of epithelial exposure to refluxed enzymes, and the Todani type dictates the operation, with complete excision the rule and the choledochocele the low-risk exception. Bile leak and stricture are the iatrogenic version, where the Strasberg level decides whether endoscopic stenting can bridge the injury at all, so a cystic-stump leak seals with a stent while a complete transection needs hepaticojejunostomy. Sphincter of Oddi dysfunction divides into a true stenosis that sphincterotomy cures, a functional pain that a procedure only harms, and a heterogeneous middle where empiric sphincterotomy beats a manometry-driven workup.\n \nTopics covered\n\nCholedochal cysts and the Todani classification\nCholangiocarcinoma risk and cyst anatomy\nCyst excision and hepaticojejunostomy\nPancreaticobiliary maljunction\nCaroli disease and syndrome\nBile leaks and the Strasberg classification\nType E transection and reconstruction\nPost-cholecystectomy strictures\nSphincter of Oddi dysfunction reclassified\n \n \nKey decisions\n\nTodani type one, two, and four choledochal cysts need complete cyst excision, cholecystectomy, and a Roux-en-Y hepaticojejunostomy, because a Whipple leaves proximal cyst epithelium and its cancer risk in place.\nThe choledochocele is the exception, where the intraduodenal location and very low malignancy risk make endoscopic sphincterotomy or limited excision sufficient.\nWhenever pancreaticobiliary maljunction is found, prophylactic cholecystectomy is part of the operation cyst or no cyst, because in maljunction without cysts gallbladder cancer develops in about a third of patients.\nAfter cyst excision, current guidance recommends lifelong MRCP every three to five years to surveil retained at-risk...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}