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. Topics covered Choledochal cysts and the Todani classification Cholangiocarcinoma risk and cyst anatomy Cyst excision and hepaticojejunostomy Pancreaticobiliary maljunction Caroli disease and syndrome Bile leaks and the Strasberg classification Type E transection and reconstruction Post-cholecystectomy strictures Sphincter of Oddi dysfunction reclassified Key decisions Todani 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. The choledochocele is the exception, where the intraduodenal location and very low malignancy risk make endoscopic sphincterotomy or limited excision sufficient. Whenever 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. After cyst excision, current guidance recommends lifelong MRCP every three to five years to surveil retained at-risk epithelium that can still progress to cholangiocarcinoma. Strasberg type A cystic-stump leaks seal in most cases with endoscopic sphincterotomy plus a transpapillary stent within four to six weeks, and type C and D injuries with luminal continuity can also be stented. Strasberg type E complete transection has no continuity for a stent to reach and requires surgical Roux-en-Y hepaticojejunostomy, with the Bismuth level predicting complexity. The former SOD type one is true mechanical stenosis treated with empiric biliary sphincterotomy without manometry, the former type three is functional pain that should not undergo ERCP, and suspected sphincter dysfunction demands aggressive prophylaxis with rectal indomethacin, lactated Ringer's, and a pancreatic duct stent. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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