6. Hepato-biliary Surgery

Question 1

What is the function of gallbladder?

Answer 1

Bile reservoir
Concentrates bile
Secretes after meal - CCK

Question 2

List diseases of gallbladder.

Answer 2

Gallstone disease
Other benign conditions of GB:
- cholesterolosis ( change in the gallbladder wall due to excess cholesterol). Aka strawberry gallbladder
- GB polyps

Question 3

What are gallstones composed of?

Answer 3

80% = mixed (>50% cholesterol containing)
20% = cholesterol
> pigment (black or brown)

Question 4

What are the risk factors predisposing gallstones?

Answer 4

• Age > 40
• Gender (females commonly affected)
• Parity (no. of kids) + OCP (oral contraception)
• Cholesterol: obesity
• Pigment (far east): M=F. Black stones are associated with all major haemolytic anaemias, such as spherocytosis, sickle cell disease and thalassaemia. Pigment stones also linked to bile infection ( with e-coli, Bacteroides etc.)

Question 5

How do patients with gallstones present?

Answer 5

• Asymptomatic mostly
• Dyspeptic symptoms (flatulent dyspepsia)
• Biliary colic (term used for the pain associated with the temporary obstruction of the cystic or common bile duct by a stone usually migrating from the gall bladder)
• Acute cholecystitis: obstruction of gallbladder emptying due to stone impacted in cystic duct etc. Such obstruction results in an increase of gall bladder glandular secretion, leading to progressive distension that, in turn, may compromise the vascular supply to the gall bladder. Inflammatory response 2ndary to retained bile in gallbladder.
• Empyema: gallbladder distended by pus.
• Perforation: gangrenous cholecystitis my perforate
• Jaundice (Mirrizi’s Syn.)
• Gallstone Ileus

Question 6

How would you investigate presence of gallstones?

Answer 6

• Blood tests: LFT’s (AST, ALT, ALP), Amylase, Lipase, WCC (moderate leucocytosis due to acute cholecystitis)
• USS
• EUS
• Oral cholecystography
• CT scan
• Radio isotope scan (HIDA)
• IV cholangiography
  MRCP: magnetic resonance cholangiopancreatography
  PTC: Percutaneous transhepatic cholangiography
  ERCP: endoscopic retrograde cholangiopancreatography

Question 7

How are gallstones managed?

Answer 7

• Asymptomatic then don’t do anything
• Non-operative treatment: Dissolution and Lithotripsy
• Operative:
  > Open cholecystectomy
  > Mini-cholecystectomy
  > Laparoscopic cholecystectomy +/- OTC (intraoperative cholangiogram): gold standard.
  > Single port cholecystectomy
  > NOTES cholecystectomy
  > Cholecystostomy
  > Subtotal Cholecystectomy

Question 8

Define choledocholithiasis.

Answer 8

Choledocholithiasis is the name given when stones move into the bile ducts, and often cause symptoms that are classed as the acute abdomen.

• Primary vs. secondary
• Incidental at cholecystectomy
• Post-cholecystectomy pain
• Obstructive jaundice (painful): Pain, jaundice, dark urine, pale stool, pruritus, steatorrhea
• Acute pancreatitis
• Ascending cholangitis (Charcot’s triad: jaundice, fever, right upper quadrant pain)

Question 9

What is the management of common bile duct stones?

Answer 9

Expectant treatment (incidental)
Lap trans-cystic CBD exploration
Lap exploration of CBD
Open exploration of CBD
ERCP: Pre-op, Intra-op, Post-op
Transhepatic stone retrieval

Question 10

List benign biliary tract disease.

Answer 10

1. Congenital:
   - biliary atresia (1 or > bile ducts are abnormally narrow, blocked or absent).
   - Choledochal cysts (cystic dilation of bile ducts: usually lead to obstruction of bile ducts and retention of bile)
2. Benin biliary stricture
   - Iatrogenic bile duct injuries: Strasberg Classification
   - Gallstone related (Mirrizi’s)
   - Inflammatory:
   > Pyogenic
   > Parasitic
   > PSC (Primary Sclerosing Cholangitis): scarring of bile ducts - progressive and chronic. IBD linked
   > Pancreatitis
   > HIV
3. Biliary-enteric fistula

Question 11

List malignant cancers that present with jaundice.

Answer 11

1. Cholangiocarcinoma (rare, increases with age). Cancer of the biliary tree. Can occur inside or outside the liver.
2. Cancer of the Head of Pancreas

Question 12

What are the risk factors associated with cholangiocarcinoma?

Answer 12

PSC: Primary Sclerosing Cholangitis (strong association)
Congenital cystic disease
Biliary-enteric drainage
Thorotrast (contrast)
Hepatolithiasis
Carcinogens: aflatoxins, etc.

Question 13

List types of cholangiocarcinoma.

Answer 13

1. Intrahepatic (above the hilum of the liver) (6%): three types (Mass-forming, periductal, intra-ductal).
2. Extrahepatic (involving the hilum or bile duct distal to the hilum): Hilar (67%) and Distal (27%)
3. Gallbladder cancer
4. Ampullary cancer

Question 14

How does cholangiocarcinoma present?

Answer 14

Obstructive jaundice
Itching
None-specific symptoms

Question 15

What investigations would you carry out if cholangiocarcinoma suspected?

Answer 15

• Lab (blood results)
• Radiology: USS, EUS, CT, MRA, MRCP, PTC, Angiography, FDG PET.
• ERCP, Cholangioscopy and Cytology
  Typical findings are of a bile duct stricture with proximal biliary dilatation, with or without a visible mass.

Question 16

How would you manage cholangiocarcinoma?

Answer 16

1. Surgical: only potential curative option
2. Palliative:
   - Surgical bypass
   - Stenting (Percutaneous vs Endoscopic)
   - Palliative radiotherapy
   - Chemotherapy
   - PDT
   - liver transplant (not standard)

Question 17

Gallbladder cancer:

1. Prognosis?
2. Treatment?

Answer 17

1. Aggressive so poor prognosis unless detected early (usually incidental when looking at gallstones).
2. Treatment depends on stage.

Question 18

Ampullary tumours:

1. What are the histological types?
2. Treatment?
3. Where do they arise from?

Answer 18

1. Most are adenocarcinoma. Some are adenomas.
2. Treatment options:
   > Endoscopic excision
   > Trans-duodenal excision
   > Pancreaticoduodenectomy
3. Ampulla of Vater (where bile duct and pancreatic duct join and empty into duodenum).