Abdomen - Biliary

Question 1

In a patient with signs and symptoms of acute cholecystitis, evaluate whether the patient is an appropriate candidate for open or laparoscopic operative approaches based on the duration of disease, severity of disease, and prior procedures.

Answer 1

Surgeon comfort level should drive the decision on operative approach. Patients presenting with longer duration of symptoms (both chronic cholecystitis and delayed presentation of acute cholecystitis) and more severe disease are more likely to have a conversion from a laparoscopic to an open approach.

Question 2

What are contraindications to the laparoscopic approach for cholecystectomy?

Answer 2

• Generalized peritonitis
• Septic shock from cholangitis
• Severe acute pancreatitis
• Coagulopathy
• Previous abdominal surgeries that prevent abdominal access
• Advanced cirrhosis
• Suspected gallbladder cancer

Question 3

In a patient admitted with biliary pancreatitis, understand the timing and approach of cholecystectomy to prevent subsequent complications from gallstone disease.

Answer 3

Once the common bile duct has been cleared of obstruction (ERCP) or has been shown to be clear by imaging, cholecystectomy should be completed in the index hospitalization when symptoms have resolved and labs normalized.

Question 4

Major biliary structures encountered during cholecystectomy?

Answer 4

Gallbladder (neck, infundibulum, body, fundus), cystic duct, common hepatic duct, common bile duct, hepatic duct bifurcation.

Question 5

Major vascular structures encountered during cholecystectomy?

Answer 5

• Proper hepatic artery branches into right and left hepatic.
• The right hepatic passes posterior to the common hepatic duct and gives off the cystic artery at the triangle of Calot.
• The arteries feeding the common bile duct run at 9- and 3-o’clock.

Question 6

30% of patients have variant biliary anatomy. What are some of the variances encountered in cholecystectomy?

Answer 6

The cystic duct can insert directly into the right hepatic duct, be short or long, course behind the common hepatic duct. An accessory right hepatic duct is also common.

Question 7

What are some arterial variations encountered in cholecystectomy?

Answer 7

• A replaced right hepatic artery (typically off the SMA) is often found along the lateral aspect of the CBD.
• A replaced left hepatic artery is found off the left gastric.
• The common hepatic can also come off the SMA.
• The cystic artery can originate in multiple places; however, you can often find it by Calot’s node.

Question 8

At what location in the biliary tree is fluoroscopic cholangiogram performed? What anatomy does it reveal?

Answer 8

• Fluoroscopic cholangiography is performed via cannulation of the cystic duct at the gallbladder-duct junction. Thus, injection of contrast should show the remaining biliary tree including the common hepatic duct, common bile duct, the bile duct bifurcation, and contrast within the duodenum.
• 2–12% of patients have been reported to have choledocholithiasis seen on IOC. 10% of these are unsuspected pre-op.

Question 9

In a patient with signs and symptoms of acute cholecystitis, order appropriate laboratory testing and imaging.

Answer 9

• CBC, LFTs, lipase
• RUQ US - safe, sensitive, inexpensive, reliable
• HIDA - confirms dx if GB fails to fill after 2 hrs
  
  • can be used to dx dyskinesia - GB EF after CCK
• CT - sensitive, delineates anatomy, r/o other abd sources

Question 10

Interpret the labarotory workup for cholecystitis to identify other biliary pathology. What further workup may be needed?

Answer 10

• ↑ ALP, bili, transaminase - choledocholithiasis - ERCP
• ↑ amylase/lipase - gallstone pancreatitis - ERCP

Question 11

In preparation for laparoscopic cholecystectomy, poisition the patient appropriately.

Answer 11

The patient should be placed supine with either both arms tucked or extended or the right arm extended and the left arm tucked to allow two surgeons on the left side.

Question 12

Trocar placement for laparoscopic cholecystectomy?

Answer 12

Typically, 4 trocars are placed:

• 5mm or 12-mm supraumbilical camera port
• 5-mm subxiphoid working port
• 5-mm right anterior axillary retractor port
• 5-mm right mid-clavicular retractor port

Question 13

Key steps to laparoscopic cholecystectomy?

Answer 13

• Retract the fundus cephalad and the infundibulum laterally
• Begin dissection at the infundibulum
• Dissect the bottom 1/3 of the GB from the hepatic bed
• Expose hepatocystic triangle - clear tissue around Calot’s node
• Establish the critical view of safety - 2 tubular structures b/w the GB and hepatoduodenal ligament with liver visible in between
• Divide the cystic duct and artery between clips
• Retract superiorly to resect the GB from the hepatic plate

Question 14

Describe the points in the operation at which errors are most likely to occur and the nature of the errors.

Answer 14

• Visual misperception accounts for 97% of bile duct injuries
• Poor technical skill or knowledge accounts for 3% of injuries.
• Great retraction is key: The fundus is retracted toward the shoulder, exposing the infundibulum. This places the cystic duct parallel with the hepatic duct. Thus, the infundibulum must be retracted laterally to open the triangle of Calot.
• Ensuring the critical view of safety before dividing relevant anatomy is key to preventing bile duct injuries.

Question 15

Describe the indications for conversion to an open procedure.

Answer 15

• Conversion to an open procedure is not a complication and the decision to convert is based on the intraoperative assessment of anatomic clarity and surgeon comfort.
• Failure to progress
• Inadequate visualization to achieve a critical view of safety
• Inability to control bleeding
• Biliary injury

Question 16

Incision for conversion to open cholecystectomy.

Answer 16

Either a right subcostal incision or midline incision.

Question 17

What is considered the gold standard in bile duct injury prevention and reduces the incidence from 0.6% to 0–0.03%?

Answer 17

Obtaining the critical view of safety

Question 18

What intraoperative procedure is associated with improved recognition of CBD injury in cholecystectomy?

Answer 18

• Intraoperative cholangiogram
• Early recognition of injury improves patients’ long-term outcomes.
• Patients should be referred immediately to experienced specialist for repair if needed.

Question 19

Options for intervention when CBD stones are encountered intraop:

Answer 19

• Psx: pt w/ moderate risk for choledocholithiasis, so ERCP not done, and MRCP deferred
• Ductal irrigation with glucagon to relax the sphincter
• If large CBD, small stone - transcystic CBD exploration with choledochoscopy
• If large stone, small CBD - choledochotomy with choledocoscopy for stone removal
• Laparoscopic endobiliary stent placement via the cystic duct with postoperative ERCP
• ERCP during or after cholecystectomy
• Transduodenal approach is morbid

Question 20

Given a patient who presents with jaundice 4 days following an elective laparoscopic cholecystectomy, conduct a diagnostic workup.

Answer 20

• DDx: obstruction from duct injury or retained CBD stone
• Labs: CBC, transaminases, bilirubin, ALP, lipase
• Initial imaging: US - collection of bile and evaluate biliary tree
• Most useful imaging: CT - vascular injury (20%), plan repair
• Confirm injury: HIDA - incapable of precise anatomic delineation
• Assess/treat biliary anatomy: ERCP - type/level of injury, treat obstructive pathology

Question 21

Be able to initiate appropriate treatment of retained and recurrent common bile duct stones.

Answer 21

Retained bile duct stones can be identified up to 2 years following cholecystectomy. Endoscopic removal is almost universally successful.

Question 22

Discuss intra-operative evaluation of the CBD for evaluation of injury or stones.

Answer 22

IOC - may prevent injury, 90% success for injury ID, set up intervention

IO US - performed prior to dissection of critical view, sensitive and specific for detection of stones, does not allow for intervention

Question 23

After routine uncomplicated laparoscopic cholecystectomy, be able to manage diet and timing of discharge.

Answer 23

Once a patient can tolerate a regular diet and his/her pain is well controlled, s/he may be discharged.

Same-day discharge is common.

Question 24

Before performing elective laparoscopic cholecystectomy, be able to correctly order appropriate antibiotics.

Answer 24

Antibiotic prophylaxis in the elective setting: Not required in low-risk patients, may reduce wound infections in high-risk patients, and if given should be limited to a single preoperative dose within 1 hour of incision.

For non-elective cholecystectomy and/or chronic cholecystitis, antibiotics should cover enterococcus and gram-negative bacteria; a first generation cephalosporin is a reasonable choice in most settings.

Question 25

Lap chole deep venous thrombosis (DVT) prophylaxis

Answer 25

DVT prophylaxis in the form of subcutaneous heparin or pneumatic compression stockings should be used for patients with two or more of the following risk factors: case duration >1 hour, history of VTE, age >40, cancer, obesity, history of CHF/MI, CKD, IBD, severe infection, multiparity (3), peripartum, oral contraceptive use, hormone replacement therapy, inherited thrombophilia.

Question 26

You are performing a laparoscopic cholecystectomy, but are struggling to obtain good visualization. What maneuvers can you use to ensure a safe operation?

Answer 26

• Convert to an open procedure.
• Use a liver retractor – epigastric or R subcostal port laterally.
• Tilt the operating table to make the best use of gravity.
• Place additional ports.
• Confirm anatomy in all such cases; perform cholangiography.
• If there is any question, leave a drain.

Question 27

You are performing a laparoscopic cholecystectomy and have a cholangiogram that shows distal filling into the duodenum but little other information. You do not clearly see the spiral portion of the cystic duct. What will you do?

Answer 27

Put the patient in Trendelenburg position to have gravity fill the right and left common hepatic ducts. Re-do cholangiography.

Carefully dissect what you believe is the cystic duct down to its expected junction with the common hepatic duct. If this junction is not seen within a reasonably short distance, it is possible that the bile duct has been divided. Look for any signs of bile staining/leakage.

Convert to an open procedure if you are not comfortable with the anatomy or this dissection.

Question 28

During a laparoscopic cholecystectomy, you are not comfortable going any further down onto the cystic duct and want to divide at the cystic duct/gallbladder junction. You are not sure that a 10-mm clip will secure this. What can you do?

Answer 28

• Convert to an open procedure.
• Use a 2.0- or 2.5-mm staple load to divide, but be careful of the tips and how far the stapler divides.
• Divide the duct and use an Endoloop to secure.
• Hand sew the stump.
• Have a very low threshold for leaving a drain.
• Do not leave overlapping clips.

Question 29

You are seeing a patient who had a Roux-en-Y gastric bypass 2 years ago and laparoscopic cholecystectomy 4 days ago. The patient is jaundiced. How will you manage this patient?

Answer 29

• Continue with routine workup including liver function tests and abdominal ultrasound.
• If endoscopic retrograde cholangiopancreatography (ERCP) is indicated, coordinate transgastric or advanced ERCP with the endoscopy service.
• Consider percutaneous transhepatic cholangiography or MRCP as an alternative to ERCP to define the anatomy if there is no leak.

Question 30

During a laparoscopic cholecystectomy, you encounter bleeding that obscures your view. It is not massive. How will you manage this?

Answer 30

• Alert Anesthesia
• Pack with 4x4 introduced via 10 port
• Tell the circulator/scrub nurse about the sponge
• Hold pressure
• Attempt to suction / bovie; or use argon beam
• Use Gelfoam and apply pressure
• Once you have control, confirm all anatomy
• If you have any questions, convert to an open procedure
• Maintain low threshold for cholangiography

Question 31

What is a temporary blockage of the cystic duct by a gallstone, resulting in intense spasmodic pain generally felt in the right upper quadrant?

Answer 31

biliary colic

Question 32

The differentiation of biliary colic from calculous cholecystitis is…

Answer 32

unresolved blockage of the cystic duct

Question 33

This occurs when the gallbladder lumen cannot fully empty because of a stone in the gallbladder neck, activating visceral pain fibers and causing pain in the epigastrium or right upper quadrant. It is the same luminal obstruction of biliary colic but less transient and associated with sufficient stasis, pressure, infection, and inflammation.

Answer 33

acute calculous cholecystitis

Question 34

This occurs when recurrent attacks of biliary colic, with only temporary occlusion of the cystic duct, causing inflammation and scarring of the neck of the gallbladder and cystic duct leading to chronic inflammatory change.

Answer 34

chronic calculous cholecystitis

Question 35

This results from gallbladder stasis and ischemia that results in a local inflammatory process in the gallbladder wall. It tends to occur in critically ill patients, especially those with multiple organ system failure/dysfunction, immunodeficiency, diabetes, trauma, burns, cardiac conditions (eg, heart failure, coronary artery disease).

Answer 35

acalculous cholecystitis

Question 36

What percentage of patients with asymptomatic stones will develop symptoms within 20 years?

Answer 36

20-30%

Question 37

Describe the development of gangrenous and emphysematous cholecystitis

Answer 37

Without resolution of cystic duct obstruction, the gallbladder will progress to ischemia and necrosis; eventually, acute cholecystitis becomes acute gangrenous cholecystitis and, when complicated by infection with a gas-forming organism, acute emphysematous cholecystitis.

Question 38

What are two absolute requirements of cholangitis?

Answer 38

obstruction of flow causing increased intraluminal pressure and bacteria in the biliary tree

Question 39

What is grade 1 of the Tokyo classification of acute cholecystitis

Answer 39

Acute cholecystitis that does not meet the criteria for a more severe grade. Mild gallbladder inflammation, no organ dysfunction.

Question 40

What is grade 2 of the Tokyo classification of acute cholecystitis?

Answer 40

One of the following:

• Elevated white blood count (> 18,000)
• Palpable tender mass in the RUQ
• Duration of complaints > 72 hours
• Marked local inflammation, including biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis

Question 41

What is grade 3 of the Tokyo classification of acute cholecystitis?

Answer 41

One of the following (evidence of organ failure):

• Cardiovascular dysfunction (hypotension requiring treatment with dopamine ≥ 5 µg per kg of BW/min, or any dose of dobutamine)
• Neurological dysfunction (decreased level of consciousness)
• Respiratory dysfunction (ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen < 300)
• Renal dysfunction (oliguria, creatinine > 2.0 mg/dL)
• Hepatic dysfunction (prothrombin-time–international normalized ratio > 1.5)
• Hematologic dysfunction (platelet count < 100,000 per cubic millimeter)

Question 42

The most frequent isolates from the gallbladder or common bile duct are…

Answer 42

Escherichia coli (41%), Enterococcus (12%), Klebsiella (11%), and Enterobacter (9%).

Question 43

What abx covers most biliary pathogens?

Answer 43

To cover the most common bacterial species, a first-, second-, or third-generation cephalosporin or fluoroquinolone should suffice.

In a patient with suspected or documented infection of the biliary tree, such as acute cholecystitis or ascending cholangitis, antibiotics should be chosen to cover gram-negative bacteria and anaerobes (Zosyn)

Question 44

What procedure is useful when patients present with sepsis due to severe acute cholecystitis and conservative treatment alone fails, especially in moribund patients who are poor candidates for surgery?

Answer 44

Percutaneous cholecystostomy

This procedure has a high success rate and a low mortality

Question 45

Perform a laparoscopic cholecystectomy on a patient with gallstone pancreatitis when?

Answer 45

before discharge

lowers recurrence and decreases cost

Question 46

The optimal timing of cholecystectomy for patients with acute cholecystitis seems to be within…

Answer 46

2 days after admission.

However, the somewhat higher frequency of adverse events on admission day may emphasize the importance of optimizing the patient before surgery and ensuring that adequate surgical resources are available.

Question 47

What happens if lap chole is delayed more than 7 days?

Answer 47

Patients who underwent an operation later during admission were more likely to require an open procedure and sustained significantly longer postoperative and overall lengths of hospitalization.

Question 48

Certain subsets of patients constitute a higher risk pool in whom prophylactic cholecystectomy should be considered. Who are these patients?

Answer 48

• Patients with hemolytic anemias, such as sickle cell anemia (these patients have an extremely high rate of pigment-stone formation and cholecystitis can precipitate a crisis)
• Patients with a calcified GB wall (porcelain gallbladder)
• Those with large (> 2.5 cm) gallstones
• Those with a long common bile and pancreatic ducts
• Patients with asymptomatic gallstones undergoing bariatric surgery also may benefit from cholecystectomy, although this is no longer the standard of care (not only does rapid weight loss favor stone formation; in addition, after gastric bypass, ERCP to remove common bile duct stones in ascending cholangitis is extremely challenging and often unsuccessful).
• Some transplant surgeons recommend prophylactic cholecystectomy before receipt of an organ transplant because severe infection can be life-threatening in the immunocompromised patient.

Question 49

The supraduodenal CBD and common hepatic duct are supplied by…

Answer 49

…the right hepatic and cystic artery. The blood supply runs along the 3- and 9-o’clock positions of the extrahepatic bile duct.

Question 50

most common cause of acute cholangitis

Answer 50

choledocholithiasis

Question 51

in an eastern Asian population, by what mechanism can recurrent pyogenic cholangitis occur?

Answer 51

• Clonorchis or Ascaris infect biliary tree →
• secrete enzymes that hydrolyze bilirubin glucuronides to form free bilirubin →
• precipitates to form brown pigment stones →
• primary choledocholithiasis →
• obstruct the biliary tree →
• recurrent episodes of cholangitis.

Question 52

How can benign biliary strictures occur?

Answer 52

• ischemia
• recurrent choledocholithiasis
• recurrent cholangitis
• primary sclerosing cholangitis
• any inflammatory condition

Question 53

Incidence of bile duct injury during open and lap chole?

Answer 53

0.2% in open, 0.1-0.6% in lap

Question 54

Describe the critical view of safety in lap chole

Answer 54

• dissection of the lower 1/3 of the gallbladder
• only 2 structures emanating from the gallbladder
• identify these two anteriorly and posteriorly

Question 55

What effect does surgeon experience have on biliary injury rates?

Answer 55

90% of bile duct injuries occurs in a surgeon’s first 30 lap choles.

FLS now required by ABS.

Question 56

When is transcystic ductal exploration more likely to be successful than transductal?

Answer 56

small stones (< 6-8 mm), fewer than eight total stones, and a large cystic duct (> 5 mm)

Question 57

When is transductal CBD exploration more likely to be successful than transcystic?

Answer 57

large stones, multiple stones, a small or friable cystic duct, or in the setting of stones proximal to the cystic duct–CBD junction

unfavorable in the setting of marked inflammation, a small CBD diameter (< 7 mm), or when the provider has poor laparoscopic suturing ability

Question 58

What equipment needs to be ready if expecting to do a CBD exploration?

Answer 58

• Saline, water-soluble contrast, and glucagon (1-2 mg)
• Cholangiogram catheter, flexible choledochoscope/ureteroscope, stone retrieval baskets, Fogarty balloon catheters, and intravenous tubing/catheter for transcystic/transductal instillation of saline
• 14F and 16F T tubes (maybe) and absorbable monofilament suture for bile duct closure

Question 59

Describe the steps for laparoscopic transcystic CBD exploration

Answer 59

• Perform a cholangiogram.
• After establishing the stone burden, replace the cholangiogram catheter with either a basket extraction implement or choledochoscope.
• Use glucagon to relieve sphincter pressure along with transcystic flushing of the duct with saline to force debris into the duodenum.
• In cases of stone impaction, use Fogarty balloon catheters to help free the stones.
• Place retrieved stones in a safe spot in the abdomen and eventually in a specimen bag with the gallbladder.

Question 60

Describe the steps for a laparoscopic transductal CBD exploration

Answer 60

• Perform a cholangiogram.
• Forcefully flush through the transcystic catheter to distend the CBD.
• Make a distal, vertical choledochotomy w/ scissors or cautery on cut mode.
• Use a cholangiogram catheter to flush the stones.
• Perform a choledochoscopy with a flexible scope.
• Retrieve stones using a basket retrieval device through the choledochoscope.
• In cases of stone impaction, use Fogarty balloon catheters to help free stones.
• Close choledochotomy primarily or w/ a T tube >14F using monofilament.
• Studies suggest transductal exploration has higher rates of bile leak and morbidity, longer length of stay than transcystic.

Question 61

What are the steps for an open CBD exploration?

Answer 61

• Perform an extensive Kocher maneuver so the ampulla can be palpated.
• Make a distal, vertical, supraduodenal choledochotomy ~1.5 cm in length.
• Pass Fogarty catheters superiorly to extract stones from CHD then inferiorly through ampulla to extract CBD stones.
• Irrigate generously with saline.
• Ensure that the CBD is clear of stones: choledochoscopy or cholangiogram.
• Close the duct primarily or over a T tube at least 14F in size.

Question 62

Describe the steps for a transduodenal sphincteroplasty (laparoscopic or open)?

Answer 62

• Perform an extensive Kocher maneuver.
• Make a transverse or longitudinal duodenotomy on the lateral duodenal wall at the junction of the lower one-third and upper two-thirds of the duodenum.
• Identify the papilla.
• Cut the sphincter in the 11 o’clock position on the papilla using cautery or scissors. Extend this to include the entire common tract of the sphincter of Oddi.
• Extract all stones.
• Suture CBD to the duodenal mucosa using interrupted fine absorbable sutures.
• Close the lateral duodenotomy.

Question 63

In closure of a choledochotomy, when is a t-tube warranted?

Answer 63

T tube or choledochal-enteric anastomosis is warranted if there is suspicion or demonstration of retained calculi that cannot be extracted. A T tube is also considered in the setting of a borderline-sized CBD or an inflammatory reaction in the area of the CBD.

Question 64

When may common bile duct exploration be used rather than ERCP for choledocholithiasis?

Answer 64

Preference for endoscopic or surgical management of choledocholithiasis depends on availability of ERCP and laparoscopic CBD exploration as well as the skill of the provider.

Limited single-institution studies have suggested that single-stage laparoscopic CBD exploration and cholecystectomy is superior to ERCP and subsequent laparoscopic cholecystectomy in terms of length of stay and cost.

Morbidity and mortality appear to be similar.

Question 65

When might transduodenal sphincteroplasty be used in the case of choledocholithiasis?

Answer 65

Transduodenal sphincteroplasty is rarely used but is most commonly indicated when the pathology involves the ampulla. Patients may have sizable stones impacted in the distal ampullary region or papillary stenosis.

Question 66

After lap CBD exploration, are retained/recurrent stones or strictures common?

Answer 66

Limited long-term studies suggest rates of retained/recurrent stones in the range of 2% to 5% after laparoscopic CBD exploration. Late biliary stricture after either primary closure or T-tube closure in these studies is rare.

Question 67

How do you manage a retained/recurrent stones in CBD exploration (intraop and postop)?

Answer 67

Intraoperatively, T-tube drainage and delayed duct clearance is a viable option when complete stone clearance is not achieved (can convert from transcystic to transductal to duodenotomy to bil/enteric anastomosis).

Postoperatively, T tubes (if present) generally provides adequate biliary drainage. Many stones pass spontaneously within 6 weeks. Percutaneous or endoscopic stone removal can be performed in 6 weeks after an adequate tract has formed if the stones have not passed spontaneously.

Question 68

When might biliary/enteric anastomosis/drainage be required in CBDE?

Answer 68

Indications for biliary-enteric drainage include stricture/stenosis at the distal CBD or sphincter of Oddi, marked dilation of the bile duct to 2 cm or more, multiple or primary bile duct stones, inability to remove all the stones from the duct, and multiple prior operations for CBD stones.

Question 69

You are asked to see a male patient for right upper quadrant pain. His ultrasound is consistent with acute calculous cholecystitis. Two weeks ago he underwent percutaneous coronary artery stenting with a drug-eluting stent for an acute myocardial infarction, and he is now on aspirin and clopidogrel. What issues are you concerned with when treating this patient?

Answer 69

• Does he have gangrene/necrosis, perforation, emphysematous chole?
• If not, find out his ASA score. If high risk, find out if critically ill or septic.
• Realize that due to his recent acute myocardial infarction, he is at high risk for perioperative cardiac complications and should not undergo surgery.
• Understand that having had a recent drug-eluting stent, he must be maintained on antiplatelet therapy at all times, because of the high risk of stent thrombosis.
• Recognize that a percutaneous cholecystostomy tube combined with intravenous antibiotics may temporize this patient until a time when he is a better candidate for surgery.

Question 70

You are performing a laparoscopic cholecystectomy and have a cholangiogram that shows distal filling into the duodenum but little other information. You do not clearly see the spiral portion of the cystic duct. What will you do?

Answer 70

• Put the patient in Trendelenburg to have gravity fill the right and left common hepatic ducts. Pull back the needle. Re-do.
• Carefully dissect what you believe is the cystic duct down to its expected junction with the common hepatic duct. If this junction is not seen within a reasonably short distance, it is possible that the bile duct has been divided. Look for any signs of bile staining/leakage.
• Convert to an open procedure or call for help if you are not comfortable with the anatomy or this dissection.

Question 71

What instrumentation can be used via the choledochoscope to extract CBD stones?

Answer 71

• Discuss endoscopic baskets.
• Consider warm saline flush.
• Discuss lithotripters.
• Understand that balloon-tipped catheters can be used but must be inserted alongside the choledochoscope because they do not fit in most working channels.

Question 72

A 60-year-old man has been found to have a cholangiocarcinoma of the lower bile duct and is in the operating room undergoing a planned elective Whipple procedure. The preoperative CT scan is not available, and on portal dissection, the hepatic artery does not appear to be present. Describe the use of intraoperative ultrasound in this situation.

Answer 72

• Discuss the types of vascular anatomic differences most commonly found - replaced hepatic artery, accessory right or left artery.
• Discuss the location in association to other portal structures and the use of duplex/Doppler to confirm the diagnosis.
• Discuss the difference in dissection during a Whipple operation or bile duct resection if a replaced/accessory right artery is found.

Question 73

A 45-year-old female presents to your surgical clinic approximately one week after a laparoscopic cholecystectomy. She is complaining of persistent right upper quadrant pain and low-grade fever. How would you evaluate this patient?

Answer 73

• look for jaundice; if unstable - sepsis tx
• ddx: stricture, abscess, retained stone, biloma, leak
• LFTs, CBC, BMP
• RUQ US - finds leak, abscess, stricture
• if leak/transx - HIDA confirms - PTC for proximal anatomy, then IR for biloma
  
  • type A, C, D can be tx 1st w/ ERCP
  • C&D - redo HIDA - C may need recon, D needs repair vs recon if large
• if abscess - CT - IR to drain
• if stricture - MRCP to define anatomy - RnYHJ

Question 74

Discuss the incidence of biliary injury in laparoscopic cholecystectomy and factors that increase or decrease this incidence.

Answer 74

• Published incidence of injury is ~ 0.3% to 0.7%.
• Patient factors: inflammation, obesity, altered anatomy
• Technical strategies: identify the critical view of safety, use an angled laparoscope, avoiding excessive cephalad retraction of the gallbladder fundus.

Question 75

Discuss the ways in which a surgeon would treat a biliary injury recognized intraoperatively.

Answer 75

• transfer if uncomfortable, do IOC to define, open if needed
• assess if proximal injury (2 cm from confluence)
• assess if long injury length from end-end (1 cm)
• assess extent of injury (50%)
• if low extent - can repair primarily
• if distal and short - end-end anastomosis
• if proximal and long - assess confluence
  
  • hepaticojejunostomy
  • +/- transanastomotic silastic stents
• use 5-0 absorbable sutures interrupted
• drains near repair/anastomosis
• postop cholangiogram POD 3-4

Question 76

During laparoscopic cholecystectomy, you diagnose a bile leak. What are the key steps for proper management?

Answer 76

• IOC - determine extent of injury
• consider converting to open
• assess if small duct - < 3 mm - ligate, place drain
• type D injury - repair primarily, leave a drain

Question 77

A 50-year-old woman presents with history of remote biliary injury that requires surgical repair. What type of operation would you offer her?

Answer 77

• d/t remote nature, this is likely a stricture
• workup: LFT’s, r/o cholangitis, r/o leak
• cholangitis - PTC or ERCP, IVF, abx
• noninfected biliary obsx - MRCP to define anatomy
• CTA to define arterial system
• hepaticojejunostomy (has more back-bleeding)

Question 78

What are the key steps of a hepaticojejunostomy performed for biliary stricture?

Answer 78

• excise the strictured portion of the bile duct, send to pathology
• excise back to healthy tissue
• no excessive dissection of the duct - maintain blood supply
• drop the hilar plate, spatulate the bifurcation of the right and left ducts, or extension into the extrahepatic left duct
• do not dissect proximally more than 5 mm out of the liver
• repair over silastic stents
• Roux-en-Y jejunal limb and perform an end-to-side mucosal-to-mucosal hepaticojejunostomy.
• place drains, cholangiogram postop, internalize stents

Question 79

A 54-year-old man is seen in follow-up after undergoing a hepaticojejunostomy and is found to have a recurrent stricture across his anastomosis. What are your next steps in management?

Answer 79

• define anatomy: PTC vs MRCP
• extend stoma to extrahepatic portion of L duct
• revision
• hepatectomy if long stricture or liver atrophy
• if unable to revise - transplant

Question 80

What is the mechanism underlying the development of biliary pancreatitis? What percentage of acute pancreatitis cases are associated with gallstones? What are the demographic characteristics of patients who develop gallstone pancreatitis compared to other forms of pancreatitis?

Answer 80

• A gallstone passes down the bile duct and partially or temporarily obstructs the pancreatic duct, leading to a secretory response. Secretion plus obstruction initiates pancreatitis. Gallstones usually continue to pass through the ampulla of Vater spontaneously.
• About 40% of acute pancreatitis cases occur as a result of gallstones.
• Patients with gallstone pancreatitis tend to be older than those with alcoholic pancreatitis and are more likely to be female.

Question 81

A 60-year-old woman with gallstone pancreatitis is admitted to the hospital. Over the first 48 hours of hospitalization, her clinical status remains unchanged, but her bilirubin level rises from 2 mg/dL to 8 mg/dL. What is the appropriate evaluation and treatment?

Answer 81

• This patient probably has a stone obstructing the ampulla of Vater.
• You should obtain ultrasound to see if the common bile duct is dilated.
• If the duct is dilated, proceed to ERCP with papillotomy and stone extraction.

Question 82

A 70-year-old man is admitted with acute pancreatitis and found to have gallstones by ultrasound. When is the appropriate time to consider laparoscopic cholecystectomy? Support your answer from the scientific literature?

Answer 82

• Studies in the literature demonstrate a 25% or greater incidence of recurrent pancreatitis within 6 weeks after the initial attack of pancreatitis.
• The best time for cholecystectomy is during the index admission after symptoms and laboratory tests have normalized.
• Most patients improve enough in a few days to undergo operation.

Question 83

A 68-year-old woman is admitted with gallstone pancreatitis, and improves clinically over a few days. Her serum amylase level, however, remains elevated. What is the possible explanation? What will you do?

Answer 83

• Persistent amylase elevation raises the possibility of persistent complicated pancreatitis.
• It is best to obtain CT to determine whether there is persistent pancreatitis before performing cholecystectomy.
• Cholecystectomy should be delayed until acute pancreatitis resolves. The presence of a peripancreatic fluid collection or pseudocyst may result in a decision to delay cholecystectomy for a few weeks.

Question 84

What is Caroli’s disease and how does its management differ from that of other choledochal cysts?

Answer 84

• Caroli’s disease is a type V choledochal cyst characterized by multifocal, segmental dilatation of large intrahepatic bile ducts.
• Supportively treat by monitoring for and treating cholangitis and sepsis episodes.
• Resect one lobe if only one is affected.
• Transplant is a potentially curative treatment for type V choledochal cysts if disease is diffuse.

Question 85

A 14-year-old male presents with jaundice, right upper quadrant pain, and intermittent fevers over the past several weeks. Develop a differential diagnosis and describe how you would proceed with the workup.

Answer 85

• choledocholithiasis, choledochal cysts, and malignancy in the differential diagnosis
• likely choledochal cyst d/t age range
• RUQ US then MRCP or CT
• ERCP can better define distal duct cysts (type 3)

Question 86

An MRI/MRCP of the patient in question 1 reveals a type I choledochal cyst. Discuss what therapy you would recommend and why.

Answer 86

• type I cysts as the most common
• choledochal cysts, when not resected, confer an increased risk of biliary tract malignancy
• resection w/ Roux-en-Y recon

Question 87

types of choledochal cysts

Answer 87

• type 1 - fusiform dilation
• type II - saccular off common
• type III - intramural cyst w/in duodenum
• type IV - intra and extrahepatic cysts
• type V - caroli disease - intrahepatic cysts, diffusely in all segments

Question 88

how do you manage a type I choledochal cyst?

Answer 88

• fusiform dilation of CBD, most common
• complete resection up to nondilation portion of duct
• cholecystectomy
• Roux-en-Y HJ
• if substantial pericystic fibrosis - can dissect intramural plane to remove epithelium

Question 89

how do you approach a type III choledochal cyst?

Answer 89

transduodenally, may be drained endoscopically

Question 90

how do you manage type IV choledochal cysts affecting a single intrahepatic lobe? what if it’s extrahepatic?

Answer 90

partial hepatectomy and recon; if it is extrahepatic, treat like type I (complete resection and recon w/ HJ)