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A1-G Surg Note Biliary System > Benign Biliary Disease 2 > Flashcards

Benign Biliary Disease 2 Flashcards

1
Q

Pseudopolyps are further divided into :

A
  • cholesterol polyps
  • focal adenomyomatosis
  • hyperplastic polyps
  • inflammatory polyps
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2
Q

Cholesterol polyps

A

> > Pedunculated echogenic lesions of the gallbladder
Usually smaller than 1 cm
Frequently multiple

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3
Q

Adenomyomatosis

A

> > sessile lesion
commonly in the fundus
microcysts within the lesion
frequently larger than 1 cm

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4
Q

Benign Biliary Masses

A

includes intraepithelial and intraductal types.

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5
Q

Intraepithelial lesions

A

Intraepithelial lesions
» precursors of epithelial malignancies of bile ducts.

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6
Q

The intraductal lesions

A

> > include mucin producing neoplasms
adenomas
papillomas
papillomatosis.

  • premalignant &raquo_space; mucin producing and papillomatosis.
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7
Q

Tx ?

A

Treatment consists of complete resection with a small rim of normal epithelium because incomplete excision of affected epithelium carries a high risk of recurrence.

These lesions occur in the periampullary duct, so a transduodenal approach can be used

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8
Q

Inflammatory Mass of the Biliary Tree

A

Mistaken for Cholangiocarcinoma
Can happens after surgery
due to ischemia to duct , fibrosis and inflammation
Commonly Extrahepatic above the bifurcation

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9
Q

Contraindications to Lap Chole

A

> > inability to tolerate general anesthesia
end-stage liver disease with portal hypertension, precluding safe portal dissection, and coagulopathy

relative Contraindications :
» severe chronic obstructive pulmonary disease, with poor ability for gas exchange,
» congestive heart failure are considered relative contraindications

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10
Q

excellent hemostasis must be achieved during this dissection ( Liver bed ) Why ?

A

Because the venous drainage of the gallbladder is directly into the liver bed through venules

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11
Q

Routine Cholangiogram, identify unsuspected stones in what percentage ?

A

10 %

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12
Q

Indications for cholangiography in the selective setting include

A

> > any questionable anatomy and difficulty identifying the structures
suspicion of intraoperative CBD injury
unexplained pain at the time of cholecystectomy
any suspicion of current or previous choledocholithiasis without preoperative duct clearance
elevated preoperative liver enzyme levels
dilated CBD in preoperative imaging
suspicion of intraoperative biliary injury

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13
Q

Bailout Procedures

A

The common bailout procedures include
» subtotal cholecystectomy
» fundus first procedure (retrograde)
» conversion to open

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14
Q

Subtotal cholecystectomy

A

> > removing as much gallbladder as possible
from fundus to infundibulum
“reconstituting” (closed gallbladder remnant) or “fenestrated” (open gallbladder remnant, with or without closure of the internal opening of the cystic duct)

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15
Q

Open CBD Exploration

A

> > right upper quadrant incision Or upper midline incision
Gentle palpation of the distal bile duct will frequently find the offending stone, which may be milked backward.
Stay sutures are then placed
choledochotomy is performed in the supraduodenal bile duct
Flushing of the duct with a soft rubber catheter will frequently remove the offending stones
Balloon catheters and, with fluoroscopic guidance, wire baskets may be useful to withdraw the stone
Flexible choledochoscopes are used to visualize the distal bile duct
With complete removal of stones, a T tube is placed, and a cholangiogram obtained before closure to document clearance.

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16
Q

When to do Choledochoduodenostomy

A

> > In the setting of a dilated common bile duct (CBD) with inability to clear all the stones from the distal duct, an anastomosis can be performed between the CBD and adjacent duodenum

> > Vertical incision on CBD
Horizontal incision on duodenum
Stay sutures on corners, creating open anastomosis.
Suturing posterior wall
Suturing anterior wall.

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17
Q

Difficult CBD Exploration ?

A

> > dilated bile ducts
multiple distal impacted stones
a distal duct stricture with stones
intrahepatic stones

  • primary bile duct stones drainage procedures:
    » choledochoduodenostomy
    » Roux-en-Y hepaticojejunostomy

A side-to-side or end-to-side choledochoduodenostomy allows future endoscopic intervention of the upper biliary tree, if necessary.

An alternative to duodenostomy is a Roux-en-Y choledochojejunostomy.

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18
Q

Downside to choledochoduodenostomy ?? sump syndrome ??

A
  • Bile duct distal to the anastomosis may drain poorly and may collect debris that obstructs the anastomosis or the pancreatic duct, a process known as sump syndrome.
  • Anastomosis to the jejunum in a Roux-en-Y arrangement provides excellent drainage of the biliary tree without a risk of sump syndrome but does not allow future endoscopic evaluation of the biliary tree
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19
Q

When to do Transduodenal sphincteroplasty

A

> > when impacted stones at the ampulla cannot be removed through choledochotomy or several stones are impacted in a nondilated tree

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20
Q

Steps ?

A

> > Kocher maneuver
longitudinal duodenotomy to lateral wall
Compression of the lateral wall against the medial wall to palpate of the ampulla
incision is made at the 11 o’clock position
elevated with stay sutures
The pancreatic duct enters at the 5 o’clock position on the ampulla and must be avoided.
inferior pancreaticoduodenal arcade is adjacent to the distal part of the ampulla and can be injured during sphincterotomy.

> > straight clamps are placed along the planned incision of the ampulla to guide visualization through hemostasis.
With each step, the duodenal mucosa is sewn to the bile duct mucosa with absorbable 4-0 or 5-0 sutures.
A 1.5-cm sphincterotomy is usually sufficient to allow stone removal and subsequent drainage.
Closure of the longitudinal duodenotomy in transverse fashion avoids a future duodenal stricture

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21
Q

Transduodenal sphincteroplasty , incision made at what position ?

A

incision is made at the 11 o’clock position

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22
Q

what position the pancreatic duct enter the ampulla ?

A

The pancreatic duct enters at the 5 o’clock position on the ampulla and must be avoided.

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23
Q

which artrey to avoid in transdudenal sphinctroplasty ?

A

inferior pancreaticoduodenal arcade is adjacent to the distal part of the ampulla and can be injured during sphincterotomy.

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24
Q

With intrahepatic stones ??

A

> > transhepatic approach to cholangiography
Percutaneous drainage catheters may be left in place and upsized to perform percutaneous stone extraction.

> > Long-term management of intrahepatic stones must be carefully tailored to the disease but frequently requires hepaticojejunostomy for optimal biliary drainage.

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25
Laparoscopic CBD Exploration approaches ?
- transcystic approach - choledochotomy.
26
transcystic approach
>> Seldinger technique after balloon dilation >> flexible choledochoscope >> or flexible ureteroscope >> A water irrigation system >> The flexible choledochoscope is advanced to the distal bile duct >> wire basket is passed to ensnare the stone, withdrawing it and the choledochoscope together.
27
In the laparoscopic choledochotomy approach
>> longitudinal incision is made in the CBD (i.e., below the cystic duct). >> two stay sutures are placed on either side of the planned choledochotomy >> The size of the incision should be at least as large as the diameter of the largest stone >> The choledochoscope can then be fed down into the distal bile duct and stone extraction performed >> At the completion of the exploration, a T tube should be placed through the choledochotomy and the bile duct closed with 4-0 absorbable sutures >> Completion cholangiography through the T tube documents stone removal
28
Duration of T-Tube Placement , and when to remove ?
>> Typically left for 7–14 days to allow CBD healing. >> Cholangiography (T-tube study) is done before removal to check for: - Biliary obstruction - Retained stones - Bile leaks >> usually clamped for 24–48 hours before removal to ensure normal bile flow into the duodenum. >> If cholangiography is normal, the T-tube is removed gradually to prevent bile leakage
29
Complications of T-Tube Use
- Bile leakage after removal - Bile peritonitis (if removed too early) - Stricture formation due to prolonged placement - Infection (ascending cholangitis) - Persistent biliary fistula
30
Contraindications to the transcystic approach
- numerous (more than eight) stones - a stone larger than 1 cm - intrahepatic stones - cystic duct that does not allow dilation and choledochoscope passage.
31
CBD exploration vs post Op ERCP
- the only difference being a shorter hospitalization and lower physician fees for patients undergoing common duct exploration as the cholecystectomy and clearance of stones are performed in one setting by a single physician
32
Postcholecystectomy Syndromes
- manifest from 2 days up to 25 years postcholecystectomy and are more common in females. Etiology : - Complication from Surgery - unrelated etiology ( Gerd, Esophagitis ) - Retained Stone - Bile Salt Diarrhea - Bile leak - Long Remnant Cystic Duct - Functional Disorder ( Sphincter of Oddi )
33
Bile Duct Injury Strasberg classification A
(A) Injury to small ducts in continuity with the biliary system with a leak in the duct of Luschka or the cystic duct.
34
B
(B) Injury to a sectoral duct, causing obstruction of portion of the biliary system
35
C
(C) Injury to a sectoral duct with bile leak; leak from a duct not continuous with the biliary system
36
D
D) Lateral injury to the extrahepatic biliary ducts.
37
E1
(E1) Bismuth type 1: injury more than 2 cm from the confluence
38
E2
(E2) Bismuth type 2: injury less than 2 cm from the confluence.
39
E3
(E3) Bismuth type 3: injury at the confluence; confluence intact
40
E4
(E4) Bismuth type 4: destruction of the biliary confluence
41
E5
(E5) Complete occlusion of all bile ducts, including sectoral ducts.
42
Bile Duct injury Manifest either as a
Leak Or Stricture >> Leakage into peritoneal cavity followed by peritonitis tends to manifest earlier than stricture
43
Recognized at the time of cholecystectomy
- conversion to an open - use of cholangiography
44
If the injury occurs to a larger than 3-mm duct but is not caused by electrocautery and involves less than 50% of the circumference of the wall
>> T-tube placement through the injury, which is effectively a choledochotomy, usually will allow healing without the need for subsequent biliary-enteric anastomosis
45
Ducts smaller than 3 mm that by cholangiography drain only a single segment or subsegment of the liver
simple ligation may suffice for management
46
thermal injury ?? or or an injury involving more than 50% of the duct circumference ??
>> the extent of thermal damage may not be manifested immediately >> an injury involving more than 50% of the duct circumference - requires resection of the injured segment with anastomosis to reestablish biliary-enteric continuity
47
Defects smaller than 1 cm and not near the hepatic duct bifurcation
can be repaired by mobilization and end-to-end anastomosis of the bile duct. This approach should be accompanied with transanastomotic T-tube placement. Tube inserted in separate incision , and not through the anastamosis
48
To ensure a tension-free anastomosis
1- generous Kocher maneuver 2- mobilizing the duodenum and the head of the pancreas out of the retroperitoneum
49
injuries occur adjacent to the bifurcation or involve more than a 1-cm defect between the ends of the bile duct
requiring reanastomosis to the gastrointestinal tract.
50
How its Done ?
>> distal end is oversewn >> proximal end debrided to normal tissue. >> choice of reconstruction depends on the location and extent of injury, history of previous attempts at repair, and preference of the surgeon. >> Low injuries to the bile duct : - reimplanted into the duodenum >> The Roux-en-Y approach to reconstruction is substantially more versatile and can be applied to injuries throughout the biliary tree.
51
Roux En y ? How ?
- resection of the injured segment - mucosa-to-mucosa anastomosis using a Roux-en-Y jejunal limb - Transanastomotic stenting has been shown to improve anastomotic patency, with longer duration of stenting providing a more favorable outcome.
52
anything else you should worry about in duct injuries?
concomitant vascular injuries are common >> Doppler ultrasonography can confirm adequate hepatic arterial and portal venous flow to the hepatic parenchyma.
53
when one is confronted with a bile duct injury and no surgeon with experience in biliary reconstruction is available
- the most appropriate management strategy is placement of a drain and immediate referral to an experienced center.
54
bile leakage can be manifested as
- biloma, whether sterile or infected or - with biliary ascites.
55
Goals of therapy in iatrogenic bile duct injury in delayed presentation
1. Control of infection, limiting inflammation * Parenteral antibiotics * Percutaneous drainage of periportal fluid collections 2. Clear and thorough delineation of entire biliary anatomy * MRCP or PTC * ERCP (especially if cystic duct stump leak is suspected) 3. Reestablishment of biliary-enteric continuity * Tension-free, mucosa-to-mucosa anastomosis * Roux-en-Y hepaticojejunostomy * Long-term transanastomotic stents if bifurcation or higher is involved
56
First, control of infection with drainage of any fluid collections
- Inflammation in the porta hepatis leads to fibrosis, which acts only to increase stricture formation. - With control of sepsis, there is no urgency for biliary reconstruction. - the retraction of an injured bile duct into the hilum of the liver, as well as inflammation in this region, makes successful repair in the immediate postoperative setting unlikely
57
A second goal of management is clear and thorough delineation of the biliary anatomy
- patients with bile duct continuity >> ERCP - PTC shows intrahepatic biliary tree, identify the location of the injury, provide drainage of bile, and possibly even allow the leak to close >> left in place during reconstruction to assist in dissection and to provide drainage perioperatively. >> Small bile leaks with bile duct continuity and cystic duct stump leaks can be successfully managed by endoscopic stenting and sphincterotomy.
58
The third goal of management is to reestablish durable biliary-enteric drainage
- anastomosis performed between a minimally inflamed bile duct - tension-free - mucosa-to-mucosa fashion.
59
When the anastomosis is within 2 cm of the hepatic duct bifurcation or involves intrahepatic ducts
>> long-term stenting may improve patency.
60
If the bifurcation is involved
>> stenting of both right and left ducts should be performed.
61
When the reconstruction involves the CBD or common hepatic duct more than 2 cm from the bifurcation
stenting is not necessary preoperatively placed transhepatic drain or intraoperatively placed T tube will provide adequate decompression in the immediate postoperative period.
62
in the setting of substantial inflammation, how to identify the bile duct ?
Needle aspiration of porta used to identify the common bile duct
63
Key Steps for the Reconstruction
- above the stricture, only a limited segment of bile duct (<5 mm) is dissected free. - Preservation of as much normal biliary tree as possible remains a goal of the reconstruction. - the bile duct can be opened - percutaneously placed catheters advanced through the incision. - exchange the catheters for long-term Silastic stents - or the catheters can be left in place for transanastomotic decompression - The mucosa-to-mucosa anastomosis can be created in an end-to-side fashion to the Roux-en-Y jejunal limb.
64
In the setting of substantial inflammation at the bifurcation
>> another reconstruction option involves anastomosis of the Roux limb to the left hepatic duct. As noted, the left hepatic duct retains a substantial extraparenchymal length, allowing an anastomosis in this portion of normal duct. cholangiography must confirm that the biliary bifurcation is widely patent, thus ensuring drainage of the right lobe across the bifurcation to the left duct system.
65
Interventional radiologic and endoscopic techniques
>> Balloon dilation can treat strictures - successful in up to 70% of patients. >> Complications include : cholangitis, hemobilia, and bile leaks requiring repeated intervention.
66
When can you use Endoscopic balloon dilation
Reserved for those with primary bile duct strictures or patients who have undergone choledochoduodenostomy for reconstruction because the Roux limb does not usually allow endoscopic strategies
67
What predicts Stricture at time of reconstruction
Sepsis at the time of reconstruction and biliary cirrhosis are predictors of stricture.
68
Who will have higher operative mortality and lower success rates
Chronic liver disease and hepatic fibrosis
69
Biliary Leak
from the cystic duct or an unrecognized duct of Luschka.
70
when bile leak presents
present within 1 week of cholecystectomy as the bile collects and becomes clinically manifested
71
If the leak is from a cystic duct stump
sphincterotomy with stenting of the common duct will allow the leak to seal without need for surgical management
72
when to consider surgery
- evidence of septic shock or - those in whom the leakage is not percutaneously accessible. If percutaneous drainage is not feasible because of overlying bowel or the fluid is not localized and thus not amenable to percutaneous drainage, a laparoscopic washout of the abdomen and placement of subhepatic drains should be considered
73
Persistence of a bile leak longer than 6 weeks should raise the suspicion of
an unrecognized bile duct injury.
74
stones lost during a cholecystectomy
can cause: - chronic abscess - fistula, - wound infection - bowel obstruction
75
Timing of leak , secondary stone and stricture
>> days to weeks after cholecystectomy suggests a secondary choledocholithiasis or a bile leak. sphincter of Oddi dysfunction. Postoperative bile duct strictures >> identified within the first year after cholecystectomy
76
Retained stone are usually what type ?
Cholesterol
77
Acute Cholangitis MC pathogens
Klebsiella, E. coli, Enterobacter, Pseudomonas, and Citrobacter spp.
78
Recurrent Pyogenic Cholangitis cause?
- secrete an enzyme that hydrolyzes water-soluble bilirubin glucuronides to form free bilirubin, which then precipitates to form brown pigment stones - e.g Clonorchis sinensis and Ascaris lumbricoides - Risk for Cholangiocarcinoma
79
What can be seen in recurrent pyogenic cholangitis ?
- Lobar or segmental atrophy or hypertrophy may be seen in chronic cases. - Diagnosis CT, MRCP and ERCP
80
Tx ?
>> intrahepatic strictures may warrant resection stricturoplasty, or Hepaticojejunostomy. - When clearance of all stones is not possible or future need for endoscopic therapy is anticipated, the terminal end of the Roux limb for a hepaticojejunostomy can be brought out as a stoma to provide easy access for choledochoscopy. Given the risk of cholangiocarcinoma, disease affecting predominantly one lobe should be resected in patients with adequate hepatic reserve

A1-G Surg Note Biliary System (5 decks)

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