Benign Biliary Ducts Flashcards
Bismuth Classification of Bile Duct Injury
- Low common hepatic duct injury with >2cm stump remaining
- Middle CHD injury with < 2cm stump remaining
- Hilar injury, confluence preserved
- Hilar injury with loss of left or right communication
- Right sectoral duct injury (aberrant) with or without CHD injury
Strasberg Classification of Bile Duct Injury
A - Cystic duct leak
B - Occlusion of aberrant right hepatic sectoral duct
C - Transection without ligation of aberrant right hepatic sectoral duct
D - Lateral injury to major bile duct
E - (Bismuth)
E1 - transection >2cm from hilum
E2 - transection < 2cm from hilum
E3 - transection at hilum
E4 - separation of major ducts in hilum
E5 - transection of right hepatic sectoral ducts and/or hilum injury
Strasberg- Bismuth Classification
Mirizzi Syndrome (extra hepatic biliary stricture due to cholelithiasis) Classification
Type 1: External compression of CHD due to impacted stone in the gallbladder neck/infundibulum
Type 2: Fistula <1/3 circumference of CBD
Type 3: Involvement of 1/3-2/3 circumference of CBD
Type 4: Destruction of entire CBD wall
Type 5: Includes presence of a cholecystoenteric fistula
Choledochal Cyst
Modified Todani Classification
Type 1: solitary cyst with fusiform dictation of the CBD
Type 2: Saccular Diverticulum of the Common Bile Duct
Type 3: Choledochocoeles/ cystic dilatation the intramural common bile duct within the duodenal wall
Type 4: Extension of cysts into intrahepatic ducts
IVa - intra and extra hepatic duct cysts
IVb - multiple cysts in extra hepatic biliary tree
Type 5 (Caroli’s Disease): Intrahepatic cysts without extra hepatic choledochal cysts
Choledochal Cysts
- Pathophysiology
Aberrant pancreaticobiliary junction usually mean pancreatic and bile ducts fuse before passing through the duodenal wall –> long common channel
Pancreatic secretions reflux into biliary tree
Causes local inflammation and damage
Results in cystic degeneration
Choledochal cysts are PREMALIGNANT LESIONS FOR CHOLANGIOCARCINOMA
22% at 20 years
43% at 60 years
Choledochal Cysts
- Management for Type 1
(Solitary cyst with fusiform dilatation of CBD)
Surgical excision and roux-en-y hepaticojejunostomy
- proximal extent to the non dilated biliary tree
- may need anastomosis of the right and left hepatic ducts
- can utilise intramural plane if pericyst fibrosis present to excise epithelium safely
- oversew distal duct without injuring the pancreatic duct
Choledochal Cysts
- Management for Type 2
(Saccular diverticulum of the CBD)
Surgical excision and roux-en-y hepaticojejunostomy if aberrant BP junction
Choledochal Cysts
- Management for Type 3
(choledochocoele/cystic dilatation of the intramural CBD within the duodenal wall)
Uncommon
Can use the duodenal approach
May not be associated with ABPJ (aberrant pancreaticobiliary junction) –> just endoscopic drainage
If duodenal or biliary obstruction present - transduodenal excision or sphincteroplasty
Choledochal Cysts
- Management for Type 4
(Extension into intrahepatic ducts)
Surgical excision of affected extra hepatic ducts and hepaticojejunostomy; liver resection if intrahepatic ducts are limited to a single area
Choledochal Cysts
- Management for Type 5
(intrahepatic without extra hepatic disease)
Liver resection or transplant.
Charcot’s Triad
RUQ pain
Jaundice
Fever
Reynold’s Pentad
RUQ pain Jaundice Fever Mental obtundation Hypotension
Bouveret’s syndrome: Gastric Outlet obstruction due to Gallstone in duodenum or pylorus
Bouveret’s syndrome: Gastric Outlet obstruction due to Gallstone in duodenum or pylorus
Bouveret’s syndrome: Gastric Outlet obstruction due to Gallstone in duodenum or pylorus
Gallbladder adenomyomatosis:
Macroscopically (a) GA is characterized by gallbladder wall thickening (lines) containing small cystic spaces (arrows) representing Rokitansky–Aschoff sinuses.
Microscopically, wall thickening is due to hyperplasia of the muscular layer (lines); a variable degree of epithelial proliferation (arrowheads) is also appreciable and epithelium-lined cystic spaces, representing RAS (arrows), can be observed within the muscular layer.
Intramural extension of mucosa creates tubules and crypts in the lamina propria that accumulate mucus → herniate through muscularis propria to form Rokitansky-Aschkoff sinuses (cystic structures visible on gross inspection as pools of bile within the GB wall)
